Policy brief: Optimising antimicrobial usage in paediatric inpatient hospital settings.

Antimicrobial resistance (AMR) poses a global threat, partly fueled by antimicrobial overuse. Paediatric inpatients are particularly vulnerable to infections, leading to high antimicrobial consumption. In low-to-middle income countries (LMICs) like South Africa, research on antimicrobial usage for neonatal and paediatric healthcare-associated infections (HAI) is limited. This cross-sectional study evaluated antimicrobial usage in three academic public sector hospitals in South Africa to improve appropriateness. 22.9% of hospitalised children received at least one prescribed antimicrobial, with neonates, infants, and adolescents having higher prescription rates for HAIs. Common antimicrobials prescribed included beta-lactamase sensitive penicillin, aminoglycosides, and carbapenems. Antimicrobial selection aligned with the WHO AWaRe classification system. HIV infection did not emerge as a risk factor for HAIs or excessive antimicrobial usage. The policy brief recommends several strategies, summarized by the acronym 'PRACTICE,' to optimize antimicrobial prescribing practices. These include implementing standardized policies for empiric antimicrobial use, routine review of antimicrobial therapy, age-specific antimicrobial stewardship programs, and continued collaborative efforts and research. Individualized treatment plans, improved infection prevention and control measures, ongoing surveillance, and exploring electronic technology for antimicrobial stewardship are also crucial. Addressing antimicrobial usage is imperative to combat the growing threat of AMR and improve patient outcomes in LMICs like South Africa.

The impact of virtual medical student surgical conferences.

BACKGROUND: In recent years, the number of people pursuing a surgical career in the UK has decreased. The COVID-19 pandemic has led to the cancellation of surgical placements for medical students and has affected surgical education. This study evaluates the perceptions and impact of a 1-day virtual surgical conference for medical students considering pursuing a surgical career. METHODS: All delegates of the 2021 Barts and The London International Surgical Conference were invited to participate in two online surveys pre- and post-conference. Data were collected and analysed to evaluate delegates' reasons for attending the conference, and attitudes towards virtual conferences and a surgical career before and after the conference. RESULTS: Out of 132 participants, 106 (80.3%) completed both the pre- and post-conference surveys. Clinical students showed a statistically significant difference in interest in pursuing a surgical career after the conference than before (P=0.03), unlike pre-clinical students (P=0.12). Post-conference, 43 (40.6%) preferred a virtual to a face-to-face conference, which was a slight increase from 40 (37.7%) pre-conference, while 73 (68.9%) and 80 (75.5%) participants favoured virtual talks and presentations respectively. In contrast, only 12 (11.3%) and 21 (19.8%) students preferred workshops and networking virtually. Furthermore, delegates liked the global accessibility and environmentally-friendly nature of virtual conferences but found they can be less engaging and be disrupted by a poor internet connection. CONCLUSIONS: Virtual surgical conferences have many benefits and can help encourage medical students towards a surgical career. They could help bridge the surgical educational gap in medical school during these unprecedented times. Virtual conferences, which have a broader and more inclusive reach, could be an important complement to conventional conferences after the pandemic.

Diagnosis and management of community-acquired pneumonia in children: South African Thoracic Society guidelines.

BACKGROUND: Pneumonia remains a major cause of morbidity and mortality amongst South African children. More comprehensive immunisation regimens, strengthening of HIV programmes, improvement in socioeconomic conditions and new preventive strategies have impacted on the epidemiology of pneumonia. Furthermore, sensitive diagnostic tests and better sampling methods in young children improve aetiological diagnosis. OBJECTIVES: To produce revised guidelines for pneumonia in South African children under 5 years of age. METHODS: The Paediatric Assembly of the South African Thoracic Society and the National Institute for Communicable Diseases established seven expert subgroups to revise existing South African guidelines focusing on: (i) epidemiology; (ii) aetiology; (iii) diagnosis; (iv) antibiotic management and supportive therapy; (v) management in intensive care; (vi) prevention; and (vii) considerations in HIV-infected or HIVexposed, uninfected (HEU) children. Each subgroup reviewed the published evidence in their area; in the absence of evidence, expert opinion was accepted. Evidence was graded using the British Thoracic Society (BTS) grading system. Sections were synthesized into an overall guideline which underwent peer review and revision. RECOMMENDATIONS: Recommendations include a diagnostic approach, investigations, management and preventive strategies. Specific recommendations for HIV infected and HEU children are provided. VALIDATION: The guideline is based on available published evidence supplemented by the consensus opinion of SA paediatric experts. Recommendations are consistent with those in published international guidelines.

