Electronic Integrated Management of Childhood Illness (eIMCI): a randomized controlled trial to evaluate an electronic clinical decision-making support system for management of sick children in primary health care facilities in South Africa.

BACKGROUND: Electronic clinical decision-making support systems (eCDSS) aim to assist clinicians making complex patient management decisions and improve adherence to evidence-based guidelines. Integrated management of Childhood Illness (IMCI) provides guidelines for management of sick children attending primary health care clinics and is widely implemented globally. An electronic version of IMCI (eIMCI) was developed in South Africa. METHODS: We conducted a cluster randomized controlled trial comparing management of sick children with eIMCI to the management when using paper-based IMCI (pIMCI) in one district in KwaZulu-Natal. From 31 clinics in the district, 15 were randomly assigned to intervention (eIMCI) or control (pIMCI) groups. Computers were deployed in eIMCI clinics, and one IMCI trained nurse was randomly selected to participate from each clinic. eIMCI participants received a one-day computer training, and all participants received a similar three-day IMCI update and two mentoring visits. A quantitative survey was conducted among mothers and sick children attending participating clinics to assess the quality of care provided by IMCI practitioners. Sick child assessments by participants in eIMCI and pIMCI groups were compared to assessment by an IMCI expert. RESULTS: Self-reported computer skills were poor among all nurse participants. IMCI knowledge was similar in both groups. Among 291 enrolled children: 152 were in the eIMCI group; 139 in the pIMCI group. The mean number of enrolled children was 9.7 per clinic (range 7-12). IMCI implementation was sub-optimal in both eIMCI and pIMCI groups. eIMCI consultations took longer than pIMCI consultations (median duration 28 minutes vs 25 minutes; p = 0.02). eIMCI participants were less likely than pIMCI participants to correctly classify children for presenting symptoms, but were more likely to correctly classify for screening conditions, particularly malnutrition. eIMCI participants were less likely to provide all required medications (124/152; 81.6% vs 126/139; 91.6%, p= 0.026), and more likely to prescribe unnecessary medication (48/152; 31.6% vs 20/139; 14.4%, p = 0.004) compared to pIMCI participants. CONCLUSIONS: Implementation of eIMCI failed to improve management of sick children, with poor IMCI implementation in both groups. Further research is needed to understand barriers to comprehensive implementation of both pIMCI and eIMCI. (349) CLINICAL TRIALS REGISTRATION: Clinicaltrials.gov ID: BFC157/19, August 2019.

Understanding psychological outcomes following exposure to potentially morally injurious events in animal care: development of the Moral Distress-Posttraumatic Growth Scale for Veterinary Professionals.

AIMS: To generate a taxonomy of potentially morally injurious events (PMIE) encountered in veterinary care and develop an instrument to measure moral distress and posttraumatic growth following exposure to PMIE in the veterinary population. METHODS: Development and preliminary evaluation of the Moral Distress-Posttraumatic Growth Scale for Veterinary Professionals (MD-PTG-VP) employed data from veterinary professionals (veterinarians, veterinary nurses, veterinary technicians) from Australia and New Zealand across three phases: (1) item generation, (2) content validation, and (3) construct validation. In Phase 1 respondents (n = 46) were asked whether they had experienced any of six PMIE and to identify any PMIE not listed that they had experienced. In Phase 2 a different group of respondents (n = 11) assessed a list of 10 PMIE for relevance, clarity and appropriateness. In Phase 3 the final instrument was tested with a third group of respondents (n = 104) who also completed the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT), a measure of posttraumatic stress, and the Stress-Related Growth Scale-Short Form (SRGS-SF) a measure of perceived posttraumatic growth. Spearman's correlation coefficients were calculated between respondent scores on each of the MD-PTG-VP subscales, the SPRINT, and the SRGS-SF to assess construct validity. RESULTS: A 10-item taxonomy of PMIE encountered in veterinary care was generated in Phase 1. Items were deemed relevant, clear and appropriate by veterinary professionals in Phase 2. These were included in the developed instrument which measures frequency and impact of exposure to 10 PMIE, yielding three subscale scores (exposure frequency, moral distress, and posttraumatic growth). Assessment of construct validity by measuring correlation with SPRINT and SRGS-SF indicated satisfactory validity. CONCLUSIONS: The MD-PTG-VP provides an informative tool that can be employed to examine professionals' mental health and wellbeing following exposure to PMIE frequently encountered in animal care. Further evaluation is required to ascertain population norms and confirm score cut-offs that reflect clinical presentation. CLINICAL RELEVANCE: Once fully validated this instrument may be useful to quantify the frequency and intensity of positive and negative aspects of PMIE exposure on veterinary professionals so that accurate population comparisons can be made and changes measured over time.

