Transformer-based structuring of free-text radiology report databases.

OBJECTIVES: To provide insights for on-site development of transformer-based structuring of free-text report databases by investigating different labeling and pre-training strategies. METHODS: A total of 93,368 German chest X-ray reports from 20,912 intensive care unit (ICU) patients were included. Two labeling strategies were investigated to tag six findings of the attending radiologist. First, a system based on human-defined rules was applied for annotation of all reports (termed "silver labels"). Second, 18,000 reports were manually annotated in 197 h (termed "gold labels") of which 10% were used for testing. An on-site pre-trained model (Tmlm) using masked-language modeling (MLM) was compared to a public, medically pre-trained model (Tmed). Both models were fine-tuned on silver labels only, gold labels only, and first with silver and then gold labels (hybrid training) for text classification, using varying numbers (N: 500, 1000, 2000, 3500, 7000, 14,580) of gold labels. Macro-averaged F1-scores (MAF1) in percent were calculated with 95% confidence intervals (CI). RESULTS: Tmlm,gold (95.5 [94.5-96.3]) showed significantly higher MAF1 than Tmed,silver (75.0 [73.4-76.5]) and Tmlm,silver (75.2 [73.6-76.7]), but not significantly higher MAF1 than Tmed,gold (94.7 [93.6-95.6]), Tmed,hybrid (94.9 [93.9-95.8]), and Tmlm,hybrid (95.2 [94.3-96.0]). When using 7000 or less gold-labeled reports, Tmlm,gold (N: 7000, 94.7 [93.5-95.7]) showed significantly higher MAF1 than Tmed,gold (N: 7000, 91.5 [90.0-92.8]). With at least 2000 gold-labeled reports, utilizing silver labels did not lead to significant improvement of Tmlm,hybrid (N: 2000, 91.8 [90.4-93.2]) over Tmlm,gold (N: 2000, 91.4 [89.9-92.8]). CONCLUSIONS: Custom pre-training of transformers and fine-tuning on manual annotations promises to be an efficient strategy to unlock report databases for data-driven medicine. KEY POINTS: • On-site development of natural language processing methods that retrospectively unlock free-text databases of radiology clinics for data-driven medicine is of great interest. • For clinics seeking to develop methods on-site for retrospective structuring of a report database of a certain department, it remains unclear which of previously proposed strategies for labeling reports and pre-training models is the most appropriate in context of, e.g., available annotator time. • Using a custom pre-trained transformer model, along with a little annotation effort, promises to be an efficient way to retrospectively structure radiological databases, even if not millions of reports are available for pre-training.

Healthcare Delivery.

We report here on the process and findings of a research prioritisation exercise for universal health coverage (UHC) in South Africa, conducted during the course of 2019. As plans to roll out National Health Insurance (NHI) gather momentum and we transition into a pandemic recovery phase, we believe that it is now time to revisit these priorities, while recognising that experiences with the COVID-19 pandemic have revealed new system challenges and strengths and introduced new priorities. The UHC research priority-setting methodology followed a stepwise process of collation of evidence, expert brainstorming and the development of a survey completed by 68 members of the Public Health Association of South Africa. Themes related to leadership and governance were ranked most highly, and with other priorities generated, provide an initial road map of knowledge needs that could guide individual institutions and commissioning by funding bodies. We further reflect on the importance of researcher-decision-maker dialogue and strengthening the contribution of health policy and systems research to policy and practice, especially as new reforms are implemented.

Improving health outcomes and quality at the subdistrict level: Evaluation of the '3 feet model' in Waterberg District, Limpopo Province, South Africa.

