Incidence of spine surgery in the South African private healthcare sector: ten-year trends within a large open medical scheme.

PURPOSE: Studies from developed countries suggest a dramatic increase in the utilization of spine surgery in recent decades, however less is known about spine surgery rates in the developing world. The aim of this study was to investigate ten-year trends in the incidence of spine surgery within South Africa's largest open medical scheme. METHODS: This retrospective review included adult inpatient spine surgeries funded by the scheme between 2008 and 2017. The incidence of spine surgery was investigated by age group-overall and for degenerative pathologies, fusion and instrumentation. Surgeons per 100,000 members were determined. Trends were evaluated by linear regression and by crude 10-year change in incidence. RESULTS: A total of 49,575 spine surgeries were included. The incidence of surgery for lumbar degenerative pathology showed a significant upward trend among 60-79 year olds but declined among 40-59 year olds. The incidence of lumbar fusion and lumbar instrumentation declined significantly among 40-59 year olds with little change among 60-79 year olds. The ratio of orthopaedic spinal surgeons decreased from 10.2 to 6.3 per 100,000 members whereas the ratio of neurosurgeons decreased from 7.6 to 6.5 per 100,000. CONCLUSION: Spine surgery in the South African private healthcare sector bears some similarity to developed countries in that it is dominated by elective procedures for degenerative pathology. However, the findings did not reflect the marked increases in the utilization of spine surgery reported elsewhere. It is hypothesized that this may be partly related to differences in the supply of spinal surgery.

Development of active tuberculosis in patients treated with biological disease-modifying antirheumatic drugs.

BACKGROUND: Biological disease-modifying antirheumatic drugs (bDMARDs) have been shown to be highly effective in the treatment of rheumatic conditions, but may increase the risk of infections. Development of tuberculosis (TB) while on bDMARD therapy is of particular concern in high TB burden settings such as Western Cape Province, South Africa. OBJECTIVES: To describe the diagnosis, management and outcome of patients who developed active TB while receiving a bDMARD. RESULTS: Ten patients who screened negative for TB prior to initiation of a bDMARD subsequently developed active TB. TB was diagnosed between 10 months and 9 years from bDMARD initiation, suggesting new infection, and included 6 cases of extrapulmonary TB. All patients required multiple tests to confirm the diagnosis of TB, and all were successfully treated. CONCLUSIONS: TB can occur in patients on bDMARD therapy despite initial screening, and may have unusual, extrapulmonary manifestations that pose a diagnostic challenge.

Loss to follow-up among patients diagnosed with spinal tuberculosis at a tertiary hospital in Western Cape Province, South Africa: A retrospective cohort study.

BACKGROUND: Patients diagnosed with spinal tuberculosis (TB) at a major tertiary hospital in Western Cape Province, South Africa, are required to attend regular follow-up at the hospital's outpatient spine clinic and to remain on TB treatment for at least 9 months. This follow-up and lengthy treatment is intended to allow for specialist monitoring of TB treatment response and early identification of secondary complications, and to reduce the risk of recurrence. However, little is known about adherence to these recommendations. OBJECTIVES: The main objectives were to describe (i) loss to spine clinic follow-up (LTFU), and (ii) TB treatment duration among patients diagnosed with spinal TB at the hospital. Secondary objectives were to investigate (i) the association between LTFU and treatment duration, and (ii) factors associated with LTFU. METHODS: This retrospective cohort study included 173 adults diagnosed with spinal TB between 2012 and 2015 and investigated follow-up within 2 years from diagnosis. Clinical, demographic and appointment data were obtained from hospital records and a dataset provided by the provincial Department of Health. LTFU was presented as frequency (%) and as a survival analysis. TB treatment duration was reported as frequency <9 months or ≥9 months, and the association between LTFU and <9 months of treatment was investigated using relative risk (RR) with 95% confidence intervals (CIs). Univariate associations between explanatory variables and LTFU were investigated using simple logistic regression analysis. RESULTS: Patients had a median (interquartile range) age of 36 (29 - 48) years and included 98 females (57%) and 151 individuals (87%) residing <50 km from the hospital. Primary outcomes were that 129 patients (75%) were LTFU within 2 years of diagnosis and 45 (30%) completed <9 months of treatment. The RR of <9 months of treatment was 1.62 (95% CI 1.39 - 1.88) among those LTFU compared with those retained in follow-up. LTFU was not associated with any of the clinical or demographic variables investigated. CONCLUSIONS: Three-quarters of the patients did not complete follow-up at the tertiary hospital spine clinic, and almost one in three received <9 months of TB treatment. Remaining in spine clinic follow-up was significantly associated with receiving at least the minimum duration of TB treatment. However, LTFU could not be predicted from routine clinical and demographic information and is likely to be related to factors not accounted for in the current analysis.

