First Measurement of Hard Exclusive π^{-}Δ^{++} Electroproduction Beam-Spin Asymmetries off the Proton

The polarized cross-section ratio σ_{LT^{'}}/σ_{0} from hard exclusive π^{-}Δ^{++} electroproduction off an unpolarized hydrogen target has been extracted based on beam-spin asymmetry measurements using a 10.2  GeV/10.6  GeV incident electron beam and the CLAS12 spectrometer at Jefferson Lab. The study, which provides the first observation of this channel in the deep-inelastic regime, focuses on very forward-pion kinematics in the valence regime, and photon virtualities ranging from 1.5  GeV^{2} up to 7  GeV^{2}. The reaction provides a novel access to the d-quark content of the nucleon and to p→Δ^{++} transition generalized parton distributions. A comparison to existing results for hard exclusive π^{+}n and π^{0}p electroproduction is provided, which shows a clear impact of the excitation mechanism, encoded in transition generalized parton distributions, on the asymmetry.

PRISM study-Pre-natal iron deficiency screening and management within an Australian regional centre

INTRODUCTION

Current Australian guidelines differ in their recommendations on optimal iron deficiency anaemia screening and management during pregnancy. A more active approach to screening and treatment of iron deficiency in pregnancy has been beneficial within a tertiary population. However, this approach has not been evaluated within a regional healthcare setting.

OBJECTIVE

To evaluate the clinical impact of standardised screening and management for iron deficiency in pregnancy within a regional Australian centre.

DESIGN

Single centre, retrospective cohort observational study that audited medical records pre and post implementation of standardised screening and management for antenatal iron deficiency. We compared rates of anaemia at birth, rates of peripartum blood transfusions and rates of peripartum iron infusions.

FINDINGS

There were 2773 participants with 1372 participants in the pre-implementation group and 1401 in the post-implementation group. Participant demographics were similar. Anaemia at admission for birth decreased from 35% to 30% (RR 0.87, 95% CI (0.75, 1.00), p 0.043) Fewer blood transfusions were required (16 (1.2%) pre-implementation, 6 (0.4%) post-implementation, RR 0.40, 95% CI(0.16, 0.99), p 0.048). Antenatal iron infusions increased from 12% to 18% of participants post implementation (RR 1.47, 95% CI(1.22, 1.76), p 〈0.001).We audited compliance with the guidelines and found improvements post implementation.

DISCUSSION

This is the first study to show clinically useful and statistically significant reduction in rates of anaemia and blood transfusions, post implementation of routine ferritin screening and management within a regional Australian population.

CONCLUSION

The results of this study suggest there is benefit to implementation of standardised ferritin screening and management packages in Australian antenatal care. It also encourages RANZCOG to review current recommendations on screening for iron deficiency anaemia during pregnancy.

First CLAS12 Measurement of Deeply Virtual Compton Scattering Beam-Spin Asymmetries in the Extended Valence Region

Deeply virtual Compton scattering (DVCS) allows one to probe generalized parton distributions describing the 3D structure of the nucleon. We report the first measurement of the DVCS beam-spin asymmetry using the CLAS12 spectrometer with a 10.2 and 10.6 GeV electron beam scattering from unpolarized protons. The results greatly extend the Q^{2} and Bjorken-x phase space beyond the existing data in the valence region and provide 1600 new data points measured with unprecedented statistical uncertainty, setting new, tight constraints for future phenomenological studies.

Observation of Correlations between Spin and Transverse Momenta in Back-to-Back Dihadron Production at CLAS12

We report the first measurements of deep inelastic scattering spin-dependent azimuthal asymmetries in back-to-back dihadron electroproduction in the deep inelastic scattering process. In this reaction, two hadrons are produced in opposite hemispheres along the z axis in the virtual photon-target nucleon center-of-mass frame, with the first hadron produced in the current-fragmentation region and the second in the target-fragmentation region. The data were taken with longitudinally polarized electron beams of 10.2 and 10.6 GeV incident on an unpolarized liquid-hydrogen target using the CLAS12 spectrometer at Jefferson Lab. Observed nonzero sinΔϕ modulations in ep→e^{'}pπ^{+}X events, where Δϕ is the difference of the azimuthal angles of the proton and pion in the virtual photon and target nucleon center-of-mass frame, indicate that correlations between the spin and transverse momenta of hadrons produced in the target- and current-fragmentation regions may be significant. The measured beam-spin asymmetries provide a first access in dihadron production to a previously unexplored leading-twist spin- and transverse-momentum-dependent fracture function. The fracture functions describe the hadronization of the target remnant after the hard scattering of a virtual photon off a quark in the target particle and provide a new avenue for studying nucleonic structure and hadronization.

