Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 111 num. 8 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[<b>Elderly, vulnerable and forgotten</b>]]> <![CDATA[<b>A call to action: Temporal trends of COVID-19 deaths in the South African Muslim community</b>]]> <![CDATA[<b>Telerheumatology in the era of COVID-19 in South Africa</b>]]> <![CDATA[<b>Discovering hypertriglyceridaemia</b>]]> <![CDATA[<b>Decentralised HIV care during the COVID-19 pandemic: Ensuring safe community-based services</b>]]> <![CDATA[<b>Beorn Cloete Uys, 21 August 1929 - 18 May 2021</b>]]> <![CDATA[<b>Familial hypercholesterolaemia in South Africa: A reminder</b>]]> <![CDATA[<b>COVID-19 vaccine hesitancy in South Africa: A complex social phenomenon</b>]]> <![CDATA[<b>Asthma in South African children: Guidelines, obstacles and solutions</b>]]> <![CDATA[<b>Childhood asthma: A best-practice strategy for diagnosis and assessment of control in South Africa</b>]]> The South African (SA) Childhood Asthma Working Group of the Allergy Society of SA (ALLSA) advises on best-practice strategy for childhood asthma management. The strategy is in accordance with current evidence and consensus. The aim of this review is to inform on a best-practice strategy for asthma diagnosis and the assessment of asthma control in SA children who attend public and private healthcare services. The diagnosis of asthma is more difficult in preschool-aged than school-aged children. This review proposes a four-step diagnostic approach in both groups, with an added obligation to objectively measure variable expiratory airflow limitation in school-aged children. Asthma control refers to the degree to which the effects of asthma can be seen in patients, or to which these have been reduced by treatment. After initiation of treatment, it is essential to assess asthma control at regular follow-up visits, and to adjust treatment accordingly. Patient education is key to attaining control. <![CDATA[<b>Management of asthma exacerbations in children</b>]]> Asthma exacerbations are episodes of worsening asthma symptoms with shortness of breath, cough, wheeze and/or tight chest that require an increase in asthma treatment. A major change in the recommendations for managing mild asthma exacerbations is the move away from using inhaled short-acting beta-2 agonists (SABAs) as the sole reliever, toward a combination of a rapid-onset, long-acting beta-2 agonist, formoterol, in combination with an inhaled corticosteroid (ICS), or a SABA used together with an ICS in separate inhalers, in older children and adolescents. In children <11 years of age who are adherent to daily ICS treatment, the ICS dose should not be increased short term. A written asthma plan should include instructions on how to self-manage asthma exacerbations, and when to present to a medical facility. Oxygen is an essential component of the management of asthma exacerbations at both primary care and emergency department facilities, together with inhaled SABAs via metered-dose inhaler and spacer, and oral corticosteroids. <![CDATA[<b>Impact of COVID-19 on routine primary healthcare services in South Africa</b>]]> BACKGROUND: The COVID-19 pandemic and responses by governments, including lockdowns, have had various consequences for lives and livelihoods. South Africa (SA) was one of the countries that implemented severely restrictive lockdowns to reduce transmission and limit the number of patients requiring hospitalisation. These interventions have had mixed consequences for routine health servicesOBJECTIVES: To assess the impact of COVID-19 and restrictions imposed to limit viral transmission on routine health services in SAMETHODS: Data routinely collected via the District Health Information System in 2019 and 2020 were analysed to assess the impact of the COVID-19 pandemicRESULTS: Access to public health services between March 2020 and December 2020 was limited in all provinces. However, this was not linear, i.e. not all services in all provinces were similarly affected. Services most severely affected were antenatal visits before 20 weeks, access to contraceptives, and HIV and TB testing. The impact on outcomes was also noticeable, with a measurable effect on maternal and