Are we doing enough? Improved breastfeeding practices at 14 weeks but challenges of non-initiation and early cessation of breastfeeding remain: findings of two consecutive cross-sectional surveys in KwaZulu-Natal, South Africa.

BACKGROUND: KwaZulu-Natal (KZN) Initiative for breastfeeding support (KIBS) was a multipronged intervention to support the initiation and sustaining of breastfeeding, implemented between 2014 and 2017. We present results of two surveys conducted before and after KIBS implementation to assess changes in infant feeding practices in KZN over this time period. METHODS: Two cross-sectional surveys were conducted in primary health care clinics. Multistage stratified random sampling was used to select clinics and participants. Sample size was calculated to provide district estimates of 14-week exclusive breastfeeding (EBF) rates at baseline (KIBS1), and provincial estimates at endpoint (KIBS2). At KIBS1 the sample required was nine participating clinics in each of 11 districts (99 clinics) with 369 participants per district (N = 4059), and at KIBS2 was 30 clinics in KZN with 30 participants per clinic (N = 900). All caregivers aged ≥15 years attending the clinic with infants aged 13- < 16 weeks were eligible to participate. Data was collected using structured interviews on android devices. Multi-variable logistic regression was used to adjust odds ratios for differences between time points. RESULTS: At KIBS1 (May2014- March2015), 4172 interviews were conducted with carers, of whom 3659 (87.6%) were mothers. At KIBS2 (January-August 2017), 929 interviews were conducted which included 788 (84.8%) mothers. Among all carers the proportion exclusively breastfeeding was 44.6 and 50.5% (p = 0.1) at KIBS1 and KIBS2 respectively, but greater improvements in EBF were shown among mothers (49.9 vs 59.1: p = 0.02). There were reductions in mixed breastfeeding among all infants (23.2% vs 16.3%; p = 0.016). Although there was no change in the proportion of carers who reported not breastfeeding (31.9% vs 32.8%; p = 0.2), the duration of breastfeeding among mothers who had stopped breastfeeding was longer at KIBS2 compared to KIBS1 (p = 0.0015). Mothers who had returned to work or school were less likely to be breastfeeding (adjusted odds ratio [AOR] 3.76; 95% CI 3.1-4.6), as were HIV positive mothers (AOR 2.1; 95% CI 1.7-2.6). CONCLUSION: Despite improvements to exclusive breastfeeding, failure to initiate and sustain breastfeeding is a challenge to achieving optimal breastfeeding practices. Interventions are required to address these challenges and support breastfeeding particularly among working mothers and HIV positive mothers.

Single-cell magnetic imaging using a quantum diamond microscope.

We apply a quantum diamond microscope for detection and imaging of immunomagnetically labeled cells. This instrument uses nitrogen-vacancy (NV) centers in diamond for correlated magnetic and fluorescence imaging. Our device provides single-cell resolution and a field of view (∼1 mm(2)) two orders of magnitude larger than that of previous NV imaging technologies, enabling practical applications. To illustrate, we quantified cancer biomarkers expressed by rare tumor cells in a large population of healthy cells.

Effect of perioperative lidocaine on metastasis after sevoflurane or ketamine-xylazine anaesthesia for breast tumour resection in a murine model.