Multidimensional, High Precision Measurements of Beam Single Spin Asymmetries in Semi-inclusive π^{+} Electroproduction off Protons in the Valence Region

High precision measurements of the polarized electron beam-spin asymmetry in semi-inclusive deep inelastic scattering (SIDIS) from the proton have been performed using a 10.6 GeV incident electron beam and the CLAS12 spectrometer at Jefferson Lab. We report here a high precision multidimensional study of single π^{+} SIDIS data over a large kinematic range in Bjorken x, fractional energy, and transverse momentum of the hadron as well as photon virtualities Q^{2} ranging from 1-7  GeV^{2}. In particular, the structure function ratio F_{LU}^{sinϕ}/F_{UU} has been determined, where F_{LU}^{sinϕ} is a twist-3 quantity that can reveal novel aspects of emergent hadron mass and quark-gluon correlations within the nucleon. The data's impact on the evolving understanding of the underlying reaction mechanisms and their kinematic variation is explored using theoretical models for the different contributing transverse momentum dependent parton distribution functions.

First Measurement of Timelike Compton Scattering

We present the first measurement of the timelike Compton scattering process, γp→p^{'}γ^{*}(γ^{*}→e^{+}e^{-}), obtained with the CLAS12 detector at Jefferson Lab. The photon beam polarization and the decay lepton angular asymmetries are reported in the range of timelike photon virtualities 2.25<Q^{'2}<9  GeV^{2}, squared momentum transferred 0.1<-t<0.8  GeV^{2}, and average total center-of-mass energy squared s=14.5  GeV^{2}. The photon beam polarization asymmetry, similar to the beam-spin asymmetry in deep virtual Compton scattering, is sensitive to the imaginary part of the Compton form factors and provides a way to test the universality of the generalized parton distributions. The angular asymmetry of the decay leptons accesses the real part of the Compton form factors and thus the D-term in the parametrization of the generalized parton distributions.

Observation of Beam Spin Asymmetries in the Process ep→e^{'}π^{+}π^{-}X with CLAS12

The observation of beam spin asymmetries in two-pion production in semi-inclusive deep inelastic scattering off an unpolarized proton target is reported. The data presented here were taken in the fall of 2018 with the CLAS12 spectrometer using a 10.6 GeV longitudinally spin-polarized electron beam delivered by CEBAF at JLab. The measured asymmetries provide the first opportunity to extract the parton distribution function e(x), which provides information about the interaction between gluons and quarks, in a collinear framework that offers cleaner access than previous measurements. The asymmetries also constitute the first ever signal sensitive to the helicity-dependent two-pion fragmentation function G_{1}^{⊥}. A clear sign change is observed around the ρ mass that appears in model calculations and is indicative of the dependence of the produced pions on the helicity of the fragmenting quark.

Role of pharmacists in the provision of palliative care services and support in South Africa

OBJECTIVES

South Africa (SA) has high demand but inequitable access to palliative care (PC). Realising this need and the growing recognition of pharmacists' in PC globally, a study was undertaken regarding the role of pharmacists in the provision of PC services and support in SA.

METHOD

A descriptive cross-sectional quantitative study was conducted among 540 community and hospital pharmacists. A self-administered, closed-ended questionnaire covering knowledge, attitude, current role, future role and barriers to PC was used. Data was coded and analysed using SPSS® Version 24.0. P-values < 0.05 were considered statistically significant.

KEY FINDINGS

Response rate was 48.7% (n = 263). Pharmacists (72.2%) were already playing a role in PC, however, only 20.5% reported frequent involvement in PC. Services provided included medicine supply (88.2%), side-effect/symptom management (82.1%), information sharing (60.8%), bereavement counselling (60.8%), treatment/care needs (57.4%) and spiritual support (52.1%). More pharmacists (96.6%) wanted to play a role in PC, beyond medicine supply to include PC team member (91.6%), medicine reviews (91.3%), referrals (80.2%) and patient visits (50.6%). Pharmacists had a good knowledge (71.4%) and a positive attitude (61.5%) towards PC despite many health system barriers such as lack of training (91.3%), inadequate clinical experience (90.5%) and insufficient resources (77.2%).

CONCLUSIONS

Pharmacists with their high level of knowledge, positive attitude and broad scope of practice are well-placed to play a role in PC. Further strengthening and integration of their roles into the continuum of care, will encourage the involvement of more pharmacists, enhancing availability, access and resources for PC.

How often are patients with clinically apparent inguinal hernias referred to a surgeon accompanied with an ultrasound? A prospective multicentre study

