Can 'life writing' be therapeutic in response to trauma? An exploratory research project in Medical Humanities in South Africa.

The therapeutic benefit of expressive writing has been well researched in the Global North but there is no literature from the Global South. Potentially healing interventions need to be investigated in different contexts, particularly where there is a need to build social cohesion. South Africa has a violent past and is a highly stressed society. An exploration of self-reports by a diverse group of South Africans on the effects of life writing on their health and well-being was conducted using qualitative methods. Twenty members of a writing collective, the Life Righting Collective (LRC: www.liferighting.co.za), were purposively sampled and interviewed by medical students as part of a Medical Humanities special study module. Five major interconnected themes emerged. The LRC as a specific intervention was central to the benefits described. The findings of this study indicated that life writing is a useful non-medical, cost-efficient method to improve resilience to trauma, as well as improving the psychological well-being of the participants. In addition, participants reported positive experiences regarding personal development, overall wellness and mental health, and that life writing can engender a sense of community. Resource-constrained countries in the Global South, like South Africa, where there have been historical and ongoing multiple traumas, need interventions for healing and wellness that are low cost and can be replicated.

Medical interns in district health services: an evaluation of the new family medicine rotation in the Western Cape of South Africa.

BACKGROUND: In 2021, South Africa introduced a 6-month internship rotation in family medicine, in the second year of a 2-year internship programme for newly qualified doctors. This was a major change from the previous 3-months training in family medicine, and expanded the training platform to smaller district hospitals and primary health care (PHC) facilities, many of which had never had interns. The medical disciplines in South Africa needed to know if this change in the internship programme was worthwhile and successful. The aim of this study was to assess the new family medicine rotation for medical interns at district health facilities in the Western Cape Province. METHODS: Descriptive exploratory qualitative research included six intern programmes across the province. Purposeful sampling identified a heterogeneous group with maximum variation in experience. Overall, eight interns, four managers, four supervisors and four intern curators were included. Individual semi-structured interviews were audio-recorded and the transcripts were thematically analysed using the framework method and Atlas-ti software. RESULTS: Four major themes emerged around the varied structure and organisational characteristics of the rotations, the orientation and arrival of interns, their learning during the rotation, and impact on health services. A programme theory was developed that defined the key inputs (i.e. infrastructure, communication, orientation, preparation, prior learning and guidelines), processes (i.e. model of the rotation, clinical training and supervision, clinical teaching), outputs (i.e. more independent decision making, approach to undifferentiated problems, approach to chronic care and continuity, development of procedural skills, approach to sequential coordination of care and referrals, working in a multidisciplinary team and inter-professional learning, integration of multiple competencies, as well as becoming more person and community orientated). CONCLUSIONS: The new rotation in family medicine was positively experienced by most interns, supervisors and managers. It should lead to improved quality of care, better preparation for obligatory community service, and an increased likelihood of considering a career in district level health services. This study will form part of an exploratory sequential mixed methods study that incorporates the key issues into a questionnaire for a descriptive survey of all interns in a subsequent study.

Knockout of Dicer-2 in the Sf9 cell line enhances the replication of Spodoptera frugiperda rhabdovirus and conditionally increases baculovirus replication.

The Sf9 cell line, originally isolated from the ovarian tissue of Spodoptera frugiperda larvae, is widely used in academia and industry for the baculovirus-mediated production of recombinant proteins and virus-like particles. RNA interference (RNAi) is a conserved antiviral pathway present in eukaryotic organisms and is the primary antiviral defence mechanism in insects. Recent evidence has implicated RNAi as an antiviral response to baculovirus infection in Sf9 cells. To test this hypothesis, CRISPR/Cas9 technology was used to disable the RNAi pathway in Sf9 cells by knocking out Dicer-2, the protein responsible for cleaving viral double-stranded RNA precursors into short interfering RNAs. Infection of Dicer-2 knockout Sf9 cells with either the wild-type baculovirus Autographa californica nucleopolyhedrovirus (AcMNPV), recombinant AcMNPV (rAcMNPV) expressing ß-galactosidase (ß-gal), or rAcMNPV expressing a wasp venom protein (Vn50) at a multiplicity of infection (m.o.i.) of 1 resulted in a modest increase in virus replication compared to control Sf9 cells under adherent culture conditions. In contrast, Dicer-2 knockout Sf9 monolayer or suspension cultures infected by the rAcMNPV expressing ß-gal at higher m.o.i.s (3.5 and 20) did not exhibit increases in either viral DNA replication or ß-gal production. Intriguingly, during long-term passaging in suspension, Dicer-2 knockout Sf9 cultures underwent transient crashes in cell proliferation and viability. It was discovered that these periods of low growth and viability coincided with a dramatic increase in the RNA levels of S. frugiperda rhabdovirus, a recently identified adventitious virus that persistently infects the Sf9 cell line, suggesting a role for Dicer-2 in managing chronic viral infections in this industrially relevant insect cell line.

