Evaluating patient factors, operative management and postoperative outcomes in trauma laparotomy patients worldwide: a protocol for a global observational multicentre trauma study

INTRODUCTION

Trauma contributes to the greatest loss of disability-adjusted life-years for adolescents and young adults worldwide. In the context of global abdominal trauma, the trauma laparotomy is the most commonly performed operation. Variation likely exists in how these patients are managed and their subsequent outcomes, yet very little global data on the topic currently exists. The objective of the GOAL-Trauma study is to evaluate both patient and injury factors for those undergoing trauma laparotomy, their clinical management and postoperative outcomes.

METHODS

We describe a planned prospective multicentre observational cohort study of patients undergoing trauma laparotomy. We will include patients of all ages who present to hospital with a blunt or penetrating injury and undergo a trauma laparotomy within 5 days of presentation to the treating centre. The study will collect system, patient, process and outcome data, following patients up until 30 days postoperatively (or until discharge or death, whichever is first). Our sample size calculation suggests we will need to recruit 552 patients from approximately 150 recruiting centres.

DISCUSSION

The GOAL-Trauma study will provide a global snapshot of the current management and outcomes for patients undergoing a trauma laparotomy. It will also provide insight into the variation seen in the time delays for receiving care, the disease and patient factors present, and patient outcomes. For current standards of trauma care to be improved worldwide, a greater understanding of the current state of trauma laparotomy care is paramount if appropriate interventions and targets are to be identified and implemented.

The academic progress of female general surgery and orthopaedic surgery trainees in South Africa

BACKGROUND

Globally, medical institutes have seen an increase in female graduates, however surgical disciplines remain male-dominated. An epidemiological shift towards non-communicable diseases and trauma may result in a shortage of surgical specialists. One strategy to improve the surgical workforce is the recruitment of female graduates.

METHODS

A non-validated questionnaire was administered to females registered for the Master of Medicine (MMED) degree in General and Orthopaedic Surgery at the University of KwaZulu-Natal (UKZN) between 2000 and 2015. The study evaluated reasons for choice of surgery as a career, challenges faced on the domestic and work front, as well as factors that assisted with successful completion of training.

RESULTS

Seventy-two female trainees in General Surgery and Orthopaedics were identified from the UKZN databases. The contact details for 62 of these trainees were available. The overall response rate was 71.0% (44/62). A total of 95.5% (42/44) of participants selected surgery due to a passion for the field. Major challenges identified were a poor home and work-life balance (72.1%, 31/43) and poor working conditions (62.8%, 27/43). Female trainees perceived that they were viewed as inferior by patients (65.9%, 29/44). Successful trainees had a good home support system (89.3%, 25/28) and mentorship during training (60.7%, 17/28), and 85.7% (24/28) did not regret their career choice.

CONCLUSION

The recruitment and retention of females in surgery will contribute to maintaining an adequate surgical workforce. Training programmes need to improve work-life balance without compromising on producing competent surgeons. Improved visibility of female surgeons in leadership roles should be encouraged to promote mentorship and recruitment of trainees.

The influence of psychological readiness of athletes when returning to sport after injury

Background

Injuries are a common occurrence in sports participation; however, they have the potential to be accompanied by negative thoughts and feelings, which may play a part in the athletes' state of mind when they return to their sport. Assessing the degree to which this occurs provides an opportunity to evaluate and address athletes' state of mind before their return to play.

Objectives

To determine if athletes are psychologically ready to return to play after an injury and if there are differences in fear avoidance behaviour between those who were and were not ready to return.

Methods

Eighty-eight athletes participated in this descriptive survey. Athletes' confidence to return to play was measured by the Injury-Psychological Readiness to Return to Play (I-PRRS) questionnaire and their fear avoidance was measured by the Athlete Fear Avoidance Questionnaire (AFAQ).

