de Villers, F P R

Ruhaya, M

South African Medical Journal (SAMJ)

SCIENTIFIC LETTERSfingerbreadths (N = 3) above the symphysis; all were due to afull bladder.In view of these findings, the curve shown in Fig. 3 wasestablished. Regardless of the condition of the bladder, it wasfound that the number of fingerbreadths above the symphysisallows the clinical estimation of the duration of pregnancy asfollows: one fingerbreadth = 6 - 7 weeks, two = 9 - 10, three =10 - 11, four = 11 - 12, and five = 13 - 14 weeks.The preliminary results were validated in a prospectiveseries of 353 women. The only difference was that twofingerbreadths tallied with a gestational age of 8 - 9 weeks(instead of 9 - 10 weeks). There were 18 false-negatives (5.1%)and 31 false-positives (8.8%). The false-negatives occurred at amean gestational age of 7.9 weeks (95% confidence interval(CI): 7.1, 8.7). The sensitivity was 93.2% and the specificity65.6%. The positive predictive value was 88.8% and thenegative predictive value 76.6%. Because some women withone or two fingerbreadths and a full bladder were found to befalse-positive, it is recommended that these clients be asked tovoid, and that the clinical examination be repeated.For practical purposes, a symphysis-fundus distance of morethan three fingerbreadths suggests a pregnancy of ‡ 12 weeksand the patient should be referred to hospital for TOP, if that isthe case. The method might be useful in PHC settings with nosonographic facilities to improve proficiency of clinicaldiagnosis of pregnancy and determination of early gestationalage.Louis-Jacques van BogaertDepartment of Obstetrics and GynaecologyMEDUNSAsatellite campus, Philadelphia HospitalDennilton1. Choice of Termination of Pregnancy Act No. 92. South African Government Gazette. CapeTown, 1996.2. Department of Health. Guidelines for Maternity Care in South Africa. Pretoria: Department ofHealth, 2000: 20.3. Theron GB. Problem orientated antenatal care. In: J Bassin, ed. Topics in Obstetrics andGynaecology. Johannesburg: Julmar Communications, 1995: 29-35.4. Crichton ED. Quoted in: Philpott RH. Graphic records in labour. BMJ 1972; 4: 163-164.281April 2003, Vol. 93, No. 4  SAMJFig. 3. Estimation of early gestational age by the fingerbreadthsmethod.To the Editor: The autopsy is an important tool for medicaltraining, research and audit. Unfortunately the autopsy ratehas declined drastically worldwide over the last half century.1For example, in Sweden the rate fell from 46% in 1969 to 31%in 1993,2 in North America from 50% in 1950 to as low as 7% insome hospitals in 1995,1 and in France from 15% in 1988 to 4%in 1997.3 Some students and medical practitioners consider theautopsy to be of little value.4,5The value of the autopsy extends beyond ascertainment ofthe cause of death to quality control in medical practice,research and education, and the provision of epidemiologicalmedical data. Many deaths occur without physicians knowingthe cause. In 24 – 30% of perinatal deaths, autopsy was the solemeans of establishing the diagnosis. 6-8 In cases where thediagnosis is supposedly ascertained by means of moderninvestigative technologies, studies have revealed that there is arelatively high rate of misdiagnosis. Seven to thirteen per centof autopsies revealed a clinically missed major diagnosis thatmight have led to a change in therapy.5,6,9,10 Lowry expressedthis well when he said that ‘Failure to perform autopsies meanssome MD’s are “walking in a fog of misplaced optimism”’.1The purpose of this study was to assess the experience ofmedical students with regard to autopsy.Data were collected by means of a self-administeredquestionnaire (validated previously),11 which covered theobjectives of the autopsy and students’ experience of autopsiesduring medical training. Informed consent was obtained andthe study approved by the Ethics Committee of the MedicalUniversity of Southern Africa (MEDUNSA).Of 254 final year MB ChB students at MEDUNSAin 1998,239 received questionnaires and 164 (65%) were available forthe study. Seven students did not know what the objectives ofautopsy were and 2 believed that the autopsy has little valuetoday. The remaining responses were: 123 students (75%)considered the ascertainment of the cause of death to be theprincipal objective of autopsy, 58 (35%) indicated medicalMedical