Atherosclerotic disease is the predominant aetiology of acute coronary syndrome in young adults.

OBJECTIVES: Few studies have evaluated young adults in their third and fourth decades with coronary artery disease (CAD). This study evaluated the clinical and angiographic profile of young adults ( < 35 years) with CAD. METHODS: A 10-year (2003-2012) retrospective chart review was performed on patients less than 35 years diagnosed with CAD at Inkosi Albert Luthuli Central Hospital, Durban. RESULTS: Of the 100 patients who met the study criteria, the majority were male (90%), of Indian ethnicity (79%), and presented with acute coronary syndrome (93%). Smoking (82%), dyslipidaemia (79%) and dysglycaemia (75%) were the most prevalent risk factors. Almost half of the subjects (48%) met criteria for the metabolic syndrome. Angiographic findings revealed multi-vessel (42%), single-vessel (36%) and non-occlusive disease (20%); only two subjects had normal epicardial vessels. Disease severity was influenced by dyslipidaemia (p = 0.002) and positive family history (p = 0.002). Non-coronary aetiologies were identified in 19% of subjects. CONCLUSION: Atherosclerotic disease associated with risk-factor clustering was highly prevalent in young adults with CAD.

Efficiency of solar water disinfection photocatalized by titanium dioxide of varying particle size.

Titanium dioxide photocatalysed water disinfection is induced by the interaction of light with TiO(2), which generates highly reactive free hydroxyl radicals (OH(*)). These free radicals create lethal damage that leads to bacterial death. Normally, decreasing TiO(2) particle size increases the area of light interaction. This may possibly increase the concentration of OH(*) generated and hence increases disinfection efficiency. Moreover, decreasing the particle size increases the force of attraction between the particles and cells, which could create aggregates that may contribute to the local OH(*) concentration. In the present investigation cells of Escherichia coli were used as the test microorganism, TiO(2) as the photocatalyst and sunlight as the light source. Four different surface areas of TiO(2) particles corresponding to 10, 50, 80-100 and > or =300 m(2) g(-1) were tested at a concentration of 1 g l(-1). Disinfection efficiency increased with increasing the surface area producing a maximum between 80-100 m(2) g(-1) followed by a reduction at > or =300 m(2) g(-1). The reduction in the efficiency at this relatively high surface area was attributed to the increase in the local concentration of OH(*). This increase may be high enough to initiate radical-radical interaction that would compete with bacterial cells and reduce the chance of bacterial cell-radical interaction taking place. Moreover, the phenomenon of TiO(2) aggregation with bacterial cells plays an important role, and the extent of aggregation increases with decreasing particle size. Such aggregation could augment the concentration of OH(*) within the cell vicinity. This suggests that surface area is a key factor in determining the efficiency of disinfection, and that concentration is a vital factor.

Mercury pollution from irrigation with treated sewage water (TSW).

