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

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

Special series on the District Health System

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

BACKGROUND

There is a gap in understanding of potential roles and actions at the subdistrict level to improve quality of care and health outcomes in South Africa (SA).

OBJECTIVES

To report on the evaluation of a subdistrict health system-strengthening initiative that aimed to reduce maternal, newborn and child mortality, referred to as the '3 feet model' in Waterberg District, Limpopo Province, SA. The model is centred on systems of real-time morbidity/mortality surveillance and co-ordinated responses. It was implemented in three of five Waterberg subdistricts over an 18-month period in 2021 and 2022.

METHODS

A prospective, process-tracing evaluation was conducted jointly between researchers, intervention partners and subdistrict decision-makers. Data sources combined ~100 hours of researcher participant observation, interviews with 14 health system actors, structured reflections by three subdistrict managers and information from the routine District Health Information System. Sources were triangulated and analysed based on a priori hypotheses on mechanisms of action.

RESULTS

Following uptake of the model, the perinatal mortality rate (PMR) improved by 28.8%, 11.5% and 28% in the three subdistricts, respectively, while the PMR worsened in two of four neighbouring subdistricts. Plausible factors in implementation successes were the presence of stable and committed hybrid (clinical-managerial) subdistrict leaders and their ability to overcome entrenched silos between a variety of system actors; new collaborative relationships between primary healthcare facilities, hospitals and emergency medical services; the generation and packaging of information in ways that directed responses ('actionable intelligence'); and support from senior district managers.

CONCLUSION

While not advocating for a cut-and-paste approach to improving quality and outcomes, positive experiences in Waterberg District suggest that the principles and mechanisms of action of the 3 feet model have wider relevance for policy and practice, especially as emphasis shifts towards the subdistrict as a core unit of population health and wellbeing in SA.

Healthcare Delivery

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

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

BACKGROUND

In X-linked hypohidrotic ectodermal dysplasia (XLHED), ectodysplasin A1 (EDA1) deficiency results in malformation of hair, teeth, and sweat glands. Lack of sweating which can cause life-threatening hyperthermia is amenable to intrauterine therapy with recombinant EDA1.

OBJECTIVES

This study aimed at evaluating reproductive decision-making by women with XLHED and at clarifying the potential impact of a prenatal treatment option.

METHODS

In a retrospective cross-sectional analysis, a 75-item questionnaire filled in by 50 women with XLHED (age 19-49 years) was assessed.

RESULTS

16 women (32%) prevented pregnancies because of the risk to pass on XLHED, 15 considered assisted reproduction for the same reason. Twelve women had a history of miscarriage, stillbirth or abortion, three women reported on previous abortion of affected fetuses. When imagining to be pregnant, all except one showed interest in prenatal diagnosis of XLHED and in the possibility of treatment before birth. In 13 out of 50 women (26%), XLHED if detected prenatally would have impact on the continuation of pregnancy. Among 35 mothers of at least one affected child, XLHED had rarely been diagnosed during the first pregnancy (17%) but regularly during subsequent pregnancies (77%). Becoming aware of the condition before birth had caused a moral conflict for 50% of these women. Subjects with an affected child less frequently considered assisted reproduction to prevent XLHED (p<0.05). In more than 66% of the women who reported an effect of XLHED on family planning, a prenatal treatment option for this disease would influence their decision-making.

CONCLUSIONS

Many pregnant XLHED carriers who seek prenatal diagnosis experience moral conflicts. A prenatal treatment option would have strong impact on reproductive decisions, underlining the importance of adequate professional counselling.

[Outpatient laparoscopic hysterectomy in France: A monocentric randomized trial]

OBJECTIVE

To demonstrate the feasibility of outpatient laparoscopic hysterectomy using the assessment of post-operative quality of life.

METHODS

A prospective randomized single-center trial was performed in France between 2013 and 2016. A total of 42 patients needed laparoscopic hysterectomy was included. Postoperative quality of life was assessed using the standardized Euroquol questionnaire. Patients filled the score before the operation and then on the 3rd and 30th postoperative day. Secondary outcomes were assessment of postoperative pain, overall quality of life, analgesic use, and anxiety. The patients were randomized into two groups, group A with a conventional hospital stay of 2 to 3 days and group B with a short stay and a discharge the day after the intervention.

RESULTS

Twenty-one patients were randomized to group A as well as group B. We did not find any significant differences between the two groups in our study either on our primary outcome or in the seconds ones. On day 3, the average of Euroquol score was 0.68 for group A against 0.50 for group B (P=0.05). Likewise, the scores for postoperative pain were similar with 70.6 in group A and 61.8 in group B (P=0.21). The trend was the same for quality of life score or anxiety.

CONCLUSION

Our study shows the possibility and the safety of outpatient laparoscopic hysterectomy.

