Self-perceived readiness of medical interns in performing basic medical procedures at the Universitas Academic Health Complex in Bloemfontein

Background: Medical internship in South Africa is a two-year period after completing the basic medical degree. Interns rotate through six different domains, where they are exposed to various clinical procedures. These skills are often not up to standard, and interns feel unprepared for future challenges. This study evaluated the self-perceived readiness of interns rotating through the Universitas Academic Health Complex in performing basic medical procedures, and the frequency of performing these procedures.Methods: This was a descriptive quantitative study. Consenting participants completed an anonymous questionnaire regarding four pre-selected medical procedures per department.Results: The majority of the 61 participants were second-year interns (52.5%), female (54.0%), with a median age of 25 years. Interns felt ready to perform the majority of procedures, but more than 50% reported not being ready to perform circumcisions, episiotomy and perineal repair, assisted delivery and appendectomies. Some procedures in Family Medicine, Internal Medicine, Obstetrics and Gynaecology, General Surgery and Psychiatry were rarely performed by at least half of the participants.Conclusions: Exposure of medical students during their clinical years to practical training is inadequate. The focus in the MBChB curriculum should be increased to a more specific practical approach during both the pre-clinical and clinical years.

Trauma-Related Risk Factors in Mineworkers with PTSD: A Prospective Follow-Up Study

The aim of this prospective follow-up study was to investigate the role of trauma-related factors in the development of acute and chronic Posttraumatic Stress Disorder (PTSD) among South African gold mineworkers involved in disabling and reportable earth-fall mine accidents. A consecutive sample of 200 mineworkers who were involved in earth-fall mine accidents was evaluated over a period of seven months. A history of previous trauma exposure was associated with both acute and chronic PTSD. Injury severity predicted acute PTSD but could not differentiate between subjects with acute PTSD that developed chronic PTSD and those whose symptoms went into remission. The intensity and severity of the precipitating earth-fall event were associated with acute and chronic PTSD. Being pinned down by rocks was the earth-fall-related event that predicted chronic PTSD most accurately. The intensity of the traumatic earth-fall event was found to be a more significant predictor for acute PTSD than previous exposure to trauma. Based on these results, recommendations were made to manage trauma in the mining sector.

The Utility of Point-of-Care Ultrasound in Detecting Distal Forearm Buckle Fractures in Paediatric Patients

BACKGROUND: Distal forearm fractures are common paediatric injuries. The use of plain radiographs is almost universal for diagnosis but this technology can be painful and time consuming. It is well known that children’s pain in the emergency department (ED) is both under-recognized and suboptimally managed. Point-of-care ultrasound (POCUS) has demonstrated good accuracy in detecting cortical disruption in adults but test characteristics in the most common paediatric fracture type (buckle or torus fractures) have not been explored. POCUS may also lead to quicker assessment and be associated with less pain and improved caregiver satisfaction compared to plain radiographs. Our results may provide support an alternative diagnostic strategy for centres where plain radiographs are not readily accessible and where severe pain is an issue.

OBJECTIVES: The objectives of this study were to: (i) evaluate the diagnostic accuracy POCUS in detecting suspected non-angulated distal forearm fractures in children presenting to the ED compared to AP and lateral plain film x-rays of the forearm, (ii) determine the length of time required to complete a POCUS evaluation for a suspected distal forearm non-angulated fracture in children in the ED, (iii) explore the differences in caregiver satisfaction with POCUS evaluation compared to plain radiography, and (iv) explore differences in associated pain between POCUS and plain radiography.

DESIGN/METHODS: This was a prospective cohort study designed to test the hypothesis that POCUS provides comparable sensitivity and specificity to plain radiography and is associated with less pain and greater caregiver satisfaction. We included children aged 4-17 years who presented to the paediatric ED with a suspected non-angulated distal forearm fracture based on a typical mechanism of injury. The patient underwent an x-ray and a POCUS evaluation of the affected region by a Canadian Emergency Ultrasound (CEUS)-trained physician who was blinded to the x-ray results. Caregivers were asked to complete a satisfaction questionnaire using a five-point Likert scale and children were asked to complete the Faces Pain Scale – Revised (FPS-R) reflecting discomfort associated with the diagnostic modality. The primary POCUS diagnosis made by the physician was compared to the x-ray diagnosis made by the staff paediatric radiologist. All POCUS images were independently interpreted by a second expert POCUS sonographer blinded to the original POCUS interpretation, x-ray, and final diagnosis. The primary outcomes were sensitivity of POCUS and pain score using the FPS-R.