BACKGROUND: Breast cancer accounts for 7% of female cancer deaths, usually attributable to metastasis. While surgery is a mainstay of treatment, perioperative interventions may influence risk of metastasis during breast tumour resection. Amide local anaesthetics influence cancer cell biology via numerous mechanisms in vitro, but in vivo data is lacking. We aimed to test the hypothesis that perioperative lidocaine reduces pulmonary metastasis after inhalation and i.v. anaesthesia in the 4T1 murine breast cancer model. METHODS: 4T1 Cancer cells were injected into the mammary fat-pad of immunocompetent BALB/c female mice. After 7 days, the resultant tumour was excised under either sevoflurane or ketamine/xylazine anaesthesia with or without perioperative i.v. lidocaine (1.5 mg kg-1 bolus followed by 25 min infusion 2 mg kg-1 h-1). Fourteen days post-surgery, posthumous lung and liver specimens were examined for metastasis. Pro-inflammatory and pro-metastatic cytokines were profiled in post-mortem serum from a small number of the mice. RESULTS: Primary tumour diameter was similar between groups. Lidocaine reduced lung metastatic colony count vs sevoflurane alone; median (inter-quartile range) 0 (0-2) compared with 22.5 (0-481), P=0.02 and reduced the proportion of animals with pulmonary metastasis (28.5% compared with 52.5%, P=0.04). In mice receiving ketamine-xylazine, lidocaine did not decrease the overall colony count: 60 (26-123) compared with 23.5 (0-225), P=0.43, but increased the proportion of animals with pulmonary metastasis (100% compared with 50%, P<0.01). Post-mortem serum analysis demonstrated reduced pro-inflammatory and angiogenic cytokine expression in animals without metastasis which received lidocaine with sevoflurane. CONCLUSIONS: In this 4T1 murine model of breast cancer, lidocaine decreased pulmonary metastasis when combined with sevoflurane anaesthesia, perhaps via anti-inflammatory and anti-angiogenic effects. It had no such effect in mice given ketamine anaesthesia.

Improved rates of exclusive breastfeeding at 14 weeks of age in KwaZulu Natal, South Africa: what are the challenges now?

BACKGROUND: Increasing the rate of exclusive breastfeeding (EBF) to 50% in the first six months of life is one of six major global targets set by the United Nations Decade of Nutrition, and is essential to achieve the sustainable development goals to eradicate hunger and end malnutrition by 2030. METHODS: A survey using multistage random sampling design included 99 primary health care (PHC) clinics in all 11 districts in KwaZulu-Natal (KZN). All mothers and caregivers of infants 14 weeks of age attending the clinics in the study period were requested to participate in a structured interview to explore feeding practices since birth. As non-maternal caregivers may not have detailed knowledge of feeding practices, they provided limited information about current feeding practices. Respondents who consistently reported giving no other food or fluids except breastmilk since birth were classified as practising exclusive breastfeeding (EBF), and those who were currently breastfeeding but had given other food or fluids since birth were categorised as practising mixed breastfeeding (MBF). RESULTS: A total of 4172 interviews were conducted with mothers and caregivers of 14 week old infants. Among mothers 49.8% were EBF, 23.1% were MBF and 27.0% were not breastfeeding. Among non-maternal caregivers 11.8% reported EBF, 23.4% MBF and 62.3% were not giving breastmilk. Higher education (OR 0.6, 95% CI 0.4-0.8) and being in the highest socio-economic tertile (OR 0.7, 95% CI 0.6-0.9) were risk factors for not practising EBF, while returning to work (OR 0.3, 95% CI 0.2-0.3) or school (OR 0.2 95% CI, 0.1-0.3) was associated with less EBF. HIV-positive mothers were more likely to have never started breastfeeding (OR 3.6, 95% CI 2.7-4.8). However, they were similar in having stopped breastfeeding by 14 weeks (OR 1.1, 95% CI 0.9-1.4) compared to HIV-negative mothers, and, they had similar rates of EBF at 14 weeks of age (OR 1.0, 95% CI 0.9-1.3). CONCLUSIONS: Estimates of breastfeeding practices at 14 weeks in KZN are higher than previously shown. However, particular challenges that should be addressed if international targets for EBF are to be achieved include improving breastfeeding practices of HIV positive mothers and supporting all mothers, particularly working or schooling mothers to continue giving breastmilk while they are away from their children.

A Rare Case of BRCA2-Associated Breast Cancer in Pregnancy.

A 30-year old woman was referred to our department with symptomatic breast cancer at 35 weeks gestation. Genetic testing revealed a pathogenic BRCA2 mutation. Labour was induced at 38 weeks. Mastectomy and axillary clearance were performed with a view to adjuvant chemotherapy, radiation and hormonal therapy. Multidisciplinary involvement is crucial for management of BRCA-associated breast cancer, especially in the context of pregnancy. Bilateral mastectomy may be indicated given the increased risk of ipsilateral and contralateral breast cancers. Tamoxifen may lower contralateral breast cancer risk in those in whom risk-reducing surgery is not performed.

Resting-state connectivity deficits associated with impaired inhibitory control in non-treatment-seeking adolescents with psychotic symptoms.

