Transformative learning through participation: experiences at a rural clinical training site in South Africa

BACKGROUND

Distributed training has been cited as an opportunity that offers transformative learning experiences in preparing a future workforce to address local needs. For this reason, rural and longitudinal placements are increasingly being adopted by medical schools across the world. Place, participation and person are considered integral in the process of transformation of medical students into responsive graduates on the distributed platform. This article aims to explore the experiences and perceptions of student learning on a rural training platform in South Africa while considering the interrelation between person, place and participation as a process of transformation to becoming a health care professional. The research forms part of a 5-year longitudinal case study, initiated in 2019 to explore a university-rural hospital collaboration on students, staff and the local health care system.

METHODS

Data was collected using interviews and surveys from 63 purposively selected and consenting participants between January and November of 2019. All qualitative data were inductively analysed using an interpretivist approach to thematic analysis for the purposes of this article. All quantitative data was analysed descriptively using Microsoft Excel. Ethics and permission for this research was granted by the Stellenbosch University Human Research Ethics Committee, the Undergraduate Students Programme Committee and the Northern Cape Department of Health, South Africa.

FINDINGS

Four themes, namely: authenticity of context; participation in a community of practice and social activities; supervision and reflection; and distance support were extracted from the data. These findings contribute to the theory of transformative learning on the distributed platform by expanding on the interrelationship of person, place and participation, specifically as it relates to participation within various communities and practices. The value of active participation in reflection and supervision, distance academic support and social support systems are explored.

CONCLUSIONS

The three dimensions and interrelationship of person, place and participation in the process of transformative learning on the rural training platform can be further unpacked by exploring the types of participation that have facilitated student learning in this research context. Participation in interprofessional teams; supervision, reflection and distance support appear to be the most crucial elements during this transformative learning process.

Training for Transformation: Opportunities and Challenges for Health Workforce Sustainability in Developing a Remote Clinical Training Platform

Background: In 2018, Stellenbosch University's Ukwanda Centre for Rural Health led a faculty initiative to expand undergraduate health professions training to a new site, 9 hours drive from the health sciences campus in the sparsely populated Northern Cape Province of South Africa in the town of Upington. This is part of a faculty strategy to extend undergraduate health sciences training into an under-resourced part of the country, where there is no medical school. During 2019, the first year of implementation, four final year medical students undertook a longitudinal integrated clerkship at this site, while final year students from other programmes undertook short 5-week rotations, with plans for extending rotations and including more disciplines in 2020. The aim of this study was to understand stakeholder perceptions regarding the development of Upington as a rural clinical training site and how this influenced existing services, workforce sustainability and health professions education.

Methods: An iterative thematic analysis of qualitative data collected from 55 participants between January and November 2019 was conducted as part of the case study. A constructivist approach to data collection was utilized to explore participants' perceptions, experiences and understanding of the new training site. Triangulation of data collection and reflexive thematic analysis contributed to the trustworthiness of the data and credibility of the findings.

Findings: The perceptions of three key groups of stakeholders are reported: (1) Dr. Harry Surtie Hospital and Academic Programme Managers; (2) Supervising and non-supervising clinical staff and (3) Students from three undergraduate programs of the Faculty. Five themes emerged regarding the development of the site. The themes include the process of development; the influence on the health service; workforce sustainability; a change in perspective and equipping a future workforce.

Discussion: This case study provides data to support the value of establishing a rural clinical training platform in a resource constrained environment. The influence of the expansion initiative on the current workforce speaks to the potential for improved capacity and competence in patient management with an impact on encouraging a rural oriented workforce. Using this case study to explore how the establishment of a new rural clinical training site is perceived to influence rural workforce sustainability and pathways, may have relevance to other institutions in similar settings. The degree of sustainability of the clinical training initiative is explored.

Description of vaccine clinical trials in Africa: a narrative review

Clinical research is important in establishing the effects of health-care interventions. Vaccine clinical trials are to examine the effectiveness and safety of vaccines for the prevention of diseases. Africa has a high burden of infectious diseases such as malaria, tuberculosis, HIV/AIDS, and Ebola virus disease. Here we report a database surveillance study of vaccine-related clinical trials conducted in Africa. An objective is to address and profile vaccine clinical trials conducted in Africa. Data were extracted from the WHO International Clinical Trials Registry Platform on 22 July 2018 and updated on 05 September 2019. We found that 61% of the 377 clinical trials were registered prospectively and 35% registered retrospectively. About 72% of the trials were single-country studies and within the country, most trials (86%) were single-center studies. The proportion of trials involving multiple African countries was 11% and that of trials involving countries outside of Africa was 16%. The biggest funder of the vaccine trials (34%) was industry, followed by governments (25%) and universities (21%). The most studied diseases were malaria (20%), HIV/AIDS (15%), tuberculosis (7%), and Ebola virus disease (6%). Most of the vaccine trials were conducted in adults (42%). The trials ranged from phase I to phase IV, with most of the trials being in phase I (18%) and phase III (18%). The conduct of vaccine clinical trials in Africa seeks to address the disease epidemics faced by the continent. There is a need for more investments from governmental bodies toward vaccine research in Africa. Further, African country collaborations are needed in efforts to find African solutions to the current infectious disease threats faced by the continent.

