New-Onset Rheumatic Immune-Mediated Inflammatory Diseases Following SARS-CoV-2 Vaccinations until May 2023: A Systematic Review.

A comprehensive, up-to-date systematic review (SR) of the new-onset rheumatic immune-mediated inflammatory diseases (R-IMIDs) following COVID-19 vaccinations is lacking. Therefore, we investigated the demographics, management, and prognosis of new R-IMIDs in adults following SARS-CoV-2 vaccinations. A systematic literature search of Medline, Embase, Google Scholar, LitCovid, and Cochrane was conducted. We included any English-language study that reported new-onset R-IMID in adults following the post-COVID-19 vaccination. A total of 271 cases were reported from 39 countries between January 2021 and May 2023. The mean age of patients was 56 (range 18-90), and most were females (170, 62.5%). Most (153, 56.5%) received the Pfizer BioNTech COVID-19 vaccine. Nearly 50% of patients developed R-IMID after the second dose of the vaccine. Vasculitis was the most prevalent clinical presentation (86, 31.7%), followed by connective tissue disease (66, 24.3%). The mean duration between the vaccine's 'trigger' dose and R-IMID was 11 days. Most (220, 81.2%) received corticosteroids; however, 42% (115) received DMARDs such as methotrexate, cyclophosphamide, tocilizumab, anakinra, IV immunoglobulins, plasma exchange, or rituximab. Complete remission was achieved in 75 patients (27.7%), and 137 (50.6%) improved following the treatment. Two patients died due to myositis. This SR highlights that SARS-CoV-2 vaccines may trigger R-IMID; however, further epidemiology studies are required.

A case of anti-neutrophil cytoplasmic antibody-associated vasculitis masquerading as Sjögren syndrome.

Anti-neutrophil cytoplasmic antibody (ANCA) -positive vasculitis is a small-vessel vasculitis that affects multiple body systems. Salivary gland involvement in ANCA-associated vasculitis is rare. When present, it mimics infection or malignancy, which might lead to misdiagnosis. In this report, we describe a 72-year-old man who presented with parotid and submandibular gland pain and swelling in addition to dry mouth and eyes. He had bilateral non-tender parotid gland lumps and no lymphadenopathies. Laboratory tests were positive for ANCA, hematuria, and proteinuria but negative for Anti-Ro and -La. He was treated with corticosteroids and cyclophosphamide for acute kidney injury. Unfortunately, the patient died a few months later. This case report sheds light on a rare manifestation of salivary gland involvement in ANCA-associated vasculitis that mimics Sjögren syndrome and the challenges associated with its diagnosis and treatment.

To Test or Not? Xpert MTB/RIF as an Alternative to Smear Microscopy to Guide Line Probe Assay Testing for Drug-Resistant Tuberculosis.

Xpert MTB/RIF (Xpert) revolutionized tuberculosis (TB) diagnosis. Laboratory decision making on whether widely-used reflex drug susceptibility assays (MTBDRplus, first-line resistance; MTBDRsl, second-line) are conducted is based on smear status, with smear-negative specimens often excluded. We performed receiver operator characteristic (ROC) curve analyses using bacterial load information (smear microscopy grade, Xpert-generated semi-quantitation categories and minimum cycle threshold [CTmin] values) from Xpert rifampicin-resistant sputum for the prediction of downstream line probe assay results as "likely non-actionable" (no resistance or susceptible results generated). We evaluated actionable-to-non-actionable result ratios and pay-offs with missed resistance versus LPAs done universally. Smear-negatives were more likely than smear-positive specimens to generate a non-actionable MTBDRplus (23% [133/559] versus 4% [15/381]) or MTBDRsl (39% [220/559] versus 12% [47/381]) result. However, excluding smear-negatives would result in missed rapid diagnoses (e.g., only 49% [264/537] of LPA-diagnosable isoniazid resistance would be detected if smear-negatives were omitted). Testing smear-negatives with a semi-quantitation category ≥ "medium" had a high ratio of actionable-to-non-actionable results (12.8 or a 4-fold improvement versus testing all using MTBDRplus, 4.5 or 3-fold improvement for MTBDRsl), which would still capture 64% (168/264) and 77% (34/44) of LPA-detectable smear-negative resistance, respectively. Use of CTmins permitted optimization of this ratio with higher specificity for non-actionable results but decreased resistance detected. Xpert quantitative information permits identification of a smear-negative subset in whom the payoffs of the ratio of actionable-to-non-actionable LPA results with missed resistance may prove acceptable to laboratories, depending on context. Our findings permit the rational expansion of direct DST to certain smear-negative sputum specimens.

