BACKGROUND: Bullying is a multifaceted problem with many consequences. AIM: This study aimed to determine the psychiatric morbidity of children involved in bullying, either as bullies or victims, treated at the Child and Adolescent Mental Health Care Centre of the Free State Psychiatric Complex (FSPC). SETTING: Free State Psychiatric Complex, Bloemfontein, South Africa. METHODS: This retrospective cross-sectional study included children under 18 years treated at the FSPC Care Centre between January and September 2017. Information was extracted from patient files. RESULTS: Of 288 patients, 98 (34.0%) were involved in bullying: 66 were bullies, 28 victims, 3 bully-victims, and 1 unspecified. For gender and family structure, there were no statistically significant differences between children involved and those not involved in bullying and between bullies and victims. Almost all bullies (95.4%) had aggression as presenting complaint compared with 39.3% of the victims (p < 0.01). Statistically significantly more victims, than bullies, reported sadness (21.4%, 4.6%, p = 0.02). Attention deficit/hyperactivity disorder (ADHD) was diagnosed in most children, both involved (73.5%) and not involved (63.2%). Statistically significant differences for the presence of conduct disorder were found between children involved and those not involved in bullying (31.6%, 10.0%, p < 0.01) and between bullies and victims (39.4%, 14.3%, p = 0.02. CONCLUSION: The prevalence of conduct disorder diagnosis was more common in bullies than in victims and those involved in bullying as opposed to those not involved. CONTRIBUTION: Psychiatric information of bullying victims and perpetrators in the Free State, which had a high prevalence of bullying in a national survey.

BACKGROUND: Functional neurological disorders (FND) lead to increased care requirements and costs, negatively impacting healthcare budgets. Healthcare expenditure in FND has escalated beyond other neurologic disorders during the past decade OBJECTIVES: To assess inpatient costs in adults admitted to the neurology ward at Universitas Academic Hospital (UAH) in central South Africa METHODS: A retrospective observational study with a comparative component was conducted on patients admitted during 2018 and 2019. All FND cases (n = 29) and a systematic sample of other neurological disorders were included in the comparison group (n = 29). Data were obtained from the Meditech billing system and clinical records RESULTS: FND patients accounted for 5.5% of 530 admissions in the neurology ward during the study period. No significant differences regarding daily median cost, age categories, gender or medical comorbidity were observed between FND and the comparison group. However, the length of stay was significantly shorter for the FND patients (median of four versus eight days), translating to approximately half the total costs of patients admitted for other neurological disorders CONCLUSION: The daily median cost was similar for FND and other neurology-related admissions. The lower overall inpatient costs for FND patients were only related to significantly shorter durations of stay, which may reflect new diagnostic approaches resulting from changes in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnostic criteria. The prevalence of FND was similar to those reported in previous studies conducted at neurology clinics CONTRIBUTION: The study contributes towards better understanding the prevalence and cost of FND in local neurology inpatient care settings

BACKGROUND: Epilepsy is responsible for a significant proportion of the world's disease burden, affecting around 50 million people globally. A seizure diary is a self-management tool for epilepsy focusing on self-monitoring, tracking seizures and other symptoms. This study aimed to determine the perceptions and attitudes to the seizure diary in patients with epilepsy in the Free State and Northern Cape of South Africa METHODS: This cross-sectional survey method included adult patients with epilepsy attending Universitas Academic Hospital Specialist Epilepsy Clinic in Bloemfontein and local clinics in Kimberley (City, Beaconsfield and Betty Gatsewe), as well as the casualty department of Kimberley hospital (Robert Mangaliso Sobukwe Hospital). The Kimberley patients were diary-unexposed, while the Bloemfontein patients were patients who had previous exposure to the seizure diary RESULTS: A total of 182 patients with epilepsy were recruited for the study, of whom 65 were patients who had previous exposure to the seizure diary, and 117 were unexposed. In the patients who had previous exposure to the seizure diary, 64 (98.5%) found the diary useful, but 15 (23.1%) reported having various challenges with using the seizure diary. Almost all of the patients who had previous exposure to the seizure diary, 64 (98.5%), were willing to continue to use the diary, while 112 (95.7%) of the diary-unexposed patients were also willing to use the diary CONCLUSION: Information from some patients using the diary confirms various challenges with its use; however, most patients support the continued usage of the diary

