Determining the death burden for prioritising public health interventions necessitates detailed data on the causal pathways to death. Postmortem minimally invasive tissue sampling (MITS), incorporating histology, molecular and microbial culture diagnostics, enhances cause-of-death attribution, particularly for infectious deaths. MITS proves a valid alternative to full diagnostic autopsies, especially in low- and middle-income countries. In Soweto, South Africa (SA), the Child Health and Mortality Prevention Surveillance (CHAMPS) programme has delineated over 1 000 child and stillbirth deaths since 2017. This SA CHAMPS site supports advocating for the use of postmortem MITS as routine practice, for more granular insights into under-5 mortality causes. This knowledge is crucial for SA's pursuit of Sustainable Development Goal 3.2, targeting reduced neonatal and under-5 mortality rates. This commentary explores the public health advantages and ethicolegal considerations surrounding implementing MITS as standard of care for stillbirths, neonatal and paediatric deaths in SA. Furthermore, based on the data from CHAMPS, we present three pragmatic algorithmic approaches to the wide array of testing options for cost-effectiveness and scalability of postmortem MITS in South African state facilities.

BACKGROUND: Thirty-day readmission rate and 30-day reoperation rate are recognised indicators of perioperative quality of care. While these indicators have been reported in numerous studies from developed countries, little is known about readmission and reoperation following spinal surgery in South Africa. The main aim of this study was to describe the overall rate of 30-day reoperation and 30-day readmission following spine surgery in a large open medical scheme. Secondary aims were to describe the reasons for 30-day reoperation and 30-day reoperation by spine region and for certain procedures. METHODS: This retrospective cohort study was based on an anonymised dataset of spine surgeries funded by the largest open medical scheme in South Africa between 2008 and 2017. The dataset was processed to identify descriptors of each surgery, including the year of operation, patient demographics, spinal pathology, spine region and certain procedures. The primary outcome was reoperation within 30 days, which was identified based on the time to the second operation, diagnostic codes and procedure codes. RESULTS: A total of 49 395 spine surgeries were included in the study, of which at least 38 218 (77%) were for degenerative pathology. Overall, 3 204 (6.5%) surgeries were associated with 30-day readmission for any cause and 415 (0.8%) patients underwent a second unplanned spine surgery within 30 days of the initial spine procedure. The most common reasons for the 415 reoperations were neural compression (n = 160, 39%) and infection (n = 79, 19%). CONCLUSION: Spine surgery in the South African private sector is associated with low rates of 30-day readmission and reoperation, suggesting good quality of perioperative care. Furthermore, the findings compare favourably with those from developed countries. Future studies should investigate long-term reoperation following spinal surgery to provide more comprehensive insight into the quality of spinal surgery care in the South African private healthcare setting. Level of evidence: Level 3

BACKGROUND: It is generally understood that the profile of spine surgery varies by setting, based on factors such as the age profile of the population, the economic context and access to healthcare. Relatively little is known about the profile of spine surgery in South Africa (SA), although one previous report from the public healthcare sector suggested a high burden of trauma and infection-related surgery. To our knowledge, there has been no formal investigation in the private sector. A holistic understanding of spine surgery within our setting may be beneficial for applications such as resource allocation and informing the training needs of future specialists OBJECTIVES: To provide insight into spinal surgery in the SA private healthcare sector by describing spine surgery characteristics within a large open medical scheme, including both patient and surgeon profiles METHODS: This retrospective review included adult inpatient spine surgeries funded by the largest open medical scheme in SA between 2008 and 2017. An anonymised dataset extracted from the scheme records included patient demographics, ICD-10 codes, procedure codes and surgeon specialisation. Descriptive patient and surgery data were presented. Furthermore, the association between patient and surgery factors and surgeon specialisation was investigated using univariate and multivariate analyses RESULTS: A total of 49 576 index spine surgeries were included. The largest proportion of surgeries involved members aged 40 - 59 years old (n=23 543, 48%), approximately half involved female members (n=25 293, 51%) and most were performed by neurosurgeons (n=35 439, 72%). At least 37 755 (76%) surgeries were for degenerative pathology, 2 100 (4%) for trauma and 242 (0.5%) for infection. Adjusted risk ratios (aRR) significantly associated with orthopaedic surgeon specialisation included cervical spine region (aRR = 0.49; 95% confidence interval (CI) 0.39 - 0.61), trauma (aRR = 1.50; 95% CI 1.20 - 1.88), deformity (aRR = 1.77; 95% CI 1.33 - 2.35) and blood transfusion (aRR = 1.46; 95% CI 1.12 - 1.91 CONCLUSION: Spine surgery in SA's largest open medical scheme was dominated by surgery for degenerative pathology in older adults, and was performed largely by neurosurgeons. This constituted a stark contrast to a previous report from the public sector and highlighted a mismatch between exposure during public sector registrar training and private practice post specialisation. The findings support the need for private-public collaboration as well as the importance of spine fellowships for all specialists intending to practise spine surgery