RESULTS: Eighty-five participants were enrolled, of whom 33 (39%) sustained a buckle fracture. The mean (SD) age of the participants was 11 (3.4) years and 52 (61%) were male. Sensitivity and sensitivity of POCUS for detecting any cortical disruption was 97% [95% CI: 84.2, 99.9] and 96% [95% CI: 86.8, 99.5], respectively. Agreement (kappa) between sonographers was 0.74 [95% CI: 0.64, 0.87] representing substantial agreement. POCUS was associated with significantly lower mean (SD) pain scores compared to plain radiography [2.3 (2.5) vs 3.6 (3.0), p < 0.01]. The median (IQR) time to perform POCUS was significantly lower that plain radiography [68 (42) vs 1200 (1440) seconds, p < 0.01]. POCUS was associated with comparable mean caregiver satisfaction compared to plain radiography [4.7 (0.7) vs 4.4 (1.0), p = 0.15].

CONCLUSION: This prospective study of POCUS for non-angulated distal forearm injuries in children suggests that POCUS is associated with excellent sensitivity and specificity for the detection of cortical disruption. Furthermore, POCUS is associated with significantly less pain and procedure time compared to plain radiography. The results suggest that POCUS could be a useful diagnostic strategy in resource-limited settings for children with suspected forearm injuries and has the added benefit of lower associated pain.

Treating and Reducing Anxiety and Pain in the Paediatric Emergency Department (The Trapped 2 Survey): Time for Action – A Pediatric Emergency Research Canada (Perc) Project

BACKGROUND: Multiples barriers to appropriate analgesia provision are reported in the paediatric emergency department (PED), including limited accessibility to effective strategies.

OBJECTIVES: To evaluate the improvement in the accessibility of pain and anxiety management strategies in PEDs in Canada, after the creation of a national pediatric pain quality improvement collaborative, through Pediatric Emergency Research Canada.

DESIGN/METHODS: In 2013, the TRAPPED 1 survey was administered across Canadian PEDs, in order to evaluate the resources in place for pain and anxiety management. Subsequent to the TRAPPED 1, a pain Quality Improvement Collaborative was created to stimulate the implementation of new pain and anxiety management strategies through the sharing of information between PEDs. The TRAPPED 2 survey involved a cross sectional survey similar to TRAPPED 1, after a two year interval. Its main focus was to evaluate the improvement in the accessibility of specific, preferred strategies reported by each centre, after participating in this collaborative between December 2014 to November 2015, and then working to implement change within their own PEDs.

RESULTS: All 15/15 Canadian PEDs responded to TRAPPED 1 in 2013. In 2014, 11/15 agreed to participate in the national pain Quality Improvement Collaborative, with a goal of introducing new pain and anxiety management strategies within their own PEDs. An in-person meeting, email communication, and telephone meetings were employed for information sharing regarding experiences/challenges within each of the participating centres. Newly introduced strategies included education, distraction, nurse-initiated protocols, and policies/education to encourage the use of intranasal (IN) medications. 11/11 centres have responded to the interim follow up surveys in 2015. At the end of the project (Fall 2105), 15/15 Canadian PEDs agreed to complete the final TRAPPED 2 survey. When comparing the results of 2015 with 2013, an increased number of PEDs used face-based pain scales (14/15 vs 6/15) and behavioural scales (5/15 vs 1/15) for pain assessment of school-aged children and infants, respectively. Use of assessment room wall decoration for distraction increased from 7/15 to 11/15. Reminder posters for pain management at triage increased from 4/15 to 6/15. Availability of electronic distraction strategies (e.g. using tablets) increased from 4/15 to 10/15 centres. For skin-piercing procedure, nurses initiated protocols to use topical anesthetic creams and oral sucrose was available in 12/15 centres (compared to 10/15 in 2013), and 14/15 (compared to 12/15 in 2013) respectively. Availability of IN medications increased in the last two years: fentanyl 14/15 (9/15 in 2013) and midazolam in at least 10/15 (8/15 in 2013). 10/11 PEDS involved in the QI strategy reported the implementation of at least one of their strategies identified.