Orthopaedic referrals using a smartphone app: uptake, response times and outcome

Background. It is well established that South Africa (SA) suffers an immense burden of violence and injuries. The responsibility of providing care for these injuries falls mainly on public health services, resulting in overloading of the health system. Prior to a recent intervention, the large burden had been exacerbated by limitations in the traditional referral system that highlighted the need for a better referral system. Vula's smartphone app was introduced at Tygerberg Hospital in August 2016. This study evaluated the uptake, response times and outcomes using this app.Objectives. The main objectives of the study were to describe: (i) the number of referrals; (ii) referral response times; (iii) referring facilities; and (iv) referral outcomes. Secondary objectives were to: (i) evaluate whether the referral outcome pathway was appropriate; and (ii) assess professional conduct and evidence of upskilling.Methods. This retrospective, descriptive study investigated Vula app referrals to the Division of Orthopaedic Surgery at Tygerberg Hospital between 1 August 2016 and 31 March 2017. Vula was advertised to key facilities in the hospital's referral network. All referrals to the division during the study period were systematically included in the analysis of operational outcomes, although some were excluded from the subsequent referral outcome analysis. Operational outcomes included the number of referrals, referring facilities and referral response times. Referral outcome analysis included the clinical diagnosis, referral pathway, whether the referral was used for upskilling and whether it was conducted in a professional manner.Results. A total of 2 275 referrals from 39 different facilities were received during the study period from 238 individual users; 50% of referrals received a response within 11 minutes, while a small percentage received no response. Clinical and demographic characteristics of 1 985 patients included in the referral outcome analysis indicated that the majority of trauma and emergency referrals involved males, with closed fractures being the most frequent clinical presentation. Although the most common referral outcome was immediate transfer, one-third of the patients were treated at the referring hospital with advice only.Conclusions. The large volume of orthopaedic referrals received through the Vula app suggests that Vula represents a successful alternative to traditional referral methods. Referrals managed by advice only could suggest that Vula facilitates some relief for the overburdened trauma services. Future research could further explore Vula's role in strengthening the public health system, including interventions for high-volume referral areas and upskilling of referring health workers

Child and adult spinal tuberculosis at tertiary hospitals in the Western Cape, South Africa: 4-year burden and trend.

The aim of this retrospective review was to assess the overall burden and trend in spinal tuberculosis (TB) at tertiary hospitals in the Western Cape Province of South Africa. All spinal TB cases seen at the province's three tertiary hospitals between 2012 and 2015 were identified and clinical records of each case assessed. Cases were subsequently classified as bacteriologically confirmed or clinically diagnosed and reported with accompanying clinical and demographic information. Odds ratios (OR) for severe spinal disease and corrective surgery in child vs. adult cases were calculated. A total of 393 cases were identified (319 adults, 74 children), of which 283 (72%) were bacteriologically confirmed. Adult cases decreased year-on-year (P = 0.04), however there was no clear trend in child cases. Kyphosis was present in 60/74 (81%) children and 243/315 (77%) adults with available imaging. Corrective spinal surgery was performed in 35/74 (47%) children and 80/319 (25%) adults (OR 2.7, 95% confidence interval 1.6-4.5, P = 0.0003). These findings suggest that Western Cape tertiary hospitals have experienced a substantial burden of spinal TB cases in recent years with a high proportion of severe presentation, particularly among children. Spinal TB remains a public health concern with increased vigilance required for earlier diagnosis, especially of child cases.

Relationship between perceived exertion during exercise and subsequent recovery measurements.

The return towards resting homeostasis in the post-exercise period has the potential to represent the internal training load of the preceding exercise bout. However, the relative potential of metabolic and autonomic recovery measurements in this role has not previously been established. Therefore the aim of this study was to investigate which of 4 recovery measurements was most closely associated with Borg's Rating of Perceived Exertion (RPE), a measurement widely acknowledged as an integrated measurement of the homeostatic stress of an exercise bout. A heterogeneous group of trained and untrained participants (n = 36) completed a bout of exercise on the treadmill (3 km at 70% of maximal oxygen uptake) followed by 1 hour of controlled recovery. Expired respiratory gases and heart rate (HR) were measured throughout the exercise and recovery phases of the trial with recovery measurements used to calculate the magnitude of excess post-exercise oxygen consumption (EPOCMAG), the time constant of the EPOC curve (EPOCτ), 1 min heart rate recovery (HRR60s) and the time constant of the HR recovery curve (HRRτ) for each participant. RPE taken in the last minute of exercise was significantly associated with HRR60s (r=-0.69), EPOCτ (r=0.52) and HRRτ (r=0.43) but not with EPOCMAG. This finding suggests that, of the 4 recovery measurements under investigation, HRR60s shows modest potential to represent inter-individual variation in the homeostatic stress of a standardized exercise bout, in a group with a range of fitness levels.

Impairment of 40-km time-trial performance but not peak power output with external iliac kinking: a case study in a world-class cyclist.

