The mechanics of setting up a COVID-19 response: Experiences of the COVID-19 epidemic from Groote Schuur Hospital, Cape Town, South Africa.

The SARS-CoV-2 pandemic has challenged the provision of healthcare in ways that are unprecedented in our lifetime. Planning for the sheer numbers expected during the surge has required public hospitals to de-escalate all non-essential clinical services to focus on COVID-19. Western Cape Province was the initial epicentre of the COVID-19 epidemic in South Africa (SA), and the Cape Town metro was its hardest-hit geographical region. We describe how we constructed our COVID-19 hospital-wide clinical service at Groote Schuur Hospital, the University of Cape Town's tertiary-level teaching hospital. By describing the barriers and enablers, we hope to provide guidance rather than a blueprint for hospitals elsewhere in SA and in low-resource countries that face similar challenges now or during subsequent waves.

Sustained reduction in antibiotic consumption in a South African public sector hospital; Four year outcomes from the Groote Schuur Hospital antibiotic stewardship program.

BACKGROUND: Overuse of antibiotics has driven global bacterial resistance to the extent that we have entered a post-antibiotic era, where infections that were once easily treatable are now becoming untreatable. Efforts to control consumption have focused on antibiotic stewardship programmes (ASPs), aimed at optimising use. OBJECTIVE: To report antibiotic consumption and cost over 4 years from a public hospital ASP in South Africa (SA). METHODS: A comprehensive ASP comprising online education, a dedicated antibiotic prescription chart and weekly dedicated ward rounds was introduced at Groote Schuur Hospital, Cape Town, in 2012. Electronic records were used to collect data on volume and cost of antibiotics and related laboratory tests, and to determine inpatient mortality and 30-day readmission rates. These data were compared with a control period before the intervention. RESULTS: Total antibiotic consumption fell from 1 046 defined daily doses/1 000 patient days in 2011 (control period) to 868 by 2013 and remained at similar levels for the next 2 years. This was driven by reductions in intravenous antibiotic use, particularly ceftriaxone. Inflation-adjusted cost savings on antibiotics were ZAR3.2 million over 4 years. Laboratory tests increased over the same period with a total increased cost of ZAR0.4 million. There was no significant change in mortality or 30-day readmission rates. CONCLUSIONS: The effects of a comprehensive ASP on medical inpatients at a public sector hospital in SA were durable over 4 years, leading to a reduction in total antibiotic consumption without adverse effect. When increased laboratory costs were offset there was a net cost saving of ZAR2.8 million.

Analysis of vessel wall morphology, blood flow velocity, and the hemostatic system in a patient with a large intracoronary thrombus.

A patient with AMI caused by a large thrombus in the proximal LAD was successfully treated with PTCA and an intracoronary lysis combined with the platelet-receptor antagonist c7E3. Analysis of cellular hemostasis after 1 and 6 months revealed a sustained platelet activation despite combined anti-platelet therapy with ASA and ticlopidine. A progredient slow-flow phenomenon appeared during control angiographies, confirmed by intracoronary Doppler examination.

[Treatment of a large intracoronary thrombus with urokinase and a chimeric monoclonal platelet aggregation inhibitor]. / Behandlung eines grossen intrakoronaren Thrombus mit Urokinase und einem chimären monoklonalen Thrombozytenaggregationshemmer.

HISTORY AND CLINICAL FINDINGS: 7 days after an operation for intervertebral disc prolapse a 43-year-old man was referred with the clinical and ECG signs of an acute posterior wall myocardial infarction. INVESTIGATIONS: Creatine kinase (CK) activity was raised to 204 U/I (myocardial-specific isoenzyme CKMB of 23.6 U/I, 11.6% of total) and glutamic-oxalate transferase (GOT) activity to 37 U/I. Emergency cardiac catheterisation, performed 4 hours after renewed onset of precordial pain showed no abnormal findings in the right coronary artery, despite the ECG signs, but a definite filling defect in the anterior interventricular branch, which on intravascular ultrasound was an echo-dense noncalcified structure. TREATMENT AND COURSE: After percutaneous transluminal coronary angioplasty in the area of the obstructing structure a free-floating mass was identified in the proximal part of the anterior interventricular branch, most likely a thrombus. Intercoronary thrombolysis was therefore undertaken with urokinase (bolus of 1 mill. IU) together with the chimeric monoclonal antibody c7E3, which inhibits platelet aggregation by blocking the platelet glycoprotein surface receptor IIb/IIIa. Coronary angiography 12 hours later revealed almost complete dissolution of the previously obstructing mass. CONCLUSION: Combining the platelet aggregation inhibitor c7E3 with a thrombolytic agent is an alternative treatment to the current management of intracoronary thrombi. Intravascular ultrasound is a suitable method for demonstrating angiographically inconspicuous or unclear but pathogenetically significant vessel changes.

Senile amyloidoses of the pituitary and adrenal glands. Morphological and statistical investigations.

The pituitary and adrenal glands are a functional endocrine unit affected by local or organ-limited senile amyloid syndromes. These occur as interstitial (pituitary only) or intracellular (pituitary and adrenal) varieties. The pituitary and right adrenal glands of each of 108 consecutive autopsy cases of individuals aged 85 years and over were investigated for the prevalence, distribution and immunostaining characteristics of local amyloid. Intracellular amyloid was detected in 77 (71%) pituitaries and 73 (68%) adrenals. Interstitial amyloid was found in 86 pituitaries (80%). Immunohistochemical studies, investigating different amyloid fibril proteins, amyloid P component, ubiquitin, intermediate filaments and pituitary hormones, failed to demonstrate any similarities, and a common origin is unlikely. Statistical analyses demonstrated significant correlations between the occurrences of all three local amyloids. The clinical and histopathological significance of local pituitary and adrenal amyloid remains obscure. The results suggested that the pathogenesis of the local senile amyloidoses of the pituitary and adrenals may be influenced by a common, still uncharacterized variable. It is not clear whether this variable also contributes to the pathogenesis of other senile amyloid syndromes, such as those associated with Alzheimers' disease.

