Acceptability, feasibility and cost of point of care testing for sexually transmitted infections among South African adolescents where syndromic management is standard of care.

BACKGROUND: Young people (YP) in southern Africa are at substantial risk of HIV and sexually transmitted infections (STIs). Despite the epidemiological and biological link between STIs and HIV transmission and acquisition, infections such as Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) remain widely undiagnosed. Syndromic STI management is the standard of care in low- and middle-income countries (LMICs) despite a high prevalence of asymptomatic infections. We conducted an observational study to explore the acceptability, feasibility, and cost of a STI test-and-treat service for YP in Cape Town. METHODS: YP attending a mobile clinic (MC) and a youth centre clinic (YC) were offered STI screening. Urine testing for CT and NG using a 90-min molecular point-of-care (POC) test on the GeneXpert platform was conducted and treatment provided. Data were collated on demographics, sexual behaviour, presence of symptoms, uptake of same-day treatment, prevalence of CT/NG, and service acceptability. RESULTS: Three hundred sixty six participants were enrolled (median age 20, 83% female).57% (209/366) of participants tested positive for either CT (126/366, 34%) or NG (57/366, 16%) or co-infection (26/366, 7%). Clinical symptoms were a poor predictor of GeneXpert diagnosed CT or NG, with a sensitivity of 46.8% and 54.0% for CT and NG respectively. Although half of participants initially chose to receive same day results and treatment, only a third waited for results on the day. The majority of participants (91%) rated the service highly via a post-visit acceptability questionnaire. CONCLUSION: Curable STIs are highly prevalent in this population. STI screening using POC testing was feasible and acceptability was high. The study provides further impetus for moving policy beyond syndromic management of STIs in South Africa.

Distinctive clinical and histological characteristics of atrophic and hypertrophic facial photoageing.

BACKGROUND: Photoageing describes complex cutaneous changes which occur following chronic exposure to solar ultraviolet radiation (UVR). Amongst White Northern Europeans, facial photoageing appears as distinct clinical phenotypes: 'hypertrophic' photoageing (HP) and 'atrophic' photoageing (AP). Deep, coarse wrinkles predominate in individuals with HP, whereas those with AP have relatively smooth, unwrinkled skin with pronounced telangiectasia. AP individuals have an increased propensity for developing keratinocyte cancers. OBJECTIVES: To investigate whether histological differences underlie these distinct phenotypes of facial photoageing. METHODS: Facial skin biopsies were obtained from participants with AP (10 M, 10 F; mean age: 78.7 years) or HP (10 M, 10 F; mean age: 74.5 years) and were assessed histologically and by immunohistochemistry. RESULTS: Demographic characterization revealed 95% of AP subjects, as compared to 35% with HP, were Fitzpatrick skin type I/II; of these, 50% had a history of one or more keratinocyte cancers. There was no history of keratinocyte cancers in the HP cohort. Analysis of UVR-induced mitochondrial DNA damage confirmed that all volunteers had received similar lifetime cumulative doses of sun exposure. Histologically, male AP had a significantly thicker epidermis than did AP females or those of either sex with HP. HP facial skin exhibited severe solar elastosis, whereas in AP facial skin, solar elastosis was apparent only in females. Loss of papillary dermal fibrillin-rich microfibrils occurred in all HP and AP female subjects, but not in AP males. Furthermore, male AP had a significant reduction in collagen VII at the dermal-epidermal junction than did AP females or those of either sex with HP. CONCLUSIONS: This study provides further evidence that AP and HP represent distinct clinical and histological entities. Knowledge of these two phenotypes is clinically relevant due to the increased prevalence of keratinocyte cancers in those - particularly males - with the AP phenotype.

The Power of the Shared Experience: MTN-020/ASPIRE Trial Participants' Descriptions of Peer Influence on Acceptability of and Adherence to the Dapivirine Vaginal Ring for HIV Prevention.