Iliac blood-flow restrictions causing painful and "powerless" legs are often attributed to overtraining and may develop for some time before being correctly diagnosed. In the current study, differences between actual performance parameters and performance parameters predicted from the Lamberts and Lambert Submaximal Cycle Test (LSCT) were studied in a world-class cyclist with bilateral kinking of the external iliac artery before and after surgery. Two performance-testing sessions, including a peak-power-output (PPO) test and a 40-km time trial (TT) were conducted before surgery, while 1 testing session was conducted after the surgery. Actual vs LSCT-predicted performance parameters in the world-class cyclists were compared with 82 symptom-free trained to elite male cyclists. No differences were found between actual and LSCT-predicted PPO before and after surgical intervention. However, there were differences between actual and LSCT-predicted 40-km TT time in the tests performed before the surgery (2:51and 2:55 min:s, respectively). These differences were no longer apparent in the postsurgery 40-km TT (2 s). This finding suggests that iliac blood-flow restrictions seem to mainly impair endurance performance rather than peak cycling performance. A standard PPO test without brachial ankle blood-pressure measurements might not be able to reflect iliac blood-flow restrictions. Differences between actual and LSCT-predicted 40-km TT time may assist in earlier referral to a cardiovascular specialist and result in earlier detection of iliac blood-flow restrictions.

Interleukin 1 and interleukin 1 inhibitor production by human macrophages exposed to influenza virus or respiratory syncytial virus. Respiratory syncytial virus is a potent inducer of inhibitor activity.

Respiratory viral infections are commonly associated with altered immune responses, such as proliferative responses to mitogens and antigens. To examine potential mechanisms, we examined production of IL-1 and IL-1 inhibitors by purified human peripheral blood-derived macrophages exposed to influenza virus or respiratory syncytial virus (RSV). IL-1 and IL-1 inhibitor activities in supernatant fluids from macrophages exposed to the viruses 24 h previously were measured using the standard mouse thymocyte comitogen assay. Crude fluids from macrophages exposed to influenza virus contained substantial IL-1 activity, whereas crude fluids from macrophages exposed to RSV contained marked IL-1 inhibitor activity. Assays with gel filtration-separated fractions revealed that both influenza virus and RSV induced production of both IL-1 and IL-1 inhibitors. Neither IL-2 nor IL-2 inhibitor activities were detected. Thus, effects of human macrophage-derived factors on thymocyte proliferation, or potentially on human lymphocyte proliferation, may reflect the total or net activity of multiple composite factors, the balance of which varies according to the challenge. The data raise the possibility that marked production of IL-1 inhibitor activity in response to RSV plays a role in the clinical recurrence of RSV infection despite the absence of clear evidence for antigenic shift or drift of the virus.

Role of polyclonal cell activation in the initiation of immune complex-mediated pulmonary injury following antigen inhalation.

The lung, by virtue of its anatomic situation, provides environmental antigens with unique access to host lymphoid tissues. In order to better understand the biologic consequences of antigen inhalation, we developed in animal model in which soluble proteins are administered in aerosol form to rabbits. By labeling these proteins with fluorochrome dyes or radioactive isotopes, the uptake, distribution, and fate of such proteins can be demonstrated both morphologically and quantitatively. Prompt host-antibody responses can be demonstrated to inhaled antigen, but not to comparable amounts of ingested antigen. Repeated administrations of antigen aerosol to immune animals produced little injury; in contrast, administration of aerosols containing phytohemagglutinin or cancanavalin A (Con A), plant lectins which activate leucocytes in a polyclonal fashion, induced a diffuse interstitial pneumonitis. When immune animals inhaled antigen plus Con A, devastating pulmonary necrosis was induced, in association with localized deposits of immune complexes containing antigen, antibody and complement. Such necrotic injury healed by scarring within 4 weeks. The necrotizing injury could be prevented by either decomplementation with cobra venom factor, or through inhibition of leucocyte responsiveness to Con A by administration of cholera toxin, a cAMP agonist. These studies indicate that antigen inhalation may serve as an important means of establishing "natural" immunity to environmental agents, but also may lead to severe pulmonary injury and fibrosis where the agents inhaled act not only as antigens but as polyclonal leucocyte activators as well.

In vivo responses to inhaled proteins. III. Inhibition of experimental immune complex pneumonitis after suppression of peripheral blood lymphocytes.

We have previously shown that inhaled Con A has a powerful enhancing effect on the formation of immune complexes between an inhaled antigen and circulating antibody. Immunohistochemical staining has demonstrated such complexes, together with host complement, in close association with foci of necrotizing destruction of the pulmonary parenchyma. We have postulated that Con A promotes immune complex formation indirectly through polyclonal activation of lymphocytes in the lung. In this paper we test this hypothesis in animals rendered unresponsive to Con A stimulation in vivo by i.v. administration of cholera toxin (CT). Such treatment raised the levels of cAMP in peripheral blood lymphocytes and inhibited their proliferative response to Con A in vitro. CT administration further blocked the local inflammatory response to intradermal injections of Con A, as well as the cell-mediated immune response to intradermal injections of BSA. Although CT failed to block the immune complex-mediated Arthus vasculitis in the skin, it did block production of immune complex pulmonary injury by antigen/mitogen aerosols, as did decomplementation with purified cobra venom factor. These findings support the hypothesis that polyclonal activation of pulmonary lymphocytes promotes immune complex-type alveolitis, possibly by facilitating interactions between humoral antibody and intra-alveolar antigen.