A convoluted path to the diagnosis of hepatocellular carcinoma in a resource-limited setting.

Worldwide, chronic hepatitis B virus infection remains the main aetiology of hepatocellular carcinoma, while human immunodeficiency virus may hasten the evolution of hepatocellular carcinoma in those co-infected with hepatitis B virus/human immunodeficiency virus. We describe a 29-year-old female with unmonitored hepatitis B virus infection for over 5 years, human immunodeficiency virus disease on a tenofovir-based antiretroviral regimen for 11 months, who presented with a 2-week history of epistaxis and abnormal vaginal bleeding, associated with unintentional weight loss of 4 months duration. After extensive investigation, a definitive diagnosis of hepatocellular carcinoma was established based on histopathological assessment in the presence of a positive hepatitis B envelope antigen, mildly raised alpha feto-protein, and a non-cirrhotic liver. Periodic surveillance for hepatocellular carcinoma in patients with chronic hepatitis B virus infection is important, particularly in those with evidence of actively replicating hepatitis B virus for early detection and implementation of curative therapies to reduce mortality and morbidity.

Quantifying the relationship of HIV infection with clinicopathological spectrum and outcome among patients with colorectal cancer in a South African population.

Introduction: Literature is limited on HIV and colorectal cancer (CRC) in sub-Saharan Africa despite it being the epicentre of the HIV epidemic. Purpose: To compare clinicopathological features and outcome of CRC in HIV-negative and HIV-positive patients. Methods: Retrospective analysis of a prospective CRC database. Demographic details, HIV status, anatomical site, disease stage, treatment and follow-up were documented. Results: Of 715 patients with CRC, 145 and 570 tested positive and negative respectively for HIV. Median age was 45 (IQR 36-53 and 57 (IQR 45-66) years among HIV-positive and HIV-negative patients respectively (p<0.0001). Tumour differentiation differed between the two groups (p=0.003) but staging was not different (p=0.6). Surgical resection rate was 52% for HIV-positive patients versus 59% for HIV-negative patients (p=0.07). Median follow-up was 9 (IQR 2-20.5) months for HIV-positive patients and 12 (IQR 6-29) months for HIV-negative patients (p=0.154). Recurrence rate was 14.7% among HIV positive patients and 6.8% in HIV negative patients (p=0.089). Conclusion: When compared with HIV-negative patients, HIV-positive patients with CRC presented at a younger age and tended to have lower surgical resection rates. There was no difference between the two groups with CRC in terms of anatomical sub-site distribution, disease staging and recurrence rates.

Diabetes in the public healthcare sector of four South African provinces: A comparative analysis.

BACKGROUND: The growing burden of diabetes has long been under the radar in developing countries such as South Africa (SA). In recent years, there has been an unprecedented and exponential increase in recorded and undiagnosed diabetes mellitus (DM) cases. Unreliable data collection, overburdened health systems and poor infrastructure have all proved to be barriers to achieving optimum disease management. The District Health Information System (DHIS) serves as the data collection tool for the SA public healthcare sector. It is used in all nine SA provinces to gather data without individual patient identifiers. OBJECTIVE: To analyse and compare the DM data collected by the DHIS in the Western Cape (WC), Eastern Cape (EC), KwaZulu-Natal (KZN) and Gauteng provinces of SA. METHODS: An audit of diabetes-related data from the DHIS for 2016 was conducted. The data were then analysed using Excel. Time-series and cross-sectional analyses were made possible using pivot tables. Graphics were designed using Thinkcell software. RESULTS: Of the four provinces surveyed, Gauteng recorded the highest incidence of DM, 67% higher than the reported global DM incidence estimate, while the WC had the lowest incidence. A similar pattern was also noted regarding the incidence of DM in people aged <18 years, with Gauteng having the highest and WC the lowest prevalence results. When comparing the number of DM-related consultations conducted in each province, the metropolitan districts were highlighted as hotspots of activity for DM care. This study found a moderate inversely proportional relationship between the incidence of DM in all provinces and education deprivation (p<0.05). Among the provinces that collected data on screening (excluding EC), KZN recorded the highest number of diabetic screenings. CONCLUSION: Metropolitan areas were highlighted as areas to be targeted, further reinforcing the current connection observed between urbanisation and DM in SA. The presence and recording of screening efforts is an excellent step in the right direction for the SA public healthcare sector and the DHIS. With improved interprovincial co-ordination regarding standardisation of the criteria and specifications of data collection fields, and enhanced training for data officers and primary collection agents, good quality and rich data is a very close possibility.