ObjectivesThis study estimated the frequency of ultrasounds ordered for clinically obvious inguinal hernias in patients referred to surgeons and evaluated the clinical value of ultrasonography for this patient population. MethodsThe present study was a prospective diagnostic and therapeutic impact study conducted in district, rural and tertiary referral hospitals in Sydney, Hawkesbury and Wagga Wagga, Australia. The study included adult patients (≥18 years of age) who had been referred to one of the participating surgeons for an elective inguinal hernia repair. The study determined the proportion of: (1) patients who underwent an inguinal hernia repair for a clinically obvious hernia and also had an ultrasound; (2) ultrasounds ordered by general practitioners (GPs); and (3) these ultrasounds that altered diagnosis and consequent surgical management from the surgeon’s perspective. ResultsIn all, 144 participants were included in this study. Of these patients, 134 had a clinically apparent inguinal hernia on physical examination, and 63 of 133 patients (47%; 95% confidence interval (CI) 39–56%) underwent an ultrasound (information was missing for one patient). Overall 68 ultrasounds were ordered, with 63 ordered by GPs. Following the ultrasound, surgeons reported that one patient (1%; 95% CI 0–8 patients) had an altered diagnosis, and five patients (8%; 95% CI 3–17 patients) had altered management. ConclusionThis study found that almost one in two patients referred to a surgeon with a clinically obvious inguinal hernia also underwent a groin ultrasound. These studies represent an unnecessary waste of limited healthcare resources and low-value medical care because they rarely affect the final diagnosis or surgical management. What is known about the topic?Inguinal hernias are one of the most common presenting complaints to surgeons in Australia. Currently, there are no accepted Australian guidelines for the diagnosis of inguinal hernias. Ultrasound investigation has been shown to aid diagnosis when there is uncertainty after physical examination. There is increasing concern regarding low-value medical care that contributes to a significant waste of healthcare resources within Australia. The use of ultrasounds for the diagnosis of clinically apparent inguinal hernias is a potential area of concern. What does this paper add?This paper is the first to estimate the frequency of ultrasounds being ordered for clinically apparent inguinal hernias. The study shows that approximately one in two patients who present to surgeons with a clinically obvious inguinal hernia have an ultrasound. GPs were the major referral source for these ultrasounds. Finally, these ultrasounds rarely altered final diagnosis or management for patients who presented to surgeons for definitive management. What are the implications for practitioners?This study confirms that ultrasounds for clinically obvious inguinal hernias represent low-value medical care. Based on the results of this study, it is estimated that the cost to Medicare for unnecessary ultrasounds is approximately A$2.5 million per annum. Although it is beyond the scope of the present study to comment on the reasons for the apparent overinvestigation of ultrasounds for inguinal hernias, the findings suggest that clinical guidelines may help address this problem.

Notification of relapse and other previously treated tuberculosis in the 52 health districts of South Africa

OBJECTIVE: To investigate the extent to which relapse and other previously treated tuberculosis (TB) contribute to the notified TB burden in South Africa.DESIGN: We conducted an ecological analysis at the level of the 52 South African health districts using national electronic TB register data. We included all bacteriologically confirmed TB cases treated for presumed drug-susceptible TB in 2011. Treatment history information was based on recorded patient categories (new vs. retreatment).RESULTS: Relapse and other previously treated TB cases constituted between 7.6% and 40% (median 17%, interquartile range 12-22) of all bacteriologically confirmed TB cases in the 52 South African districts. Multivariable analysis suggested that districts with higher proportions of previously treated TB cases had higher TB case notification rates (P < 0.001), lower estimates of antenatal human immunodeficiency virus (HIV) prevalence in the district population (P < 0.001) as well as lower HIV co-infection rates (P < 0.001) among new TB cases.CONCLUSION: Relapse and other previously treated TB cases contributed substantially to the notified TB burden in several South African health districts, particularly those with high case notification rates and lower antenatal HIV prevalence. Additional efforts to prevent TB among previously treated people, such as strengthening treatment monitoring and/or secondary preventive therapy, should be considered.

Closing the reporting gap for childhood tuberculosis in South Africa: improving hospital referrals and linkages

Setting

A referral hospital in Cape Town, Western Cape Province, Republic of South Africa.

Objective

To measure the impact of a hospital-based referral service (intervention) to reduce initial loss to follow-up among children with tuberculosis (TB) and ensure the completeness of routine TB surveillance data.

Design

A dedicated TB referral service was established in the paediatric wards at Tygerberg Hospital, Cape Town, in 2012. Allocated personnel provided TB education and counselling, TB referral support and weekly telephonic follow-up after hospital discharge. All children identified with TB were matched to electronic TB treatment registers (ETR.Net/EDRWeb). Multivariable logistic regression was used to compare reporting of culture-confirmed and drug-susceptible TB cases before (2007-2009) and during (2012) the intervention.

Results

Successful referral with linkage to care was confirmed in 267/272 (98%) and successful reporting in 227/272 (84%) children. Children with drug-susceptible, culture-confirmed TB were significantly more likely to be reported during the intervention period than in the pre-intervention period (OR 2.52, 95%CI 1.33-4.77). The intervention effect remained consistent in multivariable analysis (adjusted OR 2.62; 95%CI 1.31-5.25) after adjusting for age, sex, human immunodeficiency virus status and the presence of TB meningitis.

Conclusions

A simple hospital-based TB referral service can reduce initial loss to follow-up and improve recording and reporting of childhood TB in settings with decentralised TB services.

Improving rifampicin-resistant tuberculosis diagnosis using Xpert® MTB/RIF: modelling interventions and costs

SETTING

Cape Town, South Africa.