InspirE5: a participatory, internationally informed framework for health humanities curricula in health professions education.

BACKGROUND: Reporting on the effect of health humanities teaching in health professions education courses to facilitate sharing and mutual exchange internationally, and the generation of a more interconnected body of evidence surrounding health humanities curricula is needed. This study asked, what could an internationally informed curriculum and evaluation framework for the implementation of health humanities for health professions education look like? METHODS: The participatory action research approach applied was based on three iterative phases 1. Perspective sharing and collaboration building. 2. Evidence gathering 3. Development of an internationally relevant curriculum and evaluation framework for health humanities. Over 2 years, a series of online meetings, virtual workshops and follow up communications resulted in the production of the curriculum framework. RESULTS: Following the perspective sharing and evidence gathering, the InspirE5 model of curriculum design and evaluation framework for health humanities in health professions education was developed. Five principal foci shaped the design of the framework. ENVIRONMENT: Learning and political environment surrounding the program. Expectations: Graduate capabilities that are clearly articulated for all, integrated into core curricula and relevant to graduate destinations and associated professional standards. EXPERIENCE: Learning and teaching experience that supports learners' achievement of the stated graduate capabilities. EVIDENCE: Assessment of learning (formative and/or summative) with feedback for learners around the development of capabilities. Enhancement: Program evaluation of the students and teachers learning experiences and achievement. In all, 11 Graduate Capabilities for Health Humanities were suggested along with a summary of common core content and guiding principles for assessment of health humanities learning. DISCUSSION: Concern about objectifying, reductive biomedical approaches to health professions education has led to a growing expansion of health humanities teaching and learning around the world. The InspirE5 curriculum and evaluation framework provides a foundation for a standardised approach to describe or compare health humanities education in different contexts and across a range of health professions courses and may be adapted around the world to progress health humanities education.

Health Humanities curriculum and evaluation in health professions education: a scoping review.

BACKGROUND: The articulation of learning goals, processes and outcomes related to health humanities teaching currently lacks comparability of curricula and outcomes, and requires synthesis to provide a basis for developing a curriculum and evaluation framework for health humanities teaching and learning. This scoping review sought to answer how and why the health humanities are used in health professions education. It also sought to explore how health humanities curricula are evaluated and whether the programme evaluation aligns with the desired learning outcomes. METHODS: A focused scoping review of qualitative and mixed-methods studies that included the influence of integrated health humanities curricula in pre-registration health professions education with programme evaluate of outcomes was completed. Studies of students not enrolled in a pre-registration course, with only ad-hoc health humanities learning experiences that were not assessed or evaluated were excluded. Four databases were searched (CINAHL), (ERIC), PubMed, and Medline. RESULTS: The search over a 5 year period, identified 8621 publications. Title and abstract screening, followed by full-text screening, resulted in 24 articles selected for inclusion. Learning outcomes, learning activities and evaluation data were extracted from each included publication. DISCUSSION: Reported health humanities curricula focused on developing students' capacity for perspective, reflexivity, self- reflection and person-centred approaches to communication. However, the learning outcomes were not consistently described, identifying a limited capacity to compare health humanities curricula across programmes. A set of clearly stated generic capabilities or outcomes from learning in health humanities would be a helpful next step for benchmarking, clarification and comparison of evaluation strategy.

The rural determinants of health: using critical realism as a theoretical framework.