Results

Fifty injured athletes with a mean age of 23.3±4.0 years old responded to the I-PRRS and the AFAQ questionnaires. The average I-PRRS score was 46.5±9.1 AU. The evidence suggests that 60% of the athletes were not ready to return to sport (41.0±7.5 AU), whereas 40% were ready to return (54.8±3.1 AU). The difference in scores was not significant. The relationship between the AFAQ scores and the I-PRRS score for the 'ready' and 'not ready' groups was not significant (p=0.066). The mean AFAQ score (26.1±8.6 AU) for the 'not ready' group is marginally greater than the mean AFAQ score (21.6±7.5 AU) for the 'ready' group. There was a negative correlation between psychological readiness to return to sport and athletic fear avoidance (r =-0.508, p<0.001).

Conclusion

There needs to be a greater utilisation of psychological assessment tools like the Injury-Psychological Readiness to Return to Play (I-PRRS) questionnaire, which can assist the athlete's support team, who can help identify athletes who are apprehensive about returning to sport after injury.

Geographic variation in 5-year mortality following HIV diagnosis: implications for clinical interventions

Characterizing spatial distribution of HIV outcomes is vital for targeting interventions to areas most at risk. We performed spatial analysis to identify geographic clusters and factors associated with mortality in KwaZulu-Natal, South Africa. We utilized Sizanani trial (NCT01188941) data, which enrolled participants August 2010-January 2013 and obtained vital status at 5.8 (IQR 5.0-6.4) years of follow-up. We mapped geocoded addresses to 2011 Census-defined small area layer (SAL) centroids, used Kulldorff's spatial scan statistic to identify mortality clusters, and compared socio-demographic factors for SALs within and outside mortality clusters. We assigned 1,143 participants living with HIV (260 [23%] of whom died during follow-up) to 677 SALs. One lower mortality cluster (n = 90, RR = 0.23, p = 0.022) was identified near a hospital outside Durban. SALs in the cluster were younger (24y vs 25y, p < 0.001); had fewer bedrooms/household (3 vs 4, p < 0.001); had more females (52% vs 51%, p = 0.013) and residents with no schooling past age 20 (4% vs 3%, p < 0.001) or no education at all (4% vs 3%, p < 0.001); had fewer residents with income >3,200 ZAR/month (5% vs 9%, p < 0.001); and had reduced access to piped water (p < 0.001), refuse disposal (p < 0.001), and toilets (p < 0.001). Targeted interventions may improve outcomes in areas with similar characteristics.

The supernumerary registrar experience in KwaZulu-Natal

BACKGROUND

We sought to assess the experiences of trainees enrolled in the supernumerary registrar programme at the University of KwaZulu-Natal, South Africa, with a specific focus on their assimilation into host clinical units and their intentions to return to their home countries upon completion of the training.

METHODS

This was a cross-sectional survey involving 50 supernumerary registrars attached to six academic hospitals affiliated with the University of KwaZulu-Natal. The survey collected information on registrar's demographics and financial support, speciality, opportunities for advanced training in their home country, assimilation into host clinical units and intentions to return home upon completing the training. The survey data were analysed using descriptive statistics.

RESULTS

The majority of supernumeraries were < 36 years old (n = 32, 64%), male (n = 31, 62%), and self-funded (n = 31, 62%). Only a few supernumeraries were associated with a training facility in their home country (n = 9, 18%). Most supernumeraries (n = 44, 88%) reported not having an equivalent training programme in their home country. Awareness of the programme was predominantly acquired through self-research (n = 35, 70%), and the application process was perceived as problematic by many supernumeraries (n = 46, 92%). Most supernumeraries (n = 43, 86%) assimilated into their host clinical units, and nearly one-third (n = 16, 32%) did not plan on returning home upon completion of their training.

CONCLUSION

Most supernumerary registrars assimilate into host clinical units and play an important role in service delivery during their training. Mechanisms should be put in place to facilitate retention of these individuals in their home countries upon completion of their training.