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a leading cause of chronic kidney disease (CKD). The prevalence of CKD among T2DM patients in Africa is 22.0%. The cut-off age for dialysing diabetic patients in the resource-limited state sector in South Africa is 50 years. Type 2 diabetes mellitus patients who develop CKD are likely to be excluded from chronic dialysis and rely on control of risk factors, including blood pressure and blood glucose levels, to prevent CKD progression. We aimed to determine the prevalence of CKD among T2DM patients attending the diabetes clinic at Pelonomi Academic Hospital, Bloemfontein METHODS: In this retrospective cross-sectional study, medical records of patients (January 2016 and December 2018) were reviewed to collect demographic and clinical information RESULTS: In total, 244 records were reviewed. Sixty-one (25.0%, 95% confidence interval [CI]: 20% - 30.8%) T2DM patients had CKD. The rate of CKD was slightly higher in males (n = 24/81; 29.6%) compared with females (n = 37/163; 22.7%). Most patients with CKD (n = 58; 95.1%) were > 50 years of age. Only 17.8% of patients achieved a glycosylated haemoglobin (HbA1c) of < 7.0%. Blood pressure was controlled in 14.3% of hypertensive patients. Renin-angiotensin-aldosterone system inhibitors were used by 78.6% of patients CONCLUSION: A high prevalence of clinically significant CKD among T2DM patients with poor prospects of chronic dialysis in a resource-limited setting was observed. The risk factors for CKD development and progression should be adequately managed in T2DM patients CONTRIBUTION: This study emphasises the need for further research and innovation to improve outcomes of T2DM patients with CKD in resource-constrained settings

BACKGROUND: Burnout among doctors has been linked with decreased quality of patient care. The coronavirus disease 2019 (COVID-19) pandemic highlighted the need to protect doctors' mental health and well-being. This study aimed to investigate burnout, resilience and coping strategies among registrars in the MMed programme of the University of the Free State (UFS) in 2020 METHODS: In this quantitative, cross-sectional study, a link to an online anonymous self-administered questionnaire with socio-demographic questions, perceived stress, Copenhagen Burnout Inventory (CBI), Connor-Davidson Resilience Scale and Brief Cope was emailed to all 278 registrars RESULTS: Sixty registrars responded (response rate 21.6%). More than half (55.0%) were male and 73.3% were married. There were 28.3% second- and third-year students, respectively. Most (58.3%) had 5-10 years' work experience. The CBI personal scale had the highest median value (58.3; interquartile range [IQR]: 43.3; 70.8) with 70% scoring ≥ 50. The median score for resilience was 78 of 100 (IQR: 69; 84). There were weak negative correlations between resilience and burnout scores (r = -0.31 to r = -0.37). Planning, positive reframing and acceptance were the most frequently used adaptive coping mechanisms; self-distraction was the most frequently used maladaptive coping mechanism. There was no association between gender and burnout and resilience scores CONCLUSION: Registrars were resilient with low levels of patient- and work-related burnout, and higher personal burnout, using mostly positive coping strategies CONTRIBUTION: This study gives insight into the well-being of registrars at the UFS during COVID-19. Continuous monitoring and support for this population are essential to foster mental health and well-being

BACKGROUND: Language proficiency is beneficial for doctor-patient communication and health outcomes. Poor communication can lead to misdiagnosis by the doctor and/or non-adherence from the patient. This study aimed to evaluate medical students' proficiency in the most commonly spoken local languages METHODS: This cross-sectional study was conducted in the class of 119 fourth-year medical students at the University of the Free State (UFS) in 2019. Students' proficiency was tested for Sesotho and Afrikaans, as these are the most widely spoken languages in the Free State province. The study consisted of two phases: completing a self-administered questionnaire where students self-rated their proficiency in the two languages, followed by telephonic interviews consisting of a series of proficiency-testing questions RESULTS: Of the 119 fourth-year medical students at UFS, 96 (80.7%) completed the self-administered questionnaires. Forty-six students (47.9%) rated themselves as either advanced or proficient in Afrikaans, whereas only 23 students (23.9%) rated themselves as advanced or proficient in Sesotho. Only 28 students were subsequently interviewed. Their actual language proficiency matched their self-rating CONCLUSION: The findings suggest a need for language skills training improvement in the curriculum for undergraduate medical students for languages most commonly encountered locally. We also found that students report their language capabilities accurately CONTRIBUTION: The research findings reinforce the need for language skills training in the curriculum of undergraduate medical students regarding languages commonly encountered in the local area