Women are disproportionately at risk of acquiring HIV in East and Southern Africa, despite global declines in incidence. Female-initiated HIV prevention methods, like the dapivirine vaginal ring, are needed to end the HIV epidemic. In-depth interviews and focus groups retrospectively explored peer influence on acceptability of and adherence to the ring during the ASPIRE trial, a phase III placebo-controlled trial. Results were analyzed using an inductive analytic approach. Study participants (peers) of all ages and adherence groups developed important interpersonal connections and reported being more open and honest with each other than with external peers or study staff. Study peers who knew each other prior to joining appeared to have a stronger influence on each other's adherence than peers who met in the study. External peers provided primarily negative input about the ring and study, which sometimes led to ring removals. Peers' influence on each other's behavior in both prosocial and detrimental manners could have repercussions on adherence to a biomedical intervention, and consequently, individual disease risk and clinical trial outcomes. Future ring demonstration and implementation studies could use peer networks to intentionally influence uptake and adherence to the ring.

Recommendation to include hydroxyethyl (meth)acrylate in the British baseline patch test series.

BACKGROUND: (Meth)acrylates are potent sensitizers and a common cause of allergic contact dermatitis (ACD). The frequency of (meth)acrylate ACD has increased with soaring demand for acrylic nails. A preliminary audit has suggested a significant rate of positive patch tests to (meth)acrylates using aimed testing in patients providing a clear history of exposure. To date, (meth)acrylates have not been routinely tested in the baseline patch test series in the U.K. and Europe. OBJECTIVES: To determine whether inclusion of 2-hydroxyethyl methacrylate (2-HEMA) 2% in petrolatum (pet.) in the baseline series detects cases of treatable (meth)acrylate ACD. METHODS: During 2016-2017, 15 U.K. dermatology centres included 2-HEMA in the extended baseline patch test series. Patients with a history of (meth)acrylate exposure, or who tested positive to 2-HEMA, were selectively tested with a short series of eight (meth)acrylate allergens. RESULTS: In total 5920 patients were consecutively patch tested with the baseline series, of whom 669 were also tested with the (meth)acrylate series. Overall, 102 of 5920 (1·7%) tested positive to 2-HEMA and 140 (2·4%) to at least one (meth)acrylate. Had 2-HEMA been excluded from the baseline series, (meth)acrylate allergy would have been missed in 36 of 5920 (0·6% of all patients). The top (meth)acrylates eliciting a positive reaction were 2-HEMA (n = 102, 1·7%), 2-hydroxypropyl methacrylate (n = 61, 1·0%) and 2-hydroxyethyl acrylate (n = 57, 1·0%). CONCLUSIONS: We recommend that 2-HEMA 2% pet. be added to the British baseline patch test series. We also suggest a standardized short (meth)acrylate series, which is likely to detect most cases of (meth)acrylate allergy.

The importance of histological assessment after neoadjuvant therapy and the need for standardisation.

Neoadjuvant therapy is increasingly being recognised as a management option for patients with primary invasive breast carcinoma; this may take the form of primary endocrine treatment or primary chemotherapy. Surgical specimens from women treated with neoadjuvant treatments, particularly primary chemotherapy, may cause a challenge for the histopathologist in handling and interpretation and have, in the past, been sampled, evaluated, and reported in a non-standardised way. This limits comparison between clinical trials and potentially provides clinicians and patients with suboptimal prognostic information. We describe here some of the difficulties faced and the recommendations and standards now applied.

Saprophytic and pathogenic fungi in the Ceratocystidaceae differ in their ability to metabolize plant-derived sucrose.