OBJECTIVE: Psychotic symptoms are common in the population and index risk for a range of severe psychopathological outcomes. We wished to investigate functional connectivity in a community sample of adolescents who reported psychotic symptoms (the extended psychosis phenotype). METHOD: This study investigated intrinsic functional connectivity (iFC) during resting-state functional magnetic resonance imaging (fMRI; rs-fMRI). Following screening in schools, 11 non-treatment seeking, youth with psychotic symptoms (aged 11-13) and 14 community controls participated in the study. Seed regions of interest comprised brain regions previously shown to exhibit aberrant activation during inhibitory control in adolescents with psychotic symptoms. RESULTS: Relative to controls, adolescents with psychotic symptoms exhibited reduced iFC between regions supporting inhibitory control. Specifically, they showed weaker iFC between the right inferior frontal gyrus (IFG) and the cingulate, IFG and the striatum, anterior cingulate and claustrum, and precuneus and supramarginal gyrus. Conversely, the psychotic symptoms group exhibited stronger iFC between the superior frontal gyrus and claustrum and IFG and lingual gyrus. CONCLUSION: The present findings are the first to reveal aberrant functional connectivity in resting-state networks in a community sample of adolescents with psychotic symptoms and suggest that disruption in integration between distributed neural networks (particularly between prefrontal, cingulate and striatal brain regions) may be a key neurobiological feature of the extended psychosis phenotype.

Physiologic responses to running with a jogging stroller.

The purpose of this study was to assess the effect of running with a jogging stroller (JS) on oxygen consumption (VO2), heart rate (HR), and rating of perceived exertion (RPE). This study included 2 parts: Part 1 involved participants (N=15) running on an indoor track and Part 2 involved participants (N=12) running on a paved greenway. All participants completed 6, one-mile trials randomized over 2 visits: 3 were completed at a predetermined pace (160.8 m·min (- 1)) without a JS (NoJS), with 11.36 kg in the JS (JS1), and 22.72 kg in the JS (JS2) and 3 were self-paced and included NoJS, JS1, and JS2. VO2 and HR were measured using a portable metabolic system and telemetry. Repeated measures ANOVAs were used to determine differences among conditions. Part 1, there were no differences in VO2 across conditions, but HR and RPE were significantly higher (P<0.05) during the JS trials compared to the NoJS trials. Part 2, VO2 and RPE during JS trials were higher than NoJS trials (P<0.05). No significant differences were found in HR. The results indicate that it is feasible to run while pushing a JS with minimal increases in exertion compared to running without a JS.

Digital acrometastases as first sign of hepatocellular carcinoma.

Digital acrometastases as a primary presentation of hepatocellular carcinoma (HCC) is rare. A 66-year-old man with no history of malignancy presented to the plastic surgery department with two skin lesions, one on the bridge of his nose and one on distal phalanx of left little finger. A working diagnosis of cutaneous metastases was made. Immediately prior to admission for excision of these lesions he was admitted with right upper quadrant pain and a jaundiced discolouration of the skin. The lesions were excised as planned and histopathological examination revealed metastatic HCC. A subsequent magnetic resonance imaging showed a lobulated mass consistent with primary HCC.

A taxonomy of occupational and organisational stressors and protectors of mental health reported by veterinary professionals in Australasia.

AIM: To develop a taxonomy of positive and negative occupational and organisational factors reported that impact the mental health of veterinary professionals. METHODS: Veterinary professionals working in Australasia were surveyed between February and June of 2021. The survey comprised two questions related to participants' perceptions of the positive and negative aspects of their job role that impact their mental health and wellbeing. Reflexive thematic analysis was employed to analyse the responses and generate two taxonomies of occupational and organisation stressors and protectors reported by participants. RESULTS: Fifty-three responses from veterinary professionals were analysed. The final stressor taxonomy generated contained 9 overarching themes and 36 subthemes. The most common of these were negative work conditions, challenging relationships with clients, and adverse events and patient outcomes. The taxonomy of protectors contained 11 overarching themes and 32 subthemes, with the most common including fulfillment and satisfaction, positive work conditions, and relationships with colleagues. CONCLUSION: This study is the first to examine both positive and negative factors in the veterinary industry reported by veterinary professionals in Australasia. The results highlighted stressors that can be addressed on both an individual and organisational level to promote the mental and health well-being of professionals working in the animal care industry.

Is it feasible to use a humanoid robot to promote hand hygiene adherence in a hospital setting?