BACKGROUND: There is a gap in understanding of potential roles and actions at the subdistrict level to improve quality of care and health outcomes in South Africa (SA). OBJECTIVES: To report on the evaluation of a subdistrict health system-strengthening initiative that aimed to reduce maternal, newborn and child mortality, referred to as the '3 feet model' in Waterberg District, Limpopo Province, SA. The model is centred on systems of real-time morbidity/mortality surveillance and co-ordinated responses. It was implemented in three of five Waterberg subdistricts over an 18-month period in 2021 and 2022. METHODS: A prospective, process-tracing evaluation was conducted jointly between researchers, intervention partners and subdistrict decision-makers. Data sources combined ~100 hours of researcher participant observation, interviews with 14 health system actors, structured reflections by three subdistrict managers and information from the routine District Health Information System. Sources were triangulated and analysed based on a priori hypotheses on mechanisms of action. RESULTS: Following uptake of the model, the perinatal mortality rate (PMR) improved by 28.8%, 11.5% and 28% in the three subdistricts, respectively, while the PMR worsened in two of four neighbouring subdistricts. Plausible factors in implementation successes were the presence of stable and committed hybrid (clinical-managerial) subdistrict leaders and their ability to overcome entrenched silos between a variety of system actors; new collaborative relationships between primary healthcare facilities, hospitals and emergency medical services; the generation and packaging of information in ways that directed responses ('actionable intelligence'); and support from senior district managers. CONCLUSION: While not advocating for a cut-and-paste approach to improving quality and outcomes, positive experiences in Waterberg District suggest that the principles and mechanisms of action of the 3 feet model have wider relevance for policy and practice, especially as emphasis shifts towards the subdistrict as a core unit of population health and wellbeing in SA.

District Health System performance in South Africa: Are current monitoring systems optimal?

In this article, we review the monitoring and evaluation system that is used to measure the performance of primary healthcare delivered through the district health system and district management teams. We then review some global frameworks, especially linked to the World Health Organization, and look at some of the differences between what is internationally recommended and what we do in South Africa. We end with some recommendations to improve the system.

Reproductive decision-making by women with X-linked hypohidrotic ectodermal dysplasia.

BACKGROUND: In X-linked hypohidrotic ectodermal dysplasia (XLHED), ectodysplasin A1 (EDA1) deficiency results in malformation of hair, teeth and sweat glands. Lack of sweating which can cause life-threatening hyperthermia is amenable to intrauterine therapy with recombinant EDA1. OBJECTIVES: This study aimed at evaluating reproductive decision-making by women with XLHED and at clarifying the potential impact of a prenatal treatment option. METHODS: In a retrospective cross-sectional analysis, a 75-item questionnaire filled in by 50 women with XLHED (age 19-49 years) was assessed. RESULTS: Sixteen women (32%) prevented pregnancies because of the risk to pass on XLHED; 15 considered assisted reproduction for the same reason. Twelve women had a history of miscarriage, stillbirth or abortion, and three women reported on previous abortion of affected fetuses. When imagining to be pregnant, all except one showed interest in prenatal diagnosis of XLHED and in the possibility of treatment before birth. In 13 out of 50 women (26%), XLHED if detected prenatally would have impact on the continuation of pregnancy. Among 35 mothers of at least one affected child, XLHED had rarely been diagnosed during the first pregnancy (17%) but regularly during subsequent pregnancies (77%). Becoming aware of the condition before birth had caused a moral conflict for 50% of these women. Subjects with an affected child less frequently considered assisted reproduction to prevent XLHED (P < 0.05). In 69% of the women who reported an effect of XLHED on family planning, a prenatal treatment option for this disease would influence their decision-making. CONCLUSIONS: Many pregnant XLHED carriers who seek prenatal diagnosis experience moral conflicts. A prenatal treatment option would have strong impact on reproductive decisions, underlining the importance of adequate professional counselling.

[Outpatient laparoscopic hysterectomy in France: A monocentric randomized trial]. / Hystérectomie cœlioscopique ambulatoire en France : étude randomisée unicentrique.