OBJECTIVE

To model the diagnosis of rifampicin-resistant tuberculosis (RR-TB) and laboratory costs of smear/culture and Xpert-based algorithms and the effect of varying adherence and human immunodeficiency virus (HIV) testing in the Xpert-based algorithm.

METHODS

We used a validated operational model (100 000 population) and published laboratory cost data. We estimated the number and cost of RR-TB cases identified using the smear/culture- and Xpert-based algorithms. We modelled varying adherence and different levels of known HIV status against the Xpert-based algorithm.

RESULTS

The number of RR-TB cases identified increased from 603 with smear/culture to 1178 with the Xpert-based algorithm (100% adherence; 60% knew their HIV status). The overall laboratory cost increased from US$1 073 858 to US$2 430 050 and the cost per RR-TB case identified increased from US$1781 to US$2063 in the respective algorithms. When adherence to the Xpert-based algorithm was increased from 50% to 100% (60% knew their HIV status), the number of RR-TB cases identified increased from 721 to 1178.

CONCLUSION

The Xpert-based algorithm is efficient in identifying RR-TB, as the increase in costs is offset by the increase in the number of cases identified. Adherence to the Xpert-based algorithm is important to ensure that all presumptive TB cases receive the benefit of simultaneous TB and RR-TB testing.

Maternal miRNA-146a G/C rs2910164 variation, HIV/AIDS and nitrogen oxide pollution exposure collectively affects foetal growth

OBJECTIVE:

Nitrogen oxide (NOx) pollution and human immunodeficiency virus (HIV)/AIDS intensify inflammation during pregnancy and linked with adverse birth outcomes (ABOs). MicroRNA (miRNA)-146a plays a crucial role in regulating inflammation in the NF-κB pathway. The G/C rs2910164 dampens miRNA-146a activity and linked with inflammatory diseases. The present study investigated whether HIV/AIDS and NOx exposure throughout pregnancy further intensifies ABO in Black South African women genotyped for the rs2910164.

METHODS:

Pregnant women ( n = 300) were subdivided into low, medium and high NOx exposure groups, genotyped for the miRNA-146a G/C rs2910164 using polymerase chain reaction-restriction fragment length polymorphism, and further stratified based on HIV status.

RESULTS:

Unstratified data (HIV+ and HIV- mothers combined): Mothers from the high NOx group with the variant C-allele had low blood iron levels ( p = 0.0238), and had babies with reduced birthweights ( p = 0.0283). As NOx increased, the prevalence of preterm birth and low birth weight also increased in mothers with the variant C-allele versus wildtype G-allele. HIV-infected mothers: In all NOx exposure groups, mothers with the variant C-allele had higher systolic blood pressure (low: p = 0.0386, medium: p = 0.0367 and high: p = 0.0109) and had babies with lower Appearance, Pulse, Grimace, Activity and Respiration scores at 1 min (low: p = 0.0190, medium: p = 0.0301 and high: p = 0.0361).

CONCLUSION:

Maternal rs2910164 variant C-allele, NOx pollution and HIV/AIDS might collectively play a role in intensifying gestational hypertension and ABO.

High laboratory cost predicted per tuberculosis case diagnosed with increased case finding without a triage strategy

SETTING

Cape Town, South Africa.

OBJECTIVE

To model the effects of increased case finding and triage strategies on laboratory costs per tuberculosis (TB) case diagnosed.

METHODS

We used a validated operational model and published laboratory cost data. We modelled the effect of varying the proportion with TB among presumptive cases and Xpert cartridge price reductions on cost per TB case and per additional TB case diagnosed in the Xpert-based vs. smear/culture-based algorithms.

RESULTS

In our current scenario (18.3% with TB among presumptive cases), the proportion of cases diagnosed increased by 8.7% (16.7% vs. 15.0%), and the cost per case diagnosed increased by 142% (US$121 vs. US$50). The cost per additional case diagnosed was US$986. This would increase to US$1619 if the proportion with TB among presumptive cases was 10.6%. At 25.9-30.8% of TB prevalence among presumptive cases and a 50% reduction in Xpert cartridge price, the cost per TB case diagnosed would range from US$50 to US$59 (comparable to the US$48.77 found in routine practice with smear/culture).

CONCLUSION

The operational model illustrates the effect of increased case finding on laboratory costs per TB case diagnosed. Unless triage strategies are identified, the approach will not be sustainable, even if Xpert cartridge prices are reduced.

Operational modelling: the mechanisms influencing TB diagnostic yield in an Xpert® MTB/RIF-based algorithm

SETTING

Cape Town, South Africa.

OBJECTIVE

To compare the diagnostic yield for smear/culture and Xpert® MTB/RIF algorithms and to investigate the mechanisms influencing tuberculosis (TB) yield.