The lack of potable water in arid countries leads to the use of treated sewage water (TSW) for crop growth. Mercury accumulation (up to 500 ng/g) in agricultural soil originating from daily irrigation with TSW was found at two sites fed separately from a hospital sewage plant and an industrial plant. A control site irrigated with potable water ([Hg] <0.01 ng/ml) had much reduced levels in soil (<12 ng/g). Cold-vapour analysis of TSW revealed that Hg concentrations fluctuated widely, and were between 10-100 times higher than those of potable water. The TSW data originated from a total of 46 samples (1 L each), from both plants, collected over a 6-month period. The Hg levels varied from 0.1 to 1.0 ng/ml, which suggested that the possible source of the accumulation could be found in continuous irrigation with comparatively higher Hg levels. Remedial measures could be approached from the perspective of curbing this inconsistency to produce more consistent Hg concentrations below 0.5 ng/ml. It was found that the electrical conductivity of TSW is a useful indicator to rapidly monitor fluctuations in treatment. A novel development in the study was the potential capacity of the plastic TSW discharge-pipes to behave as crude 'chromatographic' columns for possible Hg adsorption. If this property of the pipes is developed further it could have a considerable mitigating effect on the Hg levels. Possible recommendations for remediation to limit the Hg levels and promote sustainable development are discussed.

Optimization of a high-performance liquid chromatography method to quantify bilirubin and separate it from its photoproducts: effect of column length, Ph, mobile phase composition, and flow rate.

A rapid reversed-phase (RP) high-performance liquid chromatography method for the isolation of bilirubin from its photoproducts (e.g., biliverdin) is reported. The method is based on isocratic elution using methanol:water as the mobile phase. A 24 full-factorial experimental design approach was adopted. For the optimization, the best separation was obtained using a flow rate of 1.50 mL/min, a mobile phase of 99:1 methanol:water (v/v) at pH 3.60, and a 150 x 4.6 mm id RP (C18) column containing 5-microm particles. These conditions produced the fastest total retention time of 3.38 +/- 0.055 min, and other chromatographic parameters were acceptable. Under the optimum conditions, a linear calibration curve for bilirubin was obtained over the 1.0-40.0 microg/L concentration range studied. The limit of quantification was 0.79 g/L and the limit of detection was 0.24 microg/L. Bilirubin in solution was monitored by ultraviolet detection at 450 nm.

Cutting the cost of South African antiretroviral therapy using newer, safer drugs.

Antiretrovirals are a significant cost driver for HIV programmes. Current first-line regimens have performed well in real-life programmes, but have a low barrier to virological resistance and still carry toxicity that limits adherence. New drug developments may mean that we have access to safer, more robust and cheaper regimens, but only if the appropriate clinical trials are conducted. We briefly discuss these trials, and demonstrate the large cost savings to the South African HIV programme if these are successful.

An analysis of fishing vessel accidents.

In this paper, accident data collected from the Marine Accident Investigation Branch are presented and an analysis is carried out to determine the most common causes of accidents on fishing vessels. Discussions on fishing vessel-safety assessment and data problems are given.

Raised levels of calcium-binding protein in plasma following insulin-induced hypoglycaemia in the pig.

Insulin-induced hypoglycaemia in the pig elicited sharp increases in the plasma concentrations of vitamin D-dependent calcium-binding protein (CaBP) and cortisol and a decrease in plasma inorganic phosphate. Glucose infusion following insulin administration abolished the increases in plasma CaBP and cortisol in response to insulin and reduced the hypophosphataemia. The percentage increases in plasma CaBP and cortisol in response to insulin-induced hypoglycaemia were reduced when the pigs were fed a low-calcium diet, but the hypophosphataemic response was similar. We conclude that insulin-induced hypoglycaemia leads to increased plasma CaBP in pigs fed a normal calcium diet, which is associated with the hypoglycaemia rather than being a direct effect of insulin. We therefore suggest that plasma CaBP may represent more than a mere uncontrolled leak from its sites of storage.

Endocrine control of plasma concentrations of calcium-binding protein in the pig.

