Elsie Helena Burger

Deaths caused by HIV disease under-reported in South Africa

Modelling of trends in age-specific death rates in South Africa suggests that deaths attributable to HIV are often misclassified on death notification forms. We compared the underlying cause of death from death notification forms with that based on scrutiny of medical records for 683 deaths in Cape Town. Of 129 deaths caused by HIV according to medical records, only 35 (27.1%) were ascribed to HIV on the death notification form using strict coding and 83 (64.3%) using interpretive coding.

Certification of diabetes-related mortality: the need for an international guideline

In the February 2010 issue, Adair and Rao [1] reported the subjectivity of diabetes death certification and the necessity of specific guidelines on the certification of decedents with diabetes. Differences in the practice of certifying diabetesrelated mortality have been noted and could compromise international comparisons of diabetes mortality rates [1,2]. These differences result from a clinician’s preference to report diabetes in part I of a death certificate (i.e., specifying it within the sequence between the underlying cause of death [UCOD] and the immediate cause of death) or in part II of a death certificate as a contributory cause. Most clinicians would agree that the UCOD is diabetes if the death was because of diabetic ketoacidosis, hypoglycemia, or hyperosmolar nonketotic hyperglycemia. However, the UCOD is less clear in diabetic patients with multiple coexisting conditions, particularly ischemic heart or cerebrovascular disease [1,3,4]. The tenth revision of the International Classification of Disease and Related Health Problems (ICD-10) coding rules used to process the information provided on the death certificate select diabetes as the UCOD in cases where diabetes is listed in part I of the medical certificate, alone or along with cardiovascular or infectious causes. With a few exceptions, diabetes would not be selected as the UCOD when listed in part II. In South Africa, 15,531 (36.8%) of the deaths in 2008 were diabetes related with 97% of the cases recorded in part I [5]. This is strikingly higher than any other reported in the literature. Lu et al. [6] reported a proportion of approximately 70% in Taiwan. However, depending on age and sex of the deceased, it ranged from 33% to 44% in Australia [6], 36% in the United States [7], and 21% in Sweden [7]. A study conducted in Benghazi in Libya showed that diabetes was recorded in part I in only 5.1% of the diabetes-related deaths [8]. Further analysis of the 2008 South African multiple cause of death data showed that the proportion of deaths with diabetes in part I who also had cardiovascular diseases (I10eI69) was 53.6% [5]. Hypertensive heart disease (I10eI15) occurred in 36.6%, stroke (I60eI69) in 15.6%, and ischemic heart disease (I20eI25) in 10.9%. Although ICD-10 has defined rules for coding, there are no international guidelines for certification. Development of an international guideline for certifying diabetesrelated deaths would be aided by the collection of a range

Medical certification of death in South Africa--moving forward.

Despite improvements to the Death Notification Form (DNF) used in South Africa (SA), the quality of cause-of-death information remains suboptimal. To address these inadequacies, the government ran a train-the-trainer programme on completion of the DNF, targeting doctors in public sector hospitals. Training materials were developed and workshops were held in all provinces. This article reflects on the lessons learnt from the training and highlights issues that need to be addressed to improve medical certification and cause-of-death data in SA. The DNF should be completed truthfully and accurately, and confidentiality of the information on the form should be maintained. The underlying cause of death should be entered on the lowest completed line in the cause-of-death section, and if appropriate, HIV should be entered here. Exclusion clauses for HIV in life insurance policies with Association of Savings and Investments South Africa companies were scrapped in 2005. Interactive workshops provide a good learning environment, but are logistically challenging. More use should be made of online training resources, particularly with continuing professional development accreditation and helpline support. In addition, training in the completion of the DNF should become part of the curriculum in all medical schools, and part of the orientation of interns and community service doctors in all facilities.

Death certificates: Let's get it right!

We developed a death certification educational intervention consisting of a 45-minute didactic teaching session and an educational handout that covered: (i) the importance of mortality data for public health, (ii) process of death certification, (iii) concept of a causal sequence and the underlying cause of death, (iv) distinction between cause and mechanism of death, (v) appropriate terminology to use when writing cause of death statements and (vi) common misconceptions.

The Institution of a Standardized Investigation Protocol for Sudden Infant Death in the Eastern Metropole, Cape Town, South Africa(,) (.)

The rate for the sudden infant death syndrome (SIDS) in Cape Town, South Africa, is estimated to be among the highest in the world (3.41/1000 live births). In several of these areas, including those of extreme poverty, only sporadic, nonstandardized infant autopsy, and death scene investigation (DSI) occurred. In this report, we detail a feasibility project comprising 18 autopsied infants with sudden and unexpected death whose causes of death were adjudicated according to the 1991 NICHD definitions (SIDS, n = 7; known cause of death, n = 7; and unclassified, n = 4). We instituted a standardized autopsy and infant DSI through a collaborative effort of local forensic pathology officers and clinical providers. The high standard of forensic investigation met international standards, identified preventable disease, and allowed for incorporation of research. We conclude that an effective infant autopsy and DSI protocol can be established in areas with both high sudden unexpected infant death, and elsewhere. (SUID)/SIDS risk and infrastructure challenges.

Henssge nomogram typesetting error.