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

BACKGROUND

A lack or dysfunction of the anchoring protein laminin-332 in the basement membrane leads to the skin blistering disorder junctional epidermolysis bullosa (JEB). The mutation c.628G>A in the gene LAMB3 encoding the laminin β3-chain is associated with generalized intermediate JEB; it may introduce an amino acid substitution (p.Glu210Lys) or disrupt splicing.

OBJECTIVE

This retrospective study aimed at determining the effects of aberrant splicing on the JEB phenotype.

METHODS

LAMB3 transcription was analysed in two siblings compound heterozygous for the LAMB3 mutations p.Glu210Lys and p.Arg635* with a diverging JEB phenotype from late childhood on. Laminin-332 levels in skin sections and in cultured keratinocytes were investigated by immunofluorescence staining. Real-time PCR was used to quantify LAMB3 expression in keratinocytes. RNA splice variants were identified by subcloning of a LAMB3 cDNA fraction and subsequent DNA sequencing. Structural models of laminin-332 helped to assess the impact of certain mutations on laminin-332 folding.

RESULTS

Both siblings showed diminished LAMB3 expression. Laminin-332 was equally reduced in skin sections obtained during infancy but differed in keratinocytes isolated during adolescence. Although aberrant LAMB3 splicing with 26 variants was detected in both patients, splicing differed significantly: the full-length LAMB3 transcript harbouring the p.Glu210Lys mutation was found more often in the patient affected less severely (14/108 vs. 5/106 clones; P = 0.03). Structural modelling predicted that several deletions in LAMB3, but not the point mutation p.Glu210Lys, have an effect on laminin-332 folding and secretion.

CONCLUSIONS

Differential LAMB3 mRNA splicing in the patients may explain the disparate JEB phenotype. By elucidating the regulation of laminin-332 gene expression, these findings may contribute to the development of therapeutic strategies for JEB and might help to understand phenotype modification by splice-site mutations in other hereditary diseases.

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

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

OS8.6 Sensitivity of human meningioma cells to the cyclin-dependent kinase inhibitor, TG02

BACKGROUND

Standards of care for meningioma include surgical resection, which may be curative, and radiotherapy as required. Pharmacotherapy plays only a minor role in this disease; however, novel systemic approaches are urgently needed for patients who are no longer candidates for local therapy.

MATERIAL AND METHODS

We generated primary cultures from surgically removed meningiomas to explore the activity of a novel cyclin-dependent kinase inhibitor, TG02, in meningioma cell cultures. Tumor and cell cultures were characterized by mutation profiling and DNA methylation profiling. DNA methylation data were used to allot each sample to one out of six previously established meningioma methylation classes: benign (ben)-1, 2, 3, intermediate (int)-A, B, and malignant (mal). The activity of TG02 was assessed by standard cell culture assays.

RESULTS

Cell cultures were derived from nine meningiomas. Four tumors assigned to the methylation class ben-2 showed the same class in the cell culture whereas cell cultures from five non-ben-2 tumors showed a different class, a more malignant class in four of five patients. Cell cultures were uniformly sensitive to the growth inhibitory effects of TG02 in the nanomolar range. Assignment of the cell cultures to a more malignant methylation classifier appeared to be more closely associated with TG02 sensitivity than assignment to a higher WHO grade of the primary tumors.

CONCLUSION

Primary cell cultures from meningioma facilitate the investigation of the anti-meningioma activity of novel agents. TG02, an orally available cyclin-dependent kinase inhibitor, warrants further exploration in this disease.

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

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

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

Introduction

Patients with COPD have increased respiratory loads and altered blood gases, both of which affect vascular function and sympathetic activity. Sleep, particularly rapid eye movement (REM) sleep, is known to exacerbate hypoxia and respiratory loads. Therefore, we hypothesize that nasal high flow (NHF), which lowers ventilatory loads, reduces sympathetic activity during sleep and that this effect depends on COPD severity.

Methods

We performed full polysomnography in COPD patients (n=17; FEV₁, 1.6±0.6 L) and in matched controls (n=8). Participants received room air (RA) at baseline and single night treatment with O₂ (2 L/min) and NHF (20 L/min) in a random order. Finger pulse wave amplitude (PWA), a measure of vascular sympathetic tone, was assessed by photoplethysmography. Autonomic activation (AA) events were defined as PWA attenuation ≥30% and indexed per hour for sleep stages (AA index [AAI]) at RA, NHF, and O₂).

Results

In COPD, sleep apnea improved following O₂ (REM-apnea hypopnea index [AHI] with RA, O₂, and NHF: 18.6±20.9, 12.7±18.1, and 14.4±19.8, respectively; P=0.04 for O₂ and P=0.06 for NHF). REM-AAI was reduced only following NHF in COPD patients (AAI-RA, 21.5±18.4 n/h and AAI-NHF, 9.9±6.8 n/h, P=0.02) without changes following O₂ (NHF-O₂ difference, P=0.01). REM-AAI reduction was associated with lung function expressed as FEV₁ and FVC (FEV₁: r=−0.59, P=0.001; FEV₁/FVC: r=−0.52 and P=0.007).