Quantifying the relationship of HIV infection with clinicopathological spectrum and outcome among patients with colorectal cancer in a South African population

Introduction: Literature is limited on HIV and colorectal cancer (CRC) in sub-Saharan Africa despite it being the epicentre of the HIV epidemic, Purpose: To compare clinicopathological features and outcome of CRC in HIV-negative and HIV-positive patients. Methods: Retrospective analysis of a prospective CRC database. Demographic details, HIV status, anatomical site, disease stage, treatment and follow-up were documented. Results: Of 715 patients with CRC, 145 and 570 tested positive and negative respectively for HIV. Median age was 45 (IQR 36-53 and 57 (IQR 45-66) years among HIV-positive and HIV-negative patients respectively (p<0.0001). Tumour differentiation differed between the two groups (p=0.003) but staging was not different (p=0.6). Surgical resection rate was 52% for HIV-positive patients versus 59% for HIV-negative patients (p=0.07). Median follow-up was 9 (IQR 2-20.5) months for HIV-positive patients and 12 (IQR 6-29) months for HIV-negative patients (p=0.154). Recurrence rate was 14.7% among HIV positive patients and 6.8% in HIV negative patients (p=0.089). Conclusion: When compared with HIV-negative patients, HIV-positive patients with CRC presented at a younger age and tended to have lower surgical resection rates. There was no difference between the two groups with CRC in terms of anatomical sub-site distribution, disease staging and recurrence rates

Diabetes in the public healthcare sector of four South African provinces: A comparative analysis

The growing burden of diabetes has long been under the radar in developing countries such as South Africa (SA). In recent years, there has been an unprecedented and exponential increase in recorded and undiagnosed diabetes mellitus (DM) cases. Unreliable data collection, overburdened health systems and poor infrastructure have all proved to be barriers to achieving optimum disease management. The District Health Information System (DHIS) serves as the data collection tool for the SA public healthcare sector. It is used in all nine SA provinces to gather data without individual patient identifiers. Objective. To analyse and compare the DM data collected by the DHIS in the Western Cape (WC), Eastern Cape (EC), KwaZulu-Natal (KZN) and Gauteng provinces of SA. Methods. An audit of diabetes-related data from the DHIS for 2016 was conducted. The data were then analysed using Excel. Time-series and cross-sectional analyses were made possible using pivot tables. Graphics were designed using Thinkcell software. Results. Of the four provinces surveyed, Gauteng recorded the highest incidence of DM, 67% higher than the reported global DM incidence estimate, while the WC had the lowest incidence. A similar pattern was also noted regarding the incidence of DM in people aged <18 years, with Gauteng having the highest and WC the lowest prevalence results. When comparing the number of DM-related consultations conducted in each province, the metropolitan districts were highlighted as hotspots of activity for DM care. This study found a moderate inversely proportional relationship between the incidence of DM in all provinces and education deprivation (p<0.05). Among the provinces that collected data on screening (excluding EC), KZN recorded the highest number of diabetic screenings. Conclusion. Metropolitan areas were highlighted as areas to be targeted, further reinforcing the current connection observed between urbanisation and DM in SA. The presence and recording of screening efforts is an excellent step in the right direction for the SA public healthcare sector and the DHIS. With improved interprovincial co-ordination regarding standardisation of the criteria and specifications of data collection fields, and enhanced training for data officers and primary collection agents, good quality and rich data is a very close possibility.

Glycated haemoglobin (HbA1c) use and glycaemic control in patients living with diabetes mellitus attending public healthcare facilities in KwaZulu-Natal Province, South Africa.