neonatal mortalityCONCLUSIONS: The responses to the COVID-19 pandemic, including different levels of lockdowns, the limitation of health services, lack of staff as a result of COVID-19 infection, and fear and stigma, resulted in a reduction in access to routine health services. However, the picture varies by type of service, province and district, with some faring worse than others. It is important to ensure that routine services are not significantly affected during future COVID-19 waves. This will require careful planning on the part of service providers and optimal communication with patients and communities <![CDATA[<b>Access to chloroquine in patients with rheumatic and musculoskeletal diseases attending rheumatology outpatient clinics during the COVID-19 pandemic</b>]]> Herbal medicines made from the bark of the Cinchona tree, and later quinine, have been widely used for centuries to treat medical conditions such as tropical malaria. More recently, chloroquine (CQ) and its synthetic derivatives have been used as antimalarials and to treat systemic lupus erythematosus, rheumatoid arthritis, and in the past 14 months or so, COVID-19 pneumonia. Anecdotal evidence and the erratic covering through social media of its potential efficacy in the treatment of COVID-19 pneumonia have resulted in the widespread off-label use of CQ in South Africa and worldwide. This study aimed to show that access to CQ as a chronic medication for rheumatic and musculoskeletal diseases was limited during the COVID-19 pandemic, and that this resulted in an increased incidence of flares in these patients, affecting their morbidity and potentially leading to mortality. <![CDATA[<b>Hospital-based evaluation of tuberculosis-exposed neonates: An approach to complement the South African national guidance</b>]]> The South African National Department of Health published updated guidelines in 2019 for the prevention of mother-to-child transmission of communicable diseases. The proposed management of a neonate born to a mother with tuberculosis (TB) was included, and recommended referral of all symptomatic TB-exposed neonates to hospital for TB evaluation. However, no standard approach exists for evaluating hospitalised, symptomatic TB-exposed neonates, including preterm and low-birthweight (LBW) neonates born to mothers with TB. We use a clinical case report to illustrate a suggested approach to hospital-based evaluation of TB-exposed neonates, including preterm and LBW neonates. Guidance for the interpretation of different TB screening investigations in this population is also provided. <![CDATA[<b>Using ceftazidime-avibactam for persistent carbapenem-resistant <i>Serratia marcescens </i>infection highlights antimicrobial stewardship challenges with new beta-lactam-inhibitor combination antibiotics</b>]]> The newer beta-lactam-inhibitor combination (BLIC) antibiotics are available in South Africa (SA) for the treatment of carbapenem-resistant Enterobacterales infections. We describe the successful use of ceftazidime-avibactam (CA) for the treatment of a child with persistent carbapenem-resistant Serratia marcescens bacteraemia, and the challenges faced using this lifesaving antibiotic, including access to susceptibility testing, procurement process, cost and complexity of deciding when, how and for how long to use it. Furthermore, the burden of carbapenem resistance is increasing in SA, and inappropriate use of CA and other newer BLIC antibiotics, such as ceftolozane-tazobactam, will inevitably endanger their longevity. A careful balance must be struck between removing unnecessary obstacles and delays in initiating these antibiotics for life-threatening infections, and additional antimicrobial stewardship-guided interventions aimed at preserving their therapeutic use. <![CDATA[<b>Tracking mortality in near to real time provides essential information about the impact of the COVID-19 pandemic in South Africa in 2020</b>]]> BACKGROUND: Producing timely and accurate estimates of the impact of COVID-19 on mortality is challenging for most countries, but impossible for South Africa (SA) from cause-of-death statisticsOBJECTIVES: To quantify the excess deaths and likely magnitude of COVID-19 in SA in 2020 and draw