OBJECTIVE: To demonstrate the feasibility of outpatient laparoscopic hysterectomy using the assessment of post-operative quality of life. METHODS: A prospective randomized single-center trial was performed in France between 2013 and 2016. A total of 42 patients needed laparoscopic hysterectomy was included. Postoperative quality of life was assessed using the standardized Euroquol questionnaire. Patients filled the score before the operation and then on the 3rd and 30th postoperative day. Secondary outcomes were assessment of postoperative pain, overall quality of life, analgesic use, and anxiety. The patients were randomized into two groups, group A with a conventional hospital stay of 2 to 3 days and group B with a short stay and a discharge the day after the intervention. RESULTS: Twenty-one patients were randomized to group A as well as group B. We did not find any significant differences between the two groups in our study either on our primary outcome or in the seconds ones. On day 3, the average of Euroquol score was 0.68 for group A against 0.50 for group B (P=0.05). Likewise, the scores for postoperative pain were similar with 70.6 in group A and 61.8 in group B (P=0.21). The trend was the same for quality of life score or anxiety. CONCLUSION: Our study shows the possibility and the safety of outpatient laparoscopic hysterectomy.

New insights into microstructure of neutron-irradiated tungsten.

The development of appropriate materials for fusion reactors that can sustain high neutron fluence at elevated temperatures remains a great challenge. Tungsten is one of the promising candidate materials for plasma-facing components of future fusion reactors, due to several favorable properties as for example a high melting point, a high sputtering resistivity, and a low coefficient of thermal expansion. The microstructural details of a tungsten sample with a 1.25 dpa (displacements per atom) damage dose after neutron irradiation at 800 °C were examined by transmission electron microscopy. Three types of radiation-induced defects were observed, analyzed and characterized: (1) voids with sizes ranging from 10 to 65 nm, (2) dislocation loops with a size of up to 10 nm and (3) W-Re-Os containing σ- and χ-type precipitates. The distribution of voids as well as the nature of the occurring dislocation loops were studied in detail. In addition, nano-chemical analyses revealed that the σ- and χ-type precipitates, which are sometimes attached to voids, are surrounded by a solid solution cloud enriched with Re. For the first time the crystallographic orientation relationship of the σ- and χ-phases to the W-matrix was specified. Furthermore, electron energy-loss spectroscopy could not unambiguously verify the presence of He within individual voids.

Citrin deficiency mimicking mitochondrial depletion syndrome.

BACKGROUND: Neonatal intrahepatic cholestasis caused by citrin deficiency (CD) is a rare inborn error of metabolism due to variants in the SLC25A13 gene encoding the calcium-binding protein citrin. Citrin is an aspartate-glutamate carrier located within the inner mitochondrial membrane. CASE PRESENTATION: We report on two siblings of Romanian-Vietnamese ancestry with citrin deficiency. Patient 1 is a female who presented at age 8 weeks with cholestasis, elevated lactate levels and recurrent severe hypoglycemia. Diagnosis was made by whole exome sequencing and revealed compound heterozygosity for the frameshift variant c.852_855del, p.Met285Profs*2 and a novel deletion c.(69 + 1_70-1)_(212 + 1_231-1)del in SLC25A13. The girl responded well to dietary treatment with a lactose-free, MCT-enriched formula. Her younger brother (Patient 2) was born 1 year later and also found to be carrying the same gene variants. Dietary treatment from birth was able to completely prevent clinical manifestation until his current age of 4.5 months. CONCLUSIONS: As CD is a well-treatable disorder it should be ruled out early in the differential diagnosis of neonatal cholestasis. Due to the combination of hepatopathy, lactic acidosis and recurrent hypoglycemia the clinical presentation of CD may resemble hepatic mitochondrial depletion syndrome.

Semen analysis and successful artificial insemination in the St. Vincent amazon (Amazona guildingii).