METHOD

We developed and validated an operational model of the TB diagnostic process, first with the smear/culture algorithm and then with the Xpert algorithm. We modelled scenarios by varying TB prevalence, adherence to diagnostic algorithms and human immunodeficiency virus (HIV) status. This enabled direct comparisons of diagnostic yield in the two algorithms to be made.

RESULTS

Routine data showed that diagnostic yield had decreased over the period of the Xpert algorithm roll-out compared to the yield when the smear/culture algorithm was in place. However, modelling yield under identical conditions indicated a 13.3% increase in diagnostic yield from the Xpert algorithm compared to smear/culture. The model demonstrated that the extensive use of culture in the smear/culture algorithm and the decline in TB prevalence are the main factors contributing to not finding an increase in diagnostic yield in the routine data.

CONCLUSION

We demonstrate the benefits of an operational model to determine the effect of scale-up of a new diagnostic algorithm, and recommend that policy makers use operational modelling to make appropriate decisions before new diagnostic algorithms are scaled up.

Tuberculosis in adolescents and young adults: epidemiology and treatment outcomes in the Western Cape

SETTING

Western Cape Province, South Africa.

OBJECTIVES

To characterise tuberculosis (TB) epidemiology, disease presentation and treatment outcomes among adolescents (age 10-19 years) and young adults (age 20-24 years) in the Western Cape.

DESIGN

A retrospective, cross-sectional review of routine patient-level data from the Electronic TB Register (ETR.Net) for 2013. Site of TB disease, human immunodeficiency virus (HIV) status and TB treatment outcomes were analysed by 5-year age groups (<5, 5-9, 10-14, 15-19, 20-24 and 25 years of age). TB notification rates were calculated using census data.

RESULTS

Adolescents and young adults comprised 18.0% of all new TB notifications in 2013. The notification rate was 141 TB cases/100 000 person-years (py) among 10-14 year olds, 418/100 000 py among 15-19 year olds and 627/100 000 py among 20-24 year olds. HIV prevalence among TB patients was 10.9% in 10-14 year olds, 8.8% in 15-19 year olds and 27.2% in 20-24 year olds. Older adolescents (age 15-19 years) and young adults (age 20-24 years) with HIV co-infection had poor treatment outcomes: 15.6% discontinued treatment prematurely and 4.0% died.

CONCLUSIONS

Young people in the Western Cape suffer a substantial burden of TB, and those with TB-HIV co-infection are at high risk of treatment discontinuation.

Comparing laboratory costs of smear/culture and Xpert® MTB/RIF-based tuberculosis diagnostic algorithms

SETTING

Cape Town, South Africa, where Xpert^® MTB/RIF was introduced as a screening test for all presumptive tuberculosis (TB) cases.

OBJECTIVE

To compare laboratory costs of smear/culture- and Xpert-based tuberculosis (TB) diagnostic algorithms in routine operational conditions.

METHODS

Economic costing was undertaken from a laboratory perspective, using an ingredients-based costing approach. Cost allocation was based on reviews of standard operating procedures and laboratory records, timing of test procedures, measurement of laboratory areas and manager interviews. We analysed laboratory test data to assess overall costs and cost per pulmonary TB and multidrug-resistant TB (MDR-TB) case diagnosed. Costs were expressed as 2013 Consumer Price Index-adjusted values.

RESULTS

Total TB diagnostic costs increased by 43%, from US$440 967 in the smear/culture-based algorithm (April-June 2011) to US$632 262 in the Xpert-based algorithm (April-June 2013). The cost per TB case diagnosed increased by 157%, from US$48.77 (n = 1601) to US$125.32 (n = 1281). The total cost per MDR-TB case diagnosed was similar, at US$190.14 and US$183.86, with 95 and 107 cases diagnosed in the respective algorithms.

CONCLUSION

The introduction of the Xpert-based algorithm resulted in substantial cost increases. This was not matched by the expected increase in TB diagnostic efficacy, calling into question the sustainability of this expensive new technology.

The association between biopsychosocial factors and disability in a national health survey in South Africa

The association between psychosocial factors and disability is less clear. This study investigated the biological and psychosocial (employment and psychological distress) factors associated with level of disability in an adult sample in South Africa. Data were analysed from a cross-sectional survey among adults aged 18-64 (n = 4974). Multiple linear regression was used to investigate the associations of the selected variables with disability. The mean percentage score on the WHODAS scale of disability was 5.31% (95% CI: 4.74-5.88). Age (p < 0.001) and race (p = 0.0002) were significantly associated with disability, and history of stroke (β = 7.19, 95% CI: 3.19-11.20) and heart-related conditions (β = 2.08, 95% CI: [0.23-3.93) showed positive associations. Of the psychosocial variables, psychological distress (β = 10.49 [8.63-12.35]) showed a strong positive association while employment (-1.62 [-2.36 to -0.88]) showed a negative association with disability. The association between demographic factors, medical conditions and increased disability confirms the findings in the literature. The finding that psychological distress is associated with increased disability has not been frequently reported. This study highlights specific psychosocial targets that may be usefully addressed by health policies and interventions in order to improve disability management.