conclusions on monitoring the epidemic in 2021METHODS: Basic details of deaths registered on the National Population Register by the Department of Home Affairs (DoHA) are provided to the South African Medical Research Council weekly. Adjustments are made to the numbers of weekly deaths to account for non-registration on the population register, as well as late registration of death with the DoHA. The weekly number of deaths is compared with the number predicted based on the Holt-Winters time-series analysis of past deaths for provinces and metropolitan areas. Excess deaths were calculated for all-causes deaths and natural deaths, using the predicted deaths as a baseline. In addition, an adjustment was made to the baseline for natural deaths to account for the drop in natural deaths due to lockdownRESULTS: We estimated that just over 550 000 deaths occurred among persons aged &gt;1 year during 2020, 13% higher than the 485 000 predicted before the pandemic. A pronounced increase in weekly deaths from natural causes peaked in the middle of July across all ages except <20 years, and across all provinces with slightly different timing. During December, it became clear that SA was experiencing a second wave of COVID-19 that would exceed the death toll of the first wave. In 2020, there were 70 000 - 76 000 excess deaths from natural causes, depending on the base. Using the adjusted base, the excess death rate from natural causes was 122 per 100 000 population, with a male-to-female ratio of 0.78. Deaths from unnatural causes halved for both males and females during the stringent lockdown level 5. The numbers reverted towards the predicted number with some fluctuations as lockdown restrictions varied. Just under 5 000 unnatural deaths were avertedCONCLUSIONS: Tracking the weekly numbers of deaths in near to real time has provided important information about the spatiotemporal impact of the pandemic and highlights that the -28 000 reported COVID-19 deaths during 2020 substantially understate the death toll from COVID-19. There is an urgent need to re-engineer the system of collecting and processing cause-of-death information so that it can be accessed in a timely way to inform public health actions <![CDATA[<b>The prevalence of pulmonary embolism in non-hospitalised de-isolated patients diagnosed with mild COVID-19 disease</b>]]> BACKGROUND: Pulmonary embolism (PE) is a known complication of COVID-19 disease. The mechanism of thromboembolic events appears to be stimulated by excessive thrombin production, inhibition of fibrinolysis and deposition of antiphospholipids and thrombi, as well as microvascular dysfunction in multiple vascular beds. The occurrence of PE has been well demonstrated in hospitalised patients with severe disease. Very few data are available on its incidence or prevalence in non-hospitalised patients diagnosed with a milder form of the diseaseOBJECTIVES: To assess the prevalence of PE in non-hospitalised patients diagnosed with mild COVID-19 who presented with raised D-dimer levels and persistent or new-onset cardiopulmonary symptomsMETHODS: This was a retrospective study conducted in the Department of Nuclear Medicine at Universitas Academic Hospital, Bloemfontein, South Africa. We reviewed the studies of 65 non-hospitalised patients with COVID-19 referred to the department from July 2020 to January 2021 for a perfusion-only single-photon emission computed tomography/computed tomography (SPECT/CT) study or a ventilation/ perfusion (VQ) SPECT/CT study. All 65 patients had raised D-dimer levels with persistent, worsening or new-onset cardiopulmonary symptoms after the diagnosis of COVID-19RESULTS: Sixty-five patients were studied. The median (interquartile range) age was 46 (41 - 54) years and the majority (88.2%) were female. There were 22 patients (33.8%) with lung perfusion defects in keeping with PE. Two of these patients had a false-negative computed tomography pulmonary angiography (CTPA) study for PE performed the same day as their VQ SPECT/CT studyCONCLUSIONS: We confirm a high prevalence of PE in non-hospitalised patients diagnosed with mild COVID-19 who presented with raised D-dimer levels and persistent or new-onset cardiopulmonary symptoms. We