Dietary supplements and beverages: Knowledge, attitudes, and practices among semi-professional soccer players in KwaZulu-Natal, South Africa

Background

The ingestion of dietary supplements and beverages is prevalent in soccer, at the amateur and professional level. The absence of professional advice at non-professional level makes amateur soccer players susceptible to ingesting unsafe supplements.

Objectives

To determine the knowledge, attitudes and practices of ABC Motsepe League (semi-professional) players in KwaZulu-Natal regarding the use of dietary supplements and beverages.

Methods

Three hundred and forty-three soccer players participated in a cross-sectional study. Knowledge, attitudes and practices were determined using a questionnaire. Researchers visited twelve teams. On the day of the visit to each team, information sheets and questionnaires were given to participants. Questionnaires were collected immediately following completion. Descriptive statistics were used, including means and standard deviations, where applicable. Inferential statistics, Chi-square and binomial tests were used to analyse the results. Statistical significance was set at p < 0.05.

Results

Sports beverages were the most recommended and commonly used, followed by energy beverages. Dietary supplements were the least-known used. Participants used beverages and dietary supplements to assist in providing more energy (67%), improve health (65%) and improve performance (55%) (p<0.001). Seventy-three percent of participants lacked knowledge about the anti-doping policy (p<0.001), with 87% having never attended a workshop on the safe use of supplements and beverages, or anti-doping awareness campaigns (p<0.001). Thirty-eight percent had not heard of the South African Institute for Drug-Free Sport (SAIDS), and 84% were not familiar with the yearly updated World Anti-Doping Agency's (WADA) prohibited list (p<0.001). Of the 59% who did not take dietary supplements or beverages, 75% had insufficient information regarding them (p<0.001), 66% indicated that dietary supplements and beverages were costly (p=0.001), and 55% indicated they did not need dietary supplements and beverages (p=0.32).

Conclusion

There is a need for an educational programme on the safe use of dietary supplements, and sports and energy beverages among KwaZulu-Natal semi-professional soccer players.

Current intraoperative storage and handling practices of autologous bypass conduit: A survey of the royal australasian college of surgeons

During bypass surgery for peripheral arterial occlusive disease and ischaemic heart disease, autologous graft conduit including great saphenous veins and radial arteries are frequently stored in solution. Endothelial damage adversely affects the performance and patency of autologous bypass grafts, and intraoperative graft storage solutions have been shown to influence this process. The distribution of storage solutions currently used amongst Cardiothoracic and Vascular Surgeons from Australia and New Zealand is not well defined in the literature. The aim of this study was to determine current practices regarding autologous graft storage and handling amongst this cohort of surgeons, and discuss their potential relevance in the context of early graft failure. From this survey, the most frequently used storage solutions were heparinized saline for great saphenous veins, and pH-buffered solutions for radial arteries. Duration of storage was 30–45 min for almost half of respondents, although responses to this question were limited. Further research is required to investigate whether ischaemic endothelial injury generates a prothrombotic state, whether different storage media can alter this state, and whether this is directly associated with clinical outcomes of interest such as early graft failure.

Functional connectivity of the world's protected areas

Global policies call for connecting protected areas (PAs) to conserve the flow of animals and genes across changing landscapes, yet whether global PA networks currently support animal movement-and where connectivity conservation is most critical-remain largely unknown. In this study, we map the functional connectivity of the world's terrestrial PAs and quantify national PA connectivity through the lens of moving mammals. We find that mitigating the human footprint may improve connectivity more than adding new PAs, although both strategies together maximize benefits. The most globally important areas of concentrated mammal movement remain unprotected, with 71% of these overlapping with global biodiversity priority areas and 6% occurring on land with moderate to high human modification. Conservation and restoration of critical connectivity areas could safeguard PA connectivity while supporting other global conservation priorities.