BACKGROUND: No guidelines for ethical coding practice of commonly performed soft tissue knee procedures exist in South Africa. The aim of our study was to establish and prioritise codes for these procedures via a consensus of knee surgeons. METHODS: Fifty-nine South African Knee Society (SAKS) members were approached for a blinded Delphi consensus process. In the first survey round, a list of codes was generated which was prioritised in subsequent rounds. Agreement of 70% or more was defined as consensus. These codes were then moderated during a fourth round by the SAKS committee. RESULTS: Sixteen SAKS members, performing a median of 200 knee procedures (interquartile range [IQR] 115-312) annually, participated in each round. Consensus was achieved for codes 0667, 0614 and 0673 when coding for meniscus and cartilage surgery. For anterior cruciate ligament reconstruction 0667, 0614, 0679, 0673 and 0775 all reached consensus. Here, some codes (0593) did not achieve consensus although their inclusion was promoted by the SAKS committee round. Furthermore, 88% of the participants agreed that rule 0005 should be used for multiple knee ligament reconstruction, and each should be seen as a separate procedure. Code 0592 (36%) should not be routinely used for minor debridement. No code exists to code for increased complexity in meniscal root repairs and therefore 0677 was proposed to be reassigned for meniscus repair, as well as 0296 to code for the major technical nature of the procedure. For medial patellofemoral ligament reconstructions, 0679 (88%) and 0579 (63%) were proposed along with 0667 (100%), 0775 (94%) and 0614 (69%). For osteotomy of the knee region, codes 0527 (94%) and modifier 0051 were put forth, as well as 0667 (75%), 0614 (75%) and 0673 (56%). When bone is harvested and/or grafted, 0507 (56%) and 0499 (44%) respectively are also thought to be appropriate. CONCLUSION: This consensus study is based on the coding practice of 16 members of the South African Knee Society performing a median of 200 knee procedures annually. A variety of techniques are available, some without specific allocated codes which called for moderation and reallocation of certain codes. With this work we hope to achieve transparent and consistent coding for soft tissue knee procedures. Level of evidence: Level 4

BACKGROUND: The COVID-19 pandemic has impacted on the global surgery landscapeOBJECTIVES: To analyse and describe the initial impact of the COVID-19 pandemic on orthopaedic surgery at Groote Schuur Hospital, a tertiary academic hospital in South AfricaMETHODS: The number of orthopaedic surgical cases, emergency theatre patient waiting times, and numbers of outpatient clinic visits, ward admissions, bed occupancies and total inpatient days for January - April 2019 (pre-COVID-19) were compared with the same time frame in 2020 (COVID-19). The COVID-19 timeframe included initiation of a national 'hard lockdown' from 26 March 2020, in preparation for an increasing volume of COVID-19 casesRESULTS: April 2020, the time of the imposed hard lockdown, was the most affected month, although the number of surgical cases had started to decrease slowly during the 3 preceding months. The total number of surgeries, outpatient visits and ward admissions decreased significantly during April 2020 (55.2%, 69.1% and 60.6%, respectively) compared with April 2019 (p<0.05). Trauma cases were reduced by 40% in April 2020. Overall emergency theatre patient waiting time was 30% lower for April 2020 compared with 2019CONCLUSIONS: COVID-19 and the associated lockdown has heavily impacted on both orthopaedic inpatient and outpatient services. Lockdown led to a larger reduction in the orthopaedic trauma burden than in international centres, but the overall reduction in surgeries, outpatient visits and hospital admissions was less. This lesser reduction was probably due to local factors, but also to a conscious decision to avoid total collapse of our surgical services

This article explores the elements that contribute to the poor performance of grade 12 learners in Accounting. As far as Accounting as a school subject in South Africa is concerned, there is a growing concern about the underperformance of learners, due to both a decrease in learners who enrol for the subject in grade 12 and the low pass rate in the National Senior Certificate examination. Existing research points out that fewer students elect Accounting as a grade 12 subject and that the performance of these students is below the average pass rate when compared to other subjects. This article employed as research methodology a qualitative case study in which interviews were used to collect data. Based on the case study conducted in the Frances Baard District Municipality in the Northern Cape, this article identifies critical factors that contribute to the underperformance of learners in grade 12 Accounting. Addressing these factors may contribute to the improvement of the performance of learners in Accounting. This is relevant for South Africa, which is experiencing a serious shortage of chartered accountants and other financial and auditing professionals.