Healthcare associated infections (HCAI) are a prevalent preventable cause of morbidity and mortality. Improving hand hygiene adherence is important for HCAI prevention. In this feasibility study, the objective was to determine if a humanoid robot could act as a novel single reminder intervention to improve hand hygiene adherence in a hospital setting. DAVE, a social humanoid robot, improved hand hygiene adherence at the entrance to a tertiary hospital and outpatient department, which was low at baseline, by 29%. DAVE shows promise as a novel intervention to improve hand hygiene adherence.

Pulmonary hypertension: Spectrum of disease, clinical presentation and treatment outcomes at the main respiratory pulmonary hypertension clinic in KwaZulu-Natal Province, South Africa.

BACKGROUND: There are many causes of pulmonary hypertension (PH). However, the aetiology, management and treatment outcomes in South Africa (SA), which has a high burden of HIV, are lacking in the literature. OBJECTIVES: To characterise patient demographics, aetiology, clinical presentation and management of patients presenting to the only government-funded PH clinic in Durban, SA. METHODS: We retrospectively reviewed electronic charts of patients with confirmed PH who attended the respiratory PH clinic between 2011 and 2018. Demographic and clinical data, symptoms, pulmonary function testing, pulmonary artery pressure on echocardiography and treatment were analysed. Patients with group 2 PH were excluded from the present study as they were managed by cardiologists. RESULTS: We identified 93 patients with confirmed PH and the majority were female (82.8%; n=77). The majority of the patients were between the ages of 30 and 39 years at the time of diagnosis. Most patients were black African (64.5%; n=60), followed by Indians (26.9%; n=25) and whites (8.6%; n=8). The most common cause of PH was group 1 (75%; n=70), followed by group 4 (13%; n=12) and then group 3 (12%; n=11). HIV-associated PH accounted for 27% of all patients and was the main cause of PH in those classified in group 1 (38%; n=29). Two-thirds (66%) of patients were treated with sildenafil, the only treatment that was available. Patients on treatment showed significant improvement indicated by the World Health Organization functional class, mean 6-minute walk test and reduction in mean pulmonary artery pressure on echocardiography. CONCLUSION: HIV-associated PH is the most common cause of PH in SA. Sildenafil, the only drug available in our setting, is beneficial to most patients with PH.

Significance of HbA1c levels in diabetic retinopathy extremes in South Africa.

BACKGROUND: Diabetic retinopathy (DR) is one of the leading causes of blindness in sub-Saharan Africa and globally, placing a huge disease burden on patients and the public health system. DR varies in severity from non-proliferative to proliferative DR (PDR). OBJECTIVES: Using a monitor of medium- to long-term blood glucose control, to determine the association between glycated haemoglobin (HbA1c) levels in patients with PDR and those with no DR. METHODS: A prospective, cross-sectional study was conducted at McCord Provincial Eye Hospital in Durban, South Africa. We studied only patients diagnosed with diabetes mellitus (DM) for >1 year who had either PDR or no DR, and compared their HbA1c levels. Patients with non-proliferative DR were not included. RESULTS: Patients with PDR had significantly higher HbA1c levels than those with no DR. Patients with type 1 DM had higher HbA1c levels than patients with type 2 DM in both the PDR and no-DR groups. Older patients (>70 years) had lower HbA1c levels than younger patients. Gender, race and duration of diabetes had no influence on HbA1c levels. CONCLUSIONS: PDR was associated with higher HbA1c in type 2 DM in all races and age groups and was independent of duration of disease. The trend was the same for type 1 DM, but significance could not be reached, probably because of small numbers in this subset of patients.

Aminopeptidase A (ENPEP) gene polymorphisms and preeclampsia: Descriptive analysis.