Conclusion

NHF but not elevated oxygenation reduces peripheral vascular sympathetic activity in COPD patients during REM sleep. Sympathetic off-loading by NHF, possibly related to improved breathing mechanics, showed a strong association with COPD severity.

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

OBJECTIVE

Margin analysis of Class III and IV composite restorations in vitro and in vivo occurred by scanning electron microscopy (SEM) and optical coherence tomography (OCT). The results were compared and related to clinical evaluation.

METHODS AND MATERIALS

Eight Class III composite restorations were imaged in vitro using OCT and SEM. The margins were analyzed quantitatively. OCT signals were verified by assignment to the criteria perfect margin, gap, and positive/negative ledge. In vivo quantitative margin analysis of Class III/IV composite restorations made of the micro-hybrid composite Venus combined with the self-etch adhesive iBond Gluma inside (1-SE) or etch-and-rinse adhesive Gluma Comfort Bond (2-ER) (all Heraeus Kulzer) was carried out using OCT and SEM after 90 months of clinical function. The results were compared with clinical evaluation (US Public Health Service criteria; marginal integrity, marginal discoloration).

RESULTS

In vitro, the correlation between OCT and SEM was high for all four margin criteria (Kendall tau b [τ_b] correlation: 0.64-0.92, p_i≤0.026), with no significant differences between OCT and SEM (p_i≥0.63). In vivo, a moderate correlation was observed (τ_b: 0.38-0.45, p_i<0.016). Clinically, the cumulative failure rate in the criterion marginal integrity was higher for the 1-SE group (baseline 90 M, p=0.011). Similarly, OCT and SEM detected higher percentages of the criterion gap in the 1-SE group (p: 0.027/0.002), in contrast to perfect margin. Both, gap and perfect margin ranged widely between 0.0% and 88.7% (OCT) and between 0.0% and 89.0% (SEM).

CONCLUSION

Despite the positive selection bias after 90 months with only a few patients left, quantitative margin analysis allows for differentiation between the two adhesives at this specific date. OCT in particular offers the possibility to evaluate marginal integrity directly in vivo.

[Anticorruption Act : A criminal proceedings prophylaxis for urologists]

Since the introduction of the German Act to Combat Corruption in the Healthcare Sector concerns of fear and uncertainty are present. An elementary protection against criminal investigations can be achieved by complying with the physician professional law. Service contracts with the industry can be concluded if the interest in the service is reasonable and the payment is appropriate. There is a restrictive scale for clinical trials with already authorized products regarding any compensation granted which should correspond to the amount determined by the applicable elements of the German scale of medical fees (GOÄ). Invitations to academic training events can be accepted within an appropriate framework.

Doubly Dressed Bosons: Exciton Polaritons in a Strong Terahertz Field

We demonstrate the existence of a novel quasiparticle, an exciton in a semiconductor doubly dressed with two photons of different wavelengths: a near infrared cavity photon and terahertz (THz) photon, with the THz coupling strength approaching the ultrastrong coupling regime. This quasiparticle is composed of three different bosons, being a mixture of a matter-light quasiparticle. Our observations are confirmed by a detailed theoretical analysis, treating quantum mechanically all three bosonic fields. The doubly dressed quasiparticles retain the bosonic nature of their constituents, but their internal quantum structure strongly depends on the intensity of the applied terahertz field.

Seasonal and genera-specific variations in semen availability and semen characteristics in large parrots

In large parrots electro-stimulation is suitable for collecting semen, and therefore, to facilitate semen examination and artificial insemination. Previous studies have detected differences in the semen collection success rate and semen parameters between psittacine genera. It remained unclear whether these differences were genera-related, seasonal variations or depend on the males' relationship status. To answer these questions, semen collection and spermatological analysis were performed for four psittacine groups (macaws, amazons, eclectus parrots and cockatoos) over 13 months. In one breeding facility, semen collection was attempted in 82 males using electro-stimulation twice monthly. A complete spermatological evaluation was performed on 435 semen samples. Volume, color, consistency, contamination and pH of semen, as well as motility, progressive motility, sperm concentration, total sperm count, viability, and morphology of spermatozoa were evaluated. Seasonality affected the collection success rate in macaws and amazons. Thereby, in amazons a distinct peak was observed several days before and around oviposition, whereas eclectus parrots and cockatoos produced semen all year round. The average sperm concentration was highest in eclectus parrots (2.7 × 10⁶ sperm/μl) and lowest in macaws (35.6 × 10³ sperm/μl). The differences in the semen collection success rate and semen parameters seem to coincide with the bird's breeding biology. The collected data allows a prognostic estimation when semen collection seems favorable, and may be taken as orientation values for semen analysis in these species.

