Uptake of health services among truck drivers in South Africa: analysis of routine data from nine roadside wellness centres

BACKGROUND

Long-distance truck drivers are occupationally susceptible to poor health outcomes. Their patterns of healthcare utilisation and the suitability of healthcare services available to them are not well documented. We report on truck driver healthcare utilisation across South Africa and characterise the client population of the clinics serving them for future service development.

METHODS

We analysed anonymised data routinely collected over a two-year period at nine Roadside Wellness Centres. Associations between services accessed and socio-demographic characteristics were assessed using univariable and multivariable logistic regression models.

RESULTS

We recorded 16,688 visits by 13,252 individual truck drivers (average of 1.26 visits/person) who accessed 17,885 services for an average of 1.07 services/visit and 1.35 services/person. The mean age of truck drivers was 39 years. Sixty-seven percent reported being in stable relationships. The most accessed services were primary healthcare (PHC)(62%) followed by HIV (32%). Low proportions (≤6%) accessed STI,TB and malaria services. Most visits were characterised by only one service being accessed (93%, n = 15,523/16,688). Of the remaining 7% of visits, up to five services were accessed per visit and the combination of TB /HIV services in one visit remained extremely low (<1%, n = 14/16,688). Besides PHC services at the beginning of the reporting period, all service categories displayed similar seasonal utilisation trends(i.e. service utilisation peaked in the immediate few months post clinics opening and substantially decreased before holidays). Across all service categories, younger truck drivers, those with a stable partner currently, and those of South African origin were the main clinic attendees. Older truck drivers (≥40 years) were more likely to access TB and PHC services, yet less likely to access HIV and STI services. Those with stable partners were less likely to access STI and TB services but more likely to access malaria and PHC services. South African attendees were more likely to access PHC, while attendees from other nationalities were more likely to access HIV and malaria services.

CONCLUSIONS

This utilisation analysis shows that tailored services assist in alleviating healthcare access challenges faced by truck drivers, but it underscores the importance of ensuring that service packages and clinics speak to truck drivers' needs in terms of services offered and clinic location.

Abstract 3394: CGP identifies largely non-overlapping high tumor mutational burden and HRD genomic alterations in 721 clinically advanced prostate acinar adenocarcinoma cases

Background: Effective therapies for the management of castrate resistant prostate cancer are lacking. We performed comprehensive genomic profiling (CGP) on advanced prostate carcinomas (PC) in the course of clinical care to identify genomic alterations that could suggest benefit from targeted, immune- and PARP inhibitor therapeutic strategies.

Methods: DNA was extracted from 40 microns of FFPE specimen from 721 clinically advanced PC cases. CGP was performed using a hybrid-capture, adaptor ligation based next generation sequencing assay to a mean coverage depth of over 500X. All four classes of genomic alterations (GA) - base substitutions, insertions and deletions, gene fusions, and copy number alterations (amplifications and losses) - were identified.

Results: Of the 721 PC patients - men with median age of 65 (range 34 - 88) - CGP was performed on 335 (46.5%) prostate specimens and 386 (53.5%) specimens from metastatic sites. The most common genes altered were TP53 (N=336, 46.6%), PTEN (N=254, 35.2%), TMPRSS2-ERG (N=214, all fusions, 29.7%), AR (N=173, 24%), and MYC (N=105, 14.6%). Median tumor mutational burden (TMB) for this series was 3.6 mut/Mb (range 0 - 305). AR and MYC amplifications were enriched in metastatic tumors compared to primary tumors (p &lt; 0.001 for both). Alterations characteristic of homologous recombination deficiency (HRD) were found in &gt;15% of cases, including homozygous deletions and truncating mutations in BRCA2 in 79 (11%) samples, as well as truncating mutations in ATM in 41 (5.7%) samples, with only 3 samples possessing alterations in both genes. Cases with these HRD-relevant alterations possessed overall higher genomic loss of heterozygosity (LOH) content than did those without (p = 0.02). HRD and non-HRD cases had median TMB of 4.8 versus 2.7 mut/Mb, respectively, and mean TMB of 10.4 versus 4.0 mut/Mb (p &lt; 0.01). Only 2.6% of non-HRD cases were TMB-high (20 mut/Mb or more), versus 8.4% of HRD cases, a small but significant enrichment in the latter.

