Richard Pitcher

Clinical course of hospitalised children infected with human metapneumovirus and respiratory syncytial virus

Aim:  To describe the clinical presentation and outcomes of hospitalised patients infected with human metapneumovirus (hMPV) and human respiratory syncytial virus (hRSV) in a tertiary hospital in Cape Town, South Africa.

Investigation into the effect of closed-system suctioning on the frequency of pediatric ventilator-associated pneumonia in a developing country.

Objective: To investigate the effect of closed-system vs. open endotracheal suctioning on the frequency of ventilator-associated pneumonia and outcome in a pediatric intensive care unit in a developing country. Design: Prospective observational and nonrandomized controlled clinical study. Setting: A 20-bed pediatric intensive care unit in a tertiary pediatric hospital. Patients: Infants and children mechanically ventilated for >24 hrs. Intervention: Pediatric intensive care unit suctioning systems were alternated monthly. An 8-month interim analysis was planned with a priori efficacy and futility study termination boundaries set at p < .006 and p > .52, respectively. Measurements and Main Results: Demographic, clinical, and laboratory data were prospectively recorded. Ventilator-associated pneumonia was diagnosed using the Clinical Pulmonary Infection Score, and the results were confirmed retrospectively using Centers for Disease Control criteria. A total of 250 patients (median [interquartile range] age of 3.8 [1.2–15.0] months) in 263 pediatric intensive care unit admissions were included. Fifty-nine admissions developed ventilator-associated pneumonia, with a calculated rate of 45.1 infections per 1000 ventilated days. There was no difference in characteristics or outcome between patients on closed-system suctioning (n = 83) and those on open endotracheal suctioning (n = 180). The frequencies of ventilator-associated pneumonia for patients on closed-system suctioning and open endotracheal suctioning were 20.5% and 23.3%, respectively (p = .6), reaching the a priori set limit of futility. Patients who developed ventilator-associated pneumonia spent a median (interquartile range) of 22 (13–37) and 11 (8–16) days in the hospital and pediatric intensive care unit, respectively, compared to 14.5 (10–24) and 6 (4–8) days for those without ventilator-associated pneumonia (p < .001). A 22% proportion of patients who developed ventilator-associated pneumonia died compared to 11.3% of those without ventilator-associated pneumonia (p = .03). Risk factors for ventilator-associated pneumonia identified on multiple logistic regression were duration of mechanical ventilation, transport out of the pediatric intensive care unit, and blood transfusion. Conclusion: Closed-system suctioning did not affect the frequency of ventilator-associated pneumonia or patient outcome in this setting.

The use of the Statscan digital X-ray unit in paediatric polytrauma

We present a 3-year review of clinical paediatric experience with the Statscan (Lodox Systems, Johannesburg, South Africa), a low-dose, digital, whole-body, slit-scanning X-ray machine. While focusing on the role of the unit in paediatric polytrauma, insight into its applications in other paediatric settings is provided.

Digital radiographic measurement of the atlantodental interval in children

The atlantodental interval (ADI) is assessed after trauma to the head and neck region to determine whether the transverse ligament of the atlas is intact. Atlantodental interval measurement from conventional screen-film radiographs is characterized by the need for magnification correction and by low reliability. Assessment of normal ADI values using digital radiography with computer-assisted measurement has not been reported. We compared with published values the digital radiographic measurements of ADI in children, examined the reliability of measurements, and examined the interaction between age, sex and ADI. Computer-assisted digital measurements of ADI in 101 children, aged 1 to 12 years, were obtained from lateral supine head-neutral radiographs. We found intraobserver reliability of 0.72 and 0.85, interobserver reliability of 0.50, a maximum ADI value of 3.5 mm, no effect of sex and age, and weak evidence for an interaction between sex and age. Computer-assisted digital ADI measurement provides higher intraobserver reliability than what has previously been reported, and interobserver reliability and a maximum ADI value similar to that found in the literature.

Short emergency department length of stay attributed to full-body digital radiography--a review of 3 paediatric cases.

Extracted from text ... SCIENTIFIC LETTERS 613 Multiple casualties strain the resources of emergency departments. Two polytraumatised patients arriving simultaneously can overwhelm a small community hospital, while the capacity of a large urban emergency department does not extend beyond the treatment of 3 - 4 severely injured patients at the same time using the routine trauma protocol.1 Emergency department overcrowding because of multiple casualties leads to increased length of stay and can have an adverse effect on patient outcome. Variations from the norm in trauma management, particularly during the initial assessment and resuscitation phase of care, during a multiple casualty incident, has been associated ..

Clinical and immunological correlates of chest X‐ray abnormalities in HIV‐infected South African children with limited access to anti‐retroviral therapy

The chest X‐ray (CXR) abnormalities of human immunodeficiency virus (HIV)‐infected children in low/middle income countries (LMICs) have not been well studied.