CONCLUSION: This study suggests that the use of a pain Quality Improvement Collaborative may improve the introduction of new strategies in multiple PEDs. It can help guide other centres when introducing new strategies to reduce pain and anxiety for children in community EDs. Future research can focus on the sustainability of the strategies, and as well the effect of the collaborative on the introduction of other pain treatment strategies.

Patient preferences regarding the dress code, conduct and resources used by doctors during consultations in the public healthcare sector in Bloemfontein, Free State

Background: The doctor–patient relationship is important in determining the quality of healthcare provided. This study aimed to identify patient preferences regarding dress code, conduct and resources used by doctors during consultations in the public healthcare sector, Bloemfontein. Information from this study can be of benefit in determining policies and dress codes within hospitals and medical schools.Methods: This was a descriptive, cross-sectional study. Self-administered anonymous questionnaires were distributed at Bloemfontein’s National District Hospital to patients 18 years and older, waiting in the pharmacy and consultation queues.Results: Of the 500 questionnaires distributed 410 were analysed. Patients preferred doctors to wear formal attire. For female doctors this included a neat blouse (77.9%), smart pants (62.5%) or straight-cut jeans (51.4%) and flat pumps (56.3%). Patients preferred male doctors to wear collared shirts (52.4% and 57.6% for long- and short-sleeved shirts, respectively) with smart pants (66.8%) or straight-cut jeans (45.9%), and smart shoes (70.3%). Patients did not condone eating and drinking by doctors during consultations; work-related calls were deemed acceptable. The use of technological resources was not preferred.Conclusion: Patients in the public healthcare sector prefer a formal, professional consulting environment that is determined largely by the doctor’s attire and conduct during the consultation.

Scalp Hematoma Characteristics Associated With Intracranial Injury in Pediatric Minor Head Injury

OBJECTIVES

Minor head trauma accounts for a significant proportion of pediatric emergency department (ED) visits. In children younger than 24 months, scalp hematomas are thought to be associated with the presence of intracranial injury (ICI). We investigated which scalp hematoma characteristics were associated with increased odds of ICI in children less than 17 years who presented to the ED following minor head injury and whether an underlying linear skull fracture may explain this relationship.

METHODS

This was a secondary analysis of 3,866 patients enrolled in the Canadian Assessment of Tomography of Childhood Head Injury (CATCH) study. Information about scalp hematoma presence (yes/no), location (frontal, temporal/parietal, occipital), and size (small and localized, large and boggy) was collected by emergency physicians using a structured data collection form. ICI was defined as the presence of an acute brain lesion on computed tomography. Logistic regression analyses were adjusted for age, sex, dangerous injury mechanism, irritability on examination, suspected open or depressed skull fracture, and clinical signs of basal skull fracture.

RESULTS

ICI was present in 159 (4.1%) patients. The presence of a scalp hematoma (n = 1,189) in any location was associated with significantly greater odds of ICI (odds ratio [OR] = 4.4, 95% confidence interval [CI] = 3.06 to 6.02), particularly for those located in temporal/parietal (OR = 6.0, 95% CI = 3.9 to 9.3) and occipital regions (OR = 5.6, 95% CI = 3.5 to 8.9). Both small and localized and large and boggy hematomas were significantly associated with ICI, although larger hematomas conferred larger odds (OR = 9.9, 95% CI = 6.3 to 15.5). Although the presence of a scalp hematoma was associated with greater odds of ICI in all age groups, odds were greatest in children aged 0 to 6 months (OR = 13.5, 95% CI = 1.5 to 119.3). Linear skull fractures were present in 156 (4.0%) patients. Of the 111 patients with scalp hematoma and ICI, 57 (51%) patients had a linear skull fracture and 54 (49%) did not. The association between scalp hematoma and ICI attenuated but remained significant after excluding patients with linear skull fracture (OR = 3.3, 95% CI = 2.1 to 5.1).