OBJECTIVE: The etiology of preeclampsia (PE) remains elusive. Recent genome-wide association studies have identified a number of genetic variants associated with blood pressure variations in east Asians. One of the genetic variants is the aminopeptidase A (ENPEP) gene, which converts angiotensin II to angiotensin III. The C allele of rs6825911 is a risk for hypertension. The current study investigated whether genetic variants of ENPEP play a role in the pathogenesis of preeclampsia. STUDY DESIGN: The study was a descriptive analysis of gene polymorphisms of ENPEP; 602 pregnant women of African ancestry [normotensive (n = 245) and PE (n = 357)] were recruited. The two groups were divided according to their HIV status. The PE group consisted of early- and late-onset sub-categories. A single nucleotide polymorphism of rs6825911 was analyzed using the TaqMan® Probe mix and by means of real time polymerase chain reaction. RESULTS: The risk of C allele for PE was 1.07 (95 % CI 0.83-1.38, P = 0.589) for allele comparison and the risk for preeclampsia CC to CT/TT was 1.33 (95 % CI 0.96-1.85, P = 0.086). The sub analysis for the PE group without HIV infection the risk of C allele was 1.25 (95 % CI 0.838-1.78, P = 0.199) and the risk of PE of CC to CT/TT was 1.51 (95 %CI: 0.96-2.35, P = 0.071). CONCLUSION: This is the first study in a homogenous South African population of African ancestry to show that the variant of ENPEP gene does not play a role in pathogenesis of preeclampsia.

Treatment Preferences for Cardiac Procedures of Patients With Chronic Kidney Disease in Acute Coronary Syndrome: Design and Pilot Testing of a Discrete Choice Experiment.

BACKGROUND: Chronic kidney disease is associated with a high incidence of acute coronary syndrome and related morbidity and mortality. Treatment choices for patients with chronic kidney disease involve trade-offs in the potential benefits and harms of invasive management options. OBJECTIVE: The objective was to quantify preferences of patients with chronic kidney disease toward invasive heart procedures. DESIGN: Design and pilot a discrete choice experiment. SETTING: We piloted the discrete choice experiment in 2 multidisciplinary chronic kidney disease clinics in Calgary, Alberta, using an 8-question survey. PATIENTS: Eligible patients included those aged 18 years and older, an estimated glomerular filtration rate < 45 mL/min/1.73 m2, not currently receiving dialysis, and able to communicate in English. MEASUREMENTS: Quantification of the average importances of key attributes of invasive heart procedures. METHODS: We identified attributes most important to patients and physicians concerning invasive versus conservative management for acute coronary syndrome, using semi-structured qualitative interviews. Levels for each attribute were derived from analysis of early invasive versus conservative acute coronary syndrome management clinical trials and cohort studies, where subgroups of patients with chronic kidney disease were reported. We designed the pilot study with patient partners with relevant lived experience and considered statistical efficiency to estimate main effects and interactions, as well as response efficiency. Hierarchical Bayesian estimation was used to quantify average importances of attributes. RESULTS: We recruited 43 patients with chronic kidney disease, mean (SD) age 67 (14) years, 67% male, and 35% with a history of cardiovascular disease, of whom 39 completed the survey within 2 weeks of enrollment. The results of the pilot revealed acute kidney injury requiring dialysis and permanent kidney replacement therapy, as well as death within 1 year were the most important attributes. Measures of internal validity for the pilot discrete choice experiment were comparable to those for other published discrete choice experiments. LIMITATIONS: Discrete choice experiments are complex instruments and often cognitively demanding for patients. This survey included multiple risk attributes which may have been challenging for some patients to understand. CONCLUSIONS: This pilot study demonstrates the feasibility of a discrete choice experiment to quantify preferences of patients with chronic kidney disease toward the benefits and trade-offs related to invasive versus conservative management for acute coronary syndrome. These preliminary findings suggest that patients with chronic kidney disease may be on average similarly risk averse toward kidney replacement therapy and death. This pilot information will be used to inform a larger discrete choice experiment that will refine these estimates of patient preferences and characterize subgroups with distinct treatment preferences, which should provide new knowledge that can facilitate shared decision-making between patients with chronic kidney disease and their care providers in the setting of acute coronary syndrome.