BACKGROUND: Peer review frequently improves a manuscript, but authors may consider some reviewer feedback negative, inappropriate or unclear. This study aims to summarise and analyse review comments received by authors METHODS: This longitudinal study included all submissions of which the researcher was an author, reviewed by any journal during 2020-2022. First-round reviews were retrieved from emails and documents received by the authors or the faculty's medical editors or the journal platforms. A confidential datasheet with review items compiled from literature and the researcher's experience as author and reviewer was completed for each submission. Review comments were noted verbatim for subjective items such as rude or vague statements RESULTS: The 65 submissions received 118 reviews from 36 journals, mainly in the form of unstructured narrative reports (59%). The majority of first-round reviews (58%), including those for rejected submissions, contained some positive comments. Reviewers frequently (75% of reviews, 88% of submissions) required some expansion of information. Vague and incorrect statements occurred in 15% and 18% of reviews, respectively. Only two reviews contained statements that could be considered rude. The types of comments made were associated with the review format CONCLUSION: The majority of reviews contained some positive comments and rude comments were extremely rare. Reviewers frequently requested the expansion of information provided CONTRIBUTION: This study gives insight to authors, reviewers and editors regarding the type and tone of review comments. This could guide authors during manuscript preparation and authors, reviewers and editors during the review process

BACKGROUND: Epilepsy is a neurological disease affecting adults and children globally. A seizure diary is one of the self-management tools for tracking seizures. This study aims to ascertain the experience of a new seizure diary by persons completing the diary in the Free State and Northern Cape of South Africa METHODS: Adult patients with epilepsy attending Universitas Academic Hospital epilepsy clinic in Bloemfontein, clinics in Kimberley and the casualty department of Kimberley hospital (Robert Mangaliso Sobukwe hospital) received a new seizure diary. After using the diary for 6 months, participants (patients, relatives or caregivers) completed a questionnaire RESULTS: A total of 139 epilepsy patients received a new seizure diary; 67 previously diary-unexposed participants and 33 participants who had previous exposure to a seizure diary. The majority of participants, namely 91% of previously diary-unexposed and 84.9% of participants who had previous exposure to the seizure diary, understood the new seizure diary. Participants who had previous exposure to a seizure diary were predominantly very positive about the new diary because it had more information. However, 21.2% indicated that they preferred the old one because it was easier to complete CONCLUSION: Patients, caregivers or relatives from both groups used the new seizure diary and provided important information about their experience with the new diary. Despite a few complaints about using the new diary, most participants who had previous exposure to a seizure diary preferred the new seizure diary CONTRIBUTION: This study explored participants' opinions of the new seizure diary

BACKGROUND: Preoperative anaemia has been shown to be associated with increased postoperative morbidity and mortality, prolonged hospital stay, and increased allogeneic blood transfusions. With elective surgery there is time to manage preoperative anaemia. The aim was to determine the prevalence of preoperative anaemia and evaluate how anaemia was investigated and managed in adult patients who were referred from the Orthopaedic Clinic to the Universitas Academic Hospital Anaesthesiology Clinic between January 2016 and December 2018METHODS: The retrospective file audit included patient demographics, comorbidities and chronic medication, indication for elective surgery, haemoglobin level at first clinic visit, laboratory investigations done for anaemia, dates of clinic visits and surgery, whether the anaemia was corrected before surgery, and if there were any perioperative red cell transfusionsRESULTS: A total of 178 patients were included. The cut-off value for anaemia was 13 g/dL in both sexes. Forty-four patients (25%, 95% CI 19-32%) had preoperative anaemia with a median haemoglobin of 12.25 g/dL (IQR 11.2; 12.7). Their mean age was 63.3 (SD ± 10.0) years. Fifteen patients (34%) were booked for knee arthroplasty and 24 patients (55%) for hip replacement surgery. No workup was done for the anaemia, and only 15/44 (34%) anaemic patients received any form of treatment. Eighteen anaemic patients (41%) received perioperative red cell transfusions. Eight of the transfused patients (44%) developed postoperative sepsis, while five were still anaemic postoperativelyCONCLUSION: The prevalence of preoperative anaemia before elective orthopaedic surgery (25%) was the same as that reported before patient blood management was introduced internationally. None of the anaemic patients had a diagnostic workup and therefore did not receive therapy targeted at the cause of the anaemia. Perioperative red cell transfusions could have been significantly reduced. The clinic now focuses on managing preoperative anaemiaLevel of evidence: Level 3