recommend that irrespective of disease severity, hospitalised and non-hospitalised patients with COVID-19 presenting with persistent or new-onset cardiopulmonary symptoms and raised D-dimer levels should be investigated further for PE <![CDATA[<b>Low 30-day mortality in South African orthopaedic patients undergoing surgery at an academic hospital during the first wave of the COVID-19 pandemic: It was safe to perform orthopaedic procedures at our hospital during the first COVID-19 peak</b>]]> BACKGROUND: Initial local and global evidence suggests that SARS-CoV-2-infected patients who undergo surgery, and those who become infected perioperatively, have an increased mortality risk post surgeryOBJECTIVES: To analyse and describe the 30-day mortality, presurgical COVID-19 status and hospital-acquired SARS-CoV-2 infection rates of patients, both SARS-CoV-2-positive and negative, undergoing orthopaedic surgery at a tertiary academic hospital in South Africa (SA) during the first COVID-19 peakMETHODS: This single-centre, observational, prospective study included patients who underwent orthopaedic procedures from 1 April 2020 (beginning of the COVID-19 case increase in SA) to 31 July 2020 (first COVID-19 peak in SA). All patients were screened for COVID-19 and were confirmed positive if they had a positive laboratory quantitative polymerase chain reaction test for SARS-CoV-2 RNA on a nasopharyngeal or oral swab. Thirty-day mortality, presurgical COVID-19 status and hospital-acquired SARS-CoV-2 infection were assessedRESULTS: Overall, a total of 433 operations were performed on 346 patients during the timeframe. Of these patients, 65.9% (n=228) were male and 34.1% (n=118) were female. The mean (standard deviation) age was 42.5 (16.8) years (range 9 - 89). Of the patients, 5 (1.4%) were identified as COVID-19 patients under investigation (PUI) on admission and tested positive for SARS-CoV-2 before surgery, and 1 (0.3%) contracted SARS-CoV-2 perioperatively; all survived 30 days post surgery. Twenty-nine patients were lost to follow-up, and data were missing for 6 patients. The final analysis was performed excluding these 35 patients. Of the 311 patients included in the final 30-day mortality analysis, 303 (97%) had a follow-up observation >30 days after the operation. The overall 30-day mortality for these patients was 2.5% (n=8 deaths). None of the recorded deaths were of screened COVID-19 PUICONCLUSIONS: We report a low 30-day mortality rate of 2.5% (n=8) for patients undergoing orthopaedic surgery at our hospital during the first COVID-19 peak. None of the deaths were COVID-19 related, and all patients who tested SARS-CoV-2-positive, before or after surgery, survived. Our overall 30-day mortality rate correlates with several other reports of orthopaedic centres analysing over similar timeframes during the first peak of the COVID-19 pandemic. Regarding mortality and SARS-CoV-2 infection risk, we can conclude that with the appropriate measures taken, it was safe to undergo orthopaedic procedures at our hospital during the first peak of the COVID-19 pandemic in SA <![CDATA[<b>Antiretroviral therapy non-adherence among HIV-positive patients presenting to an emergency department in Johannesburg, South Africa: Associations and reasons</b>]]> BACKGROUND: Suboptimal antiretroviral therapy (ART) adherence is associated with viral resistance, opportunistic infections and increased mortalityOBJECTIVES: To determine the rates of ART non-adherence and its associations, and also the reasons for ART non-adherence, among HIVpositive patients presenting to a major central hospital emergency department (EDMETHODS: Consecutive HIV-positive patients presenting to the Charlotte Maxeke Johannesburg Academic Hospital adult ED between 7 July 2017 and 18 October 2018 were prospectively enrolled. Self-reported adherence was assessed using the AIDS Clinical Trials Group Adherence Questionnaire (ACTG-AQRESULTS: Of the 1 224 consecutive HIV-positive participants enrolled, 761 (75.2%) were on ART at the time of ED presentation. Of these, 245 (32.2%) were non-adherent as per the ACTG-AQ. Participants not yet on ART prior to ED presentation had significantly higher in-hospital mortality than participants on ART (odds