BACKGROUND: Ideal control of diabetes mellitus (DM) remains a global goal, which has not yet been reached. As part of an integrated public healthcare strategy, data with subsequent analysis of diabetes control achieved in patients living with DM (PLWD) need to be available. Diabetes control data from KwaZulu-Natal (KZN) Province, South Africa, are scarce. Smaller studies conducted in public and private healthcare sectors of KZN have shown suboptimal DM control. OBJECTIVES: To identify the percentage of glycated haemoglobin (HbA1c) tests done in KZN public healthcare facilities, and to provide a glimpse into diabetes control being achieved in each KZN district municipality. METHODS: Data regarding the number of HbA1c tests performed, number of patients with an HbA1c ≤7% and number of diabetes visits were accessed from the KZN Department of Health Information Systems and analysed. RESULTS: The majority of HbA1c tests were performed in the metro municipality of eThekwini (p<0.001). Approximately two-thirds (64.5%) of PLWD in whom HbA1c tests had been performed, were suboptimally controlled. In 5 of the 11 KZN district municipalities more than two-thirds of PLWD had an HbA1c >7%. Most of the patients in 9 of the 11 district municipalities showed suboptimal control of their DM. The total number of HbA1c tests performed in KZN represents approximately one-tenth of the total number of diabetes treatment visits. This trend was prevalent in all 11 district municipalities, where the incidence of DM was on an upward trajectory. CONCLUSIONS: Our study demonstrated that the majority of PLWD visiting public healthcare facilities in KZN have suboptimal glycaemic control. They are at increased risk of developing diabetes-related complications, further burdening the healthcare fiscus of low- to middle-income countries. We also showed that the number of HbA1c tests being performed, in the presence of suboptimal control, was well below par. This finding serves to emphasise the need for strategies to be implemented to increase awareness of HbA1c testing for the monitoring of glycaemic control, and for making point-of-care HbA1c testing readily available in these healthcare facilities.

The spectrum of hearing abnormalities in patients living with diabetes mellitus.

BACKGROUND: Diabetes mellitus (DM) causes both micro- and macrovascular complications. The cochlea and auditory nerves are therefore at increased risk from DM-related complications due to microangiopathy, neuropathy or mitochondrial damage. Limited data are available from Africa detailing the association between DM and hearing impairment (HI). OBJECTIVES: To describe the prevalence and spectrum of and associations with HI in patients living with DM (PLWD) with and without HIV infection. METHODS: This was an analytical cross-sectional study conducted between 1 October and 31 December 2019 at the Edendale Hospital diabetes and audiology clinics in Pietermaritzburg, South Africa. PLWD had an audiological assessment using pure-tone audiometry together with a questionnaire enquiring about tinnitus, vertigo, dizziness and HI. RESULTS: A total of 296 PLWD (89.2% with type 2 DM) were enrolled, of whom 154 (52.0%) had HI. Type 2 PLWD had a significantly higher prevalence of reported symptoms and confirmed audiological HI, which was most often bilateral. The most frequent HI categories were mild to moderate, mild, and moderate to severe (33.8% v. 25.9% v. 23.9%, respectively). Significant associations were noted between dizziness (p=0.045), reported hearing loss (p<0.001) and objective evidence of HI (all categories except mild). HI was significantly associated with age >50 years, DM duration ≤10 years, female gender, hypertension, increased low-density lipoprotein and total cholesterol (TC), lower high-density lipoprotein cholesterol, suboptimal glycaemic control, non-proliferative retinopathy, sensory neuropathy and obesity (p<0.05). Approximately half (48.9%) of PLWD and HIV infection had HI, and they were significantly younger and had higher TC levels than PLWD without HIV (p<0.05). CONCLUSIONS: We showed that HI occurs in over half of PLWD, usually within the first 10 years after diagnosis of DM. Symptoms of HI were shown to have positive associations with all HI categories except mild. A high level of vigilance for HI must be maintained in PLWD.

Data of macroinvertebrates assemblage across different stretches of an urban Palmiet River in Durban, South Africa.