The St. Vincent amazon (Amazona guildingii) is an endemic parrot on the Carribean island St Vincent. Due to poaching, trade, natural events such as hurricanes and habitat loss the species declined severely throughout the 20th century to a total number of 487 adult individuals and is currently regarded as vulnerable by IUCN. Captive breeding is attempted in terms of species conservation, but reproduction rates have been low due to reproductive problems such as mate aggression, asynchronous reproductive activity and infertile eggs. The aims of the present study were; firstly, to evaluate whether semen analysis might help to assess the fertility of males and to detect potential reasons for infertile eggs; secondly, to increase the number of offspring using artificial insemination, and as a future effect, to increase the presence of genetically valuable males in the ex-situ breeding population. For semen collection electric stimulation was used in 15 mature and healthy St. Vincent amazons with a success rate of 89% (202/227 attempts) in 14/15 males. Quality assessment of the semen included the evaluation of volume, pH, color, consistency and contaminations of the ejaculate, as well as estimation of motility, viability, morphology, concentration and total count of spermatozoa. Semen pH ranged from 6.7 to 7.5. Median sperm motility was 50% and median progressively forward motility 40%. Mean sperm concentration (x¯ ± SD) was 21,313.5 ± 22,408.8 spermatozoa/µl and mean sperm viability 66 ± 16%. Semen samples contained on average 20.5% morphologically normal spermatozoa and sperm malformations were detected mainly in the head (x¯ = 47.6%) and the tail regions (x¯ = 27.7%). Interestingly round bodies were detected in the ejaculates with a mean ratio of 0.6 round bodies per sperm. Semen analysis proved to be very useful to identify males with poor semen quality. Artificial insemination was performed 46 times in 9 females with either individual or pooled semen samples and 13 eggs from 7 females were laid afterwards. In 3 eggs, embryonic development was detected and 1 chick hatched successfully. Paternity testing confirmed the fatherhood of a one-winged semen donor male, a bird which was not able to copulate naturally. The results are very promising and underline that assisted reproduction techniques are a suitable tool for species conservation in captive breeding programs for psittacines.

Aberrant splicing as potential modifier of the phenotype of junctional epidermolysis bullosa.

BACKGROUND: A lack or dysfunction of the anchoring protein laminin-332 in the basement membrane leads to the skin blistering disorder junctional epidermolysis bullosa (JEB). The mutation c.628G>A in the gene LAMB3 encoding the laminin ß3-chain is associated with generalized intermediate JEB; it may introduce an amino acid substitution (p.Glu210Lys) or disrupt splicing. OBJECTIVE: This retrospective study aimed at determining the effects of aberrant splicing on the JEB phenotype. METHODS: LAMB3 transcription was analysed in two siblings compound heterozygous for the LAMB3 mutations p.Glu210Lys and p.Arg635* with a diverging JEB phenotype from late childhood on. Laminin-332 levels in skin sections and in cultured keratinocytes were investigated by immunofluorescence staining. Real-time PCR was used to quantify LAMB3 expression in keratinocytes. RNA splice variants were identified by subcloning of a LAMB3 cDNA fraction and subsequent DNA sequencing. Structural models of laminin-332 helped to assess the impact of certain mutations on laminin-332 folding. RESULTS: Both siblings showed diminished LAMB3 expression. Laminin-332 was equally reduced in skin sections obtained during infancy but differed in keratinocytes isolated during adolescence. Although aberrant LAMB3 splicing with 26 variants was detected in both patients, splicing differed significantly: the full-length LAMB3 transcript harbouring the p.Glu210Lys mutation was found more often in the patient affected less severely (14/108 vs. 5/106 clones; P = 0.03). Structural modelling predicted that several deletions in LAMB3, but not the point mutation p.Glu210Lys, have an effect on laminin-332 folding and secretion. CONCLUSIONS: Differential LAMB3 mRNA splicing in the patients may explain the disparate JEB phenotype. By elucidating the regulation of laminin-332 gene expression, these findings may contribute to the development of therapeutic strategies for JEB and might help to understand phenotype modification by splice-site mutations in other hereditary diseases.

Trends and inequities in amenable mortality between 1997 and 2012 in South Africa.