CONCLUSIONS

Large and boggy and nonfrontal scalp hematomas had the strongest association with the presence of ICI in this large pediatric cohort. Although children 0 to 6 months of age were at highest odds, the presence of a scalp hematoma also independently increased the odds of ICI in older children and adolescents. The presence of a linear skull fracture only partially explained this relation, indicating that ruling out a skull fracture beneath a hematoma does not obviate the risk of intracranial pathology.

The needs and preferences of general practitioners regarding their CPD learning: a Free State perspective

Background: The Health Professions Council of South Africa (HPCSA) requires all registered Health Practitioners in South Africa to complete accredited learning opportunities, and provide proof thereof. CPD is the chosen model, which focuses on holistic development of the professional. The UFS Department of Family Medicine presents refresher courses for general practitioners, covering all relevant fields of interest.Aim: The aim of this study was to find reasons and possible solutions for the perceived lack of interest in refresher courses by determining general practitioners’ needs and preferences for CPD training.Methodology: A cross-sectional study design was chosen, whereby a systematic sample of 300 general practitioners registered with the HPCSA as doctors in the Free State were asked to complete a questionnaire. Needs and preferences regarding learning opportunities and factors influencing usage of these learning opportunities were assessed.Results: The responses from 60 participants revealed that general practitioners still prefer the lecture form of presentations in large or small groups. Topics that ranked highly were Infective Diseases, Cardiology and Respiratory Diseases. Respondents indicated that general practitioners prefer not to leave their practices unattended for an extended period of time.Conclusion: Free State general practitioners still prefer the traditional lecture-room style of learning. Their declared learning needs are in line with the regular ailments they encounter within their practices. Strategies to accommodate those who find it difficult to attend, due to time and distance concerns, should be considered.

An observational study on factors influencing antibiotic use in chronic obstructive pulmonary disease at Universitas Academic Hospital, Bloemfontein

Background: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are often precipitated by excessive airway inflammation caused by viral or bacterial infections. Current guidelines suggest prescribing antibiotics to patients with AECOPD and purulent sputum production, but this may lead to unnecessary or inappropriate antibiotic use. The aim of this study was to identify clinical and laboratory variables influencing antibiotic prescriptions of clinicians managing patients hospitalised for AECOPD.Methods: An observational study was conducted among patients hospitalised with AECOPD. Antibiotic prescriptions were compared with sputum appearance, white blood cell count, C-reactive protein (CRP) levels and sputum cultures. Treatment outcomes were assessed on days 3 and 5 after admission.Results: Thirteen patients were included in the study, from July to October 2013, at Universitas Academic Hospital, Bloemfontein. Antibiotics were prescribed in seven out of eight patients with an elevated CRP level. None of the patients with reported sputum purulence received antibiotics. White blood cell count and sputum cultures did not seem to influence antibiotic prescription habits.Conclusions: Clinicians managing patients with AECOPD do not follow guidelines that suggest prescribing antibiotics to patients presenting with purulent sputum production. Further studies on whether biomarkers such as CRP may be more acceptable as a deciding factor on which to base antibiotic prescriptions are required.

Prostate cancer profile and risk stratification of patients treated at Universitas Annex Department of Oncology, Bloemfontein, Free State, during 2008 to 2010

Background: Prostate cancer commonly occurs in older men. Since TNM staging excludes prostate-specific antigen (PSA) level and Gleason score, patients with prostate cancer are divided into risk groups when deciding on treatment options. This study determined the profile and risk stratification of patients with prostate cancer treated at the Department of Oncology, Universitas Annex in Bloemfontein, Free State, during 2008 to 2010. Methods: This was a cross-sectional study with retrospective data collection. Information was gathered from 497 patient files on age, race, residence, Gleason score, PSA level, TNM stage, and initial treatment. The patients’ risk group was determined from their Gleason score, PSA level, and T stage.Results: Patients were mostly (45.7%) between 65 and 75 years of age and 72.8% were in the black race group. The largest percentage of patients had a Gleason score of 8 to 10 (43.7%), PSA level 20 ng/ml (67.9%), and a T stage ≥ T3 (62.3%). Almost half of the patients (48.7%) had stage IV disease and 38.4% received palliative hormonal therapy as initial treatment. The majority of patients (82.5%) fell into the high risk group.Conclusions: The majority of patients in each age group fell into the high risk group, which means that these patients were at a higher risk of developing metastatic prostate cancer. We recommend better education of our patient population and local clinic staff, so that people in the community can understand the prevalence of the disease, the symptoms and effect of the cancer, and that it is treatable if detected early.