The aetiology of the rise in plasma calbindin-D9K (vitamin D-induced calcium-binding protein; CaBP), following insulin-induced hypoglycaemia, was studied in the pig. ACTH led to a rise in plasma concentrations of both CaBP and cortisol. Metyrapone, which blocks cortisol synthesis, abolished the increases in plasma concentrations of CaBP and cortisol normally observed in response to insulin-induced hypoglycaemia. However, there was no significant rise in plasma concentrations of CaBP in response to pharmacological or physiological doses of cortisol. Injection of clonidine, an alpha 2-adrenergic agonist, led to a rise in plasma concentrations of CaBP, whereas phenylephrine, an alpha 1-adrenergic agonist, tended to exert an inhibitory effect. Also, administration of phentolamine (an alpha-adrenergic blocker) before injection of insulin abolished the usual increase in plasma concentrations of CaBP, whereas propranolol (a beta-adrenergic blocker) enhanced the normal increase in plasma concentrations of CaBP in response to insulin-induced hypoglycaemia. Isoproterenol, a beta-adrenergic agonist, was without effect on plasma CaBP. Neither GH nor glucagon appear to be involved in the rise in plasma CaBP following insulin-induced hypoglycaemia. Although atropine abolished the effect of acute hypoglycaemia on plasma CaBP, carbamylcholine was without effect on plasma CaBP concentration. It is concluded that the increases in plasma CaBP induced by either ACTH or alpha 2-adrenergic stimulation may be interrelated since the administration of ACTH can lead to raised plasma concentrations of catecholamines.

Effect of 1,25-dihydroxyvitamin D3 on plasma concentrations of calcium-binding protein in normal and rachitic (vitamin D-dependent rickets type I) pigs.

An i.v. injection of calcitriol (1,25-(OH)2D3) had no effect within 2.5 h on plasma concentrations of calbindin-D9K (vitamin D-induced calcium-binding protein; CaBP) in hypocalcaemic pigs with inherited vitamin D-dependent rickets type I or in their normocalcaemic siblings or half-siblings. Three days later the plasma concentration of CaBP had doubled in the hypocalcaemic pigs, but was unaltered in the normocalcaemic siblings and half-siblings. Following daily i.v. injections of 1,25-(OH)2D3 for a further 5 days (days 4-8) plasma concentrations of CaBP increased in both the hypocalcaemic (days 4-8) and normocalcaemic (day 8) pigs, the effect being more rapid and greater in the hypocalcaemic 1,25-(OH)2D3-deficient animals. An i.v. injection of 1,25-(OH)2D3 to pure Yucatan pigs also had no effect on plasma concentrations of CaBP within 1.5 h, but in the following 1 h there was some indication of an increase in plasma CaBP levels. In contrast to the normal pigs, insulin-induced hypoglycaemia did not lead to a peak in plasma CaBP concentrations in the hypocalcaemic pigs. There was also no change in the plasma concentrations of 1,25-(OH)2D3 associated with the peak in plasma CaBP following insulin-induced hypoglycaemia in normocalcaemic pigs. These results suggest that changes in plasma concentrations of 1,25-(OH)2D3 are not directly involved in mediating the increase in plasma CaBP which follows hypoglycaemia induced by insulin in normal pigs, although 1,25-(OH)2D3 probably plays a permissive role.

Amplification of the DNA polymerase I gene of Treponema pallidum from whole blood of persons with syphilis.

Previous reports suggest that Treponema pallidum bacteremia occurs in persons with syphilis exposure ('incubating syphilis') and in persons with primary or secondary syphilis. During a recent syphilis outbreak, whole blood samples from 32 persons with suspected syphilis or syphilis exposure were screened using polymerase chain reaction (PCR) to amplify the DNA polymerase I gene (polA) of T. pallidum. Of the 32 samples, polA was amplified from 13 (41%). Of these 13, three were determined to have incubating syphilis; two had primary or secondary syphilis and eight had latent syphilis. This study demonstrates that spirochetemia can occur throughout the course of T. pallidum infection.

Comparison of culture media for the laboratory diagnosis of chancroid.