Rural health needs to be based on robust theory that guides efforts in practice, teaching and research. This could make the sets of assumptions that are inevitably brought to bear on prioritization and decision-making more explicit. It has not yet been described in theoretical terms because to insiders such as health practitioners it seems to be more of a practical endeavour than an academic one. The rural determinants of health, as a more specific expression of the social determinants of health, include issues of geography and topography in addition to the social, economic and political factors that result in the persistent disadvantage in health access and outcomes of rural populations. The philosophical approach of critical realism provides a theoretical framework that is inclusive of subjective, objective and abstract realities. Using a case study from South Africa to illustrate these notions, a conceptual model is proposed that displays the geographical and historical foundations of rural health alongside the political, economic, social and health system factors influencing patterns of disease and wellness in rural areas.

Body Weight, Serum Sodium Levels, and Renal Function in an Ultra-Distance Mountain Run.

OBJECTIVE: To determine body weight and serum [Na] changes in runners completing an 85-km mountain run, particularly with reference to their "in-race" hydration protocols. DESIGN: Prospective observational cohort study. SETTING: Cradle Mountain Run, Tasmania, Australia, February 2011. PARTICIPANTS: Forty-four runners (86% of starters) prospectively enrolled, with 41 runners (80% of starters) eligible for inclusion in final data set. MAIN OUTCOME MEASURES: Body weight change, serum sodium concentration change, and hydration plan (according to thirst vs preplanned fluid consumption). RESULTS: There was 1 case of exercise-associated hyponatremia (EAH) [postrace [Na], 132 mmol/L]. This runner was asymptomatic. There was a strongly significant correlation between the change in serum [Na] and body weight change during the race. There was a significant inverse correlation between serum [Na] and volume of fluid consumed. Change of serum [Na] was not correlated with the proportion of water versus electrolyte drink consumed. Runners drinking to thirst consumed significantly lower average fluid volumes and had higher postrace serum [Na] than those complying with a preplanned hydration protocol (142 mmol/L vs 139 mmol/L). More experienced runners tended to drink to thirst. CONCLUSIONS: There was a 2% incidence of EAH in this study. Serum [Na] change during an 85-km mountain run was inversely correlated with the volume of fluid consumed. The results provide further evidence that EAH is a dilutional hyponatremia caused by excessive consumption of hypotonic fluids. Drinking to thirst represents a safe hydration strategy for runners in a wilderness environment. CLINICAL RELEVANCE: Drinking to thirst during endurance running events should be promoted as a safe hydration practice.

From the periphery to inclusion within the health system: promoting community health worker empowerment as a way forward.

BACKGROUND: Community health worker programmes have the potential to contribute critically towards universal health coverage. However, CHWs globally have often continued to operate on the periphery of the health care system, viewed as a non-essential cadre. This results in a workforce that often remains disempowered and under-supported. This paper presents evidence from a study conducted in a rural part of South Africa, to better understand issues of CHW prioritisation, integration, and empowerment. METHODS: We applied an analytical lens based on empowerment theory and conducted a secondary analysis of qualitative data emerging from a sub-study of a cRCT evaluating the effectiveness of supportive supervision for CHWs within a large-scale national CHW programme. The cRCT was conducted between 2017 and 2022, and 39 CHWs were included in the study. RESULTS: We organised our findings across the four domains of structural empowerment; information, resources, support, and opportunity, and mapped these domains against the domains of psychological empowerment. Our findings show how CHWs are still working in the periphery of the healthcare system. Without sufficient prioritisation, high level-support from national and district governments, and sufficient investments in programmatic domains-such as training, equipment, and supportive supervision-it is likely that the CHW cadre will continue to be seen as informal health care workers. CONCLUSIONS: CHW empowerment could be a lever to potentially transform the current health system towards universal coverage; however, this process can only happen with sufficient high-level prioritization and investment.

Evaluating the new family medicine internship programmes in the Western Cape, South Africa.