Hierdie artikel ondersoek elemente wat bydra tot die swak prestasie van graad 12-leerders in Rekeningkunde. Wat Rekeningkunde as 'n skoolvak in Suid-Afrika betref, is daar toenemende kommer oor die onderprestasie van leerders, as gevolg van die afname in leerders wat in graad 12 vir die vak inskryf, en die lae slaagsyfer in die eksamen vir die Nasionale Senior Sertifikaat. Bestaande navorsing wys daarop dat minder leerders Rekeningkunde as graad 12-vak kies en dat die prestasie van hierdie leerders onder die gemiddelde slaagsyfer is as dit met ander vakke vergelyk word. Hierdie artikel maak van 'n kwalitatiewe gevallestudie gebruik as navorsingsmetode waarin onderhoude gebruik is om data in te samel. Op grond van die gevallestudie wat in die Frances Baard-distriksmunisipaliteit in die Noord-Kaap uitgevoer is, word 'n aantal kritiese faktore geí'dentifiseer wat bydra tot die onderprestasie van leerders in graad 12-Rekeningkunde. Die aanspreek van hierdie faktore kan bydra tot die verbetering van die prestasie van leerders in Rekeningkunde. Dit is relevant vir Suid-Afrika wat 'n ernstige tekort aan geoktrooiieerde rekenmeesters en ander finansiële en ouditpersoneel ervaar.

ABSTRACT Introduction Musculoskeletal (MSK) pain in children and adolescents is responsible for substantial personal impacts and societal costs, but it has not been intensively or systematically researched. This means our understanding of these conditions is limited, and healthcare professionals have little empirical evidence to underpin their clinical practice. In this article we summarise the state of the evidence concerning MSK pain in children and adolescents, and offer suggestions for future research. Results Rates of self-reported MSK pain in adolescents are similar to those in adult populations and they are typically higher in teenage girls than boys. Epidemiological research has identified conditions such as back and neck pain as major causes of disability in adolescents, and in up to a quarter of cases there are impacts on school or physical activities. A range of physical, psychological and social factors have been shown to be associated with MSK pain report, but the strength and direction of these relationships are unclear. There are few validated instruments available to quantify the nature and severity of MSK pain in children, but some show promise. Several national surveys have shown that adolescents with MSK pain commonly seek care and use medications for their condition. Some studies have revealed a link between MSK pain in adolescents and chronic pain in adults. Conclusion Musculoskeletal pain conditions are often recurrent in nature, occurring throughout the life-course. Attempts to understand these conditions at a time close to their initial onset may offer a better chance of developing effective prevention and treatment strategies.

OBJECTIVE: To estimate the rate of long-term poliovirus excretors in people known to have B-cell immune deficiency disorders. METHODS: An active search for chronic excretors was conducted among 306 persons known to have immunoglobulin G (IgG) deficiency in the United States, Mexico, Brazil, and the United Kingdom, and 40 people with IgA deficiency in the United States. Written informed consent or assent was obtained from the participants or their legal guardians, and the studies were formally approved. Stool samples were collected from participants and cultured for polioviruses. Calculation of the confidence interval for the proportion of participants with persistent poliovirus excretion was based on the binomial distribution. FINDINGS: No individuals with long-term excretion of polioviruses were identified. Most participants had received oral poliovirus vaccine (OPV) and almost all had been exposed to household contacts who had received OPV. Polioviruses of recent vaccine origin were transiently found in four individuals in Mexico and Brazil, where OPV is recommended for all children. CONCLUSION: Although chronic poliovirus excretion can occur in immunodeficient persons, it appears to be rare.