Seven different agar-based media were compared to determine the optimal set of culture media for primary isolation of Haemophilus ducreyi. Also, a new method for sampling genital ulcers -- with a disposable sterile plastic loop -- and processing specimens that provides a standardised inoculum for culture of H. ducreyi on various media is described. A total of 202 patients with genital ulcer disease was enrolled in this study. A sterile swab or plastic loop was used to sample the base of the ulcers and ulcer material was suspended in sterile phosphate-buffered saline. A 100-microl sample of this suspension was mixed with an equal volume of tryptic soy broth containing IsoVitaleX and centrifuged for 1 min. This suspension was used to inoculate the different media. Plates were incubated at 33 degrees C in micro-aerophilic conditions and examined for growth of H. ducreyi after 48 h. Of the 202 specimens, 77 (38.1%) were culture positive for H. ducreyi. None of the agar bases supported the growth of all H. ducreyi strains. Based on this observation, we recommend the universal use of Mueller-Hinton agar base supplemented with chocolate horse blood and IsovitaleX (MH-HBC) and Columbia agar base supplemented with bovine haemoglobin, activated charcoal, fetal calf serum and IsovitaleX (C-HgCh) to enable comparison of prevalence figures for chancroid. In addition, the novel sampling technique described in this study eliminates sampling bias normally associated with genital ulcer specimens.

Nosocomial transmission of Shigella dysenteriae type 1.

An outbreak of dysentery due to Shigella dysenteriae type 1 occurred in a chronic care psychiatric institution in Durban, South Africa. Of the 10 patients who developed dysentery, 4 (40%) died. S. dysenteriae type 1 was isolated from stool samples from two of the four patients tested and ribotyping showed that these isolates were identical but differed from other community acquired strains. The isolates were resistant to ampicillin, chloramphenicol, tetracycline and co-trimoxazole. Infection control measures including isolation, cohort nursing and strict hand disinfection resulted in rapid control of the outbreak.

An outbreak of neonatal infection with Acinetobacter linked to contaminated suction catheters.

An outbreak of multi-drug resistant Acinetobacter spp. infection in the neonatal unit at King Edward VIII hospital in Durban, South Africa, is described. Nine out of a total of 218 neonates were infected during the study period. The outbreak was characterized by early onset infection [median postnatal age 3 days (range 1-23 days)] in pre-term babies [median gestational age 33 weeks (range 30-35 weeks)] with an attributable mortality of 22%. The source of the outbreak, determined by ribotyping, was presumed to be contaminated suction bottles and catheters in the neonatal admission room. Five neonates were successfully treated with ciprofloxacin and amikacin. Enforcement of strict infection control practices curtailed the outbreak.

Developing community mental health services for children in South Africa.

As a result of South Africa's Apartheid history, mental health care for black people, especially in rural areas, has been grossly inadequate and even non-existent in many areas. Children have been severely neglected in this regard. This paper describes an attempt by clinical psychologists to develop a community intervention programme for children with emotional problems. From their hospital base the authors set out, on a monthly basis, to outlying areas up to 250 km away to (1) train primary care nurses and other personnel in the basic techniques of identifying and dealing with uncomplicated psychological problems of childhood, and (2) render consultations to psychologically disturbed children. The paper argues the need to provide primary care workers with mental health skills and thus integrate childhood mental health care into the primary care structure. Such a move could make mental health care accessible to all inhabitants, thus deviating from the policies of the past.

Chemical and photolytical transformation of biomedically significant compounds in the presence of deuterated solvents.