Conclusions: CGP for advanced PC cases identifies largely non-overlapping TMB-high and HRD positive cases, suggesting benefit from immunotherapeutics and PARP inhibitors respectively. Further investigation will assess whether HRD pathway alterations result in genomic LOH in the context of a hypermutated tumor, and enrichment or exclusivity with other GA in prostate carcinoma.

Citation Format: Ninad Dewal, Yuting He, Richard J. Lee, Alexa B. Schrock, Jon Chung, Christopher Hoimes, Zachary R. Chalmers, Garrett M. Frampton, James X. Sun, Primo N. Lara, Neeraj Agrawal, Paul Matthew, Philip J. Stephens, Vincent A. Miller, Jeffrey S. Ross, Siraj M. Ali. CGP identifies largely non-overlapping high tumor mutational burden and HRD genomic alterations in 721 clinically advanced prostate acinar adenocarcinoma cases [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3394. doi:10.1158/1538-7445.AM2017-3394

Pain and analgesic use in men with metastatic prostate cancer

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Background: Pain is an important endpoint in metastatic prostate cancer and was the basis for the 1996 FDA approval of mitoxantrone. Standards for pain assessment have evolved, and a 2006 draft FDA guidance provides new recommendations for patient- reported outcomes. Contemporary palliation models generally require pain reduction starting from baseline worst pain scores of ≥4/10, and progression models require a sufficient proportion of patients’ pain scores to worsen in order to assure an adequate effect size. The prevalence and distribution of pain severity at specific points in the prostate cancer disease continuum are not well defined. Consequently, it is unclear if sufficient numbers of patients are available to conduct prospective studies using pain palliation or prevention as primary endpoints. Methods: A questionnaire that includes the Brief Pain Inventory and additional pain/analgesia items was developed as a collaboration between the DOD/PCF-supported Prostate Cancer Clinical Trials Consortium (PCCTC) and FDA Study Endpoints and Labeling Design (SEALD) team. IRB waivers were obtained for anonymous administration at 5 PCCTC institutions (Sloan-Kettering, Duke, Johns Hopkins, Anderson, OHSU). Administration is ongoing. Results: Between August-December 2008, 325 men with prostate cancers representing different disease states being seen in outpatient clinics of participating centers were each queried once. Median age was 70 (range 49–87). More than half (n=175) self-reported metastatic disease, including 129 with bone metastases. Among those with bone metastases, 76 (59%) reported experiencing any level of pain in the last week; 49 (38%) reported a worst pain score ≥4/10 of which 38 (78%) used analgesics over the past week and 31 (63%) used daily analgesia. In addition, 70 of the 76 (92%) noted that their pain interfered with work, sleep, or enjoyment of life, with 25 (33%) noting severe interference. Among the 49 patients with pain scores ≥4/10, current or past docetaxel use was reported by 32 (65%), androgen deprivation therapy by 47 (96%), and 28 (57%) had been or were currently enrolled in a clinical trial. Conclusions: Pain is sufficiently prevalent in men with metastatic prostate cancer to enable prospective assessment of palliation endpoints in clinical trials.

No significant financial relationships to disclose.

Kikuchi's disease with systemic manifestations: a link to the Epstein-Barr virus

Kikuchi's disease is a rare benign disease that presents with fever and cervical lymphadenopathy. The importance of this disorder, lies in distinguishing it from more sinister disorders, such as lymphoma, in order to avoid unnecessary investigation and treatment. Systemic manifestations are rare in Kikuchi's disease but are not unknown. We present two cases of varying degrees of systemic involvement due to Kikuchi's disease. Both these patients, a 22-year-old woman and a 44-year-old woman, were also found to have evidence of recent Epstein-Barr virus (EBV) infection. The evidence of a causative role for EBV in Kikuchi's is also reviewed.

Hair dye poisoning

Hair dye ingestion is an uncommon form of poisoning in the west, however, in some parts of the world such as East Africa and Indian Sub-continent it is not uncommon. The main component of hair dye causing toxicity is Paraphenylenediamine (PPD). This compound has been found to cause angioneurotic edema, rhabdomyolysis and renal failure. We present a case of hair dye poisoning who presented with respiratory distress due to laryngeal edema and later developed trismus and carpopedal spasm. This case report highlights the combined toxicities of sodium EDTA and PPD.