ratio 1.69; 95% confidence interval 1.21 - 2.34; p=0.002). Younger age, male sex, CD4 count <100 cells/(μL, lack of viral suppression, a high National Early Warning Score 2 (&gt;7 points) and length of hospital stay &gt;7 days were significantly associated with ART non-adherence (p<0.05). Forgetfulness (13.9%) and lack of social support, depression/stress/mental illness, and lack of money for transport to collect medications (9.9% each) were the most common reasons given for ART non-adherenceCONCLUSIONS: Of HIV-positive patients presenting to the ED, a high proportion were either not yet initiated on ART or ART non-adherent. HIV programmes should focus on HIV-positive ED attendees with the aim of identifying high-risk patients and providing adequate ART adherence support <![CDATA[<b>Quality and turnaround times of viral load monitoring under prevention of mother-to-child transmission of HIV Option B+ in six South African districts with a high antenatal HIV burden</b>]]> BACKGROUND: Barriers to monitoring maternal HIV viral load (VL) and achieving 90% viral suppression during pregnancy and breastfeeding still need to be understood in South Africa (SAOBJECTIVES: To measure quality of VL care and turnaround times (TATs) for returning VL results to women enrolled in the prevention of mother-to-child transmission of HIV (PMTCT) programme in primary healthcare facilitiesMETHODS: Data were obtained from a 2018 cross-sectional evaluation of the PMTCT Option B+ programme in six SA districts with high antenatal and infant HIV prevalence. Quality of VL care was measured as the proportion of clients reporting that results were explained to them. TATs for VL results were calculated using dates abstracted from four to five randomly selected facility-based client records to report overall facility 'short TAT' (&gt;80% of records with TAT <7 days). Logistical regression and logit-based risk difference statistics were usedRESULTS: Achieving overall short TAT was uncommon. Only 50% of facilities in one rural district, zero in one urban metro district and 9 - 38% in other districts had short TAT. The significant difference between districts was influenced by the duration of keeping results in facilities after receipt from the laboratory. Expected quality of VL care received ranged between 66% and 85%. Client-related factors significantly associated with low quality of care, observed in two urban districts and one rural district, included lower education, recent initiation of antiretroviral treatment and experiencing barriers to clinic visits. Experiencing clinic visit barriers was also negatively associated with short TATsCONCLUSIONS: We demonstrate above-average quality of care and delayed return of results to PMTCT clients. Context-specific interventions are needed to shorten TATs <![CDATA[<b>The HIV cascade of care among serodiscordant couples in four high HIV prevalence settings in sub-Saharan Africa</b>]]> BACKGROUND: HIV-serodiscordant couples are at high risk of HIV transmission. In sub-Saharan Africa, HIV-serodiscordant couples contribute -30% of all new infections in the regionOBJECTIVES: To quantify the prevalence of HIV-serodiscordant couples and evaluate steps of the HIV cascade of care among people living with HIV in serodiscordant relationships in four high-prevalence settings in sub-Saharan AfricaMETHODS: Four HIV prevalence surveys were conducted: in Ndhiwa (Kenya) in 2012, in Chiradzulu (Malawi) in 2013, and in Gutu (Zimbabwe) and Nsanje (Malawi) in 2016. Eligible individuals aged 15-59 years were asked to participate in voluntary rapid HIV testing. Viral load and CD4 counts were measured on those who tested HIV-positive. A couple was defined as a man and a woman who reported being married or cohabiting and were living together in the same householdRESULTS: Among 4 385 couples, the prevalence of HIV serodiscordancy was 10.9% (95% confidence interval (CI) 10.2 - 11.5) overall, ranging from 6.7% (95% CI 5.6 - 7.9) in Nsanje to 15.8% (95% CI 14.5 - 17.3) in Ndhiwa. Men were the HIV-positive partner in 62.7% of the serodiscordant couples in Ndhiwa, in 60.4% in Gutu, in 48.8% in Chiradzulu and in 50.9% in Nsanje. Status awareness among HIV-positive partners in serodiscordant