The Henssge nomogram technique for estimation of post mortem interval (PMI) utilizing body cooling is used worldwide by forensic pathologists (FPs) who may photocopy the nomogram from a popular source such as the textbook Knight’s Forensic Pathology [1, 2] to calculate the PMI. The relationship of the components of the nomogram to each other is crucial for accurate calculations. Any alteration from the exact spatial layout will result in significant error. In recent cases, different FPs determined the PMI independently and observed significantly divergent answers for each case. Careful scrutiny of the calculation process showed that the only variable in the processes was that nomograms were copied from two different sources: one from Forensic Pathology by Knight and Saukko (FPKS3) [1], and the other from Knight’s Forensic Pathology (KFP2) [2]. The latter version is similar to that in the 1 edition of this text, as well as in a paper by Henssge et al. [3]. In one high-profile case, the ambient temperature was 24 C and the rectal temperature (RT) 33 C. With corrective factors, the nomogram in KFP2 showed the PMI as just over 19 h, while the nomogram in FPKS3 gave an estimated PMI of 16 h 30 min. Using the same values in an electronic version of the equation resulted in a PMI estimation of 19 h 10 min. This represents a 13 % difference in PMI between the nomograms in KFP2 and FPKS3. Careful study of the two versions of the nomogram led us to discover differences in the typesetting of the diagrams. This was visually illustrated by superimposition of the two scanned nomograms in KFP2 and FPKS3 (Fig. 1). These variations suggest to us that the nomograms printed in the textbooks mentioned are not exact replicas of the original. We do not believe that the nomogram published in the original journal [4] suffers from these spatial defects, as similar results are found when results from this nomogram are compared to those from the calculation. However, it is suggested by some, and we strongly recommend, that the nomograms reproduced in any printed format be used cautiously, and at least be correlated with a different source and/or an electronic version of the equation. These electronic resources based on the original Henssge equation are available as, among others, a web based resource [5], and Apple and Blackberry apps in the respective e-markets. The editors are aware of this problem (personal communication—email communication with Bernard Knight) and we understand that any future editions will contain a note regarding this.

Getting all the facts of death

Abstract We conducted a study of death notification form (DNF) completion relating to 844 deceased Cape Town residents, and evaluated the completeness of information on the forms. The DNFs frequently lacked important data on both the deceased and the health professional who completed the DNF (completing health professional). Urgent intervention is needed to improve the usefulness of the DNF as a source data on health statistics in South Africa.

Serotonin Receptors in the Medulla Oblongata of the Human Fetus and Infant: The Analytic Approach of the International Safe Passage Study

The Safe Passage Study is an international, prospective study of approximately 12 000 pregnancies to determine the effects of prenatal alcohol exposure (PAE) upon stillbirth and the sudden infant death syndrome (SIDS). A key objective of the study is to elucidate adverse effects of PAE upon binding to serotonin (5-HT) 1A receptors in brainstem homeostatic networks postulated to be abnormal in unexplained stillbirth and/or SIDS. We undertook a feasibility assessment of 5-HT1A receptor binding using autoradiography in the medulla oblongata (6 nuclei in 27 cases). 5-HT1A binding was compared to a reference dataset from the San Diego medical examiner’s system. There was no adverse effect of postmortem interval ⩽100 h. The distribution and quantitated values of 5-HT1A binding in Safe Passage Study cases were essentially identical to those in the reference dataset, and virtually identical between stillbirths and live born fetal cases in grossly non-macerated tissues. The pattern of binding was present at mid-gestation with dramatic changes in binding levels in the medullary 5-HT nuclei over the second half of gestation; there was a plateau at lower levels in the neonatal period and into infancy. This study demonstrates feasibility of 5-HT1A binding analysis in the medulla in the Safe Passage Study.

Optimizing the use of cadavers by integrating pathology during anatomy dissection.

An accurate knowledge of anatomy, especially natural variation within individuals, is of vital clinical importance. Cadaver dissection during anatomical training may be a valuable introduction to pathology for undergraduate students, which can contribute greatly to a successful medical career. The purpose of this study was to determine the extent and type of pathology lesions in a cadaver population (n = 127) used for medical dissection. This was done to gauge whether sufficient pathology lesions representative of all the organ systems were present in the cadaver population to warrant the use of cadavers as an additional pathology learning resource. This study demonstrated a wide variety of pathology lesions in different organ systems. The respiratory system was most affected with pulmonary tuberculosis (TB) lesions being the most common finding (seen in 76% of cadavers) followed by bronchopneumonia and emphysema. Other common pathology findings included atherosclerosis, colonic diverticula, and chronic pyelonephritis. Skeletal fractures and degenerative joint disease were also noted. This study shows that cadaveric dissection offers a chance to alert and expose students to a wide variety of gross pathology and histopathology. It has been suggested that most medical students will practice in primary health care and as such more attention should be given to the pathology of commonly encountered diseases. This is particularly true for developing countries, where diseases such as TB are commonly encountered. The integration of pathology into the dissection hall may therefore be beneficial to student learning while simultaneously optimizing the use of cadaver material. Anat Sci Educ 9: 575–582.

Fatal angioedema induced by angiotensin conversion enzyme (ACE) inhibitors

ACE inhibitors are often prescribed in the treatment of hypertension, heart failure and kidney disease. These drugs are on the Essential Drugs List, and are therefore used at primary to tertiary health care levels in South Africa. Angioedema is considered a rare, but potentially fatal side-effect of this agent, with a reported incidence of 0.1–0.2% worldwide.1 Its incidence in the South African population is, however, unknown.