Tuberculosis testing patterns in South Africa to identify groups that would benefit from increased investigation.

The National Health Laboratory Service (NHLS) collects all public health laboratory test results in South Africa, providing a cohort from which to identify groups, by age, sex, HIV, and viral suppression status, that would benefit from increased tuberculosis (TB) testing. Using NHLS data (2012-2016), we assessed levels and trends over time in TB diagnostic tests performed (count and per capita) and TB test positivity. Estimates were stratified by HIV status, viral suppression, age, sex, and province. We used logistic regression to estimate the odds of testing positive for TB by viral suppression status. Nineteen million TB diagnostic tests were conducted during period 2012-2016. Testing per capita was lower among PLHIV with viral suppression than those with unsuppressed HIV (0.08 vs 0.32) but lowest among people without HIV (0.03). Test positivity was highest among young adults (aged 15-35 years), males of all age groups, and people with unsuppressed HIV. Test positivity was higher for males without laboratory evidence of HIV than those with HIV viral suppression, despite similar individual odds of TB. Our results are an important national baseline characterizing who received TB testing in South Africa. People without evidence of HIV, young adults, and males would benefit from increased TB screening given their lower testing rates and higher test positivity. These high-test positivity groups can be used to guide future expansions of TB screening.

Integrating Molecular Diagnostics and GIS Mapping: A Multidisciplinary Approach to Understanding Tuberculosis Disease Dynamics in South Africa Using Xpert MTB/RIF.

An investigation was carried out to examine the use of national Xpert MTB/RIF data (2013-2017) and GIS technology for MTB/RIF surveillance in South Africa. The aim was to exhibit the potential of using molecular diagnostics for TB surveillance across the country. The variables analysed include Mycobacterium tuberculosis (Mtb) positivity, the mycobacterial proportion of rifampicin-resistant Mtb (RIF), and probe frequency. The summary statistics of these variables were generated and aggregated at the facility and municipal level. The spatial distribution patterns of the indicators across municipalities were determined using the Moran's I and Getis Ord (Gi) statistics. A case-control study was conducted to investigate factors associated with a high mycobacterial load. Logistic regression was used to analyse this study's results. There was striking spatial heterogeneity in the distribution of Mtb and RIF across South Africa. The median patient age, urban setting classification, and number of health care workers were found to be associated with the mycobacterial load. This study illustrates the potential of using data generated from molecular diagnostics in combination with GIS technology for Mtb surveillance in South Africa. Spatially targeted interventions can be implemented in areas where high-burden Mtb persists.

More Than a Decade of GeneXpert®Mycobacterium tuberculosis/Rifampicin (Ultra) Testing in South Africa: Laboratory Insights from Twenty-Three Million Tests.

This study seeks to describe the rollout and current state of South Africa's GeneXpert molecular diagnostic program for tuberculosis (TB). Xpert MTB/RIF was introduced in 2011 with a subsequent expansion to include extra-pulmonary and paediatric testing, followed by Xpert MTB/RIF Ultra in 2017. Through a centralised laboratory information system and the use of a standardised platform for more than a decade, over 23 million tests were analysed, describing the numbers tested, Mycobacterium tuberculosis complex detection, rifampin resistance, and the unsuccessful test rates. The stratification by province, specimen type, age, and sex identified significant heterogeneity across the program and highlighted testing gaps for men, low detection yield for paediatric pulmonary TB, and the effects of inadequate specimen quality on the detection rate. The insights gained from these data can aid in the monitoring of interventions in support of the national TB program beyond laboratory operational aspects.

Cross-municipality migration and spread of tuberculosis in South Africa.

Human migration facilitates the spread of infectious disease. However, little is known about the contribution of migration to the spread of tuberculosis in South Africa. We analyzed longitudinal data on all tuberculosis test results recorded by South Africa's National Health Laboratory Service (NHLS), January 2011-July 2017, alongside municipality-level migration flows estimated from the 2016 South African Community Survey. We first assessed migration patterns in people with laboratory-diagnosed tuberculosis and analyzed demographic predictors. We then quantified the impact of cross-municipality migration on tuberculosis incidence in municipality-level regression models. The NHLS database included 921,888 patients with multiple clinic visits with TB tests. Of these, 147,513 (16%) had tests in different municipalities. The median (IQR) distance travelled was 304 (163 to 536) km. Migration was most common at ages 20-39 years and rates were similar for men and women. In municipality-level regression models, each 1% increase in migration-adjusted tuberculosis prevalence was associated with a 0.47% (95% CI: 0.03% to 0.90%) increase in the incidence of drug-susceptible tuberculosis two years later, even after controlling for baseline prevalence. Similar results were found for rifampicin-resistant tuberculosis. Accounting for migration improved our ability to predict future incidence of tuberculosis.

