Prioritising the care of critically ill children: a pilot study using SCREEN reduces clinic waiting times

Objective In low-resource settings, childhood mortality secondary to delays in triage and treatment remains high. This paper seeks to evaluate the impact of the novel Sick Children Require Emergency Evaluation Now (SCREEN) tool on the waiting times of critically ill children who present for care to primary healthcare clinics in Cape Town, South Africa. Methods We used a pre/postevaluation study design to calculate the median waiting times of all children who presented to four randomly chosen clinics for 5 days before, and 5 days after, the implementation of SCREEN. Findings The SCREEN programme resulted in statistical and clinically significant reductions in waiting times for children with critical illness to see a professional nurse (2 hours 45 min to 1 hour 12 min; p<0.001). There was also a statistically significant reduction in the proportion of children who left without being seen by a professional nurse (25.8% to 18.48%; p<0.001). Conclusions SCREEN is a novel programme that uses readily available laypersons, trained to make a subjective assessment of children arriving at primary healthcare centres, and provides a low cost, simple methodology to prioritise children and reduce waiting times in low-resource healthcare clinics

Assessing the reliability and accuracy of nurse triage ratings when using the South African Triage Scale in the Emergency Department of District Headquarter Hospital of Timergara, Pakistan

ObjectiveTo assess inter and intra-rater reliability, as well as accuracy of nurse triage ratings when using the South African Triage Scale (SATS) in the Emergency Department (ED) of District Headquarter (DHQ) Hospital of Timergara, Pakistan.MethodsThis is a cross-sectional study using 42 previously validated paper based vignettes. Fifteen ED nurses assigned triage ratings to each of the 42 vignettes under classroom conditions. Validation of the SATS was done using the vignettes as a reference standard. Graphical displays portrayed rating distribution and validation measures of sensitivity, specificity, overtriage and undertriage across different acuity levels.ResultsThe estimated Quadratically weighted Kappa (QWK) and Interclass Correlation was found to be substantial at 0.77(CI 0.69–0.85). Intra-rater reliability with exact agreement was shown to be 87% (CI 67–100) with one category discrepancy showing 100% agreement. An average sensitivity, 70%; specificity, 97%; overtriage, 14.7% and undertriage, 21.6% was shown. The Graphical displayed showed that Very Urgent, Urgent and routine acuity levels had acceptable levels of overtriage and undertriage.ConclusionThe SATS has been shown to be a reliable triage scale for a developing country such as Pakistan. With accuracy being acceptable in the context of Timergara, we would suggest further validation studies looking at simple ways of validating the triage scale bearing in mind the challenges facing a developing country ED

Comparative evaluation of INNO-LiPA HBV assay, direct DNA sequencing and subtractive PCR-RFLP for genotyping of clinical HBV isolates

Genotypes (A to H) of hepatitis B virus (HBV) influence liver disease progression and response to antiviral therapy in HBV-infected patients. Several methods have been developed for rapid genotyping of HBV strains. However, some of these methods may not be suitable for developing countries. The performance of INNO-LiPA HBV Genotyping assay (LiPA), direct DNA sequencing and subtractive PCR-RFLP of genotype-specific HBV genome regions were evaluated for accurately determining the HBV genotypes by analyzing sera (n = 80) samples from chronic HBV patients. Both, LiPA and DNA sequencing identified 63, 4 and 13 HBV strains as belonging to genotype D, genotype A and mixed genotype A and D, respectively. On the contrary, the PCR-RFLP-based method correctly identified all 4 genotype A but only 56 of 63 genotype D strains. Seven genotype D strains yielded indeterminate results. DNA sequence comparisons showed that a single nucleotide change in the target region generated an additional restriction site for Nla IV that compromised the accuracy of this method. Furthermore, all the mixed genotype A and D strains were identified only as genotype A strains. The data show that the PCR-RFLP-based method incorrectly identified some genotype D strains and failed to identify mixed genotype infections while LiPA and DNA sequencing yielded accurate results

Diagnosing pericardial effusions

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A patient with both Gilles de la Tourette's syndrome and chromosome 22q11 deletion syndrome: clue to the genetics of Gilles de la Tourette's syndrome?

This is the first published case description of the association of Gilles de la Tourette's syndrome (GTS) and chromosome 22q11.2 deletion syndrome (22q11DS; previously referred to as CATCH-22 syndrome). The co-occurrence of GTS, 22q11DS, and their behavioral/neuropsychiatric abnormalities may be due to the common endophenotypic mechanisms shared by these disorders, rather than due to specificity for GTS. Research into this genomic region may lead to advancement in neurobehavioral/neuropsychiatric genetics, which will help us in further explicating a broader perspective of gene–brain–behavior interrelationships and of the genetic underpinnings of various developmental psychopathologies and behavioral/neuropsychiatric disorders that are common to both GTS and 22q11DS. Our report should warrant further genetic investigations of the chromosome 22q11.2 deletion site using alternative strategies to the quantitative trait loci endophenotype-based approach, which would be useful for establishing the biological and molecular underpinnings of obsessive–compulsive disorder, attention-deficit/hyperactivity disorder, and GTS

Implementation of a triage score system in an emergency room in Timergara, Pakistan [Short communication]

Following implementation of the South African Triage Scale (SATS) system in the emergency department (ED) at the District Headquarter Hospital in Timergara, Pakistan, we 1) describe the implementation process, and 2) report on how accurately emergency staff used the system. Of the 370 triage forms evaluated, 320 (86%) were completed without errors, resulting in the correct triage priority being assigned. Fifty completed forms displayed errors, but only 16 (4%) resulted in an incorrect triage priority being assigned. This experience shows that the SATS can be implemented successfully and used accurately by nurses in an ED in Pakistan