Comparative outcome analysis of trauma and non-trauma emergency laparotomy using a modified NELA tool format

BACKGROUND

Emergency laparotomy (EL) encompasses a diverse range of procedures that general surgeons commonly perform for both trauma and non-trauma related conditions in South Africa (SA). Despite differences in the underlying pathology and influence of the surgical procedure, these patients share one care pathway for preoperative, operative and postoperative care. This study reviewed patients undergoing trauma EL and non-trauma EL in a general surgery setting at a rural KwaZulu-Natal tertiary hospital to compare results between the groups using a modified National Emergency Laparotomy Audit (NELA) tool format.

METHODS

Consecutive adult patients undergoing midline EL at Ngwelezana Hospital between 1 March and 31 May 2018 were included. Patient factors analysed were demographic data (age, gender) and risk factors: National Confidential Enquiry into Perioperative Deaths (NCEPOD) grade, American Society of Anesthesiologists (ASA) grade, and comorbidity. Process of care factors included grade of the physician, time to surgery, time of surgery and duration of surgery. The primary outcome measure was mortality. Secondary outcome measures were intensive care unit (ICU) admissions, complications, and length of stay (LOS) > 14 days.

RESULTS

The study included 110 participants who met the inclusion criteria representing a total of 174 laparotomies. The trauma EL group had lower ASA grades (p = 0.003), less comorbidities (p = 0.002), more often went to theatre within six hours (42/56; 75.0%) (p < 0.001), more admissions to ICU (23/56; 41.1%) (p < 0.001), more complications (29/56; 51.8%) (p = 0.039), and higher length of stay > 14 days (16/56; 28.6%) (p = 0.037).

CONCLUSION

The trauma EL group represents a high-risk group for morbidity and mortality at Ngwelezana Hospital.

The Isokinetic Rugby Union Physical Work Evaluation (RUPWE) protocol: Can Rugby Union Players meet the physical work demands of the game?

Background

To protect the lumbar spine from excessive forces, rugby union players need to demonstrate the work ability of the trunk extensors and flexors to meet the physical demands.

Aim

To measure and evaluate whether rugby union players were able to meet the imposed physical work demand, considering limitations, tolerances and resistance to fatigue, using isokinetic dynamometry for trunk extensors (TE) and trunk flexors (TF).

Methods

Fifty-five male players, between the ages of 18 and 23 years, participated in the study. All participants completed a PAR-Q (pre-activity risk) questionnaire before the isokinetic testing. Their height was between 1.80 ± 0.67 m and body mass was 86.0 ± 17.5 kg. Participants were subjected to a newly designed protocol using the Biodex Isokinetic System 3 Dynamometer, called the Rugby Union Physical Work Evaluation (RUPWE).

Results

There was a significant difference between the forwards' trunk extensor peak torque to body weight 488% ± 119% and the trunk flexor peak torque to body weight 289% ± 73%. Furthermore, there was a large effect size between trunk extensor and trunk flexor muscle performance for the forwards (d =2.0) and backs (d =1.9) for peak torque to body weight. Spearman's rank-order correlations (r_s) showed a moderate negative correlation for the forwards between trunk extensor peak torque to body weight and time to peak torque, (r_s = -0.4; p=0.018). There is a strong negative correlation for the backs between trunk extensor peak torque to body weight and time to peak torque, (r_s = -0.6; p=0.003).

Conclusion

The physical work evaluation protocol can be used as a screening tool for rugby players as it measures the extensive mechanical load placed on the lumbar region. This has the potential to evaluate their athletic performance for the demands of tackling and scrumming.

Evaluating the impacts of protected areas on human well-being across the developing world

Protected areas (PAs) are fundamental for biodiversity conservation, yet their impacts on nearby residents are contested. We synthesized environmental and socioeconomic conditions of >87,000 children in >60,000 households situated either near or far from >600 PAs within 34 developing countries. We used quasi-experimental hierarchical regression to isolate the impact of living near a PA on several aspects of human well-being. Households near PAs with tourism also had higher wealth levels (by 17%) and a lower likelihood of poverty (by 16%) than similar households living far from PAs. Children under 5 years old living near multiple-use PAs with tourism also had higher height-for-age scores (by 10%) and were less likely to be stunted (by 13%) than similar children living far from PAs. For the largest and most comprehensive socioeconomic-environmental dataset yet assembled, we found no evidence of negative PA impacts and consistent statistical evidence to suggest PAs can positively affect human well-being.