Postpartum Acute Aortic Dissection in a Patient Without a Connective Tissue Disorder: A Case Report.

Type A acute aortic dissection is a rare life-threatening event that occurs most commonly in the third trimester or early postpartum and in women with connective tissue disorders. However, this case describes a type A aortic dissection diagnosed on postpartum day 2 in a woman with preeclampsia without a history of a connective tissue disease. The case emphasizes the importance of considering dissection in any parturient complaining of chest pain, especially in the setting of hypertension and a new murmur. Emergent imaging must be considered to decrease delays in surgical repair and to minimize maternal morbidity and mortality.

An Accessible Clinical Decision Support System to Curtail Anesthetic Greenhouse Gases in a Large Health Network: Implementation Study.

BACKGROUND: Inhaled anesthetics in the operating room are potent greenhouse gases and are a key contributor to carbon emissions from health care facilities. Real-time clinical decision support (CDS) systems lower anesthetic gas waste by prompting anesthesia professionals to reduce fresh gas flow (FGF) when a set threshold is exceeded. However, previous CDS systems have relied on proprietary or highly customized anesthesia information management systems, significantly reducing other institutions' accessibility to the technology and thus limiting overall environmental benefit. OBJECTIVE: In 2018, a CDS system that lowers anesthetic gas waste using methods that can be easily adopted by other institutions was developed at the University of California San Francisco (UCSF). This study aims to facilitate wider uptake of our CDS system and further reduce gas waste by describing the implementation of the FGF CDS toolkit at UCSF and the subsequent implementation at other medical campuses within the University of California Health network. METHODS: We developed a noninterruptive active CDS system to alert anesthesia professionals when FGF rates exceeded 0.7 L per minute for common volatile anesthetics. The implementation process at UCSF was documented and assembled into an informational toolkit to aid in the integration of the CDS system at other health care institutions. Before implementation, presentation-based education initiatives were used to disseminate information regarding the safety of low FGF use and its relationship to environmental sustainability. Our FGF CDS toolkit consisted of 4 main components for implementation: sustainability-focused education of anesthesia professionals, hardware integration of the CDS technology, software build of the CDS system, and data reporting of measured outcomes. RESULTS: The FGF CDS system was successfully deployed at 5 University of California Health network campuses. Four of the institutions are independent from the institution that created the CDS system. The CDS system was deployed at each facility using the FGF CDS toolkit, which describes the main components of the technology and implementation. Each campus made modifications to the CDS tool to best suit their institution, emphasizing the versatility and adoptability of the technology and implementation framework. CONCLUSIONS: It has previously been shown that the FGF CDS system reduces anesthetic gas waste, leading to environmental and fiscal benefits. Here, we demonstrate that the CDS system can be transferred to other medical facilities using our toolkit for implementation, making the technology and associated benefits globally accessible to advance mitigation of health care-related emissions.

A review of surrogate motherhood regulation in south American countries: pointing to a need for an international legal framework.