BACKGROUND: Proteins in the Glycoside Hydrolase family 32 (GH32) are carbohydrate-active enzymes known as invertases that hydrolyse the glycosidic bonds of complex saccharides. Fungi rely on these enzymes to gain access to and utilize plant-derived sucrose. In fungi, GH32 invertase genes are found in higher copy numbers in the genomes of pathogens when compared to closely related saprophytes, suggesting an association between invertases and ecological strategy. The aim of this study was to investigate the distribution and evolution of GH32 invertases in the Ceratocystidaceae using a comparative genomics approach. This fungal family provides an interesting model to study the evolution of these genes, because it includes economically important pathogenic species such as Ceratocystis fimbriata, C. manginecans and C. albifundus, as well as saprophytic species such as Huntiella moniliformis, H. omanensis and H. savannae. RESULTS: The publicly available Ceratocystidaceae genome sequences, as well as the H. savannae genome sequenced here, allowed for the identification of novel GH32-like sequences. The de novo assembly of the H. savannae draft genome consisted of 28.54 megabases that coded for 7 687 putative genes of which one represented a GH32 family member. The number of GH32 gene family members appeared to be related to the ecological adaptations of these fungi. The pathogenic Ceratocystis species all contained two GH32 family genes (a putative cell wall and a putative vacuolar invertase), while the saprophytic Huntiella species had only one of these genes (a putative cell wall invertase). Further analysis showed that the evolution of the GH32 gene family in the Ceratocystidaceae involved transposable element-based retro-transposition and translocation. As an example, the activity of a Fot5-like element likely facilitated the assembly of the genomic regions harbouring the GH32 family genes in Ceratocystis. CONCLUSIONS: This study provides insight into the evolutionary history of the GH32 gene family in Ceratocystidaceae. Our findings suggest that transposable elements shaped the evolution of the GH32 gene family, which in turn determines the sucrolytic activities and related ecological strategies of the Ceratocystidaceae species that harbour them. The study also provides insights into the role of carbohydrate-active enzymes in plant-fungal interactions and adds to our understanding of the evolution of these enzymes and their role in the life style of these fungi.

Clinical evaluation of the OneStep Gonorrhea RapiCard InstaTest for detection of Neisseria gonorrhoeae in symptomatic patients from KwaZulu-Natal, South Africa.

We evaluated a point-of-care test for the detection of Neisseria gonorrhoeae in patients attending a public health clinic in KwaZulu-Natal, South Africa. The test showed a low sensitivity against PCR and culture (<40%); however, a higher specificity was observed (>95%). This test is unsuitable as a screening tool for gonorrhea.

Clofazimine in the treatment of extensively drug-resistant tuberculosis with HIV coinfection in South Africa: a retrospective cohort study.

BACKGROUND: Extensively drug-resistant (XDR) tuberculosis (TB) and HIV coinfection is associated with low cure rates and high mortality. Clofazimine has shown activity in vitro against Mycobacterium tuberculosis, but clinical experience with clofazimine in XDR-TB and HIV coinfection is limited. METHODS: This was a retrospective cohort study of adult XDR-TB patients in KwaZulu-Natal, South Africa, treated with either a clofazimine- or non-clofazimine-containing XDR-TB treatment regimen. The primary outcome measure was TB culture conversion at 6 months. Survival analysis and multivariate logistic regression compared time to event in different strata and identified risk factors for TB culture conversion. RESULTS: Between August 2009 and July 2011, eligible XDR-TB patients (n = 85) were initiated on treatment for XDR-TB. Most patients (86%) were HIV-infected and receiving antiretroviral therapy (90%). Patients receiving a clofazimine-containing regimen (n = 50) had a higher percentage of culture conversion (40%) compared with patients (n = 35) receiving a non-clofazimine regimen (28.6%). On multivariate analysis, there was a 2-fold increase in TB culture conversion at 6 months (hazard rate ratio 2.54, 95% CI 0.99-6.52, P = 0.05) in the group receiving a clofazimine-containing regimen. Adverse effects due to clofazimine were minor and rarely life-threatening. CONCLUSIONS: Clofazimine was associated with improved culture conversion in the treatment of XDR-TB/HIV. Adverse effects were minor and non-life-threatening. Based on these preliminary data, further study of clofazimine in XDR-TB/HIV treatment is warranted. Given the present low rates of culture conversion in XDR-TB treatment, we recommend empirical inclusion of clofazimine in treatment regimens for XDR-TB.

Clinical impact of plasma concentrations of first-line antituberculosis drugs.

