Right of Reply.

To the Editor: The article by Bhorat et al. [1] in the SAMJ, entitled 'Cerebral palsy and criteria implicating intrapartum hypoxia in neonatal encephalopathy - an obstetric perspective for the South African setting', starts off by raising concerns about 'steep rises in insurance premiums, placing service delivery under serious threat'. It does not acknowledge any service delivery issues that already exist in the public sector obstetric services in South Africa (SA). According to Whittaker,[2] in 2019, there were 303 obstetricians and gynaecologists employed in the SA public sector and 579 in the private sector, and of those employed in the public sector, 190 were performing private sector work. That a large number of the children with cerebral palsy (CP) were delivered in the public sector service was not noted by Bhorat et al.,[1] nor was the fact that the overwhelming majority of court cases are against the state (not against individual doctors) in provinces and hospitals with significant medical staffing and resource issues. For example, the liabilities for Eastern Cape Province in the 2019/20 period were ZAR36 751 207 v. only ZAR33 155 in Western Cape Province for the same period.[2].

Thalamus L-Sign: A Potential Biomarker of Neonatal Partial, Prolonged Hypoxic-Ischemic Brain Injury or Hypoglycemic Encephalopathy?

BACKGROUND AND PURPOSE: Considerable overlap exists in the MR imaging features of hypoglycemic injury and hypoxic-ischemic brain injury, with similar predilections for the occipital and parietal lobes. In partial, prolonged hypoxia-ischemia, there is cortical destruction at the interarterial watershed zones, and in concomitant hypoglycemia and hypoxia-ischemia, an exaggerated final common pathway injury occurs. We interrogated secondary white matter tract-based thalamic injury as a tool to separate pure injuries in each group. MATERIALS AND METHODS: A retrospective observational study of the MRIs of 320 children with a history of hypoxia-ischemia and/or hypoglycemia was undertaken with 3 major subgroups: 1) watershed-type hypoxic-ischemic injury, 2) neonatal hypoglycemia, and 3) both perinatal hypoxia-ischemia and proved hypoglycemia. Cerebral and thalamic injuries were assessed, particularly hyperintensity of the posterolateral margin of the thalami. A modified Poisson regression model was used to assess factors associated with such thalamic injury. RESULTS: Parieto-occipital injuries occurred commonly in patients with hypoglycemia and/or hypoxia-ischemia. Eighty-five of 99 (86%) patients with partial, prolonged hypoxia-ischemia exhibited the thalamus L-sign. This sign was also observed in patients who had both hypoglycemia and hypoxia-ischemia, predominantly attributable to the latter. Notably, the risk of a thalamus L-sign injury was 2.79 times higher when both the parietal and occipital lobes were injured compared with when they were not involved (95% CI, 1.25-6.23; P = .012). The thalamus L-sign was not depicted in patients with pure hypoglycemia. CONCLUSIONS: We propose the thalamus L-sign as a biomarker of partial, prolonged hypoxia-ischemia, which is exaggerated in combined hypoglycemic/hypoxic-ischemic injury.

Evaluation of a radiological severity score to predict treatment outcome in adults with pulmonary tuberculosis.

OBJECTIVE: To refine and evaluate a recently published radiological disease severity score for the prediction of month 2 and end of treatment outcomes in pulmonary tuberculosis (TB). Radiological extent of disease has been linked to early and late outcomes of anti-tuberculosis treatment, but no validated tools are available to quantify this parameter. DESIGN: We enrolled 449 adult, human immunodeficiency virus negative participants with smear- or culture-proven TB from three TB biomarker studies in Cape Town, South Africa. Full-size posteroanterior baseline chest X-rays (CXRs) were evaluated by two clinicians after standardising the published scoring method and the predictive ability assessed for month 2 and final treatment outcomes. RESULTS: Baseline CXR scores were significantly different in the favourable and unfavourable outcome groups; however, the predictive ability for outcomes at all time points was poor (ROC area under curve â©¿0.68). Inter-reader reliability was high (r = 0.86, P < 0.001), but agreement in cavity identification was modest. CONCLUSION: Standardised application of a CXR score derived from the presence of cavities and overall extent of parenchymal disease in active TB showed good inter- and intrareader reliability. Scores differed significantly in treatment outcome groups, but did not allow accurate outcome prediction.

Nuclear magnetic resonance imaging. Experience with the first 100 cases at Tygerberg Hospital.

Facilities for magnetic resonance imaging (MRI) have been available in South Africa since November 1985. This article summarizes our experience with this new imaging modality, illustrates normal anatomical features and pathological conditions in sagittal, coronal and axial planes, and compares MRI with computed tomography scans of the same regions.

Computed tomography (CT) in parenchymatous cerebral cysticercosis.

Cysticercosis is an infection with a larval or a bladder-worm stage of the species of Taenia. Cysticerci have a predeliction for the nervous system where they may be found in the meninges, the ventricles and within the brain itself. Brain involvement or parenchymatous form has an acute and chronic phase. Before the advent of CT scanning radiology was of little value in the acute parenchymatous cysticercosis, but with CT the changes within the brain can be recognised. In reviewing 14 cases of acute parenchymatous cysticercosis three CT patterns were found. 1. A diffuse low density pattern with no or little change after contrast medium 2. Multiple low densities with small rounded central areas of enhancement. 3. Large cystic lesions which may become ring lesions after contrast medium. We conclude that in an endemic area for cysticercosis, when one of these CT patterns is present, cysticercosis should be considered in the differential diagnosis. In a child where the clinical features are suggestive, the CT pattern may be diagnostic of cysticercosis. In the chronic parenchymatous stage the cysts have calcified and this may occur within one year of the acute onset. In 11 cases of chronic parenchymatous cysticercosis where the calcification was visible on the plain skull radiographs the CT scan added very little additional information. It may however be of value in confirming intracranial calcifications where their presence on the plain skull radiograph is in doubt.

Oral telescoping orthosis: an aid to functional rehabilitation of quadriplegic patients.

The possibility of periodontal disease, chipping of various teeth, or extrusion from use of a mouthstick is minimized with a mouthpiece that covers the complete dentition. Even the simplest of these devices permits increased function for the quadriplegic patient. A case is reported of a young man for whom the oral telescoping orthosis was fitted with a mouthpiece that covered the complete dentition. Damage to the hard or soft tissue structures has not been apparent in eight years of use. Furthermore, the functional capability of the patient has been enhanced. The oral telescoping orthosis is recommended for motivated quadriplegic patients who retain sufficient control of the head and oral and pharyngeal muscles.