students’ experiences of the autopsyApril 2003, Vol. 93, No. 4  SAMJSCIENTIFIC LETTERSresearch as an important purpose of autopsy, 46 (28%) believedthat the autopsy has an important role to play in medicaltraining, and 39 (24%) considered the autopsy to be useful inthe control of the effects of care and treatment. Only 21students considered all four statements to be legitimateobjectives of the autopsy. The mean number of answers was1.65 ± 1.15.During their medical training, 108 students (66%) had nevertaken part in an autopsy procedure (as an assistant operator tothe pathologist). Fifty-six had participated in 1 or moreautopsies, of whom 31 students (19%) participated in morethan 7 autopsies. On the other hand, all students had attendedat least 1 autopsy demonstration with 44 attending 3 - 6, and118 (72%) attending more than 7 autopsies. The minimumFaculty requirement is that students should attend forensicautopsies on four different occasions during their fourth year.There is no requirement that they should participate or thatthey should attend hospital autopsies. Two students attendedonly one autopsy.Concerning their emotional reaction to their first autopsy, 33students (20%) claimed not to have experienced anydiscomfort, while 16 (10%) had a reaction of revulsion. Thelarge middle group (111, 68%) did not experience strongreactions, but felt uncomfortable. Ninety-five students (58%)found it to be of value, 32 (20%) found it not very rewarding,and 9 (5%) found it not rewarding at all.Locally, the decline of the autopsy in medical practice hasnot attracted the attention of the profession. There are fewstudies on the autopsy 12 and practically no publications on theattitudes of people involved in conducting autopsies.The question on the objectives of the autopsy may assessstudents’ knowledge or may reflect their beliefs about thevalue of the autopsy regardless of teaching. Studentsconsidered establishment of the cause of death to be the mostimportant objective of the autopsy, and less importantly,research, medical training and control of the effects oftreatment. Other studies elicited similar ranking. 2,5,11,13 However,in our study the percentage of positive answers for the otherobjectives of the autopsy tended to be lower.5,11 For example,Sanner,11 using the same questionnaire, found that all fourobjectives scored more than 80%. The mean number of answerswas 3.52 ± 0.14 whereas in our study it was 1.6 ± 1.15. It can beconcluded that students as MEDUNSAhave a lesserappreciation of the value of autopsy. Unfortunately, this is notunique to students at MEDUNSA. It has been noticed in manyother teaching institutions worldwide.4,5 For example, in NewYork about 18% of medical and 10% of pathology house staffthought that the autopsy offered little value. 5 Furthermore, 17%of general practitioners do not know that they can request anon-coroner postmortem examination.14In our study, students attended an acceptable number ofautopsies. About 67% observed 7 autopsies, but only 6.7%observed more than 15. However, two-thirds never took part inan autopsy. In her survey in Sweden, Sanner11 found that 92%of third-year medical students had observed at least 7autopsies and 50% of them attended more than 15demonstrations. In some medical schools students graduatewithout observing a formal autopsy procedure.1,15 Medicaltraining must encourage students to take part in autopsies, andthey should be involved in writing autopsy reports.16It is encouraging that the majority of students considered thefirst autopsy they attended to be rewarding. The percentage iseven higher in other studies.1,11 This confirms the educationalvalue of the autopsy. However, despite its educational valuethe autopsy evokes reactions of discomfort in most students.These reactions are aggravated because students are notprepared psychologically for what they see at autopsy.4,17 Whenthe discomfort reactions are strong, the capacity to appreciatethe advantages of autopsy is reduced. Students shouldtherefore be prepared psychologically to avoid autopsy-relatedemotional shock, and to benefit fully from these procedures.4,17Medical students need to observe and to participate in aminimum number of mandatory autopsies during thepathology course. During their clinical attachments, studentsshould be encouraged to follow up, and to