Urban rivers have been overlooked as they are regarded as unnatural with poor ecological conditions to support aquatic life. This dataset presents the abundance and taxa richness of macroinvertebrates collected in an urban Palmiet River, which showed highly variable stretches with respect to water quality and physical habitat availability. A YSI 556 MPS handheld multiparameter instrument was used to measure physical variables of the water, whereas samples were taken using sampling bottles and kept in the fridge prior to nutrient analysis. Habitat assessment was carried out following the integrated habitat assessment score (IHAS) protocol. Macroinvertebrates were collected using modified SASS5 protocol, where stone, vegetation, and gravel sand, and mud biotopes were sampled. Macroinvertebrates were identified to family levels, and abundance and taxa richness were calculated. This data affirms the capacity of urban rivers to harbor aquatic biota and to self-purify along the longitudinal gradient. The data further attest that the response of urban rivers to anthropogenic activities does not differ from natural streams, and the assemblage of macroinvertebrates is driven by water quality and physical habitat. Moreover, the role played by anthropogenic litter in the absence of natural habitat is stressed. Lastly, this data can guide urban ecologists when designing studies for highly variable urban river systems as it illustrates the dynamics of urban ecosystems and their potential to harbor aquatic biota.

Demographics and clinical characteristics of hospitalised patients under investigation for COVID-19 with an initial negative SARS-CoV-2 PCR test result.

BACKGROUND: The COVID-19 pandemic is placing abnormally high and ongoing demands on healthcare systems. Little is known about the full effect of the COVID-19 pandemic on diseases other than COVID-19 in the South African setting. OBJECTIVE: To describe a cohort of hospitalised patients under investigation for SARS-CoV-2 that initially tested negative. METHODS: Consecutive patients hospitalised at Khayelitsha Hospital from April to June 2020, whose initial polymerase chain reaction test for SARS-CoV-2 was negative were included. Patient demographics, clinical characteristics, ICD-10 (International Statistical Classification of Diseases and Related Health Problems 10th Revision) diagnosis, referral to tertiary level facilities and ICU, and all-cause in-hospital mortality were collected. The 90-day re-test rate was determined and comparisons were made using the χ2-test and the independent samples median test. RESULTS: Overall, 261 patients were included: median age 39.8 years, 55.6% female (n = 145). Frequent comorbidities included HIV (41.4%), hypertension (26.4%), and previous or current tuberculosis (24.1%). Nine (3.7%) patients were admitted to ICU and 38 (15.6%) patients died. Ninety-three patients (35.6%) were re-tested and 21 (22.6%) were positive for SARS-CoV-2. The top primary diagnoses related to respiratory diseases (n = 82, 33.6%), and infectious and parasitic diseases (n = 62, 25.4%). Thirty-five (14.3%) had a COVID-19 diagnostic code assigned (26 without microbiological confirmation) and 43 (16.5%) had tuberculosis. Older age (p = 0.001), chronic renal impairment (p = 0.03) and referral to higher level of care (all p < 0.001; ICU p = 0.03) were more frequent in those that died. CONCLUSION: Patients with tuberculosis and other diseases are still presenting to emergency centres with symptoms that may be attributable to SARS-CoV-2 and requiring admission. Extreme vigilance will be necessary to diagnosis and treat tuberculosis and other diseases as we emerge from the COVID-19 pandemic.

Evaluation of Tween 80 incorporated media to increase pathogen isolation from peritoneal fluid of CAPD patients at Hospital Kuala Lumpur.

INTRODUCTION: Continuous ambulatory peritoneal dialysis (CAPD)-associated peritonitis remains a major complication in patients on CAPD leading to increased morbidity and mortality. Successful therapy of peritonitis is highly dependent on a positive microbiological culture because narrow spectrum antibiotics are essential to efficiently combat infection. Therefore, this study evaluated the performance of Tween 80 containing media at three different concentrations (0.1%, 1.0% and 2.0%) to increase the pathogen yield from peritoneal fluid in comparison with the standard culture media. MATERIALS AND METHODS: Peritoneal fluid samples (n=121) obtained from CAPD patients suspected of peritonitis at Hospital Kuala Lumpur were analysed macroscopically and microscopically prior to culture. All samples were cultured on seven different culture media, including sheep blood agar, MacConkey agar, Sabouraud dextrose agar, brain heart infusion agar and Tween 80 incorporated blood agar. All plates were incubated at an optimum temperature up to 48 hours. RESULTS AND CONCLUSION: Among all the culture media investigated, 0.1% to 2.0% Tween 80 incorporated blood agar yielded the highest positive culture (23/121) in comparison with all other standard media, thus lowering the negative culture rate among CAPD patients. Statistical analysis by Chi Square revealed significant differences (p <0.001) between the three concentrations of Tween 80 tested in this study. Among the three different concentrations of Tween 80 optimised in this study, blood agar containing 0.1% Tween 80 generated the best results, achieved by optimum growth of all Gram-positive organisms, Gram-negative organisms and yeast cells simultaneously. Using a small amount of detergent at low cost significantly increased the pathogen yield during CAPD-associated peritonitis.

