Capacity building for quality care and education for children with severe to profound intellectual disabilities in South Africa.

In the South African context, children with severe to profound intellectual disabilities are not accommodated in the compulsory education system, although steps are being taken in this direction in acknowledgement of their right to education. Critical to this development is the training of educators and caregivers. There is a paucity of studies from South Africa addressing the training of educators and caregivers. The Teacher Empowerment for Disability Inclusion (TEDI) project developed a course on the education and care of children with severe to profound intellectual disabilities to facilitate and empower teachers to provide quality education for these learners. This paper explores, through a qualitative analysis, the ways in which 30 participants attending this course developed professionally and personally. The findings show that there was personal as well as professional learning in the areas of disability approaches, collaboration, advocacy, self-care, and confidence. These findings are discussed and future implications are addressed.

'Their status will be affected by that child': How masculinity influences father involvement in the education of learners with intellectual disabilities.

BACKGROUND: Parents play a critical role in the formal education of their children. However, a limited body of scientific knowledge exists on fathers' involvement in the formal education of their children with disabilities, particularly in Global South settings. This study sought to understand how father involvement is constructed in the formal education of learners with intellectual disabilities in an African context. METHODS: The study uses data from a broad qualitative case study of one special school in Kenya. Data were collected from eight fathers, six mothers, nine teachers and six children with disabilities using individual interviews, key informant interviews and focus group discussions. A document review was also conducted. The data were analysed thematically. RESULTS: Two themes emerging from the data are presented, named using selected quotes from the participants thus: 'He's a monster, you're the one who gave birth to him' and 'The excuse that he has work to do'. Father involvement in the education of learners with intellectual disabilities is influenced by the need of the fathers to protect their identities as men in a society whose cultural norms and values associates manliness with strength and perfection, and disability with weakness and imperfection. Father involvement is also impacted by the teachers' perceptions of the fathers' masculinity. Additionally, father involvement is influenced by the ways fathers cope with the threats to their masculinity. CONCLUSION: Perceptions of masculinity and disability intersect to construct father involvement in the formal education of learners with intellectual disabilities in this African context.

Outcomes of an Intervention to Increase Physicians Underrepresented in Medicine in Occupational Medicine Training.

CONTEXT: Diversity in the US physician workforce is important. Physicians Underrepresented in Medicine (UIM) are more likely to serve poor, uninsured, and vulnerable populations. OBJECTIVE: To increase the number of UIM physicians in Occupational Medicine. PROGRAM: An Inclusion and Diversity Committee, consisting of the program director, trainees, and graduates, was created with the goal of recruiting and developing UIM residents and increasing Occupational and Environmental Medicine awareness. Outreach to UIM residents and medical students at local, regional, and national meetings, creation and distribution of descriptive brochures, and supervised 1-day observerships were some of the interventions. RESULTS: Only 4 Underrepresented Minorities physicians out of 65 (6%) graduated during the first decade of the program 1997-2007; this increased to (16/70) 23% during the following decade subsequent to establishing the Inclusion and Diversity Committee. CONCLUSION: A multifaceted strategic approach can help increase UIM physician participation in graduate training programs, helping address health equity.

Effect of CDC Opioid-Prescribing Guidelines in a Community Hospital Emergency Department.

The United States continues to battle the addiction and overdose deaths with the opioid epidemic. Prescription opioids are responsible for more than half of these deaths. This before-after study was conducted to assess the effect of the Centers for Disease Control and Prevention's (CDC's) opioid prescription guidelines. Data were abstracted from electronic health records of adult patients presenting with low back pain seen in the emergency department during the study period. SAS statistical software was used to compare opioid prescription practices before and after the intervention. A total of 1006 patients were included in the analysis. Opioid prescriptions decreased by 11% post-CDC guidelines (45% vs 34%). Of patients receiving opioids (n = 383), there was a 6% reduction in the number of days (<5 days) for which opioids were prescribed post-CDC guidelines (14% vs 8%). CDC guidelines on opioid prescribing were associated with a significant reduction in opioid prescribing in terms of both quantity and length of time prescribed. Public health policies as guidelines may positively influence provider decision making and behaviors.

Outcomes of a Survey-Based Approach to Determine Factors Contributing to the Shortage of Occupational Medicine Physicians in the United States.