A versatile UHV transport and measurement chamber for neutron reflectometry under UHV conditions

We report on a versatile mini ultra-high vacuum (UHV) chamber which is designed to be used on the MAgnetic Reflectometer with high Incident Angle of the Jülich Centre for Neutron Science at Heinz Maier-Leibnitz Zentrum in Garching, Germany. Samples are prepared in the adjacent thin film laboratory by molecular beam epitaxy and moved into the compact chamber for transfer without exposure to ambient air. The chamber is based on DN 40 CF flanges and equipped with sapphire view ports, a small getter pump, and a wobble stick, which serves also as sample holder. Here, we present polarized neutron reflectivity measurements which have been performed on Co thin films at room temperature in UHV and in ambient air in a magnetic field of 200 mT and in the Q-range of 0.18 Å^-1. The results confirm that the Co film is not contaminated during the polarized neutron reflectivity measurement. Herewith it is demonstrated that the mini UHV transport chamber also works as a measurement chamber which opens new possibilities for polarized neutron measurements under UHV conditions.

Shear Bond Strength and Tooth-Composite Interaction With Self-Adhering Flowable Composites

PURPOSE

To evaluate the tooth-composite interaction (A) and shear bond strength (SBS; B) of self-adhering flowables.

METHODS AND MATERIALS

(A) Thirty-two human molars with one Class V cavity were restored with Vertise Flow (VF), Fusio Liquid Dentin (FLD), an experimental self-adhering flowable (EF), or Adper Prompt-L-Pop/Filtek Supreme XT Flowable (PLP). Teeth were prepared according to laboratory standard and stored in water (24 hours, 37°C). Microleakage (ML; percentage interface length at enamel [E]/dentin [D]) and tooth-composite interaction were investigated. (B) The buccal surface of 160 embedded human molars was abraded to expose an enamel/dentin area of diameter ≥3 mm. Composite specimens were produced on enamel/dentin with VF, FLD, EF, or PLP. Prior to loading, 80 samples were water stored (24 hours, 37°C) and 80 thermocycled (5°C-55°C, 1500 cycles). The SBS was measured, and failure modes were classified by scanning electron microscopy.

STATISTICS

Kruskal-Wallis, Mann-Whitney U, and Fisher exact tests were performed (α=0.05).

RESULTS

(A) At enamel margins, EF and VF showed significantly lower ML than did FLD and PLP (p_i≤0.009; 81%-89%); in dentin, lower values resulted with FLD and VF compared with PLP and EF (p_i≤0.01; 77%-94%). Adhesive tags at E were consistently verifiable with EF and VF but irregularly with FLD and PLP. At D, tags were detectable with all systems. (B) In all groups, SBS decreased by up to 97% after thermocycling. It was generally diminished with self-adhering flowables (E: 50%-98%, D: 59%-98%; p_i<0.02). More cohesive defects were observed with PLP (p_i<0.009).

CONCLUSION

Tooth-composite morphology and bond strength indicate that the clinical use of self-adhering flowables must be pursued cautiously.

Dentin Protection of Different Desensitizing Varnishes During Stress Simulation: An In Vitro Study

OBJECTIVE

The aim of this study was to investigate dentin protection of different desensitizing varnishes (light- and self-curing) during acid action/abrasion stress and thermocyclic loading in vitro.

METHODS

Dentin discs of 2 mm thickness were cut from 120 human molars, embedded, and polished. Specimens were randomized into five groups (n=24): A, negative control; B, Gluma Desensitizer; C, Cervitec plus (self-curing); D, Seal&Protect; and E, Admira Protect (light-curing). In groups B-E, varnish was applied on two-thirds of the dentin surface, and one-third acted as internal control. Stress cycle (2 cycles/day) for specimens were as follows: 1, acid action (pH: 2.9: five minutes); 2, remineralization (synthetic saliva: 60 minutes); 3, brushing (100 strokes); 4, thermocycling (five cycles); and 5, remineralization (synthetic saliva: six hours) for each group (n=12) for 30 (15 days) or 60 times (30 days). Specimens were analyzed using an incident light microscope. Substance loss was measured in micrometers. Statistical analysis was performed with the multiple contrast test (p<0.05).

RESULTS

Groups B and C had a significantly lower dentin loss than A (p<0.01). After 30 days, group A showed the highest dentin loss (p<0.01), whereas the other groups lacked a significant difference regarding their substance loss (dentin and/or varnish; p>0.05). Varnish layer loss was shown for groups D and E with a remaining protective layer; groups A-C showed dentin removal.

CONCLUSION

All four varnishes are protective compared with an untreated control. Light-curing varnishes might provide higher dentin protection than self-curing materials.