BACKGROUND: The clinical significance of low antituberculosis (anti-TB) drug concentrations has not been fully elucidated. OBJECTIVES: To investigate the clinical consequences of first-line drug concentrations in adult patients with drug-susceptible pulmonary TBin South Africa (SA). METHOD: We conducted a pharmacokinetic study nested within the control arm of the Improving Treatment Success (IMPRESS) trial(NCT02114684) in Durban, SA. During the first 2 months of treatment, participants received weight-based dosing of first-line anti-TBdrugs (rifampicin, isoniazid, pyrazinamide and ethambutol), and had plasma drug concentrations measured at 2 and 6 hours after drugadministration during the 8th week of treatment. Intermediate (8 weeks), end-of-treatment (6 months) and follow-up TB outcomes wereassessed using World Health Organization criteria. RESULTS: We measured plasma drug concentrations on available samples in 43 participants. Peak drug concentrations were below thetherapeutic range in 39/43 (90.7%) for rifampicin, 32/43 (74.4%) for isoniazid, 27/42 (64.3%) for pyrazinamide and 5/41 (12.2%) forethambutol. At the end of the intensive phase of treatment (week 8), 20.9% (n=9/43) of participants remained culture positive. We did notfind a relationship between the concentrations of first-line drugs and treatment outcomes at week 8. All participants were cured at the endof treatment, and there were no relapses during the 12-month follow-up period. CONCLUSION: Treatment outcomes were favourable despite low drug concentrations as defined by current reference thresholds.

Resilience from the perspective of diagnostic radiography students.

INTRODUCTION: Resilience is a concept associated with the ability to overcome, adapt, and recover from stressors. The radiography profession is known to be stressful, and one can reason that radiographers must be resilient in order to cope with the clinical environment. Research shows there are varied understandings of resilience. However, little is known about the concept of resilience specifically as it relates to the perspectives of diagnostic radiography students within the clinical workplace. This paper reports on one aspect of a comprehensive study of resilience amongst radiography students. The objective of this paper is, therefore, to present the exploration of the concept of resilience drawing from the data gathered from first-year diagnostic radiography students. METHODS: A qualitative, explorative, descriptive and contextual approach was adopted for this study. Qualitative data was collected through focus group interviews. A purposive sampling method was employed, selecting from first-year diagnostic radiography students at a University of Technology (UoT) in the Western Cape, South Africa. Interviews were audio-recorded transcribed and thematically analysed. Data was collected until saturation was reached. RESULTS: The meaning of resilience as explained from the perspective of radiography students included three subthemes namely: (1) fundamentals of resilience; (2) external protective factors and (3) internal protective factors. CONCLUSION: This study demonstrated that radiography students associated resilience with positive attributes. Furthermore, the study identified various resilience enhancement strategies to better support diagnostic radiography students in the clinical environment like supportive radiographers and talking to peers. IMPLICATIONS FOR PRACTICE: The identification of resilience enhancement strategies is important as it will assist with the introduction of curriculum renewal initiatives tailored to support first-year diagnostic radiography students as they develop their resilience to stressors in the clinical environment.

Elements in muscle tissue of three dolphin species from the east coast of South Africa.

We investigated elemental concentrations in muscle tissue of three species of dolphins incidentally bycaught off the KwaZulu-Natal coastline, South Africa. Thirty-six major, minor and trace elements were analysed in Indian Ocean humpback dolphin Sousa plumbea (n = 36), Indo-Pacific bottlenose dolphin Tursiops aduncus (n = 32) and the Common dolphin Delphinus delphis (n = 8). Significant differences in concentration between the three species were observed for 11 elements (cadmium, iron, manganese, sodium, platinum, antimony, selenium, strontium, uranium, vanadium and zinc). Mercury concentrations (maximum 29 mg/kg dry mass) were generally higher than those reported for coastal dolphin species found elsewhere. Our results reflect a combination of species differences in habitat, feeding ecology, age, and possibly species physiology and exposure to pollution levels. This study confirms the high organic pollutant concentrations documented previously for these species from the same location, and provides a well-founded case for the need to reduce pollutant sources.

Global cost of correcting vision impairment from uncorrected refractive error.

OBJECTIVE: To estimate the global cost of establishing and operating the educational and refractive care facilities required to provide care to all individuals who currently have vision impairment resulting from uncorrected refractive error (URE). METHODS: The global cost of correcting URE was estimated using data on the population, the prevalence of URE and the number of existing refractive care practitioners in individual countries, the cost of establishing and operating educational programmes for practitioners and the cost of establishing and operating refractive care facilities. The assumptions made ensured that costs were not underestimated and an upper limit to the costs was derived using the most expensive extreme for each assumption. FINDINGS: There were an estimated 158 million cases of distance vision impairment and 544 million cases of near vision impairment caused by URE worldwide in 2007. Approximately 47 000 additional full-time functional clinical refractionists and 18 000 ophthalmic dispensers would be required to provide refractive care services for these individuals. The global cost of educating the additional personnel and of establishing, maintaining and operating the refractive care facilities needed was estimated to be around 20 000 million United States dollars (US$) and the upper-limit cost was US$ 28 000 million. The estimated loss in global gross domestic product due to distance vision impairment caused by URE was US$ 202 000 million annually. CONCLUSION: The cost of establishing and operating the educational and refractive care facilities required to deal with vision impairment resulting from URE was a small proportion of the global loss in productivity associated with that vision impairment.