Assessment of certain ionic liquids for separation of binary mixtures based on gamma infinity data measurements

Limiting activity coefficients for 64 solutes in [BzMIM][NTf₂] and [BzMIM][DCA], the gas–liquid partition coefficients, K_L, thermodynamic functions and selectivity for hexane/hex-1-ene, cyclohexane/cyclohexene and ethylbenzene/styrene separation were presented.

Psychopathology in Urban and Rural/Peri-Urban Children Seeking Mental Health Care

While childhood psychopathology may not necessarily be expected to vary between urban and rural children, social and political factors could be influential in the variances in presentation across these different environments. A comparative investigation was undertaken in the KwaZulu-Natal region to examine childhood presentations at (i) an urban psychological clinic in a low socio-economic environment, and (ii) a few visiting psychological clinics serving rural and peri-urban communities. Data were collected over a five-year period. The results revealed several notable differences, for example, attention-deficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (other than ADHD) were significantly more prevalent in the urban sample. However, mental retardation, post-traumatic stress disorder and sexual abuse were significantly more common in the rural/peri-urban sample. The results are discussed within the context of children's life experiences, available facilities, and psychopathology detection rates in these two types of environments.

Global-to-local policy transfer in the introduction of new molecular tuberculosis diagnostics in South Africa

SETTING

Lack of innovation in diagnostics has contributed to tuberculosis (TB) remaining a global health challenge. It is critical to understand how new diagnostic technologies are translated into policies and how these are implemented.

OBJECTIVE

To examine policy transfer for two rapid molecular diagnostic tests, GenoType(®) MDRTBplus and Xpert(®) MTB/RIF, to understand policy development, uptake and implementation in South Africa.

METHODS

A policy transfer analysis framework integrating the key dimensions of policy transfer into one coherent model was used. Two phases of key informant interviews were undertaken with a wide range of stakeholders.

RESULTS

Both tests were developed through innovative partnerships and responded to urgent public health needs. GenoType was introduced through a process that was more inclusive than that for Xpert. National policy and planning processes were opaque for both tests. Their implementation, maintenance and expansion suffered from poor communication and coordination, insufficient attention to resource implications, technical challenges and a lack of broader health systems thinking.

CONCLUSION

Our analysis identified the risks and benefits of partnerships for technological innovation, the complex intersections between global and national actors and the impact of health systems on policy transfer, and the risks of rescue- and technology-focused thinking in addressing public health challenges.

Comparing multidrug-resistant tuberculosis patient costs under molecular diagnostic algorithms in South Africa

SETTING

Ten primary health care facilities in Cape Town, South Africa, 2010-2013.

OBJECTIVE

A comparison of costs incurred by patients in GenoType MDRTBplus line-probe assay (LPA) and Xpert MTB/RIF-based diagnostic algorithms from symptom onset until treatment initiation for multidrug-resistant tuberculosis (MDR-TB).

METHODS

Eligible patients identified from laboratory and facility records were interviewed 3-6 months after treatment initiation and a cost questionnaire completed. Direct and indirect costs, individual and household income, loss of individual income and change in household income were recorded in local currency, adjusted to 2013 costs and converted to $US.

RESULTS

Median number of visits to initiation of MDR-TB treatment was reduced from 20 to 7 (P < 0.001) and median costs fell from US$68.1 to US$38.3 (P = 0.004) in the Xpert group. From symptom onset to being interviewed, the proportion of unemployed increased from 39% to 73% in the LPA group (P < 0.001) and from 53% to 89% in the Xpert group (P < 0.001). Median household income decreased by 16% in the LPA group and by 13% in the Xpert group.

CONCLUSION

The introduction of an Xpert-based algorithm brought relief by reducing the costs incurred by patients, but loss of employment and income persist. Patients require support to mitigate this impact.

Optimizing Mycobacterial Culture in Smear-Negative, Human Immunodeficiency Virus-Infected Tuberculosis Cases

Introduction

Tuberculosis (TB) is a significant public health problem and the diagnosis in human immunodeficiency virus (HIV)—infected individuals is challenging. The use of mycobacterial culture remains an important complementary tool and optimizing it has important benefits. We sought to determine the effect of an increase in the number of specimens evaluated, addition of nutritional supplementation to the culture medium, sputum appearance and volume on diagnostic yield and time to detection of pulmonary TB among smear-negative, HIV-infected adults.

Methods

In this prospective study conducted at the Tshwane District Hospital and Academic TB Laboratory, Pretoria, South Africa we collected three sputum specimens an hour apart from presumptive TB cases at an antiretroviral treatment site. We analysed specimens from 236 patients. Specimen appearance and volume were recorded. All specimens were processed for culture using both standard and supplemented media.