Low-energy endocardial defibrillation using dual, triple, and quadruple electrode systems

The feasibility of achieving both universal application of nonthoracotomy leads and low (< or = 15 J) defibrillation energy requirements by optimizing lead system configuration for use with low-output (<30 J) biphasic shock pulse generators was examined. Sixteen patients (mean age 62 +/- 8 years and mean left ventricular ejection fraction of 38 +/- 15%) were included in the study. All patients had either experienced syncope with induced ventricular tachycardia (n = 4) or had documented sustained ventricular tachycardia (n = 7) or ventricular fibrillation (n = 5). Defibrillation threshold testing was performed in 2 stages on different days in these patients. In the first stage, 2 defibrillation catheter electrodes were positioned in the right ventricle and superior vena cava with an axillary cutaneous patch. Fifteen-joule, 10- and 5-J biphasic shocks were delivered across 3 different electrode configurations-right ventricle to superior vena cava, right ventricle to axillary patch, right ventricle to a combination of superior vena cava and axillary patch. In the second stage, an 80-ml can electrode was added subcutaneously in a pectoral location to the previous leads. Configurations compared were the right ventricle to pectoral can, and right ventricle to an "array"-combining superior vena cava, can, and axillary patch leads. The defibrillation threshold was determined using a step-down method. In stage 1, mean defibrillation threshold for the right ventricle to axillary patch (12.7 +/- 5.9 J) and right ventricle to superior vena cava plus axillary patch (9.8 +/- 5.2 J) configurations was lower than the right ventricle to superior vena cava configuration (14.2 +/- 6.4 J, p <0.05). In stage 2, the defibrillation was higher for the right ventricle to pectoral can (9.2 +/- 5.1 J) configuration compared with the right ventricle to the array (5.6 +/- 3.6 J, p < or =0.05). The right ventricle to array had the lowest defibrillation threshold, whereas the right ventricle to pectoral can was the best dual electrode system. Low-energy endocardial defibrillation (< or =10 J) was feasible in 72% of tested patients with > 1 electrode configuration at 10 J, whereas only 53% of successful patients could be reverted at >1 electrode configuration at 5 J (p <0.05). Reduction in maximum pulse generator output to < or =25 J using these electrode configurations with bidirectional shocks is feasible and maintains an adequate safety margin.

Structure and chromosomal localization of the genomic locus encoding the Kiz1 LIM-kinase gene

We have cloned and characterized the mouse gene encoding Kiz1/Limk1, a new member of the zinc-finger LIM family that also has a kinase domain. The gene encompasses 25 kb of the mouse genome, and the organization of its 16 exons does not correlate with its functional domains. The promoter region of Kiz1/Limk1 was identified by cloning a 1.06-kb genomic fragment upstream from the first ATG in a promotorless CAT vector. This construct was demonstrated to drive CAT expression in Jurkat cells. The promoter sequence lacks conventional TATA and CAAT motifs but contains consensus binding sequences for several transcriptional regulators implicated in control of transcription in many different cell types, including Sp1, Ets, and E2A. Analysis of the chromosomal localization of KIZ1/LIMK1 indicates that it lies on human chromosome 17 in the region 17q25 and on mouse Chromosome 5, band G2.

An association between ADH protein levels and polymorphic nucleotide variation in the Adh gene of Drosophila melanogaster

Southern analysis of the Adh region of 212 Drosophila melanogaster lines collected from the Tahbilk winery revealed linkage disequilibrium between a 37-bp insertion [designated delta 2 by Kreitman (1983)] and the fast electrophoretic variant of alcohol dehydrogenase (ADH-F). Among these lines 34% contained the insert and encoded ADH-F, 33.5% encoded ADH-F and did not have the insert, and 32.5% encoded the slow electrophoretic variant of alcohol dehydrogenase (ADH-S). Strong linkage association between this insert and ADH-F is evident worldwide. Twenty-nine of the second chromosome lines were characterized for ADH protein quantity by using radial immunodiffusion. ADH quantity was estimated in both larvae and adult males raised in the presence and absence of alcohol supplement to each of two different food media. Analyses of variance indicated higher levels of ADH protein in larvae from lines with the insert (all ADH-F), compared with those without (both ADH-F and ADH-S), independent of either dietary alcohol or media type. No such difference in ADH quantity between insert- and noninsert-containing ADH-F lines was detected in adults, although the expected higher levels occurred in ADH-F lines compared with ADH-S lines. Given the high levels of linkage disequilibrium in the Adh region, these data suggest that either polymorphic nucleotide-site variants positively associated with delta 2 on the second chromosome or delta 2 itself increases larval levels of ADH protein.