CONTEXT: There is a long-standing shortage of formally trained Occupational & Environmental Medicine (OEM) physicians despite OEM practitioners experiencing high satisfaction and low burnout. OBJECTIVE: To explore the root causes of this shortage and suggest potential remedies. METHODS: Cross-sectional surveys were administered to medical students queried regarding OEM training, practicing OEM physicians queried regarding timing of specialty choice, and OEM Train-in-Place (TIP) program graduates queried regarding satisfaction with training. RESULTS: Of 247 medical student respondents, 70% had heard of OEM, 60% through one lecture. Of the 160 OEM physicians, 17% first became aware of OEM as medical students, and most would have chosen a different path had they heard sooner. Most TIP program trainees reported that they would not have undertaken specialty training without a TIP program (89%). CONCLUSIONS: Strategies to introduce OEM earlier in medical education and TIP programs for mid-career physicians may help overcome persistent shortages of OEM specialists.

Community participation of families of children with profound intellectual and multiple disabilities in South Africa.

BACKGROUND: Families struggle to support family members with profound intellectual and multiple disabilities (PIMD), especially in low resourced settings where formal services may not be available. METHOD: The adapted Family Community Participation survey, measuring perceptions of community participation, was administered to 67 primary caregivers of children with PIMD in Cape Town by community-based rehabilitation workers. RESULTS: Families were most satisfied going to religious activities and getting together with family and friends. They were most dissatisfied with doing activities together in public and working or volunteering outside the home. Barriers to participation included negative attitudes, insufficient money and unavailability of community activities. Transportation, safety and security were additional challenges. CONCLUSIONS: Participants advocate awareness raising, community support and provision of services to address barriers to community participation. Families should be consulted on community issues to integrate their specific family needs into the overall needs of the community.

Functional effects of immune complexes formed between pembrolizumab and patient-generated anti-drug antibodies.

The PD-1-targeting IgG4 antibody pembrolizumab has significant anti-tumor activity in a proportion of stage IV melanoma patients. A subset of patients develop anti-drug antibodies (ADA) which can form immune complexes (IC) with pembrolizumab. Although IC can induce powerful, Fc-mediated, immune-regulatory effects, their functional impact during pembrolizumab treatment is unclear. The functional effects of IC generated in vitro using pembrolizumab and patient-derived ADA was, therefore, investigated. Screening identified a patient whose trough serum samples from three treatment cycles contained both ADA with neutralizing activity and low levels of pembrolizumab. This patient responded well to therapy over 2 years and had ongoing, infusion-related, hypersensitivity reactions despite the later absence of detectable ADA. The components of IC were mimicked by forming a complex of pembrolizumab by absorption onto a solid phase with or without subsequent exposure to the ADA+ patient sera. Complexes comprised of pembrolizumab alone significantly inhibited TLR4 (LPS)-driven IL-10 production by PBMC and stimulated the generation of reactive oxygen species by granulocytes. In contrast, soluble and solid-phase F(ab´)2 fragments of pembrolizumab had no effect demonstrating the requirement for cross-linked Fc regions. IC containing pembrolizumab and ADA could additionally induce complement and NK activation. The results of this study demonstrate that, when oligomerized, the Fc region of pembrolizumab alone can provide immuno-regulatory signals. Furthermore, IC containing both pembrolizumab and patient-generated ADA can induce additional signals. These Fc-mediated signals may modulate both hypersensitivity reactions and anti-tumor responses associated with pembrolizumab therapy.

Microbial community composition and dolomite formation in the hypersaline microbial mats of the Khor Al-Adaid sabkhas, Qatar.

The Khor Al-Adaid sabkha in Qatar is among the rare extreme environments on Earth where it is possible to study the formation of dolomite-a carbonate mineral whose origin remains unclear and has been hypothetically linked to microbial activity. By combining geochemical measurements with microbiological analysis, we have investigated the microbial mats colonizing the intertidal areas of sabhka. The main aim of this study was to identify communities and conditions that are favorable for dolomite formation. We inspected and sampled two locations. The first site was colonized by microbial mats that graded vertically from photo-oxic to anoxic conditions and were dominated by cyanobacteria. The second site, with higher salinity, had mats with an uppermost photo-oxic layer dominated by filamentous anoxygenic photosynthetic bacteria (FAPB), which potentially act as a protective layer against salinity for cyanobacterial species within the deeper layers. Porewater in the uppermost layers of the both investigated microbial mats was supersaturated with respect to dolomite. Corresponding to the variation of the microbial community's vertical structure, a difference in crystallinity and morphology of dolomitic phases was observed: dumbbell-shaped proto-dolomite in the mats dominated by cyanobacteria and rhombohedral ordered-dolomite in the mat dominated by FAPB.