Melatonin has profound effects on mitochondrial dynamics in myocardial ischaemia/reperfusion

Research focus recently shifted to mitochondrial dynamics and the role of fusion and fission in cardioprotection. The aim of this study was to evaluate (i) the function and dynamics of mitochondria isolated from hearts exposed to ischaemia/reperfusion (I/R) (ii) the effects of melatonin, a powerful cardioprotectant, on mitochondrial dynamics in I/R. Isolated perfused rat hearts were stabilized for 30 min, subjected to 20 min global ischaemia, followed by 30 min reperfusion. Tissue was collected, mitochondria isolated for measurement of mitochondrial oxidative function and lysates from mitochondrial and cytosolic fractions prepared for western blotting. Melatonin (0.3 or 50 μM) was administered for 10 min immediately before the onset of ischaemia and for 10 min at the onset of reperfusion. Infarct size was assessed after 35 min regional ischaemia/60 min reperfusion using triphenyltetrazolium staining. The results show that reperfusion significantly reduced mitochondrial QO2 (states 3 and 4), with minor effects by melatonin. Cytosolic Beclin 1 and the LC3 II/I ratio were reduced by ischaemia and increased by reperfusion. Both ischaemia and reperfusion reduced mitochondrial PINK1 and Parkin levels, while reperfusion increased p62. An alternative mitophagy pathway mediated by Rab9 is activated during myocardial ischaemia/reperfusion. Ischaemia reduced and reperfusion increased cytosolic ULK1 expression, associated with redistribution of Rab9 and Drp1 between the cytosol and mitochondria. Melatonin significantly reduced mitochondrial p62 expression upon reperfusion. Throughout the protocol, melatonin significantly (i) increased cytosolic total (t) and phospho (p) ULK1, and Rab9 levels (ii) increased the cytosolic and reduced the mitochondrial pDrp1 levels and p/t Drp1 ratio, suggesting inhibition of mitochondrial fission. Fusion was affected to a lesser extent. Cardioprotection by melatonin is associated with substantial effects on mitophagy, the significance thereof remains to be established.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

Supporting clinical laboratory test-ordering protocol specification, execution and management: an event-condition-action rule and database approach

The cost of clinical laboratory testing has increased considerably during the past decade. This has prompted research and initiatives aimed at controlling clinical laboratory utilization without affecting the continued improvement of the quality of patient care. One of the most effective and proven approaches to clinical laboratory utilization management is the use of clinical test-ordering protocols. The major challenges being faced are those of modelling and specifying clinical guidelines and protocols in a manner that facilitates their integration into information systems, their subsequent management and their linking with electronic healthcare records. It is the authors’ belief that the event-condition-action (ECA) rule paradigm and modern database technology are of great potential in this area, and their applications here should be vigorously researched. This paper describes a generic model and language, called PLAN, based on the ECA rule paradigm for supporting clinical test-ordering protocols. The paper also discusses a database-based approach to the specification, execution and management of test ordering protocols.

PUFA and LC-PUFA intake during the first year of life: can dietary practice achieve a guideline diet?

BACKGROUND

An appropriate supply of n-3 long-chain polyunsaturated fatty acids (LC-PUFAs) during early childhood may enhance cognitive development. Little attention is paid to the fatty acid (FA) supply during the complementary feeding period. We examined the polyunsaturated fatty acids (PUFAs) and LC-PUFAs pattern in dietary practice of two study groups and evaluated the results against the present Dietary Guidelines in Germany.

METHODS

The food consumption and FA pattern of dietary practice in subjects from two prospective studies (n=102 and n=184, respectively) at the age of 3, 6 and 9 months was assessed by weighed diet records, and changes during the first year of life were compared with the food-based dietary guidelines for the first year of life.

RESULTS

Dietary practice in the complementary feeding period was clearly dominated by commercial food products. The FA composition in dietary practice was different from the Guideline Diet and the ratio of n-6/n-3 PUFAs was less favorable. Consumption of breast milk or formula was still of major importance for the intake of LC-PUFAs in the complementary feeding period.

