'They are inconveniencing us' - exploring how gaps in patient education and patient centred approaches interfere with TB treatment adherence: perspectives from patients and clinicians in the Free State Province, South Africa.

BACKGROUND: Tuberculosis (TB) treatment loss to follow up (LTFU) plays an important contributory role to the staggering TB epidemic in South Africa. Reasons for treatment interruption are poorly understood. Treatment interruption appears to be the culmination of poor health literacy of patients and inadequate health education provided by clinicians. We explored clinician and patient perspectives of the gaps in TB messaging that influence TB treatment LTFU. METHODS: We conducted semi-structured in-depth interviews between January and May 2018 with a sample of 15 clinicians managing TB and 7 patients identified as LTFU in public clinics in the Free State Province, South Africa. Thematic analysis using a mixed deductive/inductive thematic approach was used. RESULTS: Limited occupational opportunities, fear of disclosure and stigmatization all contributed to treatment LTFU. Patients felt that the TB messaging received was inadequate. Many of the clinicians interviewed felt that improving patient's TB knowledge would reinforce adherence to treatment and thus focused on sharing information on treatment completion, side effects and infection control. However, the inability of clinicians to establish rapport with patients or to identify social support challenged TB treatment adherence by patients. Clinicians perceived this as patients not following their instructions despite what they considered lengthy TB education. Having said this, clinicians concurred that their medical management of TB lacked the psycho-social dimension to treat a social disease of this magnitude. CONCLUSIONS: Limited occupational opportunities, fear of disclosure and stigmatization all contributed to treatment LTFU. Clinicians concurred that poor patient understanding of TB and that biomedical management lacking a psycho-social dimension further exacerbated the poor treatment outcome. TB remains a social disease, the successful management of which hinges on patient-centred care.

The usefulness of routine histological examination of appendicectomy specimens in a South African tertiary centre.

BACKGROUND: It is accepted surgical practice to send all appendicectomy specimens for histological examination, but the usefulness and cost associated with this practice have not been established in our setting, a tertiary hospital in KwaZulu-Natal Province, South Africa (SA). OBJECTIVES: To determine the histological diagnoses of appendicectomy specimens in our centre, and the cost of identifying an alternative histological diagnosis requiring further treatment. METHODS: Clinical data on patients undergoing appendicectomy for suspected acute appendicitis during the study period December 2012 - August 2015 were retrospectively retrieved from the hybrid electronic medical registry. Histological data were then extracted from the National Health Laboratory Service database. The cost of an appendicitis histology report was sourced from a private laboratory service. RESULTS: A total of 290 patients were identified during the study period. Males had a significantly higher risk (p<0.0001) than females of histologically confirmed appendicitis (odds ratio 3.2, 95% confidence interval 1.7 - 5.8). The negative appendicectomy rate was 22.4% (65/290). In 5.9% of specimens (17/290) an alternative diagnosis was made on histological examination, which influenced the management plan. These were parasitic co-infections in 13 cases (4.5%), premalignant conditions in 2 and tuberculosis in 2. The average cost of processing each appendicectomy specimen was ZAR871. The cost of identifying each patient with an alternative diagnosis that required treatment was ZAR14 858 ([290 × ZAR871]/17). CONCLUSIONS: This audit correlates with other SA studies showing that the aetiological differential for appendicitis is broad. Histological examination therefore remains critical in the management of patients with suspected acute appendicitis in our clinical setting.

Current trauma patterns in Pietermaritzburg.

BACKGROUND: The aim of this observational study was to audit the burden of trauma with which patients present at the three hospitals that comprise the Pietermaritzburg Metropolitan Complex, as well as their intensive care units (ICUs) and the government medico-legal mortuary. METHOD: A retrospective audit was conducted by assessing emergency department, critical care unit admission record books and medico-legal mortuary report files over a period of two years as well as reviewing patient demographics and the mechanism of trauma in patients. Data were manually entered into a data spreadsheet for the period 1 January 2010 to 31 December 2011. Recorded data included basic demographic information, mechanism of injury and the facility. Details of the injury precipitating the ICU admission and the length of stay were included in the ICU data. RESULTS: During the period 10 644 patients presented to the Pietermaritzburg Metropolitan Trauma Service as a result of trauma-related injuries. Of the 10 644 trauma patients seen, there were 3 688 assault-related injuries (35%), 3 715 motor vehicle accident (MVA)-related injuries (35%), 516 gunshot wound (GSW)-related injuries (5%) and 2 725 stabbings (26%). The trauma burden consisted predominantly of blunt trauma (70%), followed by penetrating trauma (30%). The majority of trauma patients were male (77%). Of the 10 644 trauma patients seen, 510 (5%) needed admission to an ICU. The composition of the group requiring ICU was assault (8%), MVAs (48%), GSWs (14%) and stabbings (30%). A total of 1 105 (10%) trauma victims died, 471 of whom survived long enough to be admitted to a medical facility. The mortuary group consisted of 56% incidents of blunt trauma and 44% of penetrating trauma. There were 153 (14%) assault-related deaths, 462 (42%) MVA-related deaths, 181 (17%) GSW-related deaths and 309 (28%) stabbing-related deaths. CONCLUSION: Although the rate of penetrating trauma remains high, it is being overtaken by blunt trauma. Almost half of this blunt trauma load is nonintentional. MVAs are expensive to treat, consume ICU resources and are associated with significant mortality. Injury-prevention strategies are a priority, and should address the high rate of MVAs and the high rate of interpersonal violence. The decline in GSW-related trauma is cause for cautious optimism.