Results

A single specimen identified 79% of PTB cases using standard media; the second and third specimens added 12.5% and 8.3% respectively. Media supplementation, sputum appearance and specimen volume had no effect on culture yield or contamination rates. The mean time to detection was reduced from 19.8 days in standard cultures to 11.8 days in nutrient supplemented cultures (p = 0.002). For every 1 ml increase in sputum volume, time to detection was decreased by a factor of 0.797 (p = 0.011).

Conclusion

Use of an inexpensive culture supplement substantially reduced time to detection and could contribute to reducing treatment delay among HIV-infected cases.

Is physical access an impediment to tuberculosis diagnosis and treatment? A study from a rural district in North India

SETTING

All designated microscopy centres (DMCs) in Fatehgarh Sahib District, Punjab, India.

OBJECTIVE

To study the association of distance (physical access) to DMCs with loss to follow-up (LTFU) of presumptive tuberculosis (TB) cases while undergoing diagnostic sputum examination and failure to initiate treatment among smear-positive TB patients after diagnosis.

DESIGN

A cross-sectional, record-based study was undertaken to analyse patient records from routine laboratory registers in all DMCs from January to June 2012.

RESULT

More than 50% of presumptive TB cases had to travel >7 km to reach the DMC, totalling >28 km for two sputum examinations for the evaluation of an episode. The distance (>10 km) to the diagnostic facility was found to be significantly associated (P < 0.01), both with LTFU during diagnosis and with a delay (>7 days) in initiating treatment after diagnosis. There was a significant correlation (r = 0.7) between distance to the DMC and time to initiate treatment among smear-positive TB cases.

CONCLUSION

Distance from the nearest facility represents a significant risk for LTFU during diagnosis and delayed initiation of treatment after diagnosis. Further decentralisation of TB care services to the community level is required by expanding the network of DMCs or by organising sputum collection and transportation.

Lower limb complications of diabetes mellitus: a comprehensive review with clinicopathological insights from a dedicated high-risk diabetic foot multidisciplinary team

Diabetic complications in the lower extremity are associated with significant morbidity and mortality, and impact heavily upon the public health system. Early and accurate recognition of these abnormalities is crucial, enabling the early initiation of treatments and thus avoiding or minimizing deformity, dysfunction and amputation. Following careful clinical assessment, radiological imaging is central to the diagnostic and follow-up process. We aim to provide a comprehensive review of diabetic lower limb complications designed to assist radiologists and to contribute to better outcomes for these patients.

Reasons for the low bacteriological coverage of tuberculosis reported in Mpumalanga Province, South Africa

SETTING

Public sector hospitals and primary health clinics in the Mpumalanga Province of South Africa.

OBJECTIVE

To determine whether failure to adhere to tuberculosis (TB) diagnostic guidelines (i.e., submit sputum for smear microscopy) contributed to the low bacteriological coverage reported for TB in 2008 in Mpumalanga Province.

METHODS

We reviewed clinical records for new pulmonary TB cases at 30 of 118 randomly selected facilities that met the bacteriological coverage target of 80% and 30/87 facilities that did not. Data for hospital and clinic cases were abstracted into case report forms, captured electronically and compared with data from the electronic TB register (ETR). We assessed age, sex, human immunodeficiency virus (HIV) infection and facility type as potential confounders for recording of smear microscopy results.

RESULTS

Age, sex and HIV infection did not influence recording of results. In hospitals, 61.8% of pulmonary TB cases had sputum smear results in their clinical records compared to 93.6% at clinics (P < 0.001). Of the 711 cases (30.3%) that did not have smear results in the ETR, 342 (48.1%) did have smear results in their clinical records.

CONCLUSION

Both poor clinical practice (especially in hospitals) and poor record keeping have contributed to the low bacteriological coverage reported. These shortcomings need to be addressed to improve patient care and programme management.

A comparative study of tuberculosis patients initiated on ART and receiving different models of TB-HIV care

SETTING

Although health policy in South Africa calls for the integration of services, the effectiveness of different models of integration on patient outcomes has not been well demonstrated.

OBJECTIVE

To evaluate the outcomes of coinfected patients starting antiretroviral treatment (ART) in a tuberculosis (TB) hospital who received different models of ongoing care.

DESIGN

This cohort study compared outcomes for 271 coinfected patients who started ART in a TB hospital in the Western Cape. After discharge, one group of patients received anti-tuberculosis treatment and ART from different providers, in the same or in different clinics (vertical care). The other group received anti-tuberculosis treatment and ART at the same visit from the same service provider (integrated care). Demographic and clinical data and TB and ART outcomes were compared.

RESULTS

The vertical care model had more unfavourable outcomes for anti-tuberculosis treatment (28.7% vs. 5.9%, P < 0.001) and ART (30.1% vs. 7.4%, P < 0.001) than the integrated care model. The vertical care model showed no difference whether services were provided by two service providers in the same or in geographically separate primary health care clinics.

CONCLUSION

Patient outcomes were better when TB and HIV care was received from the same service provider at the same visit.