CONTEXTE: L'insuffisance rénale chronique (IRC) est associée à une forte incidence du syndrome coronarien aigu, de même qu'à la morbidité et à la mortalité qui y sont liées. Les options de traitement pour les patients atteints d'IRC impliquent de faire des compromis sur les avantages et inconvénients des options invasives. OBJECTIF: Quantifier les préférences des patients atteints d'IRC quant aux procédures cardiaques invasives. CONCEPTION: Concevoir et piloter une expérience avec choix discrets. CADRE: Nous avons mené cette expérience avec choix discrets dans deux cliniques multidisciplinaires de néphropathie chronique de Calgary (Alberta) à l'aide d'un sondage en huit questions. SUJETS: Les patients admissibles étaient des adultes avec un débit de filtration glomérulaire estimé (DFGe) inférieur à 45 mL/min/1,73 m 2 et ne suivant pas de traitements de dialyse. Les patients inclus devaient être capables de communiquer en anglais. MESURES: Quantification de l'importance moyenne des principaux attributs des procédures cardiaques effractives. MÉTHODOLOGIE: Les attributs les plus importants pour les patients et les médecins concernant une gestion invasive par rapport à une gestion conservatrice du syndrome coronarien aigu ont été déterminés à l'aide d'interviews qualitatives semi-structurées. L'analyse d'essais cliniques et d'études de cohorte ayant inclus des sous-groupes de patients atteints d'IRC et portant sur la gestion invasive précoce du syndrome coronarien aigu par opposition à une gestion conservatrice a permis de dériver les le degré d'importance pour chaque attribut. Nous avons conçu l'étude pilote en compagnie de patients partenaires ayant une expérience vécue pertinente et nous avons tenu compte de l'efficacité statistique pour estimer les principaux effets et interactions, de même que l'efficacité de la réponse. Une estimation hiérarchique bayésienne a été employée pour quantifier l'importance moyenne des attributs. RÉSULTATS: Nous avons recruté 43 patients atteints d'IRC dont l'âge moyen (É-T) était de 67 ans (14). La cohorte était constituée à 67 % d'hommes et 35 % des sujets avaient des antécédents de maladies cardiovasculaires. L'étude porte sur les 39 patients ayant rempli le questionnaire dans les deux semaines suivant le recrutement. Les résultats de l'étude pilote ont révélé que la mortalité dans la première année et l'insuffisance rénale aiguë (IRA) nécessitant la dialyse et une thérapie de remplacement rénal permanente étaient les attributs les plus importants. Les mesures des intervalles de validité de cette expérience pilote avec choix discrets étaient similaires à ceux des autres expériences publiées du même type. LIMITES: Les expériences avec choix discrets sont des outils complexes et souvent exigeants pour les patients sur le plan cognitif. Ce questionnaire comportait plusieurs attributs de risque qui ont peut-être été difficiles à comprendre pour certains patients. CONCLUSION: Cette étude pilote démontre la faisabilité d'une expérience avec choix discrets pour qualifier les préférences des patients atteints d'IRC en ce qui concerne les avantages et les compromis liés à une gestion invasive ou conservatrice du syndrome coronarien aigu. Ces résultats préliminaires semblent indiquer que les patients atteints d'IRC seraient en moyenne tout aussi réticents envers le risque de thérapie de remplacement rénal qu'envers le risque de décès. Les informations tirées de ce pilote serviront à orienter une plus vaste expérience avec choix discrets qui raffinera ces estimations des préférences des patients et caractérisera les sous-groupes ayant des préférences de traitements distinctes. Ceci fournira de nouvelles connaissances susceptibles de faciliter la prise de décision partagée entre les patients atteints d'IRC et leurs fournisseurs de soins dans le contexte du syndrome coronarien aigu.

Risk of disease transmission from flexible nasoendoscopy during the coronavirus disease 2019 pandemic.

BACKGROUND: Concerns have emerged regarding infection transmission during flexible nasoendoscopy. METHODS: Information was gathered prospectively on flexible nasoendoscopy procedures performed between March and June 2020. Patients and healthcare workers were followed up to assess for coronavirus disease 2019 development. One-sided 97.5 per cent Poisson confidence intervals were calculated for upper limits of risk where zero events were observed. RESULTS: A total of 286 patients were recruited. The most common indication for flexible nasoendoscopy was investigation of 'red flag' symptoms (67 per cent). Forty-seven patients (16 per cent, 95 per cent confidence interval = 13-21 per cent) had suspicious findings on flexible nasoendoscopy requiring further investigation. Twenty patients (7.1 per cent, 95 per cent confidence interval = 4.4-11 per cent) had new cancer diagnoses. Zero coronavirus disease 2019 infections were recorded in the 273 patients. No. 27 endoscopists (the doctors and nurses who carried out the procedures) were followed up.The risk of developing coronavirus disease 2019 after flexible nasoendoscopy was determined to be 0-1.3 per cent. CONCLUSION: The risk of coronavirus disease 2019 transmission associated with performing flexible nasoendoscopy in asymptomatic patients, while using appropriate personal protective equipment, is very low. Additional data are required to confirm these findings in the setting of further disease surges.

Human papillomavirus (HPV)-type distribution in relation to oral contraceptive use in women with cervical intraepithelial neoplasia, Durban, South Africa.