BACKGROUND: Sexual assault in South Africa has reached alarming proportions. Mental illness amongst offenders accused of rape is one of the complicating factors AIM: To describe the sociodemographic, clinical and forensic profile of alleged offenders accused of rape referred to a South African tertiary public psychiatric hospital for forensic evaluation, as well as describe the profile of the reported victims SETTING: Free State Psychiatric Complex (FSPC) Observation Ward, Bloemfontein, South Africa METHODS: This cross-sectional retrospective study compiled a sociodemographic, clinical and forensic profile of offenders accused of rape referred to the FSPC for forensic assessment between 2011 and 2015. The study population comprised 159 alleged offenders. Sociodemographic data, mental status, clinical diagnoses, comorbid substance use and forensic outcomes were collected from clinical files RESULTS: All accused offenders were male with a median age of 30 years. About half obtained primary school level education. Unemployment was common (37.3%) with 40% receiving government grants. Most accused offenders were single (78.0%). Clinically, schizophrenia spectrum and other psychotic disorders were the most common diagnoses (30.8%), followed by intellectual disability (16.3%). Almost a third of the accused offenders did not suffer from any mental illness. Alcohol (20.1%) and cannabis use disorders (12.6%) were dominant comorbidities. After a 30-day evaluation period, 53.2% of alleged offenders were found competent to stand trial. The verdict of criminal responsibility was made for 43.7% of this sample CONCLUSION: This study contributes data on sociodemographics, psychiatric morbidities and comorbidities and forensic findings amongst alleged offenders of rape referred for forensic assessment

BACKGROUND: South Africa has high healthcare expenses. Improving cost-consciousness could decrease government expenditure on healthcare. OBJECTIVES: To determine cost awareness of radiological studies among doctors at a tertiary hospital. The objective was met by assessing the accuracy of cost estimation according to the level of training and speciality, whether participants had received prior education/training related to cost awareness and if they had a desire to learn more about the cost of radiological imaging. METHOD: A cross-sectional survey was conducted in six clinical departments at Universitas Academic Hospital using an anonymous questionnaire that determined doctors' cost awareness of five radiological studies. Each radiological study was answered using six different cost ranges, with one correct option. Costs were based on the Department of Health's 2019 Uniform Patients Fee Schedule (UPFS). RESULTS: In total, 131 (67.2%) of 195 questionnaires distributed to registrars and consultants were returned. Overall, low accuracy of cost estimation was observed, with 45.2% of the participants choosing only incorrect options. No participant estimated all five costs correctly. Only the Internal Medicine clinicians demonstrated a significant difference between registrars and consultants for the number of correct answers (median 0 and 1, respectively) (p = 0.04). No significant differences were found between specialities stratified by registrars/consultants. Most participants (88.6%) would like to learn about imaging costs. Only 2.3% of the participants had received prior education/training related to cost awareness of radiological studies. CONCLUSION: Doctors were consistently inaccurate in estimating the cost of radiological studies. Educating doctors about the cost of radiological imaging could have a positive effect on healthcare expenditure.

BACKGROUND: The introduction of the Subaxial Cervical Spine Injury Classification system has created the need for a holistic imaging approach that encompasses both functional (neurological) and morphological informationOBJECTIVES: This study aimed to determine if there was a correlation between the blunt cervical spinal cord injury diffusion tensor imaging (DTI) fraction anisotropy (FA) value and the American Spine Injury Association (ASIA) impairment scale motor scoreMETHOD: Diffusion tensor imaging was performed on 26 patients with blunt cervical spine injury (all men with a median age of 46 years) admitted to the Pelonomi Tertiary Hospital spinal unit. Imaging was performed using the 1.5T Siemens Magnetom Aera machine's built-in spine DTI protocol. Sagittal FA values were acquired at four different cervical spine regions (medulla oblongata, above the injury site, at the injury site and below the injury siteRESULTS: Eight of the 26 patients had complete neurological fallout. Of the participants, 30% had injuries at the C4/C5 level, whilst injuries involving segments below and above C4/C5 affected 15% and 55% of participants, respectively. Injury site FA values (median 0.30) were significantly lower (p < 0.001) than the above injury site FA (median 0.46, p = 0.26) and below injury site FA (median 0.42 and p = 0.019). A significant correlation was noted between the injury site FA values and the ASIA impairment scale motor scores (p = 0.001, r = 0.87CONCLUSION: FA value showed excellent correlation with the ASIA impairment scale motor scores