BACKGROUND:  In 2021, South Africa introduced a new 6-month internship in family medicine and primary care. This study aimed to assess the new rotation at district health facilities in the Western Cape. METHODS:  A descriptive survey of interns and supervisors, as phase-two of an exploratory sequential mixed methods study. Questionnaires were developed from a descriptive exploratory qualitative study. Data were analysed with the Statistical Package for Social Sciences. RESULTS:  Questionnaires were completed by 72 interns (response rate 21%) and 36 supervisors (response rate 90%), across 10 training programmes. Interns felt more independent (97.2%), confident (90.3%) and resilient (91.6%). They learnt to manage undifferentiated and chronic conditions (91.6%), to refer patients (94.3%) and conduct procedures (77.8%). Most interns were not exposed to community-based services (68.0%) and continuity of care (54.1%). Supervision was mostly adequate during the day (79.1%) and afterhours (80.6%). Many interns reported no structured teaching programme (41.7% - 55.6%). Most supervision was from medical officers and registrars. Supervisors saw interns as valuable members of the clinical team (100.0%), who required extra support and administration (42.5%). The majority of interns (75.0%) and supervisors (72.7%) thought the rotation was the right length and the best preparation for community service (67.6%). CONCLUSION:  The rotation met most expectations of the Health Professions Council of South Africa. Programmes need to improve exposure to community-orientated primary care, public health medicine, palliative and ongoing care. Supervision and orientation of interns needs improvement.Contribution: This is the first evaluation of the new family medicine internship programme in South Africa.

Book Review of South African Family Practice Manual: 4th edition.

No abstract available.

Optimizing Lipid Nanoparticles for Delivery in Primates.

Lipid nanoparticles (LNPs) are clinically proven to successfully deliver both small interfering RNA (siRNA) therapeutics and larger mRNA payloads for prophylactic vaccine applications. Non-human primates (NHPs) are generally considered to be the most predictive of human responses. However, for ethical and economic reasons, LNP compositions have historically been optimized in rodents. It has been difficult to translate LNP potency data from rodents to NHPs for intravenously (IV) administered products in particular. This presents a major challenge for preclinical drug development. An attempt to investigate LNP parameters, which have historically been optimized in rodents, is carried out, and seemingly innocuous changes are found to result in large potency differences between species. For example, the ideal particle size for NHPs (50-60 nm) is found to be smaller than for rodents (70-80 nm). Surface chemistry requirements are also different, with almost double the amount of poly(ethylene glycol) (PEG)-conjugated lipid needed for maximal potency in NHPs. By optimizing these two parameters, approximately eight-fold increase in protein expression from intravenously administered messenger RNA (mRNA)-LNP in NHP is gained. The optimized formulations are well tolerated when administered repeatedly with no loss of potency. This advancement enables the design of optimal LNP products for clinical development.

Tackling the First COVID-19 Wave at the Cape Town Hospital of Hope: Why Was It Such a Positive Experience for Staff?

Background: In contrast to alarming reports of exhaustion and burnout amongst healthcare workers in the first wave of the COVID-19 pandemic, we noticed surprisingly positive staff experiences of working in a COVID-19 field hospital in South Africa. The 862-bed "Hospital of Hope" was established at the Cape Town International Convention Centre specifically to cope with the effects of the first wave of the COVID-19 pandemic in Cape Town. Methods: We aimed to systematically describe and assess the effects on staff and the local health system. A cross-sectional descriptive study design was employed using mixed methods including record reviews and interviews with key informants. Results: Quantitative results confirmed high job satisfaction and low staff infection rates. The emerging themes from the qualitative data are grouped around a "bull's eye" of the common purpose of person-centeredness, from both patient and staff perspectives, and include staff safety and support, rapid communication, continuous learning and adaptability, underpinned by excellent teamwork. The explanations for the positive feedback included good disaster planning, adequate resources, and an extraordinary responsiveness to the need. Conclusions: The "Hospital of Hope" staff experience produced valuable lessons for designing and managing routine health services outside of a disaster. The adaptability and responsiveness of the facility and its staff were largely a product of the unprecedented nature of the pandemic, but such approaches could benefit routine health services enormously, as individual hospitals and health facilities realize their place in a system that is "more than the sum of its parts".

Deliberate self-harm and trauma - A descriptive analysis from a London major trauma centre.