Pharmacological management of post-traumatic seizures in a South African paediatric intensive care unit.

Background: Traumatic brain injury (TBI) is a common cause of paediatric intensive care unit (PICU) admissions in South Africa. Optimal care of these patients includes the prevention and control of post-traumatic seizures (PTS) in order to minimise secondary brain injury. Objectives: To describe the demographics of children admitted to a South African PICU, to describe the characteristics of PTS, and to describe the prophylactic and therapeutic management of PTS within the unit. Methods: A 3-year retrospective chart review was conducted at the PICU of the Chris Hani Baragwanath Academic Hospital (CHBAH) in Soweto, Johannesburg, from 1 July 2015 to 30 June 2018. Results: Seventy-eight patients were admitted to the PICU, all with severe TBI. A total of 66 patient files were available for analysis. The median age of admission was 6 years (interquartile range (IQR) 4 - 9) with the majority of trauma secondary to mechanical injury (89%). Prophylactic anti-epileptic drugs (AEDs) were initiated in 44 (79%) patients. Early PTS occurred in 11 (25%) patients who received prophylaxis and 4 (33%) who did not. Three (5%) patients developed late PTS, resulting in an overall incidence of PTS of 43%. The most common seizure type was generalised tonic clonic (82%). Children diagnosed with PTS were a median of 2 years younger than those without PTS, with increased prevalence of seizures (83% v. 38%) in children below 2 years of age. Maintenance therapy was initiated in all patients consistent with recommended dosages. Of the total 167 anti-epileptic levels taken during maintenance, only 56% were within target range. Of the initial 78 patients, 8 died (10%). The median length of stay was 7 (IQR 5 - 12) and 8 (IQR 8 - 24) days longer in ICU and hospital respectively, in children with PTS. Conclusion: PTS is a frequent complication of severe TBI in children. There was considerable variation in the approach to both prophylaxis and maintenance therapy of PTS in terms of choice of agent, dosage, frequency of drug monitoring and approach to subtherapeutic levels. It is clear that more high-level studies are required in order to better inform these practices. Contributions of the study: To the best of our knowledge, this article represents the first description of incidence and management practices of paediatric post traumatic seizures.

Radiography lecturers' understanding of a socially responsive curriculum.

INTRODUCTION: In health professions education (HPE), focus is placed on developing clinically competent practitioners who can function within their professional scope in a broad range of health care contexts. In this study, the authors investigated diagnostic radiography lecturers' understanding of how students become socially responsive. The concept of 'critical consciousness' was explored as an intervention of being a transformer in the local environment. This places focus on learning and teaching that aims to develop radiography graduates who are critically conscious, such that they can take up the challenges of healthcare in their environment, in addition to being clinically competent in their field. The study under discussion therefore sought to find out how radiography lecturers understand a socially responsive curriculum at a University of Technology in the South African context. METHOD: A qualitative, exploratory design was used where curriculum documents were reviewed and from which stimulus points were identified for a semi-structured focus group interview with radiography lecturers followed by five individual interviews. All interviews were audio-recorded, transcribed, coded and analysed through a process of thematic analysis. RESULTS: Four dominant themes emerged from the analysis, namely i) diverse understandings of critical consciousness, ii) becoming a reflective practitioner, iii) a need for curriculum transformation and iv) emerging pedagogies. CONCLUSION: Critical reflection by both the radiography students and lecturers is key to developing social awareness and critical consciousness which could drive critical motivation and critical action to effect social change. It is recommended that the current curriculum should be reviewed and transformed to include constructive reflective practice. IMPLICATIONS FOR PRACTICE: Dedicated time should be scheduled, in the curriculum, to allow students and lecturers to engage in meaningful constructive reflection to enhance socially responsive practice.