OBJETIVO: Estimar la tasa de excretores crónicos de poliovirus entre las personas con trastornos de inmunodeficiencia de células B. MÉTODOS: Se llevó a cabo una búsqueda activa de excretores crónicos entre 306 personas con deficiencia demostrada de inmunoglobulina G (IgG) en los Estados Unidos, México, el Brasil y el Reino Unido, y entre 40 personas con deficiencia de IgA en los Estados Unidos. Se obtuvo el consentimiento o asentimiento informado de los participantes o de sus representantes legales, así como la autorización oficial pertinente para realizar el estudio. Se recogieron muestras de heces de los participantes para determinar en cultivo la presencia de poliovirus. A partir de la distribución binomial se calculó el intervalo de confianza del porcentaje de pacientes con excreción persistente del poliovirus. RESULTADOS: Ninguno de los individuos resultó ser excretor crónico del poliovirus. La mayoría de los participantes habían recibido vacuna antipoliomielítica oral (OPV), y casi todos habían estado expuestos a contactos familiares que habían recibido OPV. Se encontraron transitoriamente poliovirus de origen vacunal reciente en cuatro personas de México y el Brasil, donde se recomienda administrar OPV a todos los niños. CONCLUSIÓN: Aunque se puede dar una excreción crónica de poliovirus entre las personas con inmunodeficiencia, el fenómeno parece ser infrecuente.

OBJECTIF: Estimer la proportion de sujets excrétant des poliovirus sur le long terme chez les personnes présentant une immunodéficience liée aux lymphocytes B. MÉTHODE: Les auteurs ont recherché activement les cas d'excrétion chronique de virus parmi 306 personnes connues pour avoir une carence en immunoglobulines G (IgG) au Brésil, aux Etats-Unis d'Amérique, au Mexique et au Royaume-Uni et chez 40 autres ayant une carence en immunoglobulines A (IgA) aux Etats-Unis d'Amérique. Les participants ou leurs tuteurs légaux ont donné par écrit leur consentement éclairé et les études ont été officiellement approuvées. Des échantillons de selles ont été prélevés pour tous les participants et mis en culture pour rechercher les poliovirus. Le calcul de l'intervalle de confiance pour la proportion de participants présentant une excrétion persistante repose sur la loi binomiale. RÉSULTATS: Les auteurs n'ont trouvé aucun sujet présentant une excrétion prolongée de poliovirus. Le vaccin antipoliomyélitique buccal (VPO) avait été administré à la plupart des participants et presque tous avaient été en contact dans leur foyer avec des sujets vaccinés par le VPO. Des poliovirus d'origine vaccinale récente ont été retrouvés de manière transitoire chez quatre sujets au Brésil et au Mexique où la vaccination par le VPO est recommandée pour tous les enfants. CONCLUSION: Bien que l'excrétion chronique de poliovirus soit possible chez le sujet immunodéficient, elle semble rare.

Nos últimos anos tem sido observado aumento do uso de crack (uma forma de cocaína fumada) em pesquisas epidemiológicas e em apreensões policiais. Até o presente, não havia dados brasileiros relacionando a procura de tratamento para a dependência de cocaína com as vias habituais de administração OBJETIVO. Analisar as modificações das vias de administração da cocaína em uma população de 245 pacientes atendidos em dois serviços ambulatoriais especializados (PROAD e UDED), na cidade de São Paulo, entre os anos de 1990 e 1993. MÉTODOS. Dados de entrevistas padronizadas realizadas na admissão dos pacientes aos serviços foram estudados e determinada a prevalência de uso das diferentes vias de administração de cocaína. RESULTADOS. A percentagem de pacientes que relataram uso de cocaína fumada (crack) aumentou de 17%, em 1990, para 64%, em 1993 (p<0,01). O uso de cocaína aspirada não variou durante esse período, permanecendo a via mais freqüentemente relatada (80%), enquanto a via endovenosa variou de 40%, em 1990, para 18%, em 1992, e para 28%, em 1993. CONCLUSÕES. As implicações do aumento de usuários de crack que procuram tratamento são discutidas em função do planejamento de tratamento e de programas de prevenção, com ênfase no risco de transmissão do vírus HIV.

An increase in crack use has been detected in epidemiological research and police data. Currently, in Brazil, no data are available linking the route of administration and attendance to treatment for cocaine dependence OBJECTIVE - The purpose of this paper was to analyze the changes in cocaine routes of administration in a cocaine dependent population treated in two outpatient public services (PROAD and UDED). METHOD - Standardized interview data, collected at admission to treatment were compared from 1990 to 1993. The prevalence rates of smoked ("crack"), injected and snorted cocaine were compared. RESULTS - The percentage of patients who reported "crack" cocaine use increased from 17% in 1990 to 64% in 1993 (p<0.01) The prevalence of snorted cocaine remained stable in the period of time analyzed, being the most frequent route reported. The intravenous route tended to decrease from 40% in 1990 to 28% in 1993. CONCLUSION - The implications of the increase of "crack" cocaine users who sought treatment are discussed. These data are important in planning prevention and treatment strategies, mainly in AIDS prevention.