BACKGROUND: Advances in science and technology coupled with globalization are changing access to and utilization of reproductive health services. This includes the transnational phenomenon of families who use surrogate mothers to reproduce, with forms of altruistic and commercial surrogacy becoming more commonplace. Simultaneously, changes in law, regulation, and policy are necessary to protect surrogates, intended parents, and resulting children. These developments have been slow to adapt to challenges inherent to surrogacy arrangements, most specifically in low-and middle-income countries, including in South American countries. METHODS: We conducted an interdisciplinary non-systematic literature review and legal analysis of existing and pending policy, laws, and regulations related to commercial surrogacy arrangements in Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Paraguay, Peru, Uruguay, and Venezuela. The review focused on articles that discussed topics of domestic and international law, policy, regulation, and governance related to commercial surrogacy. We queried PubMed, JSTOR, and Google Scholar for Spanish and English-language articles limited to those published between 2000 and 2016. RESULTS: Our literature and legal review found a wide variance in how different countries address the issue, including two (Brazil and Uruguay) that have issued guidance attempting to clarify the legality of commercial surrogacy, others who have introduced surrogacy-specific legislation, and a final group with no specific legal mechanisms in place. Our extracted legal case studies also indicate that courts have a hard time interpreting existing law and its applicability to surrogacy. The influence of Catholicism also played a role in the adoption of surrogacy and other advanced reproductive technology (ART)-related legislation. CONCLUSIONS: Changes in global infertility rates, the emergence of new family structures, and advancement of ART are factors that will influence future development of legal frameworks addressing surrogacy in South America. Despite a growing transnational market for commercial surrogacy in many of the countries examined, the current patchwork of policy does little to clarify what forms of surrogacy are legally permissible, nor do they adequately protect surrogates, intended parents, or the children themselves. This points to an urgent need for regional legal and policy harmonization specifically designed to align with public health and human rights principles.

Estimating epidemic arrival times using linear spreading theory.

We study the dynamics of a spatially structured model of worldwide epidemics and formulate predictions for arrival times of the disease at any city in the network. The model is composed of a system of ordinary differential equations describing a meta-population susceptible-infected-recovered compartmental model defined on a network where each node represents a city and the edges represent the flight paths connecting cities. Making use of the linear determinacy of the system, we consider spreading speeds and arrival times in the system linearized about the unstable disease free state and compare these to arrival times in the nonlinear system. Two predictions are presented. The first is based upon expansion of the heat kernel for the linearized system. The second assumes that the dominant transmission pathway between any two cities can be approximated by a one dimensional lattice or a homogeneous tree and gives a uniform prediction for arrival times independent of the specific network features. We test these predictions on a real network describing worldwide airline traffic.

Semantic clustering indexes for the Hopkins Verbal Learning Test-Revised: initial exploration in elder control and dementia groups.

This study examined the validity of semantic clustering indexes developed for the Hopkins Verbal Learning Test-Revised (HVLT-R). Participants were healthy adults and patients diagnosed with probable dementia of the Alzheimer's type (DAT) or vascular dementia (VaD). Neuropsychological test records, which included the HVLT-R, were collected from an archival database. Ratio semantic clustering (RSC) scores were calculated for each HVLT-R recall trial. Factor analysis including RSC and other HVLT-R scores yielded high loadings of RSC scores on a distinct clustering factor. Group comparisons showed that normal controls had higher HVLT-R recall and RSC scores than DAT and VaD patients. Only the DAT group showed significant decline in RSC from the final learning trial to delayed recall, and only the DAT group performed more poorly than controls on other semantic processing measures (e.g., HVLT-R semantically-related false positives, Boston Naming Test). Results suggest that these newly developed semantic clustering indexes are easily calculated and potentially useful for discriminating between elder controls and dementia patients.

A quantitative review of the effects of traumatic brain injury on cognitive functioning.

Changes in cognitive functioning often result from traumatic brain injury (TBI) and predict other important aspects of psychosocial recovery. Despite this pivotal role, no quantitative review of cognitive functioning across the spectrum of TBI severity has been reported. We therefore conducted a meta-analysis of 39 mostly cross-sectional studies of the cognitive effects of mild head injury (MHI) and moderate-severe TBI from the acute phase through long-term follow-up. The studies reported 48 comparisons of patients (n = 1716) and control subjects (n = 1164). Averaged across all follow-up periods, the effect of moderate-severe TBI (weighted mean Cohen's d = -0.74) was more than three times the effect of MHI (weighted mean d = -0.24) on overall cognitive functioning. Further, the natural logarithm of the follow-up interval correlated very strongly with estimates of d among patients with MHI, but less so among those with moderate-severe TBI. In short, findings from published research suggest that overall cognitive functioning recovers most rapidly during the first few weeks following MHI, and essentially returns to baseline within 1-3 months. Cognitive functioning also improves during the first two years after moderate-severe TBI, but remains markedly impaired even among patients tested > 2 years post-injury.