OBJECTIVE: To determine HPV-type distribution among women with cervical dysplasia in relation to oral contraceptive usage. METHODS: Prospective cross-sectional study of four groups of patients according to oral contraceptive usage: non-users, users of less than five years duration, users of between five years and ten years, and users of more than ten years duration. Swabs of the cervix were analysed for HPV DNA using the polymerase chain reaction method. RESULTS: A total of 124 women were recruited for the study. There were 75 patients who were HIV-infected (seroprevalence 61%). There were 102 patients who were HPV positive (82%), of which 79 patients had high-risk HPV DNA (78%). In terms of the four oral contraceptive groups, high-risk HPV DNA was detected in 70% (n = 21), 79% (n = 22), 90% (n = 21) and 71% (n = 15) of patient, respectively. The odds of having HPV DNA was six times higher for the combination of contraceptive users of less than five years duration/non-users (OR 5.9, 95% CI: 1.87-18.77). There was no change when adjustment was made for age (OR 6.1, 95% CI: 1.9-19.4). HPV DNA type 16 and/or 18 was present in a total of 21 patients (49%) (non-contraceptive users and users < 5 years duration) versus 15 patients (42%) (oral contraceptive users of more than 5 years duration) (p = 0.524). HPV type 16 was the commonest HPV type detected (20.2%) and HPV type 58 was the next commonest hihg-risk HPV type (16.1%). HPV types 58 and 33 were detected in a much greater percentage of our population and HPV 16 in a much smaller percentage of our population compared with a non-South African population. CONCLUSION: The findings of this study demonstrate an interesting distribution of HPV types in a South African population.

Primary nephrotic syndrome in the new millennium in KwaZulu-Natal, South Africa.

BACKGROUND: The outcome and response of idiopathic nephrotic syndrome (NS) to steroids have been linked to race. OBJECTIVES: To determine the age of presentation, sex, race, histopathology, kidney function and disease status at the last hospital visit and correlate these with steroid response in Indian and black African children with idiopathic NS. METHODS: This is a retrospective review of 231 children aged 1 - 14 years, who were seen at Inkosi Albert Luthuli Central Hospital, Durban, South Africa (SA) from 2003 to 2018. RESULTS: The mean (standard deviation (SD)) age of presentation was 6.2 (3.4) years, with the majority of children (n=107; 46.3%) presenting at an early age (1 - 3 years) with a mean (SD) follow-up of 3.0 (2.4) years. One-hundred and twenty-one (52.4%) were males and 110 (47.6%) were females, with a male/female ratio of 1.1:1. There were 166 (71.9%) black African and 65 (28.1%) Indian children. The latter presented at a younger age than black African children (p<0.001). Seventy-six (32.9%) children were steroid sensitive (SS) and 155 (67.1%) were steroid resistant (SR). Black African children were more likely to be SR (odds ratio (OR) 2.0; p=0.02; 95% confidence interval (CI) 1.1 - 3.7). A kidney biopsy was performed in 209 (90.5%) children. Minimal change disease (MCD) was observed in 32 (13.9%) children and 162 (70.1%) had focal segmental glomerulosclerosis (FSGS). Black African children were slightly more likely to have FSGS; this, however, did not reach statistical significance (122/166 (73.5%) v. 40/65 (61.5%); OR 1.73; p=0.08; 95% CI 0.94 - 3.18). On comparing disease status at last hospital visit by race, 49/65 (75.4%) Indian and 94/166 (56.6%) black African children were in remission. At last hospital visit, black African children were less likely to be in remission than Indian children (OR 0.47; p=0.02; 95% CI 0.2 - 0.9), while 15/65 (23.1%) Indian and 47/166 (28.3%) black African children had relapsed, with no significant difference between the two groups. One (1.5%) Indian child and 25 (15.1%) black African children had end-stage kidney disease (ESKD) (OR 9.27; p=0.03; 95% CI 1.2 - 70.4) ‒ the majority had FSGS. Sixteen (61.5%) received renal replacement therapy. CONCLUSIONS: Our study shows a rising incidence of FSGS, with the majority of patients having SRNS, particularly black African children. This highlights the need for alternative efficacious therapy in the management of this disease. Also, a higher percentage of black African children with both MCD and FSGS were SS on histopathological examination, which was in keeping with reports from other regions in SA. There are still major challenges for the inclusion of all children into a chronic dialysis and transplant programme.