An audit of trauma-related mortality in a provincial capital in South Africa.

BACKGROUND: It has been shown repeatedly that hospital-based mortality data do not capture the actual mortality rate in South Africa, as many corpses are taken directly to the state mortuary. METHOD: A retrospective audit was conducted by reviewing all mortuary reports for the period 1 January 2010 - 31 December 2011. The data recorded included demographics, mechanism of trauma, and cause and site of death. RESULTS: A total of 1 105 trauma victims died. There were 930 males (84.2%) and 175 females (15.8%), of whom 615 were victims of blunt trauma (55.7%) and 490 victims of penetrating trauma (44.3%). The scenes of death were: on scene 584 (52.9%), Edendale Hospital 259 (23.4%), Grey's Hospital 144 (13.0%), Northdale Hospital 68 (6.2%), and 'other' 50 (4.5%). The 'other' group comprised nine deaths at primary healthcare clinics and 41 at private hospitals in Pietermaritzburg. Of deaths related to blunt trauma, 153 (24.9%) were secondary to assault and 462 (75.1%) to a road traffic collision. Of the victims of penetrating trauma, 81 (36.9%) had sustained gunshot wounds and 309 (63.1%) stab wounds. The three leading causes of trauma-related deaths were head injuries (32.6%), polytrauma (29.7%) and chest injuries (27.4%). CONCLUSION: Pietermaritzburg has both a high rate of trauma-related mortality and an immature trauma system, resulting in a significant number of preventable deaths.

Heavy metal contamination in a school vegetable garden in Johannesburg.

BACKGROUND: Feeding schemes based on school garden produce have been proposed as an effective solution to food insecurity and hunger among learners in South Africa. However, few studies have looked at the potential contamination of school food gardens when situated near mine tailing dams. OBJECTIVES: The aim of the study was to evaluate the potential heavy metal contamination in a school vegetable garden in Johannesburg. METHODS: Twenty soil samples were collected from the study school and a comparison school. Surface and deep (±10 cm beneath the surface) soil samples were analysed using X-ray fluorescence for levels of arsenic, chromium, copper, lead and zinc. Thirteen vegetables samples were collected from the school garden, and compared with six samples from a national retailer and four obtained from a private organic garden. The heavy metal concentrations of the vegetable samples were analysed in the laboratories of the South African Agricultural Research Council. RESULTS: High levels of arsenic were found in the school soil samples, and elevated concentrations of lead and mercury in the school vegetables. Calculation of the estimated daily intake for a child of 30 kg however, indicated that levels of lead, mercury and arsenic in vegetables were within acceptable limits. However, the levels of lead in the vegetable samples were high across all three sites. CONCLUSION: Further investigation and research should be undertaken to assess the source/s and extent of public exposure to heavy metals in vegetables in South Africa.

NK2 receptors mediate tachykinin-induced contractions of rat uterus during the oestrous cycle.