couples ranged from 45.4% in Ndhiwa to 70.7% in Gutu. Viral load suppression (VLS) ranged from 33.9% in Ndhiwa to 68.5% in Nsanje. VLS was similar by sex in three settings, Ndhiwa (37.8% (men) v. 27.8% (women); p=0.16), Nsanje (60.7% v. 76.9%; p=0.21) and Gutu (48.2% v. 55.6%; p=0.63), and dissimilar by sex in Chiradzulu (44.4% v. 62.7%; p=0.03CONCLUSIONS: Low HIV status awareness and poor VLS among HIV-positive partners are major gaps in preventing transmission among serodiscordant couples. Intensifying programmes that target couples to test for HIV and timely antiretroviral therapy initiation could increase VLS and reduce HIV transmission <![CDATA[<b>Evaluating an antimicrobial stewardship programme implemented in an intensive care unit of a large academic hospital, using the RE-AIM framework</b>]]> BACKGROUND: The threat of antimicrobial resistance driven by inappropriate and unnecessary use of antimicrobials is a global issue of great concern. Evidence-based approaches to optimising antimicrobial prescribing to improve patient care while reducing the rate of antimicrobial resistance continue to be implemented worldwide. However, the successes or failures of implementation of such approaches are seldom evaluatedOBJECTIVES: To evaluate the impact of an implemented antimicrobial stewardship programme (ASP) in reducing the spread of antimicrobial resistance in the intensive care unit (ICU) of a large academic hospital using the RE-AIM frameworkMETHODS: A descriptive quasi-experimental study was conducted with adult patients who had been admitted to the ICU of an academic hospital in Johannesburg, South Africa. Data were extracted from patients' records using a structured questionnaire. Descriptive statistics of four RE-AIM dimensions (reach, effectiveness, adoption and implementation) and the overall impact of the implemented antimicrobial stewardship programme were calculatedRESULTS: From the 59 participant records, 21 patients (35.6%) developed hospital-acquired infections and all were prescribed antimicrobials during their stay in the ICU. Twenty-seven pathogens (bacterial species) were isolated from samples acquired from the patients, including Staphylococcus aureus (n=6; 22.2%), Escherichia coli (n=4; 14.8%), Acinetobacter baumannii (n=4; 14.8%) and Streptococcus pnuemoniae (n=3; 11.11%), as well as 10 other bacterial species (37.0%) including Corynebacterium species, Enterococcus faecium, Haemophilus influenzae, Klebsiella species, Clostridium difficile and Salmonella species. Of the 27 pathogens isolated, 19 (70.4 %) were resistant to the prescribed antimicrobials. The overall impact of the ASP implemented in the studied facility was 67.2%CONCLUSIONS: An ASP requires both thorough implementation and leadership support to have an impact in the reduction of antimicrobial resistance. Lack of leadership support poses a significant challenge to sustainability. There is an urgent need for behavioural change in hospital leadership <![CDATA[<b>Expanding the epidemiological understanding of hepatitis C in South Africa: Perspectives from a patient cohort in a rural town</b>]]> BACKGROUND: The epidemiology of hepatitis C virus (HCV) in the general population of South Africa (SA) is incompletely understood. A high HCV prevalence in key populations is known, but data are limited in terms of a broader understanding of transmission risks in our general populationOBJECTIVES: To investigate a patient cohort with HCV infection clustering in a rural SA town, in order to identify possible HCV transmission risks, virological characteristics, phylogenetic data and treatment outcomesMETHODS: A cluster of patients with positive HCV serology, previously identified from laboratory records, were contacted by a local district hospital and offered confirmatory testing for HCV viraemia where needed. Those with confirmed HCV RNA were invited to a local hospital visit, where relevant demographic information was recorded, clinical assessment performed and a confidential questionnaire administered. HCV population-based sequencing was performed on HCV NS3/4A, NS5A and NS5B using polymerase chain reaction-specific or M13 universal primers, and sequences were aligned using BioEdit 7.2.5. Phylogenetic trees