OBJECTIVES: The objective of this study is to present a retrospective analysis of patients presenting to a Major Trauma Centre (MTC) following deliberate self-harm (DSH) and identifying the precipitants of DSH and psychiatric morbidity that will serve to inform the provision of care for these patients. PATIENTS AND METHODS: This was a retrospective observational study from a London Major Trauma Centre that identified all injured patients that presented with deliberate self-harm. Data was analysed from our established trauma database. The data was analysed using descriptive statistics. RESULTS: This included 347 patients of whom 253 were male and 94 were female. The median age was 36 (range 14-93) years. Penetrating injuries (shooting and stabbing) occurred in 187 (54%) patients and blunt injuries in 160 (46%) patients. Self-stabbing (52%) was the most common cause for presentation followed by jumping from a height (26%). The median Injury Severity Score (ISS) was 4 (range 1-9). The median LOS was 3 days (range 0-109), with a mean stay of 8 days. Over half of the patients (n = 189) had previous contact with mental health services. Social and mental health were the main triggers for DSH. CONCLUSIONS: Societal and economic factors as well as a mental disorder are associated with trauma related DSH. These complex group of patients presenting to MTCs have not only acute surgical needs but social and psychological as well. Raising awareness of patients' mental health needs across the whole pathway for the major trauma patient is crucial to ensure that appropriate risk assessments are undertaken at every stage. It is also essential to provide psychological support to the multi-disciplinary team for their wellbeing.

ASL mRNA-LNP Therapeutic for the Treatment of Argininosuccinic Aciduria Enables Survival Benefit in a Mouse Model.

Argininosuccinic aciduria (ASA) is a metabolic disorder caused by a deficiency in argininosuccinate lyase (ASL), which cleaves argininosuccinic acid to arginine and fumarate in the urea cycle. ASL deficiency (ASLD) leads to hepatocyte dysfunction, hyperammonemia, encephalopathy, and respiratory alkalosis. Here we describe a novel therapeutic approach for treating ASA, based on nucleoside-modified messenger RNA (modRNA) formulated in lipid nanoparticles (LNP). To optimize ASL-encoding mRNA, we modified its cap, 5' and 3' untranslated regions, coding sequence, and the poly(A) tail. We tested multiple optimizations of the formulated mRNA in human cells and wild-type C57BL/6 mice. The ASL protein showed robust expression in vitro and in vivo and a favorable safety profile, with low cytokine and chemokine secretion even upon administration of increasing doses of ASL mRNA-LNP. In the ASLNeo/Neo mouse model of ASLD, intravenous administration of the lead therapeutic candidate LNP-ASL CDS2 drastically improved the survival of the mice. When administered twice a week lower doses partially protected and 3 mg/kg LNP-ASL CDS2 fully protected the mice. These results demonstrate the considerable potential of LNP-formulated, modified ASL-encoding mRNA as an effective alternative to AAV-based approaches for the treatment of ASA.

Geospatial distribution and bypassing health facilities among National Health Insurance Scheme enrollees: implications for universal health coverage in Nigeria.

BACKGROUND: This study was carried out to enable an assessment of geospatial distribution and access to healthcare facilities under the National Health Insurance Scheme (NHIS) of Nigeria. The findings will be useful for efficient planning and equitable distribution of healthcare resources. METHODS: Data, including the distribution of selected health facilities, were collected in Ibadan, Nigeria. The location of all facilities was recorded using Global Positioning System and was subsequently mapped using ArcGIS software to produce spider-web diagrams displaying the spatial distribution of all health facilities. RESULTS: The result of clustering analysis of health facilities shows that there is a statistically significant hotspot of health facility at 99% confidence located around the urban areas of Ibadan. The significant hotspot result is dominated by a feature with a high value and is surrounded by other features also with high values. Away from the urban built-up area of Ibadan, health facility clustering is not statistically significant. There was also a high level (94%) of bypassing of NHIS-accredited facilities among the enrollees. CONCLUSIONS: Lopsided distribution of health facilities in the study area should be corrected as this may result in inequity of access to available health services.

Factors Influencing Satisfaction with Service Delivery Among National Health Insurance Scheme Enrollees in Ibadan, Southwest Nigeria.