BACKGROUND: Amenable mortality comprises causes of death that should not occur with timely and effective healthcare. It is commonly used to assess healthcare performance. It could also be used to assess the effectiveness of the pending National Health Insurance (NHI) in South Africa (SA), but to do this, the level and distribution of amenable mortality are required using a local list of amenable causes. OBJECTIVES: To establish an amenable cause-of-death list appropriate for SA and to determine the levels, trends, geographical distribution, population group differences and international comparisons of mortality amenable to healthcare. METHODS: A local list of amenable causes of death was developed with input from public health and disease-specific medical experts. The Second SA National Burden of Disease estimates were reclassified into amenable mortality. Analyses of age-standardised death rates (ASDRs) and amenable mortality proportions were conducted by province and population group between 1997 and 2012. Excess mortality in relation to the best- performing province and population group was also analysed. ASDRs for SA were compared with those of European Union (EU) and Organisation for Economic Co-operation and Development (OECD) countries. RESULTS: The local list of amenable conditions contained 45 causes of death. There were large disparities in amenable mortality between provinces and population groups, which did not attenuate over time. There was an average annual percentage increase in amenable ASDRs, but when HIV/AIDS was excluded from the analysis there was an average annual decrease of 1.12%. In the post-peak HIV/AIDS period between 2008 and 2012, an annual average of 207 810 amenable deaths could have been saved if all provinces had the same ASDR as the Western Cape. SA's ASDR was 2.6 and 2.2 times higher than that of the worst-performing EU and OECD country, respectively. CONCLUSIONS: This is the first study known to the authors that has established a local amenable mortality list and described the epidemiology of amenable mortality in SA. Amenable mortality could be used as an indicator of the performance of the pending NHI over time and, in combination with other indicators, could identify areas of the health system that require improvement. Benchmarking could also quantify gaps in health system performance between geographical regions and indicate whether these are reduced with time.

Black TiO2 nanotubes: Efficient electrodes for triggering electric field-induced stimulation of stem cell growth.

TiO2 nanostructures represent a key platform for biomedical applications, due to the combination of biocompatibility and high surface area. Especially TiO2 nanotube layers have been widely investigated due to controllable nanotopographic effects as well as for electrodes in electrostimulation experiments. In the present work we produce Ar/H2-reduced 'black' TiO2 nanotube arrays with a strongly enhanced electrical conductivity and explore their interaction with mesenchymal stem cells when used as electrodes to apply electric fields (EF) across the cells. While we observe no significant change in cell adhesion and their focal contact formation on these high conductivity nanotubes, we do observe a rapid stem cell response when EF is engaged using the 'black' TiO2 nanotube arrays as electrodes. Compared to as-formed nanotube arrays, a faster stem cell growth was observed and a lower EF intensity caused an intracellular calcium level elevation. Our results indicate that the increased conductivity in TiO2 nanotubes significantly enhances the early stem cell response to minimal electric field stimuli. STATEMENT OF SIGNIFICANCE: The use of TiO2 nanostructures in biomedical applications is widely investigated, especially considering the nanostructured surface influence on the biomaterial-cell interactions. We have previously shown that an applied electric field (EF) on stem cells grown on TiO2 nanotubes leads to synergistic osteogenic stimulation in the absence of biochemical bone-inducing supplements. Here we report that black (i.e. highly conductive nanotubes obtained by reduction treatments) TiO2 nanotubes enable short-time EF effects on stem cells: we observe a faster stem cell growth and a significantly enhanced early stem cell response to minimal EF stimuli. The application of such nanostructures under electric field is promising for therapeutic interventions for bone regeneration and tissue engineering approaches.

Semen collection, semen analysis and artificial insemination in Columbian sharp-tailed grouse (Tympanuchus phasianellus columbianus) as part of a species conservation project.