Pre-interventional assessment and calcification score of the aortic valve and annulus, with multi-detector CT, in transcatheter aortic valve implantation (TAVI) using the Medtronic CoreValve

Background: Transcatheter aortic valve implantation (TAVI) provides an acceptable alternative for aortic valve replacement in the elderly, but needs accurate pre-procedural imaging to optimise intervention. Objectives: To evaluate an alternative manual aortic valve calcification scoring system with computed tomography, for patients undergoing TAVI. We hypothesise a correlation between the Free State aortic valve calcium computed tomography score (FACTS) scoring system, valve plaque density and procedure-related complications. Methods: Twenty patients suitable for TAVI were selected according to standard international guidelines and received multimodality imaging prior to intervention. Images were reviewed by two reviewers who were blinded to each other’s scores. Where large inter-individual score variations existed, retraining was done and scores repeated, using a double-blinded method. Matched scores were included in the final analysis. Rosenhek calcification scores were used as a standard of reference. Results: The study comprised 9 (45%) men and 11 (55%) women, with a median age of 83.5 years. Median EuroSCORE was 15.5. FACTS scores ≥6 were associated with the presence of a paravalvular leak (p = 0.01). Procedure-related complications (left bundle branch block, repositioning of the valve and anaemia) were seen in patients with plaques measuring ≥1000 HU (p = 0.07). Conclusion: The FACTS score and averaged valve plaque HU showed potential for predicting a paravalvular leak and procedure-related complications, and could be valuable in the future for optimising patient selection for TAVI.

The design of a multicentre Canadian surveillance study of sedation safety in the paediatric emergency department

INTRODUCTION

Procedural sedation and analgesia have become standard practice in paediatric emergency departments worldwide. Although generally regarded as safe, serious adverse events such as bradycardia, asystole, pulmonary aspiration, permanent neurological injury and death have been reported, but their incidence is unknown due to the infrequency of their occurrence and lack of surveillance of sedation safety. To improve our understanding of the safety, comparative effectiveness and variation in care in paediatric procedural sedation, we are establishing a multicentre patient registry with the goal of conducting regular and ongoing surveillance for adverse events in procedural sedation.

METHODS

This multicentre, prospective cohort study is enrolling patients under 18 years of age from six paediatric emergency departments across Canada. Data collection is fully integrated into clinical care and is performed electronically in real time by the healthcare professionals caring for the patient. The primary outcome is the proportion of patients who experience a serious adverse event as a result of their sedation. Secondary outcomes include the proportion of patients who experience an adverse event that could lead to a serious adverse event, proportion of patients who receive a significant intervention in response to an adverse event, proportion of patients who experience a successful sedation, and proportion of patients who experience a paradoxical reaction to sedation. There is no predetermined end date for data collection.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from participating sites. Results will be disseminated using a multifaceted knowledge translation strategy by presenting at international conferences, publication in peer-reviewed journals, and through established networks.

Acetaldehyde production capacity of salivary microflora in alcoholics during early recovery