Impact of increased access to novel agents on the survival of multiple myeloma patients treated at a single New Zealand centre.

BACKGROUND: The impact of changes in novel agent (NA) usage on the survival of multiple myeloma (MM) patients in real-world hospital settings is unclear. In New Zealand (NZ) in 2011, frontline bortezomib became available and thalidomide availability was expanded. AIM: This retrospective study analyses the impact these change had on the survival of MM patients treated at a NZ hospital. METHODS: Clinical and overall survival (OS) data were collected on MM patients who were treated at Christchurch Hospital during 2000-2009 (pre-cohort, n = 337) and 2011-2017 (post-cohort, n = 343). Outcomes were compared using pre-cohort data truncated at 2011. RESULTS: Patients in the post-cohort had significant increases (P < 0.001) in not only NA usage (85 vs 55%) and OS (median = 56 vs 44 months) but also the proportion (74 vs 49%) of young patients (age < 70) who received an autologous stem cell transplant (ASCT). Separate analysis of older patients demonstrated that those in the post-cohort had significantly longer OS (median OS 28 vs 17, P < 0.001) although 5-year relative survival remained less than 50%. Separate analysis of young patients demonstrated that those in the post-cohort had significantly increased initial OS with the survival curves converging at 5 years. Although ASCT-treated patients had similar OS in each cohort, their progression-free survival (PFS) was significantly increased in the post-cohort (median 40 vs 20 months, P < 0.0001). CONCLUSION: In the setting of a NZ hospital the increased availability of NA was associated with a significant improvement in both the OS of older patients and the PFS of ASCT patients.

Discourse of needs versus discourse of rights: family caregivers responding to the sexuality of young South African adults with intellectual disability.

Although most people with intellectual disability remain under the lifelong care and support of their families, there is a hiatus in research that explores the sexuality of people with intellectual disability within the family setting. Little is known about how the responses of family caregivers align with a human rights approach to the sexuality of people with intellectual disability, particularly in the South African context. This study used a constructivist grounded theory approach to explore how 25 South African family caregivers responded to the sexuality of their young adults with intellectual disability. Findings revealed that family caregivers prioritise what they deem as being the immediate needs of themselves and the young adults, over the young adults' rights to sexual autonomy. Practitioners, guided by the human rights approach, need to understand the individual and family context so as to better collaborate with family caregivers in supporting people with intellectual disability to realise their sexual rights. We apply two theories of needs to illuminate the conflict between needs-centred ethics and human rights approaches in a context where the family caregivers are the ones determining the sexuality needs of young adults with intellectual disability.

Discrimination of Anti-drug Antibodies With Neutralizing Capacity in Infliximab- and Adalimumab-Treated Patients: Comparison of the Homogeneous Mobility Shift Assay and the Affinity Capture and Elution Assay.

BACKGROUND: The measurement of anti-drug antibody (ADA) levels in adalimumab (ADAL)-treated and infliximab (IFX)-treated patients is critical for guiding therapeutic strategies. The homogeneous mobility shift assay (HMSA) and affinity capture elution (ACE) assay provide effective, drug-tolerant formats for measuring total ADA levels. However, their ability to discriminate between ADA from samples with or without neutralizing capacity is unclear and therefore was analyzed in this study. METHODS: Sera from ADAL and IFX patients with low drug levels (<1 mcg/mL) were analyzed by ACE, HMSA, and bridging assay. Neutralizing capacity was determined by competitive ligand-binding assay. RESULTS: HMSA and ACE detected high ADA levels in all ADAL (19/42) and IFX (27/64) samples with neutralizing capacity. ADA was also detected in most of the samples without neutralizing capacity, but levels were significantly lower (P < 0.0001). Receiver operator characteristic curve analysis demonstrated that for both assays, ADA levels were a strong discriminatory marker of neutralizing ADA (area under the curve > 0.9, P < 0.0001). Using a signal >8× background as a cut-point, neutralizing ADA could be identified with high specificity (HMSA > 95%, ACE > 85%) and sensitivity (HMSA > 70%, ACE > 80%). The detection of multimeric drug-ADA complexes after HMSA was also a highly specific marker (specificity > 95%) of neutralizing ADA in both ADAL and IFX patients. Results using ACE and HMSA were highly correlated. CONCLUSIONS: Results obtained after HMSA and ACE analysis are strongly correlated, and in both assays, high ADA levels are a specific marker of neutralizing capacity. The detection of multimeric complexes by HMSA also selectively identifies sera with neutralizing capacity. These data support the use of these assays as quantitative rather than simple qualitative measures of ADA.