Parental access to hospitalised children during infectious disease pandemics such as COVID-19.

The COVID-19 pandemic has resulted in many hospitals severely limiting or denying parents access to their hospitalised children. This article provides guidance for hospital managers, healthcare staff, district-level managers and provincial managers on parental access to hospitalised children during a pandemic such as COVID-19. It: (i) summarises legal and ethical issues around parental visitation rights; (ii) highlights four guiding principles; (iii) provides 10 practical recommendations to facilitate safe parental access to hospitalised children; (iv) highlights additional considerations if the mother is COVID-19-positive; and (v) provides considerations for fathers. In summary, it is a child's right to have access to his or her parents during hospitalisation, and parents should have access to their hospitalised children; during an infectious disease pandemic such as COVID-19, there is a responsibility to ensure that parental visitation is implemented in a reasonable and safe manner. Separation should only occur in exceptional circumstances, e.g. if adequate in-hospital facilities do not exist to jointly accommodate the parent/caregiver and the newborn/infant/child. Both parents should be allowed access to hospitalised children, under strict infection prevention and control (IPC) measures and with implementation of non-pharmaceutical interventions (NPIs), including handwashing/sanitisation, face masks and physical distancing. Newborns/infants and their parents/caregivers have a reasonably high likelihood of having similar COVID-19 status, and should be managed as a dyad rather than as individuals. Every hospital should provide lodger/boarder facilities for mothers who are COVID-19-positive, COVID-19-negative or persons under investigation (PUI), separately, with stringent IPC measures and NPIs. If facilities are limited, breastfeeding mothers should be prioritised, in the following order: (i) COVID-19-negative; (ii) COVID-19 PUI; and (iii) COVID-19-positive. Breastfeeding, or breastmilk feeding, should be promoted, supported and protected, and skin-to-skin care of newborns with the mother/caregiver (with IPC measures) should be discussed and practised as far as possible. Surgical masks should be provided to all parents/caregivers and replaced daily throughout the hospital stay. Parents should be referred to social services and local community resources to ensure that multidisciplinary support is provided. Hospitals should develop individual-level policies and share these with staff and parents. Additionally, hospitals should ideally track the effect of parental visitation rights on hospital-based COVID-19 outbreaks, the mental health of hospitalised children, and their rate of recovery.

The burden of hypertension in KwaZulu-Natal Province, South Africa: A 6-year perspective.