Columbian sharp-tailed grouse (Tympanuchus phasianellus columbianus; hereafter CSTG) have experienced substantial decreases in population numbers and geographic range during the early 20th century, primarily due to habitat loss. The conservation aim of this project was to re-establish a self-sustaining population of CSTG within an unoccupied portion of their historic range in northeastern Nevada via reintroduction from source populations in Idaho, USA. Female nest initiation rates post-translocation due to low fertilization rates are believed to be one limiting factor in the establishment of some translocated CSTG populations. However, studies on semen collection and artificial insemination in this species are absent. Assisted reproduction was evaluated as an additional tool in this species conservation project in order to gain knowledge on the reproductive status of yearling and adult male CSTG, establish orientation values for semen parameters and evaluate artificial insemination procedures on female CSTG. In two consecutive breeding seasons, semen collection was attempted 51 times in 47 males using the established massage method, and a novel electro-stimulation technique. Semen collection was successful in all attempts, even in yearling grouse, which represents a novel confirmation that yearling male CSTG can produce live spermatozoa in their first breeding season. Volume, color, consistency, contamination, pH of semen, and the motility, concentration, viability and morphology of spermatozoa were analyzed. Extracted semen volume ranged between 6 and 74 µl and the mean pH was 6.9 ±â€¯0.5 (x¯ ± SD). Morphology analysis revealed that on average, 42.8% of sperm was morphologically normal, but 34.8% had malformed tails. Additionally, artificial insemination was practiced in 17 females (sham-insemination group; insemination lacking spermatozoa) and performed in 17 females. Intravenous catheters G20 1.0 mm × 32 mm enabled safe intravaginal insemination under visual control. Significant (p ≤ 0.05) differences in semen parameters between adult and yearling birds were detected. It is well established that adult males receive a majority of copulations during lekking, but our novel findings also indicate that they produce significantly more spermatozoa which is of higher quality than yearling males. This finding offers insights into male reproductive biology in a lekking grouse species.

Initial free cortisol dynamics following blunt multiple trauma and traumatic brain injury: A clinical study.

OBJECTIVE: To determine free and total cortisol serum concentrations in the first 24 h after trauma and to evaluate the influence of traumatic brain injury (TBI) on their dynamics. METHODS: This prospective cohort study enrolled patients who had experienced multiple trauma and were admitted to a level 1 trauma centre. The patients were divided in two groups based on the presence of TBI according to clinical and radiological findings. Blood was collected initially as well as at 12 h and 24 h after the traumatic injury. Total cortisol, corticosteroid binding globulin (CBG) and free cortisol levels were determined. RESULTS: The study analysed data from 49 patients (36 males and 13 females) with a mean ± SD age of 45.0 ± 16.0 years. Of these, 36 presented with TBI and 13 had multiple injuries without TBI. Patients with TBI showed significantly lower concentrations of total cortisol and free cortisol compared with patients without TBI. Repeated measures analysis revealed different concentration dynamics in patients with TBI, with no increase in cortisol after trauma. CONCLUSION: Multiple trauma patients with TBI are at risk of acute impaired cortisol secretion and show an attenuated stress response as early as 12 h after injury.

Is Optical Coherence Tomography a Potential Tool to Evaluate Marginal Adaptation of Class III/IV Composite Restorations In Vivo?

OBJECTIVE: Margin analysis of Class III and IV composite restorations in vitro and in vivo occurred by scanning electron microscopy (SEM) and optical coherence tomography (OCT). The results were compared and related to clinical evaluation. METHODS AND MATERIALS: Eight Class III composite restorations were imaged in vitro using OCT and SEM. The margins were analyzed quantitatively. OCT signals were verified by assignment to the criteria perfect margin, gap, and positive/negative ledge. In vivo quantitative margin analysis of Class III/IV composite restorations made of the micro-hybrid composite Venus combined with the self-etch adhesive iBond Gluma inside (1-SE) or etch-and-rinse adhesive Gluma Comfort Bond (2-ER) (all Heraeus Kulzer) was carried out using OCT and SEM after 90 months of clinical function. The results were compared with clinical evaluation (US Public Health Service criteria; marginal integrity, marginal discoloration). RESULTS: In vitro, the correlation between OCT and SEM was high for all four margin criteria (Kendall tau b [τb] correlation: 0.64-0.92, pi≤0.026), with no significant differences between OCT and SEM (pi≥0.63). In vivo, a moderate correlation was observed (τb: 0.38-0.45, pi<0.016). Clinically, the cumulative failure rate in the criterion marginal integrity was higher for the 1-SE group (baseline 90 M, p=0.011). Similarly, OCT and SEM detected higher percentages of the criterion gap in the 1-SE group (p: 0.027/0.002), in contrast to perfect margin. Both, gap and perfect margin ranged widely between 0.0% and 88.7% (OCT) and between 0.0% and 89.0% (SEM). CONCLUSION: Despite the positive selection bias after 90 months with only a few patients left, quantitative margin analysis allows for differentiation between the two adhesives at this specific date. OCT in particular offers the possibility to evaluate marginal integrity directly in vivo.