were constructed. Clinical assessments included liver fibrosis determination with FibroScan (cut-off >12.5 kPa = F4). Patients were offered treatment, and sustained virological response (SVR) was confirmed by undetectable HCV RNA at least 12 weeks after the end of treatmentRESULTS: Twenty-one patients, all from the same town, median (interquartile range (IQR)) age 64 (59 - 70) years, 57% female, were evaluated. Of these, 24% (n=5) were HIV co-infected, stable on antiretrovirals. The median (IQR) alanine aminotransferase level was 51 (31 - 89) U/L, with fibrosis distribution including 29% F1, 29% F2, 9% F3 and 33% F4 METAVIR fibrosis. Virologically, two genotypes were observed: 62% (n=13) genotype (GT) 1b and 38% (n=8) GT5a. No patient had ever used injecting drugs, 14% (n=3) had received blood products before 1992, and 9.5% (n=2) had undergone traditional healer-administered scarification. All (n=21) reported attendance at a single primary care clinic in the past, with most (n=20) recalling having received parenteral therapies at the clinic. Phylogenetic analysis of the HCV NS5A and NS5B regions confirmed GT1b and GT5a genotypes and formed two separate clusters within their respective genotypes, suggesting a common source for each genotype infection. Most patients received treatment with sofosbuvir/daclatasvir, 1 was treated with sofosbuvir/velpatasvir, and 1 was re-treated with sofosbuvir/velpatasvir/voxilaprevir. Per protocol SVR was 95%, with the non-SVR patient successfully re-treatedCONCLUSIONS: Data from a rural town cluster of patients suggest parenteral medical exposure as the probable common source of hepatitis C transmission risk. The cohort was of older age with a significant number having advanced fibrosis or cirrhosis, suggesting HCV acquisition in the distant past. Using a simplified care approach, treatment outcomes were very good <![CDATA[<b>The epidemiology of traumatic brain injuries sustained by children under 10 years of age presenting to a tertiary hospital in Soweto, South Africa</b>]]> BACKGROUND: Traumatic brain injury (TBI) in the paediatric population is a significant contributor to death and disability worldwide. In sub-Saharan Africa, death and disability from TBI are still superseded by infectious disease. Mechanisms of injury differ by region and socioeconomics, but in general, falls, road traffic collisions (RTCs), being 'struck by/against objects' and non-accidental injuries (NAIs) are responsible for most casesOBJECTIVES: To: (i) quantify the burden of TBI in terms of demographics, causes and severity; (ii) explore resource utilisation regarding length of stay, computed tomography (CT) brain scan use and multidisciplinary participation; (iii) interrogate possible temporal patterns of injury; and (iv) thus identify potential targets for community-based prevention strategiesMETHODS: In a 5-year retrospective review of all children aged <10 years admitted with TBI between September 2013 and August 2018, demographics, date of injury, mechanism of injury, severity of TBI based on the Glasgow Coma Scale, and requirement for a CT brain scan were collected for each patient. Outcomes were reported as discharge, transfer or death. Outcomes for children sustaining isolated TBI were compared with those for children sustaining TBI with polytraumaRESULTS: A total of 2 153 patients were included, with a mean (standard deviation) age of 4.6 (2.7) years and a male/female ratio of 1.7:1. RTCs were the most frequent cause of injury at 59% (80% of these were pedestrian-vehicle collisions), followed by falls at 24%. Mild TBIs accounted for 87% of admissions, moderate injuries for 6%, and severe injuries for 7%. Polytrauma was associated with increased severity of TBI. The cohort had a 2.3% mortality. NAIs accounted for 6% of injuries and carried a 4% mortality. The median (interquartile range) duration of hospitalisation was 1(1-3) days, ranging from <24 hours to 132 days. CT scans were performed on 43% of admitted patients, and 48% of patients had consultations with another medical or allied medical discipline. Injuries were more frequent during the summer months and over weekends. Infants aged < 1 year were identified as a group particularly vulnerable to