BACKGROUND: Hypertension (HPT) and its complications continue to pose a global threat and contribute to premature mortality worldwide. The adverse interactions between HPT, obesity and COVID-19 are currently being witnessed globally and represent a collision of pandemics. Understanding the burden that this non-communicable disease (NCD) poses in KwaZulu-Natal (KZN) Province, South Africa (SA), would help in developing improved public healthcare strategies. OBJECTIVES: To describe the burden of HPT in all the districts of KZN over a 6-year period. METHODS: HPT data are routinely collected from all KZN public health facilities (both clinics and hospitals) as part of the District Health Information System (DHIS). In this retrospective study, we accessed HPT records from the DHIS over a period of 6 years (2014 - 2019, inclusive). Data collected included the number of patients screened, diagnosed and initiated on therapy for HPT, together with the number of obese patients. RESULTS: The slopes for HPT screening were positive at both clinics and hospitals in KZN (considerably more at clinics than hospitals, with a difference in elevations of slopes of p<0.001), with a significantly greater percentage of the population having been screened at rural clinics than at hospitals (difference in elevation of slopes p<0.001). A significantly greater number of patients aged <40 years (p<0.001) were being screened for HPT at clinics than at hospitals (2017/18, 2018/19, 2019/20), while hospitals screened considerably more patients aged ≥40 years in 2017 - 2018 (p<0.001). The numbers of new hypertensives diagnosed and having treatment initiated were on an upward slope at both clinics and hospitals, with clinics having a greater elevation of slope than hospitals (p<0.001), irrespective of patient age. A significantly greater number of patients aged ≥40 years (p<0.05) were diagnosed with HPT at both clinics and hospitals in KZN (2017/18, 2018/19, 2019/20). KZN clinics remained the first port of call for known hypertensives throughout the study period. Obesity was prevalent at both clinic and hospital level, although figures were significantly higher at clinics. Over 80% of the obesity burden was carried by the rural clinics and hospitals. CONCLUSIONS: Screening, diagnosis, treatment initiation and chronic management of HPT occur mainly at rural clinic level. The SA government needs to heed these findings and redirect resources (staffing and equipment) to this level. The prevalence of obesity was highest at rural healthcare facilities (clinics more than hospitals). More needs to be done to combat the obesity pandemic if we are to win the battle against NCDs (HPT and diabetes mellitus). A significant number of patients aged <40 years are being screened for HPT, which bodes well for the province, as early diagnosis and treatment of HPT are vital to prevent complications.

A nurse-led intervention to improve management of virological failure in public sector HIV clinics in Durban, South Africa: A pre- and post-implementation evaluation.

BACKGROUND: Identification of patients on antiretroviral therapy (ART) with virological failure (VF) and the response in the public health sector remain significant challenges. We previously reported improvement in routine viral load (VL) monitoring after ART commencement through a health system-strengthening, nurse-led 'VL champion' programme as part of a multidisciplinary team in three public sector clinics in Durban, South Africa. OBJECTIVES: To report on the impact of the VL champion model adapted to identify, support and co-ordinate the management of individuals with VF on first-line ART in a setting with limited electronic-based record capacity. METHODS: We evaluated the VL champion model using a controlled before-after study design. A paper-based tool, the 'high VL register', was piloted under the supervision of the VL champion to improve data management, monitoring of counselling support, and enacting of clinical decisions. We abstracted chart and electronic data (TIER.net) for eligible individuals with VF in the year before and after implementation of the programme, and compared outcomes for individuals during these periods. Our primary outcome was successful completion of the VF pathway, defined as a repeat VL <1 000 copies/mL or a change to second-line ART within 6 months of VF. In a secondary analysis, we assessed the completion of each step in the pathway. RESULTS: We identified 60 and 56 individuals in the pre-intervention and post-intervention periods, respectively, with VF who met the inclusion criteria. Sociodemographic and clinical characteristics were similar between the periods. Repeat VL testing was completed in 61.7% and 57.8% of individuals in these two groups, respectively. We found no difference in the proportion achieving our primary outcome in the pre- and post-intervention periods: 11/60 (18.3%; 95% confidence interval (CI) 9 - 28) and 15/56 (22.8%; 95% CI 15 - 38), respectively (p=0.28). In multivariable logistic regression models adjusted for potential confounding factors, individuals in the post-intervention period had a non-significant doubling of the odds of achieving the primary outcome (adjusted odds ratio 2.07; 95% CI 0.75 - 5.72). However, there was no difference in the rates of completion of each step along the first-line VF cascade of care. CONCLUSIONS: This enhanced intervention to improve VF in the public sector using a paper-based data management system failed to achieve significant improvements in first-line VF management over the standard of care. In addition to interventions that better address patient-centred factors that contribute to VF, we believe that there are substantial limitations to and staffing requirements involved in the ongoing utilisation of a paper-based tool. A prioritisation is needed to further expand and upgrade the electronic medical record system with capabilities for prompting staff regarding patients with missed visits and critical laboratory results demonstrating VF.

NeoCLEAN: a multimodal strategy to enhance environmental cleaning in a resource-limited neonatal unit.