Trends and inequities in amenable mortality between 1997 and 2012 in South Africa

Background. Amenable mortality comprises causes of death that should not occur with timely and effective healthcare. It is commonly used to assess healthcare performance. It could also be used to assess the effectiveness of the pending National Health Insurance (NHI) in South Africa (SA), but to do this, the level and distribution of amenable mortality are required using a local list of amenable causes. Objectives. To establish an amenable cause-of-death list appropriate for SA and to determine the levels, trends, geographical distribution, population group differences and international comparisons of mortality amenable to healthcare. Methods. A local list of amenable causes of death was developed with input from public health and disease-specific medical experts. The Second SA National Burden of Disease estimates were reclassified into amenable mortality. Analyses of age-standardised death rates (ASDRs) and amenable mortality proportions were conducted by province and population group between 1997 and 2012. Excess mortality in relation to the best- performing province and population group was also analysed. ASDRs for SA were compared with those of European Union (EU) and Organisation for Economic Co-operation and Development (OECD) countries. Results. The local list of amenable conditions contained 45 causes of death. There were large disparities in amenable mortality between provinces and population groups, which did not attenuate over time. There was an average annual percentage increase in amenable ASDRs, but when HIV/AIDS was excluded from the analysis there was an average annual decrease of 1.12%. In the post-peak HIV/AIDS period between 2008 and 2012, an annual average of 207 810 amenable deaths could have been saved if all provinces had the same ASDR as the Western Cape. SA's ASDR was 2.6 and 2.2 times higher than that of the worst-performing EU and OECD country, respectively. Conclusions. This is the first study known to the authors that has established a local amenable mortality list and described the epidemiology of amenable mortality in SA. Amenable mortality could be used as an indicator of the performance of the pending NHI over time and, in combination with other indicators, could identify areas of the health system that require improvement. Benchmarking could also quantify gaps in health system performance between geographical regions and indicate whether these are reduced with time

Nasal high flow, but not supplemental O2, reduces peripheral vascular sympathetic activity during sleep in COPD patients.

INTRODUCTION: Patients with COPD have increased respiratory loads and altered blood gases, both of which affect vascular function and sympathetic activity. Sleep, particularly rapid eye movement (REM) sleep, is known to exacerbate hypoxia and respiratory loads. Therefore, we hypothesize that nasal high flow (NHF), which lowers ventilatory loads, reduces sympathetic activity during sleep and that this effect depends on COPD severity. METHODS: We performed full polysomnography in COPD patients (n=17; FEV1, 1.6±0.6 L) and in matched controls (n=8). Participants received room air (RA) at baseline and single night treatment with O2 (2 L/min) and NHF (20 L/min) in a random order. Finger pulse wave amplitude (PWA), a measure of vascular sympathetic tone, was assessed by photoplethysmography. Autonomic activation (AA) events were defined as PWA attenuation ≥30% and indexed per hour for sleep stages (AA index [AAI]) at RA, NHF, and O2). RESULTS: In COPD, sleep apnea improved following O2 (REM-apnea hypopnea index [AHI] with RA, O2, and NHF: 18.6±20.9, 12.7±18.1, and 14.4±19.8, respectively; P=0.04 for O2 and P=0.06 for NHF). REM-AAI was reduced only following NHF in COPD patients (AAI-RA, 21.5±18.4 n/h and AAI-NHF, 9.9±6.8 n/h, P=0.02) without changes following O2 (NHF-O2 difference, P=0.01). REM-AAI reduction was associated with lung function expressed as FEV1 and FVC (FEV1: r=-0.59, P=0.001; FEV1/FVC: r=-0.52 and P=0.007). CONCLUSION: NHF but not elevated oxygenation reduces peripheral vascular sympathetic activity in COPD patients during REM sleep. Sympathetic off-loading by NHF, possibly related to improved breathing mechanics, showed a strong association with COPD severity.