attend the autopsiesof patients of theirs who have died. This will not occur,however, if students’ teachers are not interested in theprocedure. Clinical staff should act as role models in showing astrong interest in the autopsy. It has been shown that highautopsy rates can be maintained by efficient administration,quality control of the autopsy, close interaction with clinicians(including speedy communication of results) and the fosteringof a positive attitude among clinicians.18M RuhayaF P R de VilliersDepartment of Paediatrics and Child HealthMedical University of Southern AfricaPO Box 221Medunsa02041. Lowry F. Failure to perform autopsies means some MD’s ‘walking in a fog of misplacedoptimism’. CMAJ 1995; 153: 811-814.2. Sanner MA. In perspective of the declining autopsy rate: attitudes of the public. Arch PatholLab Med 1994; 118: 878-883.3. Chariot P, Witt K, Pautot V, et al. Declining autopsy rate in a French hospital: physician’sattitudes to the autopsy and the use of autopsy material in research publications. Arch PatholLab Med 2000; 124: 739-745.4. Benbow EW. The attitudes of second and third year medical students to the autopsy. ArchPathol Lab Med 1991; 115: 1171-1176.5. Wilkes MS, Link N, Jacobs TA, Fortin AH, Felix JC. Attitudes of house officers towards theautopsy. J Gen Intern Med 1990; 5: 122-125.6. Cartlidge PHT, Dawson AT, Stewart JH, Vujanic GM. Value and quality of perinatal andinfant postmortem examination. BMJ 1995; 310: 155-158.7. Byard RW, Bourne AJ. The autopsy: a dying art? A paediatric perspective. J Paediatr ChildHealth 1990; 26: 119-121.8. Meier PR, Manchester DK, Shikes RH, Clewell WH, Stewart M. Perinatal autopsy: Its clinicalvalue. Obstet Gynecol 1986; 67: 349-351.9. Rushton DI. Should perinatal postmortems be carried out by specialist pathologists? Br JObstet Gynaecol 1995; 102: 182-185.10. Goldman L, Sayson R, Robbins S, Cohn LH, Bettman M, Weisberg M. The value of autopsyin three medical eras. N Engl J Med 1983; 308: 1000-1005.282SCIENTIFIC LETTERS11. Sanner MA. Medical students’ attitudes towards autopsy. Arch Pathol Lab Med 1995; 119: 851-858.1 2 . Muthuphei MN. The value of perinatal autopsy in medical practice. Pedmed 1998; 11(3): 16-18.13. Cottreau C, McIntyre L, Favara BE. Professional attitudes toward the autopsy: a survey ofclinicians and pathologists. Am J Clin Pathol 1989; 92: 673-67614. Berlin A, Wagstaff R, Bhopal R, Spencer J. Post-mortem examinations: general practitioners’knowledge, behaviour and attitudes. BMJ 1994; 308: 1080-1081.15. Friederici HHR. Reflections on the postmortem audit. JAMA 1988; 260: 3461-3465.16. Fernandez-Segoviano P, Lazaro A, Estabau A, Rubio JM, Iruretagoyena JR. Autopsy asquality assurance in the intensive care unit. Crit Care Med 1988; 16: 683-685.17. Charlton R, Doney SM, Jones DG, Blunt A. Effects of cadaver dissection on the attitudes ofmedical students. Med Educ 1994; 28: 290-295.18. Haque AK, Patterson RC, Grafe MR. High autopsy rates at a university medical centre. Whathas gone right? Arch Pathol Lab Med 1996; 120: 727-732.283April 2003, Vol. 93, No. 4  SAMJCorrelation between erythromycin and azithromycinresistance in Streptococcus pneumoniaeTo the Editor: Erythromycin has long been used as analternative to penicillin for the treatment of upper and lowerrespiratory tract infections in children.  Modifications of theoriginal chemical structure of erythromycin have producedmacrolides such as azithromycin that have improvedtherapeutic properties. Azithromycin given as a single dailydose for 3 days is used for the treatment of acute group Astreptococcal pharyngitis1 and a meta-analysis of randomisedcontrolled trials found 30 mg/kg of azithromycin, given over 3 - 5 days, to be as effective as longer courses of otherantibiotics for the treatment of upper respiratory tractinfections.2 There have, however, been recent reports ofmacrolide resistance resulting in azithromycin failure for thetreatment of group A streptococcal pharyngitis.3In South Africa, azithromycin is frequently prescribed for thetreatment of acute otitis media in children; however, theincreasing prevalence of erythromycin resistance inStreptococcus pneumoniae isolates may adversely affect theefficacy of this therapy. A survey of pneumococci isolated fromblood and cerebrospinal fluid (CSF) of children in the publicsector of