The effect of the nature of solvent on the properties of biomedically important compounds is of particular importance. The conversion of certain biomedical compounds with deuterated solvents is an area of research that has not been accorded adequate recognition in the literature. We explored this area in the interest of shedding some light on the possible effects of solvent on the nature of the solute. The transformation of specific medically important compounds such as bilirubin, thymine, uracil, dehydrocholesterol (7-DHC) and vitamin D(3) was observed in the presence of deuterated solvents such as heavy water and deuterated chloroform. The products of the relevant reactions were confirmed spectrophotometrically. An additional feature to our investigation involved the photolysis of the aforementioned compounds by solar irradiation. The pure samples were dissolved in solutions of the deuterated solvents, corresponding to concentrations of typically 10(-2) mM, and exposed to sunlight for about 15-30 min. The deuterated solvents caused chemical transformation in all chemical compounds tested, and produced intense characteristic absorbance maxima between 200 and 700 nm. Sunlight exposure was also effective in either augmenting the effects of deuterated solvent as in bilirubin and 7-DHC or reducing it as with thymine or having no effect as with uracil or completely changing it as in vitamin D(3). It has been shown that the use of deuterated solvents produces unique chemical and photochemical conversions of bilirubin, 7-DHC, thymine, uracil and vitamin D(3). This was attributed to the fact that deuterated compounds display a somewhat different chemistry to their ordinary counterparts and that possibly thermodynamic considerations could be responsible for the novel transformations.

Monitoring of cadmium in "on" and "off" date palms.

The study demonstrated that the mature dates we investigated were considered safe for human consumption. However, our findings revealed that much of the early fruit and leaves, which appeared at the advent of the fruiting season, possessed elevated levels of cadmium (Cd) that could accumulate in the food chain and thus impact adversely on the environment. In addition, animal feed for livestock contains date leaves, which should be restricted to the mature ones. The monitoring of cadmium in date palms is of considerable interest to environmental science and the thrust of this work, therefore, involved measurement, by ICP, of Cd in dates and corresponding leaf specimens, and evaluation of its distribution during the developmental stages of the fruiting season. Thirty-six date samples and 36 leaf specimens of the Fard cultivar were collected from "on" and "off" date palms during the Kimri, Bisir and Rutab stages of the fruiting season and subjected to suitable digestion procedures. Sample masses of typically 1 g (dry weight) were prepared in 25 ml dilute acid solution and investigated for trace levels of Cd by ICP-AES. Special attention was paid to contamination and the validation of our methodology. The Cd "threshold" in our study was 50 ng/g, in keeping with the levels of tolerance appearing in the literature. For the dates we found elevated levels of Cd [> 50 ng/g] in most of the samples, for both categories of "on" and "off" trees, during the Kimri stage. In the case of the leaves, the "on" samples revealed significant values up to 125 ng/g in Bisir, in some cases, but the trend for the "off" trees remained the same with the highest levels [> 100 ng/g] recorded during Kimri. Safe levels were attained during Rutab for all specimens. The possibility of a connection between Cd toxicity and the alternate-bearing phenomenon is discussed and this could be the subject of future interest.

Risk assessment of chromium and arsenic in date palm leaves used as livestock feed.

Appreciable levels of total chromium (Cr) and arsenic (As) were found (by emission spectroscopy) in date palm leaves, which form a significant ingredient in livestock feed. The levels in the fruit were considered safe for human consumption. Our work involved evaluation of the distribution of these elements in the leaves during the developmental stages of the fruiting season. Thirty-six leaf specimens of the Fard cultivar were collected 9, 15 and 20 weeks, respectively, after pollination and subjected to a standard digestion procedure. Sample masses of typically 1 g (dry weight) were prepared in 25 ml dilute acid solution and investigated for trace levels of Cr and As by ICP-AES. Eleven soil samples collected at random during the growth stages were subjected to a similar digestion procedure and analysis. According to the literature, the permissible mean levels of Cr and As in plants are 200 and 80 ng/g (dry weight), respectively. We used these values as our guideline to assess the "risk" levels in our samples of interest. In the case of Cr, about 45% of the specimens possessed levels between 250 and 700 ng/g, while a significant number produced levels between 1000 and 5000 ng/g. With regard to As, about 70% of the samples were above the documented permissible mean value. As a result of the unusually high Cr concentrations in some cases, the feasibility of Cr "accumulation" in the leaves was examined. Insects and other organisms subsist on the leaves and an added concern was the accumulation of these elements in the food chain. The study formed an interesting contribution to environmental research, and the impact of our assessment on the environment is discussed.