Ketone body supplement label claims: what supplement has been supplemented?

Background

There is a keen interest in performance-enhancing supplementation and the associated benefits, despite reports of incorrect label claims made by manufacturers and the questionable efficacy of the supplements. The use of ketone body supplements as a source of fuel during exercise and sporting performance, in particular, is of interest to sportspeople. By increasing blood ketone body levels, with an accompanying decrease in blood glucose, may indicate a state of nutritional ketosis, whereby the body no longer relies on glucose metabolism but rather the metabolism of ketone bodies. This could be beneficial for long, slow steady-state endurance exercise.

Discussion

There are numerous ketone body supplements on the market manufactured in South Africa and internationally. However, unlike medicines, the sports supplementation industry is poorly regulated. Furthermore, ketone body supplementation with regard to its effects on improving exercise and athletic performance is still unconvincing.

Conclusion

Within the ever-changing sports supplementation industry, ketone body supplements are being used despite controversies regarding the accuracy and scientific merit of label claims. The ingredients and their quantities, as well as the performance benefits, need to be objectively validated.

The Short-term Effects of a Sports Stacking Intervention on the Cognitive and Perceptual Motor Functioning In Geriatrics

Background: Sport stacking has been beneficial in improving reaction time, as well as hand-eye-co-ordination; predominantly in children. Sport stacking intervention studies, although limited, have shown improvements in motor and cognitive functioning in both children and adults, post-intervention. Similar intervention studies on geriatrics are limited. Aim: The aim of this study was to determine the effects of a sport stacking physical activity intervention on the motor and cognitive functioning of geriatrics. Methods: An intact, convenient sample of 58 geriatrics from a retirement home in KwaZulu-Natal, South Africa was selected to participate in this study. All participants performed selected motor and cognitive functioning tests, pre- and post-intervention. Twenty eight participants were exposed to an eight-week intervention while the control group (30 individuals) continued with activities as usual. Results: The intervention group showed improvements in their mean reaction time and plate tapping (hand-eye co-ordination) times. Overall, there were no changes in the balance test results pre- and post-intervention. There were no significant results from the memory and quality of life tests. Conclusions:   A sport stacking activity intervention has the potential to improve motor functioning in geriatrics, and its clinical application is recommended.

The Short-term Effects of a Sports Stacking Intervention on the Cognitive and Perceptual Motor Functioning In Geriatrics

Background: Sport stacking has been beneficial in improving reaction time, as well as hand-eye-co-ordination; predominantly in children. Sport stacking intervention studies, although limited, have shown improvements in motor and cognitive functioning in both children and adults, post-intervention. Similar intervention studies on geriatrics are limited. Aim: The aim of this study was to determine the effects of a sport stacking physical activity intervention on the motor and cognitive functioning of geriatrics. Methods: An intact, convenient sample of 58 geriatrics from a retirement home in KwaZulu-Natal, South Africa was selected to participate in this study. All participants performed selected motor and cognitive functioning tests, pre- and post-intervention. Twenty eight participants were exposed to an eight-week intervention while the control group (30 individuals) continued with activities as usual. Results: The intervention group showed improvements in their mean reaction time and plate tapping (hand-eye co-ordination) times. Overall, there were no changes in the balance test results pre- and post-intervention. There were no significant results from the memory and quality of life tests. Conclusions:   A sport stacking activity intervention has the potential to improve motor functioning in geriatrics, and its clinical application is recommended.

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.