Neurological Manifestations Among US Government Personnel Reporting Directional Audible and Sensory Phenomena in Havana, Cuba.

Importance: From late 2016 through August 2017, US government personnel serving on diplomatic assignment in Havana, Cuba, reported neurological symptoms associated with exposure to auditory and sensory phenomena. Objective: To describe the neurological manifestations that followed exposure to an unknown energy source associated with auditory and sensory phenomena. Design, Setting, and Participants: Preliminary results from a retrospective case series of US government personnel in Havana, Cuba. Following reported exposure to auditory and sensory phenomena in their homes or hotel rooms, the individuals reported a similar constellation of neurological symptoms resembling brain injury. These individuals were referred to an academic brain injury center for multidisciplinary evaluation and treatment. Exposures: Report of experiencing audible and sensory phenomena emanating from a distinct direction (directional phenomena) associated with an undetermined source, while serving on US government assignments in Havana, Cuba, since 2016. Main Outcomes and Measures: Descriptions of the exposures and symptoms were obtained from medical record review of multidisciplinary clinical interviews and examinations. Additional objective assessments included clinical tests of vestibular (dynamic and static balance, vestibulo-ocular reflex testing, caloric testing), oculomotor (measurement of convergence, saccadic, and smooth pursuit eye movements), cognitive (comprehensive neuropsychological battery), and audiometric (pure tone and speech audiometry) functioning. Neuroimaging was also obtained. Results: Of 24 individuals with suspected exposure identified by the US Department of State, 21 completed multidisciplinary evaluation an average of 203 days after exposure. Persistent symptoms (>3 months after exposure) were reported by these individuals including cognitive (n = 17, 81%), balance (n = 15, 71%), visual (n = 18, 86%), and auditory (n = 15, 68%) dysfunction, sleep impairment (n = 18, 86%), and headaches (n = 16, 76%). Objective findings included cognitive (n = 16, 76%), vestibular (n = 17, 81%), and oculomotor (n = 15, 71%) abnormalities. Moderate to severe sensorineural hearing loss was identified in 3 individuals. Pharmacologic intervention was required for persistent sleep dysfunction (n = 15, 71%) and headache (n = 12, 57%). Fourteen individuals (67%) were held from work at the time of multidisciplinary evaluation. Of those, 7 began graduated return to work with restrictions in place, home exercise programs, and higher-level work-focused cognitive rehabilitation. Conclusions and Relevance: In this preliminary report of a retrospective case series, persistent cognitive, vestibular, and oculomotor dysfunction, as well as sleep impairment and headaches, were observed among US government personnel in Havana, Cuba, associated with reports of directional audible and/or sensory phenomena of unclear origin. These individuals appeared to have sustained injury to widespread brain networks without an associated history of head trauma.

Caring for Adults with Intellectual Disability: The Perspectives of Family Carers in South Africa.

BACKGROUND: Internationally adults with intellectual disability are largely cared for by their families, especially in low- to middle-income countries (LAMIC). Compared to high-income countries, little is known about their experiences in LAMIC such as South Africa. METHODS: Focus group discussions were carried out with 37 family caregivers (FCGs) in the Cape Town metropole. These were transcribed and analysed thematically. Core categories were identified and validated through member checking. RESULTS: Family caregivers showed strong commitment to care despite the heavy responsibility and burden of care that women especially experience. They recognize the limited personal growth opportunities for people with intellectual disability that increases the caregiving burden. FCGs identify supports and resources in the community that assist them with their care responsibilities but often feel let down by services. CONCLUSIONS: Improved family supports appropriate to the resources in LAMIC are needed especially when existing carers are no longer able to provide care.

The Covid-19 Pandemic and The Future of Work.

INTRODUCTION: The "future of work" refers to workplace modifications projected to occur following large scale events impacting workforce health and safety such as pandemics, technological advancements, or economic shifts. This paper examines the influence of the COVID-19 pandemic on the future of work. METHODS: The electronic databases PubMed, Google Scholar, and Scopus were explored using search terms such as "post-pandemic," "working force," and "future of work" to retrieve papers published between 2000 and 2023. RESULTS: The main characteristics of the future of work modification revealed are blurring of work-home boundaries, increase in telework and the gig economy, demand for artificial intelligence, smart working, quiet hiring, diversity and inclusion, and algocratic governance. Needed skills include virtual collaboration capability, cross-cultural competency, computational thinking, news media literacy, transdisciplinarity, sense making, and focusing on mental health and well-being. CONCLUSIONS: Organizations are remodeling workforces to meet employee, employer, regulatory, and market expectations to adapt to future workplace needs.