[Normalization of myocardial perfusion reserve after coronary stent implantation in comparison with balloon angioplasty alone]. / Normalisierung der myokardialen Perfusionsreserve nach koronarer Stentimplantation im Gegensatz zur alleinigen Ballonangioplastie.

Stents scaffold coronary arteries after angioplastic treatment and inhibit elastic recoil resulting in a larger and more circular focal lumen. In 25 patients with significant stenoses of the left anterior descending coronary artery, presenting no collaterals or myocardial infarction, EKG-gated digital subtraction angiograms were recorded at baseline and during hyperemia induced by intracoronary injection of 12 mg papaverine before and after balloon angioplasty, and after adjunct implantation of a single Palmaz-Schatz stent. Densitometric evaluation revealed the time parameters contrast medium appearance time (MCAT) rise time (RT) and mean transit time (MTT) and maximum intensity (Imax). Myocardial perfusion reserve (MPR1) was calculated as the ratio of baseline MCAT and hyperemic MCAT multiplied by the ratio of hyperemic Imax and baseline Imax while MPR2 was calculated as the ratio of baseline RT and hyperemic RT. Maximum flow ratio (MaxFR) was calculated as the ratio of preprocedural hyperemic MTT and postprocedural hyperemic MTT. Post-stenotic MPR1 increased from 1.36 +/- 0.28 to 2.50 +/- 1.20 and to 3.40 +/- 0.58 (ANOVA p < 0.05), while reference MPR1 remained unchanged with 3.40 +/- 0.60. Post-stenotic MPR2 increased from 1.57 +/- 0.14 to 2.59 +/- 0.86 after balloon angioplasty and to 3.10 +/- 0.41 after stenting (ANOVA p < 0.05), while reference MPR2 remained unchanged with 3.10 +/- 0.40. MaxFR was 2.13 +/- 0.53 after balloon angioplasty and 2.83 +/- 0.35 after stenting (p < 0.05). A good correlation was found between minimal stenosis diameter and MPR1 or MPR2 (MPR1: r = 0.94; MPR2: r = 0.87) and between luminal gain and MaxFR (r = 0.75). A negative correlation was measured between recoil, defined as the difference between inflated balloon diameter and resulting minimal stenosis diameter, and MPR1 and MPR2 and MaxFR (MPR1: r = -0.86; MPR2 r = -0.80; MaxFR r = -0.83). In conclusion, adjunct coronary stent implantation normalized post-stenotic myocardial perfusion immediately in contrast to balloon angioplasty alone resulting from a larger postprocedural lumen and a more pronounced inhibition of elastic recoil.

[High frequency rotational angioplasty]. / Hochfrequenzrotationsangioplastie.

High-speed rotational coronary atherectomy is an alternative method to treat complex, especially calcified coronary stenoses. A rotating burr tip removes the occlusive plaque tissue. The applied rotating frequency is between 160 000 to 190 000 rpm. The primary technical success-rate for high frequency rotational atherectomy alone yields between 50 to 60% on average. Associated with consecutive additional balloon angioplasty, the success rate is between 80 and 95% when treating complex type B II or C stenoses. Today, the usage of a single burr tip size with adjunctive balloon angioplasty has become a standard procedure. The occurrence of serious complications such as extensive dissections or thrombotic vessel occlusion is a rare phenomenon after high-speed rotational atherectomy compared to coronary balloon angioplasty, whereas coronary spasm is more common after high-speed rotational atherectomy. According to the actual results, high-speed rotational angioplasty did not lower the rate of long-term restenosis, compared to the results achieved by balloon angioplasty alone. The rate of long-term restenosis is reported to be between 40 to 50% after highspeed rotational angioplasty with or without adjunctive balloon angioplasty.

[Relationship between Na+ and monosaccharide influx across the microvilli membrane depending on the energy state of the intestinal mucosa wall]. / Relation zwischen Na+- und Monosaccharid-Influx über die Mikrovillimembran in Abhängigkeit vom Energiezustand der intestinalen Mukosazelle.

1. An energy dependence of the Na+ influx and of the "extra-Na+ influx" across the microvilli membrane was demonstrated in an in vitro preparation of the rat jejunum by adjustment of low ATP/ADP quotients. The monosaccharide influx does not show this dependence. 2. The similar relationship of monosaccharide-dependent Na+ influx and Na+ influx without monosaccharide with the energy state in the mucosa cells suggests a common control system. 3. A constant stoichiometry between monosaccharide and "extra-Na+ influx" can be maintained only under constant intracellular conditions. 4. The changes of the Na+ and K+ influxes by so-called Na+ dependently transported monosaccharides correspond to those which can be elicited by lowering the ATP/ADP ratio in the in vitro preparation. 5. A mechanism is discussed in which an ATP-utilizing reaction is stimulated in the microvilli owing to the monosaccharide transport, thus locally discontinuing the condition for uncoupling of an (Na, K)-ATPase and eliciting an "extra-Na+ influx".