South Africa between 1991 and 1998 found a small butstatistically significant increase in resistance to erythromycin,from 1.8% of pneumococci isolated between 1991 and 1994 to4.2% of  pneumococci isolated from 1995 to 1998.4 In contrast,39% of pneumococci carried in the nasopharynx of childrenaged 1 month - 5 years who were sampled prospectively whileattending private paediatricians in Johannesburg were resistantto erythromycin.5To evaluate the correlation between resistance toerythromycin and azithromycin, 100 erythromycin-resistant S. pneumoniae isolates (minimum inhibitory concentrationsMICs) ranged from 1µg/ml to > 256 µg/ml were tested forconcomitant resistance to azithromycin.  The isolates had beenobtained from middle-ear fluid of children with acute otitismedia (N = 34), cases of invasive pneumococcal disease (N = 19), and from the nasopharynx of asymptomatic children(N = 47).  MICs were determined by agar dilution (100 isolates)and E-test (98 isolates) using standardised methods and criteriafor determination of resistance.6 The azithromycin powder andmethods for susceptibility testing were obtained from themanufacturer. For the pneumococci tested, the MICs forazithromycin correlated with the MICs for erythromycin for100% of the isolates using both the agar dilution and E-testmethods.   Therefore, resistance to erythromycin can be used asa surrogate for resistance to azithromycin.  Similar results werefound in a study of 120 isolates from the USA.7In addition, a study of the impact of azithromycin oncarriage of antibiotic-resistant pneumococci found that 5 daysof azithromycin treatment resulted in a four-fold increase in theprevalence of erythromycin-resistant pneumococci.8 Theseresults suggest that in South Africa, where erythromycin-resistant pneumococci are common, macrolide treatment forotitis media infections in children under 4 years of age mayhave reduced efficacy.Avril D WasasRobin E HuebnerMaurice HockmanMedical Research Council/National Health Laboratory Service/University of theWitwatersrand Respiratory and Meningeal Pathogens Research UnitNational Health Laboratory ServiceJohannesburgKeith P KlugmanMedical Research Council/National Health Laboratory Service/University of theWitwatersrand Respiratory and Meningeal Pathogens Research UnitNational Health Laboratory ServiceJohannesburg, andRollins School of Public HealthEmory UniversityAtlantaUSA1. Pfizer Laboratories (Pty) Ltd.  Zithromax (azithromycin) package insert. 20 September 1993.2. Ioannidis JP, Contopoulos-Ioannidis DG, Chew P, Lau J. Meta-analysis of randomizedcontrolled trials on the comparitive efficacy and safety of azithromycin against otherantibiotics for upper respiratory tract infections.  J Antimicrob Chemother 2001; 48: 677-689.3. Bingen E, Leclercq R, Fitoussi F, et al. Emergence of group a streptococcus strains withdifferent mechanisms of macrolide resistance. Antimicrob Agents Chemother 2002; 46: 1199-1203. 4. Huebner RE, Wasas, AD, Klugman KP. Trends in antimicrobial resistance and serotypedistribution of blood and cerebrospinal fluid isolates of Streptococcus pneumoniae in SouthAfrica, 1991-1998.  Int J Infect Dis 2000; 4: 214-218.5. Huebner RE, Wasas AD, Klugman KPand the Paediatric Study Group. Prevalence ofnasopharyngeal antibiotic-resistant pneumococcal carriage in children attending privatepaediatric practices in Johannesburg. S Afr Med J 2000; 90: 1116-1121.6. National Committee for Clinical Laboratory Standards. Performance Standards for AntimicrobialSusceptibility Testing: Twelfth Informational Supplement.  NCCLS document M100-S12.Villanova, Pennsylvania: National Committee for Clinical Laboratory Standards, 2002.7. Ednie LM, Visalli MA, Jacobs MR, Appelbaum PC. Comparative activities of clarithromycin,erythromycin, and azithromycin against penicillin-susceptible and penicillin-resistantpneumococci. Antimicrob Agents Chemother 1996; 40: 1950-1952.8. Morita JY, Kahn E, Thompson T, et al. Impact of azithromycin on oropharyngeal carriage ofGroup A Streptococcus and nasopharyngeal carriage of macrolide-resistant Streptococcuspneumoniae. Pediatr Infect Dis J 2000; 19: 41-46.

Medical students' experiences of the autopsy

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Medical students' experiences of the autopsy

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