Understanding the Amino Acid Profile of Whey Protein Products

BACKGROUND: The South African dietary supplement market will undergo a period of transition within the next few years due to the establishment of the South African Health Products Regulatory Authority (SAHPRA), which has superseded the former Medicines Control Council (MCC). While regulatory steps are yet to be fully outlined, products such as whey protein, regarded as food, will be governed by the Department of Health R429 draft Regulations Relating to the Labelling and Advertising of Foods. The guideline provides for the minimum value of essential amino acids (plus cysteine and tyrosine) per gram of protein that products claiming to contain protein will be required to comply with. Determining the compliance levels of whey protein products currently available will assist in establishing the readiness of the dietary supplement industry for regulation, and provide an indication of the overall state of the industry.OBJECTIVES: To determine the amino acid profile of whey protein powder and compare analysed content to manufacturer stated content.To compare analysed amino acid content to the Department of Health R429 draft Regulations Relating to the Labelling and Advertising of Food template amino acid profile.METHOD: 15 of the best-selling whey protein products available in South Africa were selected for amino acid analysis. Tested amino acid content were compared to the label stated claim and the amino acid reference pattern, as stated in the Department of Health R429 draft Regulations Relating to the Labelling and Advertising of Foods.RESULTS: Sixty percent (60%) of products tested were non-compliant with the Department of Health R429 draft Regulations Relating to the Labelling and Advertising of Foods. Of the 15 products tested, 11 were manufactured in South Africa, with 8 being non-compliant to the guideline amino acid profile. Considerable variance was noted in the manufacturer stated and the tested amino acid content (ranging from 16–48% variance).CONCLUSION: Many of the whey protein products available in South Africa are not compliant to proposed industry guidelines. The considerable variance noted highlights the need for greater oversight of the industry with clearly defined regulatory procedures.

Gallbladder duplication masquerading as a dilated common bile duct with choledocholithiasis

A duplicate gall bladder was diagnosed at laparoscopy, having been erroneously diagnosed on ultrasonography as a dilated common bile duct with choledocholithiasis. Gallbladder duplication is a congenital abnormality with a rare incidence, occuring in approximately 1 in 4 000 births and 0.020% in al large autopsy series. This report highlights its existence to improve awareness and lessen the potential for biliary injury.

A morphological and immunohistochemical evaluation of gastric carcinoma in the Western Cape province of South Africa

BACKGROUND

Gastric resections for carcinoma are common, but gastric carcinoma in South Africa, and particularly within the Western Cape province, has not been well documented.

METHOD

The objective of the study was to immunohistochemically evaluate HER2/ neu overexpression, determine aberrations in β-catenin and epithelial-cadherin (E-cadherin) expression, and correlate these fi ndings with gastric carcinoma subtypes.

RESULTS

Ninety-seven gastric adenocarcinoma resections were morphologically categorised as intestinal-, diffuse- or mixed-type adenocarcinomas, and immunohistochemically stained for β-catenin, E-cadherin (extracellular and cytoplasmic domains) and HER2/neu. The results of staining were compared between the subtypes for statistically signifi cant differences. All 97 cases were confi rmed as gastric adenocarcinomas, with 39 (40%) intestinal- type, 51 (53%) diffuse-type, and 7 (7%) mixed-type tumours identifi ed. Patient ages ranged from 18-84 years. HER2/neu was overexpressed in 12 (12%) cases, with intestinal-type morphology (p = 0.017) reported in nine. Fourteen cases (14%) demonstrated abnormal β-catenin localisation. Aberrant E-cadherin (extracellular domain) localisation occurred in 36 (37%) cases. Diffuse-type morphology was associated with a signifi cantly high proportion (p = ≤ 0.001). Aberrant E-cadherin (cytoplasmic domain) localisation occurred in 7 (7%) cases. A signifi cantly high proportion (six of these cases) (p = 0.023) of these was diffuse-type morphology. Eleven (11%) adenocarcinomas occurred in patients aged ≤ 40 years, with intestinal morphology reported in nine of these 11. Aberrant E-cadherin (extracellular domain) localisation was noted in seven of the 11, a signifi cantly high proportion when compared to that in the older patients (p = 0.025).