BACKGROUND: Contamination of the hospital environment contributes to neonatal bacterial colonization and infection. Cleaning of hospital surfaces and equipment is seldom audited in resource-limited settings. METHODS: A quasi-experimental study was conducted to assess the impact of a multimodal cleaning intervention for surfaces and equipment in a 30-bed neonatal ward. The intervention included cleaning audits with feedback, cleaning checklists, in-room cleaning wipes and training of staff and mothers in cleaning methods. Cleaning adequacy was evaluated for 100 items (58 surfaces, 42 equipment) using quantitative bacterial surface cultures, adenosine triphosphate bioluminescence assays and fluorescent ultraviolet markers, performed at baseline (P1, October 2019), early intervention (P2, November 2019) and late intervention (P3, February 2020). RESULTS: Environmental swabs (55/300; 18.3%) yielded growth of 78 potential neonatal pathogens with Enterococci, S. marcescens, K. pneumoniae, S. aureus and A. baumannii predominating. Highest aerobic colony counts were noted from moist surfaces such as sinks, milk kitchen surfaces, humidifiers and suction tubing. The proportion of surfaces and equipment exhibiting no bacterial growth increased between phases (P1 = 49%, P2 = 66%, P3 = 69%; p = 0.007). The proportion of surfaces and equipment meeting the ATP "cleanliness" threshold (< 200 relative light units) increased over time (P1 = 40%, P2 = 54%, P3 = 65%; p = 0.002), as did the UV marker removal rate (P1 = 23%, P2 = 71%, P3 = 74%; p < 0.001). CONCLUSION: Routine environmental cleaning of this neonatal ward was sub-optimal at baseline but improved significantly following a multimodal cleaning intervention. Involving mothers and nursing staff was key to achieving improved environmental and equipment cleaning in this resource-limited neonatal unit.

A packaged intervention to improve viral load monitoring within a deeply rural health district of South Africa.

BACKGROUND: The KwaZulu-Natal (KZN) province of South Africa has the highest prevalence of HIV infection in the world. Viral load (VL) testing is a crucial tool for clinical and programmatic monitoring. Within uMkhanyakude district, VL suppression rates were 91% among patients with VL data; however, VL performance rates averaged only 38·7%. The objective of this study was to determine if enhanced clinic processes and community outreach could improve VL monitoring within this district. METHODS: A packaged intervention was implemented at three rural clinics in the setting of the KZN HIV AIDS Drug Resistance Surveillance Study. This included file hygiene, outreach, a VL register and documentation revisions. Chart audits were used to assess fidelity. Outcome measures included percentage VL performed and suppressed. Each rural clinic was matched with a peri-urban clinic for comparison before and after the start of each phase of the intervention. Monthly sample proportions were modelled using quasi-likelihood regression methods for over-dispersed binomial data. RESULTS: Mkuze and Jozini clinics increased VL performance overall from 33·9% and 35·3% to 75·8% and 72·4%, respectively which was significantly greater than the increases in the comparison clinics (RR 1·86 and 1·68, p < 0·01). VL suppression rates similarly increased overall by 39·3% and 36·2% (RR 1·84 and 1·70, p < 0·01). The Chart Intervention phase showed significant increases in fidelity 16 months after implementation. CONCLUSIONS: The packaged intervention improved VL performance and suppression rates overall but was significant in Mkuze and Jozini. Larger sustained efforts will be needed to have a similar impact throughout the province.

IL-4R alpha deficiency influences hippocampal-BDNF signaling pathway to impair reference memory.

Like pro-inflammatory cytokines, the role of anti-inflammatory cytokines in both learning and memory has been investigated, revealing beneficial effects for both interleukin-4 and interleukin-13 via the common interleukin-4 receptor alpha chain complex. In this study, using the Morris water maze spatial task for cognition, we compared interleukin-4 receptor alpha- deficient mice and their ligands interleukin-4/ interleukin-13 double deficient mice, on a Balb/c background. We demonstrate that while interleukin-4/ interleukin-13 double deficient mice are significantly impaired in both learning and reference memory, interleukin-4 receptor alpha-deficiency impairs only reference memory, compared to the wild-type control mice. In order to better understand how interleukin-4 receptor alpha- deficient mice are able to learn but not remember, we investigated the BDNF/TrkB- and the ARC-signaling pathways. We show that interleukin-4 receptor alpha-deficiency disrupts activation of BDNF/TrkB- and ARC-signaling pathways during reference memory, while the pathway for spatial learning is spared.