[Beginners' operations and medical specialist standards : Avoidance of criminal liability and civil liability]. / Anfängeroperationen und Facharztstandard : Vermeidung strafrechtlicher Verantwortlichkeit und zivilrechtlicher Haftung.

BACKGROUND: In all phases, patients are entitled to receive medical treatment according to medical specialist standards. This does not mean that patients necessarily have to be treated by a medical specialist. Operations performed by "beginners", e. g. assistant physicians, are permitted. However, there are increased liability risks, both for the specialist and the assistant physician. Furthermore, there are risks of criminal responsibility for causing bodily harm by negligence or negligent manslaughter. OBJECTIVES AND METHODS: This article portrays the requirements of civil liability and criminal responsibility concerning beginners' operations on the basis of cases and judgments of the Federal Court and the Higher Regional Courts in Germany. Additionally, the reception of the jurisprudence by the relevant legal literature will be discussed. RESULTS: Jurisprudence and legal literature categorize breaches of duty of care. Assistant physicians can be subject to contributory negligence liabilities, while specialists can bear liabilities for negligent selection, organization or supervision. Responsible specialist and assistant physicians can protect themselves (and the patient) and avoid legal risks by only performing operations adequate to their educational level or by delegating operations to beginners and ensuring intervention by a specialist by supervision of the operation which is suitable to the assistant physician's level of education.

Evaluating the effect of ward-based outreach teams on primary healthcare performance in North West Province, South Africa: A plausibility design using routine data.

BACKGROUND: North West Province (NWP), South Africa, was an early adopter of the primary healthcare (PHC) ward-based outreach team (WBOT) strategy and has made considerable progress in implementing it. Given the interest in and expectations of greater investment in WBOTs, assessing their impact on and contribution to PHC outputs and health outcomes is becoming increasingly important. OBJECTIVES: To describe the application of a plausibility evaluation design for assessing the contribution of WBOTs to PHC performance in NWP, comparing changes in coverage, utilisation and outcome indicators in facilities with and without WBOTs. METHODS: Routine data from the District Health Information System on both WBOTs and PHC facilities for the period 2011/12 (prior to implementation) to 2014/15 (3 years after implementation began) were extracted. Analysis involved the following three steps: (i) selection of indicators sensitive to community-based action; (ii) data cleaning; and (iii) comparison of the degree of change in median indicator values between 2011/12 and 2014/15 in facilities with and without WBOTs (a difference-in-differences analysis). RESULTS: Changes in indicator values in facilities were grouped into four categories: (i) indicators where there was greater (statistically significant) improvement in facilities with WBOTs (couple year protection rate, measles immunisation coverage in children aged <1 year, incidence of children aged <5 years with severe diarrhoea with dehydration); (ii) indicators that declined or worsened, but less so in facilities with WBOTs at statistically significant levels (antenatal first visits as a percentage of children born in that year, PHC utilisation rate of children aged <5 years); (iii) indicators that improved in all facilities with no significant difference between facilities with and without WBOTs (antenatal attendance before 20 weeks, prophylactic vitamin A coverage to children aged 12 - 59 months); and (iv) indicators that remained unchanged in all facilities (immunisation coverage in children aged <1 year, postnatal mother visits at 6 days, cervical cancer screening coverage in women aged ≥30 years, PHC utilisation rate of children aged ≥5 years). CONCLUSION: Notwithstanding the limitations of routine data and the need to approach the findings with caution, this analysis suggests that WBOTs plausibly had some positive effects on the overall performance of the PHC system. We propose a methodology to monitor the performance of WBOTs using routine PHC indicators that programme managers could apply elsewhere.