This study investigated whether a relationship exists between the acetaldehyde production capacity of salivary microflora (sAPC) in recovering alcoholics, and craving, and/or resumption of drinking within 12 weeks after embarking on an abstinence-based treatment program. Serial sAPC measurements were determined by gas chromatography on spontaneous saliva samples of 30 male alcoholics on days 2, 4, 11, and 18 during a 21-day in-patient treatment program. Craving was measured simultaneously with the Penn Alcohol Craving Scale. Outcome over 12 weeks was assessed by telephone interviews. There was no significant change in sAPC values from day 2 to day 18, while craving scores decreased markedly between day 2 to day 4. Sixteen participants remained abstinent for the full 12 weeks. Statistically significant differences were found between the sAPC values of the group that remained abstinent and the group that resumed drinking within 12 weeks. The highest sAPC value measured on day 2 had a strong predictive value for maintained abstinence at 12 weeks for beer-only drinkers or drinkers consuming less than 320 g of alcohol per week. The study is the first investigation into a potential relationship between the acetaldehyde production capacity of salivary microflora and early resumption of drinking in recovering alcoholics. The findings suggest that such a relationship indeed exists for beer-only drinkers, possibly linked to lower alcohol intake, and that it is unrelated to withdrawal craving. sAPC is proposed as a candidate biomarker with diagnostic and/or prognostic potential.

Causes of prematurity in the Bloemfontein Academic Complex

Background: Prematurity is globally the leading cause of neonatal mortality, morbidity and long-term disability. The Millennium Development Goals (MDG) of the United Nations, and specifically MDG 4, address child mortality. Neonatal mortality rates contribute to 37% of all under-five mortality, with the largest proportion (30%) due to prematurity. The overall purpose of this study was to determine factors associated with prematurity and to identify treatable and preventable causes at the Bloemfontein Academic Complex in order to decrease the morbidity and mortality associated with prematurity in line with MDG.Methods: A case control study design was used including all premature babies referred to the Kangaroo Care Unit of the National District Hospital between December 2010 and March 2011. Each baby was included with his/her mother as a pair. For each premature baby and mother pair a term baby and mother pair was included as a control. Data were collected on a data sheet from the mothers’ antenatal records, and from maternal notes as well as the neonatal follow-up and discharge notes. Data gathered included baseline characteristics, habits, diseases and medication of the mother during the antenatal period and delivery as well as baseline demographics of the babies. Results: A total of 194 mothers and 198 babies were included in the study with 109 case mothers and 85 control mothers . Pre-existing medical conditions were more prevalent in the premature group (69%) compared with the control group (27%) with p 0.0001. These conditions included hypertension, HIV disease and syphilis. Possible causes for prematurity identified in this study included teenage mothers and premature rupture of membranes.Conclusion: Risk factors identified for prematurity were: teenage mothers, pre-existing medical conditions in the mother, and preterm rupture of membranes. Smoking and alcohol consumption during pregnancy could not be identified as risk factors for prematurity. It is recommended that patients with any of the above-mentioned identified risk factors be classified as high risk for the development of prematurity and shorter follow-up intervals and more aggressive management of pre-existing medical conditions should be practised.

Diagnosing clinically significant dehydration in children with acute gastroenteritis using noninvasive methods: a meta-analysis

OBJECTIVE

To determine the most accurate, noninvasive method of assessing dehydration.

STUDY DESIGN

The following data sources were searched: electronic databases, gray literature, scientific meetings, reference lists, and authors of unpublished studies. Eligible studies were comparative outpatient evaluations that used an accepted reference standard and were conducted in developed countries in children aged <18 years with gastroenteritis. Data extraction was completed independently by multiple reviewers before a consensus was made.

RESULTS

Nine studies that included 1039 participants were identified. The 4-item Clinical Dehydration Scale (CDS), the "Gorelick" score, and unstructured physician assessment were evaluated in 3, 2, and 5 studies, respectively. Bedside ultrasound, capillary digital videography, and urinary measurements were each evaluated in one study. The CDS had a positive likelihood ratio (LR) range of 1.87-11.79 and a negative LR range of 0.30-0.71 to predict 6% dehydration. When combined with the 4-item Gorelick Score, the positive LR was 1.93 (95% CI 1.07-3.49) and negative LR was of 0.40 (95% CI 0.24-0.68). Unstructured dehydration assessment had a pooled positive LR of 2.13 (95% CI 1.33-3.44) and negative LR of 0.48 (95% CI 0.28-0.82) to detect ≥ 5% dehydration.

CONCLUSIONS

Overall, the clinical scales evaluated provide some improved diagnostic accuracy. However, test characteristics indicate that their ability to identify children both with and without dehydration is suboptimal. Current evidence does not support the routine use of ultrasound or urinalysis to determine dehydration severity.