CONCLUSION

Distinct immunomorphological correlations are apparent in tumours demonstrating HER2/neu overexpression or abnormal E-cadherin localisation. Intestinal morphology, poor differentiation and E-cadherin abnormalities are frequently demonstrated in tumours occurring in younger individuals.

Clofazimine in the treatment of extensively drug-resistant tuberculosis with HIV coinfection in South Africa: a retrospective cohort study

BACKGROUND

Extensively drug-resistant (XDR) tuberculosis (TB) and HIV coinfection is associated with low cure rates and high mortality. Clofazimine has shown activity in vitro against Mycobacterium tuberculosis, but clinical experience with clofazimine in XDR-TB and HIV coinfection is limited.

METHODS

This was a retrospective cohort study of adult XDR-TB patients in KwaZulu-Natal, South Africa, treated with either a clofazimine- or non-clofazimine-containing XDR-TB treatment regimen. The primary outcome measure was TB culture conversion at 6 months. Survival analysis and multivariate logistic regression compared time to event in different strata and identified risk factors for TB culture conversion.

RESULTS

Between August 2009 and July 2011, eligible XDR-TB patients (n = 85) were initiated on treatment for XDR-TB. Most patients (86%) were HIV-infected and receiving antiretroviral therapy (90%). Patients receiving a clofazimine-containing regimen (n = 50) had a higher percentage of culture conversion (40%) compared with patients (n = 35) receiving a non-clofazimine regimen (28.6%). On multivariate analysis, there was a 2-fold increase in TB culture conversion at 6 months (hazard rate ratio 2.54, 95% CI 0.99-6.52, P = 0.05) in the group receiving a clofazimine-containing regimen. Adverse effects due to clofazimine were minor and rarely life-threatening.

CONCLUSIONS

Clofazimine was associated with improved culture conversion in the treatment of XDR-TB/HIV. Adverse effects were minor and non-life-threatening. Based on these preliminary data, further study of clofazimine in XDR-TB/HIV treatment is warranted. Given the present low rates of culture conversion in XDR-TB treatment, we recommend empirical inclusion of clofazimine in treatment regimens for XDR-TB.

Neonatal invasive fungal infection in England 2004-2010

Rates of invasive fungal infection are highest among neonates, especially those of low birthweight. This study aimed to describe the current epidemiology of invasive neonatal fungal infections in a UK neonatal infection surveillance network. From 2004 to 2010 prospective multicentre surveillance was conducted by 14 neonatal units using a web-based database. Clinicians then completed a standardized pro forma for each positive fungal blood and/or cerebrospinal fluid culture. The overall incidence was 2.4/1000 neonatal unit admissions and was highest among babies <1000 g (extreme low birthweight, 18.8/1000). Only five infants (6%) were >1500 g. The majority of infections were caused by Candida albicans (59; 69%) and Candida parapsilosis (17; 20%); 33% of infants had received antifungal prophylaxis. Known risk factors (use of central venous catheter, parenteral nutrition, previous antibiotic use) were common among cases. The attributable case fatality rate was 21% (18/84). Extreme low birthweight infants remain at highest risk of invasive fungal infection and prophylaxis should be particularly considered for this group. The number needing to receive prophylaxis to prevent one case varies significantly among units, hence unit-specific decisions are required. Further research is still needed into the optimal empiric and therapeutic strategies.

A novel CYBB mutation with the first genetically confirmed case of chronic granulomatous disease in South Africa

A case of a child with chronic granulomatous disease (CGD) presenting with recurrent mycobacterial infections and invasive Aspergillus fumigatus disease is described. Genetic analysis confirmed X-linked CGD with a novel mutation in exon 10 of the CYBB gene - the first South African report of genetically confirmed CGD.

Impact of a primary school-based nutrition and physical activity intervention on learners in KwaZulu-Natal, South Africa: A pilot study

No Abstract.