BACKGROUND: Medical studies place students at risk for burnout. Resilience enables students to cope with adversity. Students' coping skills will ensure the well-being of future healthcare professisonals. OBJECTIVES: This study investigated resilience and coping among undergraduate medical students. SETTING: Undergraduate students at the University of the Free State medical school. METHODS: A cross-sectional study was performed. Quantitative data regarding resilience (Connor-Davidson Resilience Scale), coping strategies (Brief COPE questionnaire) and relevant information were collected by means of an anonymous self-administered questionnaire. RESULTS: Five hundred students (pre-clinical n = 270; clinical n = 230; approximately 62% female) participated. Most students self-reported high resilience (84.6% pre-clinical; 91.8% clinical). Mean resilience scores were 72.5 (pre-clinical) and 75.4 (clinical). Clinical students had higher resilience scores, while black, pre-clinical, first-generation and female students scored lower Academic stress was most prominent (> 85%) and associated with lower resilience scores. Most students used adaptive coping strategies (e.g. instrumental or emotional support) associated with significantly increased resilience scores. Students who used dysfunctional strategies (e.g. substance abuse) had significantly lower resilience scores. CONCLUSION: Associations between resilience scores and year of study, gender, ethnicity, levels and type of stress varied. Academic pressure was a major source of stress. Adaptive coping strategies were associated with higher resilience scores

BACKGROUND: Neural tube defects (NTDs) are anomalies of the central nervous system caused by the defective closure of the neural tube during early embryogenesis. A significant decline in the incidence of NTDs after folic acid fortification of food in South Africa was previously shown. Recently, clinical geneticists have voiced concerns that there is a possible resurgence in the number of NTDs. OBJECTIVES: The aim of this study was to determine the incidence of NTDs at a South African Hospital from 2012 to 2016. METHODS: This is a retrospective cross-sectional study where all babies with NTDs born in, or referred to Universitas Hospital were included as study participants. Information was collected for both the mother and the baby from hospital records and data forms RESULTS: Seventy-seven cases of NTDs were captured from 2012 to 2016. The incidence of NTDs was 0.34/1000 births in the Free State province, and 1.21/1000 births if only the data for babies born in Universitas Hospital and Pelonomi Hospital were used. Further analysis showed a male: female ratio of 1:1. Open spina bifida was the most common defect at 71.4%. CONCLUSION: The incidence of NTDs in the Free State province was low compared to other South African and international studies. The incidence for the metropolitan hospitals is comparable to that of previous studies. This discrepancy is a marker of poor data recording and will impact healthcare planning. A statistically significant increase in NTDs could not be proven.

BACKGROUND: Assessment should form an integral part of curriculum design in higher education and should be robust enough to ensure clinical competence. AIM: This article reports on current assessment practices and makes recommendations to improve clinical assessment in the undergraduate medical programme at the University of the Free State. METHODS: A descriptive cross-sectional study design was used. Qualitative and quantitative data were gathered by means of open- and closed-ended questions in a self-administered questionnaire, which was completed by teaching and learning coordinators in 13 disciplines RESULTS: All disciplines in the undergraduate medical programme are represented. They used different assessment methods to assess the competencies required of entry-level healthcare professionals. Workplace-based assessment was performed by 30.1% of disciplines, while multiple-choice questions (MCQs) (76.9%) and objective structured clinical examinations (OSCEs) (53.6%) were the main methods used during formative assessment. Not all assessors were well prepared for assessment, with 38.5% never having received any formal training on assessment. Few disciplines (15.4%) made use of post-assessment moderation as a standard practice, and few disciplines always gave feedback after assessments. CONCLUSION: The current assessment practices for clinical students in the undergraduate medical programme at the University of the Free State cover the spectrum that is necessary to assess all the different competencies required. Multiple-choice questions and OSCEs, which are valid and reliable assessment methods, are used frequently. Poor feedback and moderation practices should be addressed. More formative assessments, and less emphasis on summative assessment, should be considered. Workplace-based and continuous assessments may be good ways to assess clinical competence.