Changing mortality amongst hospitalised children with Severe Acute Malnutrition in KwaZulu-Natal, South Africa, 2009 - 2018.

BACKGROUND: The under-five mortality rates of children in South Africa (SA) remain high despite successful HIV prevention and treatment programs. The in-hospital mortality of children with severe acute malnutrition remains a key obstacle. This study identifies and describes changes in the mortality of under-five children with severe acute malnutrition (SAM) following the implementation of HIV and malnutrition prevention and treatment programmes. METHODS: This was a retrospective review of in-hospital mortality records and databases. The study was based at a large referral hospital in KwaZulu-Natal (KZN), where HIV and malnutrition rates are high, and SAM children are managed with standard WHO guidelines. Records of children under five years old who died from 2009 to 2018 were analysed. RESULTS: Of the 698 under-five children who died in this period, 285 (40, 8% of all under-5 deaths) were classified as having SAM. The number of HIV-infected SAM deaths dropped significantly, especially those below six months of age, mirroring the expansion of HIV treatment and prevention programmes. Despite this and a significant drop in the proportion of SAM admissions identified, there was no change in SAM case fatality rates over the ten years. Septicaemia remained the most common cause of death in children with SAM. CONCLUSIONS: Despite significant decreases in HIV-related malnutrition deaths over ten years, the lack of change in SAM case fatality rates is a concern at this referral hospital. Standardised WHO inpatient management protocols, may require review, especially where underlying medical conditions may contribute to SAM deaths in HIV-negative children.

A third-line antiretroviral therapy register to track patient clinical and virological outcomes.

In 2021, South Africa (SA) had an estimated 7.8 million people living with HIV, of whom 5.6 million were receiving antiretroviral therapy (ART),[1] with 3.4 million on first-line ART, 145 000 on second-line ART (SLART) and >700 on third-line ART (TLART).

A cross-sectional observational study of endotracheal intubation and extubation practices among doctors treating adult COVID-19 and suspected COVID-19 patients in South Africa.

BACKGROUND: Patients with severe COVID-19 may require endotracheal intubation. Unique adjustments to endotracheal intubation and extubation practices are necessary to decrease the risk of SARS-CoV-2 transmission to healthcare workers (HCWs) while avoiding complications of airway management. OBJECTIVES: To investigate the practice of endotracheal intubation and extubation, resources available and complications encountered by clinicians performing endotracheal intubation and extubation of COVID-19 and suspected COVID-19 patients in South Africa (SA). METHOD: A cross-sectional observational study was conducted during the initial surge of COVID-19 cases in SA. Data were collected by means of a self-administered questionnaire completed by clinicians in the private and public healthcare sectors after performing an endotracheal intubation and/or extubation of a patient with confirmed or suspected COVID-19. RESULTS: Data from 135 endotracheal intubations and 45 extubations were collected. Anaesthetists accounted for 87.0% (n=120) of the study participants, specialist clinicians in their respective fields for 59.4% (n=82), and public HCWs for 71.0% (n=98). Cases from Gauteng Province made up 76.8% (n=106) of the database. Haemoglobin desaturation was the most frequent complication encountered during endotracheal intubation (40.0%; n=54). Endotracheal intubations performed at private healthcare institutions were associated with a significantly lower complication rate of 17.5% (n=7) compared with 52.6% (n=50) in the public healthcare sector (p<0.001). Endotracheal intubations performed in theatre had the lowest complication rate of 10.4% (n=5; p<0.001). Propofol was used in 90 endotracheal intubations (66.7%), and its use was associated with fewer complications relative to other induction agents. Minimising the number of intubation attempts (p=0.009) and the use of checklists (p=0.013) significantly reduced the frequency of complications encountered during endotracheal intubation. Intravenous induction technique, neuromuscular blocking agent used, intubating device used and time at which intubation was performed did not affect the incidence of complications. The majority of endotracheal extubations were uncomplicated (88.9%). CONCLUSIONS: The study provides valuable insight into the resources used by clinicians and complications encountered when endotracheal intubations and/or extubations were performed. Data from this study may be used to guide future clinical practice and research, especially in resource-limited settings.