Chest radiographic pulmonary changes reflecting extrapulmonary involvement in paediatric HIV disease

Respiratory infections are the commonest cause of pulmonary change on chest radiographs of HIV-infected children. However, HIV-related neurological, oropharyngeal, oesophageal, cardiac and haematological abnormalities may also manifest with pulmonary changes and must be considered in the interpretation of the chest radiograph in HIV-infected children.

Towards task shifting? A comparison of the accuracy of acute trauma-radiograph reporting by medical officers and senior radiographers in an African hospital

Introduction Due to the universal shortage of radiologists, medical officers are largely responsible for acute trauma radiograph reporting in public sector healthcare facilities in well-resourced countries. In poorly-resourced countries, a shortage of medical officers results in most acute trauma radiographs being unreported. In the European Union (EU), experienced radiographers with no specific training have been shown to be more accurate than medical officers in trauma radiograph reporting, while EU radiographers who receive additional training can reach accuracies comparable to radiologists. In some EU countries, the role of the radiographer has been extended to include trauma reporting. However, there has been no study of the accuracy of trauma radiograph reporting by radiographers in Africa, where task-shifting could yield potentially greater benefits, due to shortages of both radiologists and medical officers. The aim of this study was therefore to compare the accuracy of acute trauma-radiograph reporting by medical officers and senior radiographers in an African setting Methods A prospective study was conducted at a South African hospital from November 2013-April 2014. Medical officers and senior radiographers reported the same set of appendicular skeleton trauma radiographs. Reporting accuracy, sensitivity and specificity were calculated using a consultant radiologists report as the reference standard. Differences were evaluated using the Mann-Whitney U test, with p < 0.05 significant Results Senior radiographers achieved significantly higher reporting accuracy and sensitivity than medical officers (81.5% vs 67.8%, p = 0.002) Conclusion Senior radiographers represent a potentially important resource for acute trauma-radiograph reporting in the public healthcare sector in Africa.

Bilateral tuberculous mastoiditis and facial palsy

The patient was first seen at Red Cross Children’s Hospital in September 2001, aged 3 years and 2 months. He was living with his unemployed single-parent mother in an informal settlement. He had bilateral suppurative submandibular lymphadenitis, requiring incision and drainage. Two weeks after discharge, pus swabs revealed a positive culture for Mycobacterium tuberculosis. The local TB clinic was notified, but his mother could not be contacted, having relocated to central Cape Town where she had obtained temporary employment. In March 2002 he was seen at Somerset Hospital, Cape Town, with a suppurative discharge from both ears. Pus swabs again cultured M. tuberculosis. Attempts at contact via the local TB clinic faced the same problems as previously and the follow-up outpatient appointment was not kept. The third contact with the health care system was in May 2002, when his aunt, who had taken over his care, brought him to Red Cross Hospital. He had bilateral profuse suppurative discharges from his ears, discharging neck sinuses, facial palsies, profound conduction deafness, microcytic anaemia and kwashiorkor. There was no evidence of exposure to HIV. Pus swabs from the ears and neck yielded mixed bacterial and M. tuberculosis culture. Computed tomography (CT) of the temporal bones demonstrated extensive destruction of the mastoid bone and ossicular chain bilaterally, consistent with tuberculous mastoiditis (Fig. 1).

The accuracy of radiology speech recognition reports in a multilingual South African teaching hospital

BackgroundSpeech recognition (SR) technology, the process whereby spoken words are converted to digital text, has been used in radiology reporting since 1981. It was initially anticipated that SR would dominate radiology reporting, with claims of up to 99% accuracy, reduced turnaround times and significant cost savings. However, expectations have not yet been realised. The limited data available suggest SR reports have significantly higher levels of inaccuracy than traditional dictation transcription (DT) reports, as well as incurring greater aggregate costs.There has been little work on the clinical significance of such errors, however, and little is known of the impact of reporter seniority on the generation of errors, or the influence of system familiarity on reducing error rates.Furthermore, there have been conflicting findings on the accuracy of SR amongst users with English as first- and second-language respectively.MethodsThe aim of the study was to compare the accuracy of SR and DT reports in a resource-limited setting. The first 300 SR and the first 300 DT reports generated during March 2010 were retrieved from the hospital’s PACS, and reviewed by a single observer. Text errors were identified, and then classified as either clinically significant or insignificant based on their potential impact on patient management. In addition, a follow-up analysis was conducted exactly 4 years later.ResultsOf the original 300 SR reports analysed, 25.6% contained errors, with 9.6% being clinically significant. Only 9.3% of the DT reports contained errors, 2.3% having potential clinical impact. Both the overall difference in SR and DT error rates, and the difference in ‘clinically significant’ error rates (9.6% vs. 2.3%) were statistically significant. In the follow-up study, the overall SR error rate was strikingly similar at 24.3%, 6% being clinically significant.Radiologists with second-language English were more likely to generate reports containing errors, but level of seniority had no bearing.ConclusionSR technology consistently increased inaccuracies in Tygerberg Hospital (TBH) radiology reports, thereby potentially compromising patient care. Awareness of increased error rates in SR reports, particularly amongst those transcribing in a second-language, is important for effective implementation of SR in a multilingual healthcare environment.