CONCLUSION

LC-PUFAs are predominantly provided by breast milk and formula during the first year of life and consequently decrease when milk consumption decreases. For compensation, commercial complementary food might come closer to the Guideline Diet by lowering the n-6/n-3 PUFA ratio through appropriate vegetable oil along with an increase in total fat content up to the legal limit.

Modification of dietary polyunsaturated fatty acids via complementary food enhances n-3 long-chain polyunsaturated fatty acid synthesis in healthy infants: a double blinded randomised controlled trial

OBJECTIVE

To study the effect of modified polyunsaturated fatty acid (PUFA) profiles of complementary food on long-chain (LC) PUFA composition in healthy infants.

DESIGN

Double blinded, randomised, controlled intervention trial.

SETTING

Dortmund, Germany.

PATIENTS

Free-living sample of healthy term infants.

METHODS

Participants were randomly assigned within the first 2 months of life. During the intervention period from 4 to 10 months, the control group (n = 53) received commercial complementary meals with corn oil (3.4 g/meal) rich in n-6 linoleic acid (LA), the intervention group (n = 49) received the same meals with rapeseed oil (1.6 g/meal) rich in n-3 alpha-linolenic acid (ALA). Fatty acid intake was assessed from dietary records throughout the intervention period. Fatty acid proportions (% of total fatty acid) in total plasma were analysed before and after the intervention.

RESULTS

Plasma fatty acid profiles did not differ between the intervention and control groups before the intervention. During the intervention, the only difference in fatty acid intake between the intervention and control groups was a higher intake of ALA in the intervention group, 21% deriving from study food and a lower ratio of LA/ALA (10.7 vs 14.8). At the end of the intervention, the plasma proportions of total n-3 fatty acids and of n-3 LC-PUFA, but not of ALA, were higher and the ratios of n-6/n-3 fatty acids were lower in the intervention group.

CONCLUSIONS

Feasible dietary modifications of the precursor fatty acid profile via n-3 PUFA-rich vegetable oil favoured n-3 LC-PUFA synthesis in the complementary feeding period when LC-PUFA intake from breast milk and formula is decreasing.

Calcium transport by isolated anterior and posterior Malpighian tubules of Drosophila melanogaster: roles of sequestration and secretion

Ca(2+) transport was examined in isolated Malpighian tubules (MTs) of adult Drosophila melanogaster. All segments of both anterior and posterior MTs have substantial capacity to transport Ca(2+) and to play a role, therefore, in calcium homeostasis and elimination of excess dietary Ca(2+). Approximately 85% of Ca(2+) which enters the tubule is sequestered, and approximately 15% is secreted in soluble form into the tubule lumen. Tubules secreting fluid at maximal rates can remove an amount of Ca(2+) equal to the whole animal calcium content in approximately 9 h. Distal segments of the pair of anterior MTs can sequester the same amount of Ca(2+) in <2 h. Functional advantages of high Ca(2+) turnover rates are discussed. Transepithelial Ca(2+) secretion is increased by treatments which depolarize the transepithelial potential (thapsigargin, high K(+)), or acidify the secreted fluids (bicarbonate-free salines). The effects of pharmacological reagents and variations in bathing saline ionic composition indicate that the processes of secretion and sequestration are controlled independently, and that diltiazem-sensitive Ca(2+) channels are an important component of sequestration. The contribution of some form of apical Ca(2+) pump is evaluated.

HTLV-II risk factors in Native Americans in Florida

Earlier virologic studies established that human T-cell lymphotropic virus type II (HTLV-II) is the predominant retrovirus type found among Seminole Indians in southern Florida. We studied 46 members of the Seminole tribe living on 3 reservations to determine the risk factors for HTLV-II and to investigate disease association with the virus. The donors' plasma samples were evaluated with the enzyme-linked immunosorbent and Western blot assays. DNA extracted from their peripheral blood mononuclear cells were analyzed by type-specific polymerase chain reaction amplification and detection of the HTLV pol gene using the primer pair SK110/SK111, and the probes SK112 or SK188. One of 46 (2%) subjects was identified as HTLV-I positive and 11 (24%) were identified as HTLV-II positive. Restriction fragment length polymorphism and sequence analyses indicated that all of the HTLV-II strains were subtype b. Mitochondrial DNA analyses indicated that all of the HTLV-II-positive subjects had an Amerindian haplotype. HTLV-II was more prevalent in Indians who were >45 years of age or female, had multiple sex partners or had received a blood transfusion. However, only the latter risk factor was statistically significant. Three of the HTLV-II-positive Indians demonstrated signs and symptoms of an ataxic neuropathy. The data support that HTLV-IIb is endemic among the Seminoles and that they will be a key population for further virologic studies.