Perceived quality of care is a determinant of uptake of health services. This study aimed to assess the determinants of quality of care of enrollees in the National Health Insurance Scheme (NHIS) in Nigeria. The outcome was satisfaction with health care services, which was used as a proxy for quality. Findings will assist in the intervention to enhance enrollment in the scheme and for universal health coverage attainment. This was a descriptive cross-sectional study conducted among enrollees in selected NHIS facilities in Ibadan, Nigeria. Data on satisfaction with health care were collected among selected 432 enrollees with the aid of an adapted semi-structured WHO-USAID interviewer-administered questionnaire. Data were analyzed using chi-square and multiple logistic regression models (α = 0.05). Among predictors of satisfaction with health services were younger age (OR = 1.85, 95% CI = 1.05-3.25, p = .024), working in the private sector (OR = 1.84, 95% CI = 1.03-3.28, p = .022), and seeking information about quality of services prior enrollment (OR = 1.63, 95% CI = 1.04-2.53, p = .013). Targeted intervention based on the findings of this study should be implemented to improve satisfaction with the services offered.

Corrigendum: Non-communicable disease care and management in two sites of the Cape Town Metro during the first wave of COVID-19: A rapid appraisal.

No abstract available.

Non-communicable disease care and management in two sites of the Cape Town Metro during the first wave of COVID-19: A rapid appraisal.

BACKGROUND:  Non-communicable diseases (NCDs), including type-2 diabetes and hypertension, have been associated with increased morbidity and mortality rates because of coronavirus disease 2019 (COVID-19). Maintaining quality care for these conditions is important but data on the impact of COVID-19 on NCD care in South Africa are sparse. AIM:  This study aimed to assess the impact of COVID-19 on facility and community-based NCD care and management during the first COVID-19 wave. SETTING:  Two public health sector primary care sites in the Cape Town Metro, including a Community Orientated Primary Care (COPC) learning site. METHODS:  A rapid appraisal with convergent mixed-methods design, including semi-structured interviews with facility and community health workers (CHWs) (n = 20) and patients living with NCDs (n = 8), was used. Interviews were conducted in English and Afrikaans by qualified interviewers. Transcripts were analysed by thematic content analysis. Quantitative data of health facility attendance, chronic dispensing unit (CDU) prescriptions and routine diabetes control were sourced from the Provincial Health Data Centre and analysed descriptively. RESULTS:  Qualitative analysis revealed three themes: disruption (cancellation of services, fear of infection, stress and anxiety), service reorganisation (communication, home delivery of medication, CHW scope of work, risk stratification and change management) and outcomes (workload and morale, stigma, appreciation and impact on NCD control). There was a drop in primary care attendance and an increase in CDU prescriptions and uncontrolled diabetes. CONCLUSION:  This study described the service disruption together with rapid reorganisation and change management at primary care level during the first COVID-19 wave. The changes were strengthened by the COPC foundation in one of the study sites. The impact of COVID-19 on primary-level NCD care and management requires more investigation.

The Role of Trust in the Pattern of Enrollment to a Social Health Insurance Scheme and Distribution of Healthcare Facilities in Ibadan, Southwest Nigeria.

The National Health Insurance Scheme (NHIS) of Nigeria established in the year 2005 aims to minimize the inequity of access to quality healthcare services in Nigeria. As of the year 2017, enrollment in NHIS-accredited facilities in the southwest region of Nigeria was significantly clustered, with more than three-quarters of NHIS enrollees registered with only 10% of the available NHIS-accredited facilities in the six states of the region. This study explored the factors associated with the skewed distribution of enrollees across facilities and the influence of stakeholders. This is a descriptive, qualitative, case study design among stakeholders of the NHIS in Ibadan, Oyo State, Southwest, Nigeria. In-depth interviews were conducted between March and June, 2019, with all selected individual stakeholders as listed earlier. Data analysis was done using an inductive thematic approach. Across the board, there was a low level of trust in government and government policies among healthcare providers and enrollees. Few healthcare providers were willing to render services under the scheme at inception. The majority of the enrollees were compelled to register with the few available healthcare providers. Among the enrollees, a few personally chose healthcare facilities and providers that were perceived to render better quality services to receive care. Priority should be given to building trust among stakeholders in the NHIS as this would facilitate cooperation and better working relationship, and reposition the scheme for better performance.