injury, specifically NAICONCLUSIONS: Paediatric TBI was demonstrated to be a resource-intensive public health concern. From the results, we identified potential primary prevention targets that could perhaps be incorporated into broader community-based intervention programmes. We also identified a need to study long-term consequences of mild TBI further in our paediatric population <![CDATA[<b>Incidence of febrile seizures and associated factors in children in Soweto, South Africa</b>]]> BACKGROUND: Febrile seizures (FSs) are a common cause of paediatric emergencies, but there is limited research on the aetiology and epidemiology of FSs, especially in AfricaOBJECTIVES: To determine the incidence of FS hospitalisations in children aged 6-59 months in Soweto, South Africa, and factors associated with FS hospitalisationsMETHOD: In a secondary data analysis using a cohort of children enrolled in a 9-valent pneumococcal conjugate vaccine efficacy trial conducted in Soweto during 1998 - 2005, the incidence of FS hospitalisation was calculated and stratified by age group. Regression analysis was used to investigate factors associated with FS at the time of hospitalisation. Influenza A, influenza B, respiratory syncytial virus (RSV), adenovirus and parainfluenza were investigated for among those with respiratory symptoms using immunofluorescent assaysRESULTS: FSs accounted for 780 (11.0%) of 7 126 hospitalisations during the study period. The overall incidence of FSs was 4.4 (95% confidence interval (CI) 4.10 - 4.97) per 1 000 person-years, with the highest incidence in children aged 12 - 23 months (7.25; 95% CI 6.44 -8.14). Among hospitalised children, FS hospitalisation was associated with HIV-negative status (odds ratio (OR) 6.25; 95% CI 4.34 - 8.99), body temperature >39°C (OR 2.03; 95% CI 1.56 - 2.64) and concurrent diagnosis of acute otitis media (OR 2.16; 95% CI 1.74 - 2.67). Influenza A was identified in 44/515 FS hospitalisations (8.5%) compared with 123/3 794 non-FS hospitalisations (3.2%) (OR 2.22; 95% CI 1.56 - 3.16). In contrast, RSV detection was less commonly identified in children with FSs (21; 4.1%) than without (419; 11.0%) (OR 0.36; 95% CI 0.24 - 0.54CONCLUSIONS: FSs contributed significantly to the burden of paediatric hospitalisations in Soweto, and were strongly associated with influenza A virus infection <![CDATA[<b>Obstructive jaundice: Studies on predictors of biliary infection and microbiological analysis in an HIV setting</b>]]> BACKGROUND: Early diagnosis of biliary infection is critical for timely antimicrobial therapy and biliary drainage. HIV infection may influence the spectrum and severity of biliary infection in an environment with a high HIV prevalence. Charcot's triad has low sensitivity and higher specificity for biliary infection, and more sensitive markers are requiredOBJECTIVES: To investigate possible predictors of biliary infection (bacteriobilia) and identify the microbiological spectrum in patients presenting with biliary obstruction to a tertiary institute in an environment with a high prevalence of HIVMETHODS: Bile was assessed for infection at endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography and surgery, and the roles of clinical/haematological factors, C-reactive protein (CRP) and procalcitonin (PCT) in determining biliary infection were evaluatedRESULTS: One hundred and six patients with obstructive jaundice had a mean age of 52 years (range 21 - 58); most were female (74%), and 36 (34%) were infected with HIV, with a mean CD4 count of 495 cells/μL. Choledocholithiasis (53%), biliary strictures (21%) and head of pancreas tumour (8%) were the main aetiopathologies. Bile was obtained for microbial culture from 104 patients (98%), and 56 (54%) were infected. Gram-negative bacteria were most frequent (58%), and 2 HIV-infected patients had fungal infections (Candida albicans and Aspergillus fumigatus). Screening for endoscopy-associated infections revealed Pseudomonas aeruginosa. PCT was a poor predictor of bacterial infection, whereas CRP was a fair predictorCONCLUSIONS: The majority of bacteria cultured were sensitive to ciprofloxacin or amoxicillin-clavulanate. Duodenoscopes were a potential source of Pseudomonas infection