Rotator Cuff Tears, Repairs, and Shoulder Arthroplasties Among Workers' Compensation Claimants: A 16-year study of workers' compensation claims from a large nationwide workers' compensation insurance carrier.

BACKGROUND: Rotator cuff repair (RCR) is increasingly being performed for both acute traumatic and degenerative tears of the rotator cuff, while total shoulder arthroplasty (TSA) is reserved for osteonecrosis of the humeral head, arthritis of the glenohumeral joint and failed RCR. OBJECTIVE: To assess the incidence and patient characteristics of rotator cuff tears (RCTs), RCRs, and TSAs among workers' compensation (WC) claimants. METHOD: 8,347 RCT indemnity claims filed to Accident Fund Group from 2007 to 2022 were studied. RESULTS: Over the study period, the percentages of RCTs increased from 41% to 65% among shoulder injury indemnity claimants, RCRs increased from 88% to 92% of RCTs and TSAs increased from 1% to 5%. CONCLUSION: RCT, RCR, and TSA have increased dramatically among WC claimants, age of the injured worker being the primary determinant of the increase.

Is Arthroscopic Meniscectomy Associated With an Increased Risk of Total Knee Arthroplasty for Claimants in the Workers' Compensation System? A 10-Year Study of Workers' Compensation Claims From a Large Nationwide Workers' Compensation Insurance Carrier.

BACKGROUND: Total knee arthroplasty (TKA) is a commonly performed knee surgery and prior arthroscopic meniscectomy (AM) has been linked to an increased risk of TKA in the general population. OBJECTIVE: To study the relationship between AM and TKA among injured workers whose medical care is paid for under workers' compensation (WC). METHOD: A total of 17,247 lost-time claims depicting all arthroscopic knee surgical procedures performed from 2007 to 2017 were followed to the end of 2022 and analyzed. RESULTS: The odds ratio of undergoing a TKA for those with a preceding AM is 2.20, controlling for age, sex, and attorney involvement. CONCLUSIONS: Undergoing an AM is associated with an increased risk of TKA in WC claimants.

Outcomes for a Heat Illness Prevention Program in Outdoor Workers: A 9-Year Overview.

OBJECTIVE: To describe the outcomes effect of removing the medical surveillance component from a heat illness prevention program (HIPP) for outdoor workers from a Central Texas municipality. METHODS: Heat-related illness (HRI) frequency and workers' compensation (WC) cost were assessed retrospectively in a cohort of 329 workers from 2011-2019. During 2011-2017, the HIPP included training, acclimatization, and medical surveillance. In 2018-2019, a modified (mHIPP) was implemented that included training and acclimatization, but without medical surveillance. RESULTS: The HRI rate during HIPP averaged 19.5 per 1000 workers during the first 4 years, dropped to 1.01 per 1,000 workers over the next 3 years, (2015-2017), and increased during mHIPP, to 7.6 per 1,000 workers. DISCUSSION: Although the case increase during the mHIPP was small, medical surveillance may be an important component in lowering workforce HRI.

Disabled people in rural South Africa talk about sexuality.

Disability is emerging as a human rights issue of public concern, rather than an individual tragedy requiring medical attention. The issue of sexuality remains relatively neglected in this agenda, particularly as regards the exploration of the complexities of sexuality encountered by disabled people themselves. This paper focuses on the experiences of sexuality of disabled people and parents of disabled children in settings of poverty in the Eastern Cape Province of South Africa. Three individual interviews and two focus groups were conducted with disabled adults and parents of disabled children. Thematic analysis of the interviews identified three principal themes (1) sexuality development in the family of origin, (2) sexuality in the community and (3) adult sexuality and creating families. Each of these larger themes encompasses various sub-themes that are discussed in the findings. The paper concludes that while sexuality is a very difficult aspect of life for a disabled person due to myths and discrimination against disabled people, it is also an important arena for affirmation and establishing self-worth. It is therefore critical to consider the development of a healthy sexuality amongst disabled people and the promotion of their sexual rights.