We examined tachykinin-induced contractions of uteri from rats during the oestrous cycle. The potencies of substance P, neurokinin A, neurokinin B and the tachykinin NK2 receptor-selective agonist, [Lys5, MeLeu9, Nle10] neurokinin A-(4-10), and of the non-peptide tachykinin NK1, NK2 and NK3 receptor antagonists (S)1-[2-[3-(3,4-dichlorophenyl)-1-(3-isopropoxyphenylacetyl)pip eridin-3-yl]ethyl]-4phenyl-1-azonia-bicyclo[2.2.2]octane (SR 140333), (S)-N-methyl-N [4-(4-acetylamino-4-phenylpiperidino)-2-(3,4-dichlorophenyl)butyl]benzam ide (SR 48968) and (S)-(N)-(1-(3-(1-benzoyl-3-(3,4-dichlorophenyl)piperidin-3-yl)prop yl)-4-phenylpiperidin-4-yl)-N-methylacetamide (SR 142801), were examined. The relative agonist potencies, i.e., [Lys5, MeLeu9, Nle10] neurokinin A-(4-10) > or = neurokinin A > neurokinin B > or = substance P were similar in preparations from rats in dioestrus/metoestrus and those in proestrus/oestrus. Apparent pK(B) values for SR 48968 versus neurokinin A and [Lys5, MeLeu9, Nle10] neurokinin A-(4-10), were 9.9 and 9.2, respectively, indicating activation of an NK2 receptor. SR 140333 (10 nM) produced only a small rightward shift of the log concentration-response curve to substance P. SR 48968 (3 nM), but not SR 142801 (100-300 nM) reduced the effect of neurokinin B. These data indicate that in the rat tachykinin-induced contractions of the uteri during the oestrous cycle are mediated primarily by tachykinin NK2 receptors, and that fluctuations in ovarian hormonal levels during the oestrous cycle have little influence on the uterine response to tachykinins.

Comparison of passive haemagglutination test with Widal agglutination test for serological diagnosis of typhoid fever in an endemic area.

A passive haemagglutination test, using sheep red blood cells sensitised with Salmonella typhi lipopolysaccharide, was compared with the Widal test for the serological diagnosis of typhoid fever in an endemic area. The results obtained on sera from 152 patients with bacteriologically confirmed typhoid and 183 patients who did not have typhoid were analysed in terms of sensitivity, specificity, simplicity, and rapidity of the respective tests. The passive haemagglutination test was found to be more sensitive (80%) than the S typhi O antigen (71%) but marginally less sensitive than the H antigen (82%) of the Widal test. The false positive rate on control sera was 1.2% and 6.6%, respectively, for the Widal O and H antigens, and 1.6% for the passive haemagglutination test. Our findings indicate that the passive haemagglutination test is comparable with the Widal test for the serological diagnosis of typhoid fever in endemic areas, but is more simple, rapid, and economic. The passive haemagglutination test may be a useful alternative to the Widal test for the serological diagnosis of typhoid fever in busy microbiology laboratories in areas in which the disease is endemic.

Binding of DNA to albumin and transferrin modified by treatment with water-soluble carbodiimides.

N-Acylurea derivatives of albumin and transferrin prepared with the water-soluble carbodiimides N-ethyl-N'-(3-dimethylaminopropyl)carbodiimide and N-ethyl-N'-(3-trimethylpropylammonium)carbodiimide iodide have been found to bind different types of DNA. The two proteins were reacted with varying amounts of carbodiimide in water at pH 5.5 for 36-60 hr at 20 degrees, and then purified. In the case of iron-loaded transferrin, reactions with carbodiimides were in phosphate-buffered saline (pH 7.5) to prevent loss of iron from the protein. [3H]N-Ethyl-N'-(3-trimethylpropylammonium)carbodiimide iodide was used for the determination of covalently attached N-acylurea groups in the modified proteins, and gel electrophoresis for changes in charge and possible aggregation through cross-linking. Binding of DNA to N-acylurea proteins was studied by means of gel electrophoresis and nitrocellulose filter binding. N-Acylurea albumin and N-acylurea transferrin at low concentrations retarded the migration of lambda-Pstl restriction fragments, pBR322 plasmid and M13 mp8 single-stranded DNA on agarose gels, while at higher concentrations of modified protein the N-acylurea protein-DNA complexes were unable to enter the gel. Nitrocellulose filter assays showed that binding pBR322 DNA and calf thymus DNA to N-acylurea proteins is rapid and dependent on protein concentration and the ionic strength of the medium. N-Acylurea albumins prepared with each each of the two carbodiimides gave comparable plots for DNA bound versus protein concentration. On the other hand, binding of DNA by N-acylurea transferrins differed according to the carbodiimide used in the synthesis. N-Acylurea CDI-tkransferrin (prepared with tertiary carbodiimide) was less effective than either of the two N-acylurea albumins in binding DNA. In contrast with these results, N-acylurea Me+-CDI-transferrin (prepared with quaternary carbodiimide) was far more effective in binding DNA and in this respect was similar to the N-acylurea albumins. On the basis of experiments in which N-acylurea protein-DNA complexes were treated with heparin, two types of binding could be distinguished. These were a weak binding occurring in the initial stages of interaction and a tight binding which developed on further incubation of the complexes. These studies show that binding of DNA by N-acylurea proteins is a reversible process dependent on ionic strength; interaction appears to be electrostatic in nature, although other forms of binding might be involved.(ABSTRACT TRUNCATED AT 400 WORDS)