HIV, vascular surgery and cardiovascular outcomes: a South African cohort study

Risk factors for peri-operative cardiac morbidity are poorly described in HIV-positive patients. This prospective observational study describes cardiovascular risk factors in a cohort of vascular surgical patients of known HIV status. We recruited 225 patients with 73 (32%) being HIV-positive. When compared with HIV-negative patients, the HIV-positive patients were younger (mean (SD) 56.4 (13.3) vs 40.5 (10.4) years, respectively, p < 0.01). They had fewer Revised Cardiac Risk Index cardiovascular risk factors (median (range [IQR]) 1 (0-5 [0-2]) vs 0 (0-2 [0-0]), respectively, p < 0.001), with the exception of congestive cardiac failure (p = 0.23) and renal dysfunction (p = 0.32), and so were of a significantly lower Revised Cardiac Risk Index risk category (p < 0.01). HIV-positive and -negative patients had similar outcomes in: 30-day mortality (p = 0.78); three-day postoperative troponin leak (p = 0.66); and a composite outcome of mortality and troponin release (p = 0.69). We conclude that although HIV-positive patients have fewer cardiovascular risk factors, they have similar peri-operative major adverse cardiac events to HIV-negative patients. Research should focus on why this is the case, and if alternative clinical risk predictors can be developed for HIV patients.

Isothermal method for hydrate studies using a transparent variable volume cell

The measurements of hydrate dissociation points are generally achieved using the well-established isochoric method. This method implies determination of the total pressure of the system under study, as a function of temperature. It is quite time consuming, especially at higher pressures. Working at higher pressures requires equilibrium cells with thicker walls, which compromises on fast heat exchange. The use of a variable volume cell is therefore quite attractive as it allows for the measurements of hydrate dissociation pressure under isothermal conditions. This paper describes a transparent variable volume cell used for efficient and rapid measurements via the isothermal procedure.

Meningitis and stridor in advanced Human immunodeficiency virus/acquired immune deficiency syndrome

A 37-year-old female presented confused with a preceding history of severe headache. After clinical examination and investigations, she was diagnosed with disseminated tuberculosis (including central nervous system involvement), and Human immunodeficiency virus/acquired immune deficiency syndrome. Her hospital stay was complicated. She developed stridor and a cerebrovascular accident with left hemiplegia. She died approximately 2 weeks after admission. The potential causes of her stridor included a mediastinal mass or a central mechanism secondary to tuberculosis meningitis. Limited resources precluded definitive imaging of the chest to rule out a mediastinal mass. Further, an autopsy was not done. Despite these limitations, this case is unique because it reports the presence of both stridor and tuberculosis meningitis in an adult patient.

Predictors of non-uptake of human immunodeficiency virus testing by tuberculosis public primary patients in three districts, South Africa

BACKGROUND

The acceptance of HIV testing among patients with tuberculosis (TB) is low in South Africa. The aim of this study was to assess the prevalence, associated factors and reasons of non-uptake of human immunodeficiency virus (HIV) testing by tuberculosis public primary care patients in three districts, South Africa.

METHODS

In May-October 2011, this cross-sectional survey was conducted amongst 4726 TB patients across 42 primary health care facilities in three districts in South Africa. All new TB and new retreatment patients (N=4726) were consecutively interviewed within one month of anti-tuberculosis treatment. The outcome was self-reported HIV testing after TB diagnosis, validated using clinic registers.

RESULTS

Almost one in ten (9.6%) of the 4726 participants had not undergone HIV testing, with the most often offered explanation being that they were not knowing where to get tested (21.3%), followed by believing not to have or at risk for HIV (24.3%), emotional concerns (not ready for test: 13.2%; afraid to get to know: 12.1%; concerns over confidentiality: 6.3%) and concerns about stigma (3.3%) and losing the job (2.0%). In multivariable analysis being male, severe psychological distress, having sex with someone HIV negative or unknown and frequency of sex without a condom were associated with not having been tested for HIV.

CONCLUSIONS

The level of HIV testing among TB public primary care patients was suboptimal, as per policy all patients should be tested. The South African Department of Health should continue to scale-up HIV testing and other collaborative TB-HIV services at health facilities.

Imaging of systemic lupus erythematosus. Part II: gastrointestinal, renal, and musculoskeletal manifestations

Systemic lupus erythematosus (SLE) is a chronic, multisystem autoimmune disease that has a relapsing and remitting course. It has a wide range of presentations with various organ manifestations. In this review, we have compiled the radiological findings of gastrointestinal, renal, and musculoskeletal manifestations of SLE.

Smooth muscle myopathy as an underrecognized manifestation of active systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease with protean manifestations. We here present a case of unexplained diarrhoea and abdominal pain in a patient with SLE. Investigations revealed dilatation of stomach, small bowel and colonic wall, biliary and pancreatic ducts, renal collecting systems and ureters as well as thoracic aorta and major pulmonary arteries, as manifestations of a smooth muscle myopathy that was responsive to immunosuppressive therapy with cyclosporin A.