GP trainees' values and knowledge regarding global health competencies

Globalisation is having a significant impact on health through the increasingly interconnected nature of our world, population movement and effects of political and environmental issues. In response, medical educators are urged to review postgraduate training programmes to ensure that doctors are up-to-date with training in contemporary global health issues. Positioned on the frontline of healthcare provision, GPs have an integral role to play in addressing local and global health inequities. However, GP trainees in the UK currently receive little formal education on global health. We sought to investigate GP trainees' understanding and perceived competence in relation to global health issues and cross-cultural practice and their views regarding whether it is indeed time for GP postgraduate training to 'go global'. We invited trainees across Health Education England: Wessex (N = 476) to complete an anonymous online questionnaire. The majority of respondents either 'agreed' or 'strongly agreed' that 'it is important for doctors training to be GPs in the UK to have education on global health' (89%). Similarly, the majority either 'agreed' or 'strongly agreed' that 'it is important for doctors training to be GPs in the UK to develop intercultural competence' (93%). In contrast to the high degree of importance that GP trainees placed on establishing proficiency in these domains, approximately half (45-54%) reported their current level of competence as only being 'average'. Our findings indicate a mismatch and unmet need for further training in the postgraduate setting, with strong GP trainee support for a shift in curriculum design and delivery, towards more globally competent general practice.

'This is what is going to help me': Developing a co-designed and theoretically informed harm reduction intervention for mobile youth in South Africa and Uganda

ABSTRACTYoung migrants in sub-Saharan Africa are particularly vulnerable to HIV-acquisition. Despite this, they are consistently under-served by services, with low uptake and engagement. We adopted a community-based participatory research approach to conduct longitudinal qualitative research among 78 young migrants in South Africa and Uganda. Using repeat in-depth interviews and participatory workshops we sought to identify their specific support needs, and to collaboratively design an intervention appropriate for delivery in their local contexts. Applying a protection-risk conceptual framework, we developed a harm reduction intervention which aims to foster protective factors, and thereby nurture resilience, for youth 'on the move' within high-risk settings. Specifically, by establishing peer supporter networks, offering a 'drop-in' resource centre, and by identifying local adult champions to enable a supportive local environment. Creating this supportive edifice, through an accessible and cohesive peer support network underpinned by effective training, supervision and remuneration, was considered pivotal to nurture solidarity and potentially resilience. This practical example offers insights into how researchers may facilitate the co-design of acceptable, sustainable interventions.

Bittersweet: infective complications of drug-induced glycosuria in patients with diabetes mellitus on SGLT2-inhibitors: two case reports

Background

Sodium-glucose co-transporter 2 (SGLT2) inhibitors are novel hypoglycemic agents which reduce reabsorption of glucose at the renal proximal tubule, resulting in significant glycosuria and increased risk of genital mycotic infections (GMI). These infections are typically not severe as reported in large systematic reviews and meta-analyses of the medications. These reviews have also demonstrated significant cardiovascular benefits through other mechanisms of action, making them attractive options for the management of Type 2 diabetes mellitus (T2DM). We present two cases with underlying abnormalities of the urogenital tract in which the GMI were complicated and necessitated cessation of the SGLT2 inhibitor.

Case presentations

Both cases are patients with T2DM on empagliflozin, an SGLT2 inhibitor. The first case is a 64 year old man with Candida albicans balanitis and candidemia who was found to have an obstructing renal calculus and prostatic abscess requiring operative management. The second case describes a 72 year old man with Candida glabrata candidemia who was found to have prostatomegaly, balanitis xerotica obliterans with significant urethral stricture and bladder diverticulae. His treatment was more complex due to fluconazole resistance and concerns about urinary tract penetration of other antifungals. Both patients recovered following prolonged courses of antifungal therapy and in both cases the SGLT2 inhibitor was ceased.

Conclusions

Despite their cardiovascular benefits, SGLT2 inhibitors can be associated with complicated fungal infections including candidemia and patients with anatomical abnormalities of the urogenital tract may be more susceptible to these infections as demonstrated in these cases. Clinicians should be aware of their mechanism of action and associated risk of infection and prior to prescription, assessment of urogenital anatomical abnormalities should be performed to identify patients who may be at risk of complicated infection.

"Because we all have to grow up": supporting adolescents in Uganda to develop core competencies to transition towards managing their HIV more independently

INTRODUCTION

Sustaining optimal adherence is the major challenge facing adolescents living with HIV (ALHIV), particularly in low-resource settings, where "second-line" is often the last accessible treatment option. We explored the knowledge and skills adolescents need in order to maintain improved adherence behaviours, and the specific ways clinicians and caregivers may support young people to do so more independently.

METHODS

We conducted individual, in-depth interviews with 20 ALHIV aged 10 to 18 years in Uganda in 2017 to 2018. All participants had recently commenced second-line treatment as part of a clinical trial. We used thematic qualitative analysis to examine adherence experiences and challenges while on first-line therapy, as well as specific supports necessary to optimise treatment-taking longer-term.

RESULTS

Adherence difficulties are exacerbated by relatively rapid shifts from caregiver-led approaches during childhood, to an expectation of autonomous treatment-taking with onset of adolescence. For many participants this shift compounded their ongoing struggles managing physical side effects and poor treatment literacy. Switching to second-line typically prompted reversion back to supervised adherence, with positive impacts on self-reported adherence in the immediate term. However, this measure is unlikely to be sustainable for caregivers due to significant caregiver burden (as on first line), and provided little opportunity for clinicians to guide and develop young people's capacity to successfully adopt responsibility for their own treatment-taking.

CONCLUSIONS

As ALHIV in sub-Saharan Africa are attributed increasing responsibility for treatment adherence and HIV management, they must be equipped with the core knowledge and skills required for successful, self-directed care. Young people need to be relationally supported to develop necessary "adherence competencies" within the supportive framework of a gradual "transition" period. Clinic conversations during this period should be adolescent-focussed and collaborative, and treatment-taking strategies situated within the context of their lived environments and support networks, to facilitate sustained adherence. The disclosure of adherence difficulties must be encouraged so that issues can be identified and addressed prior to treatment failure.

Does a computerized neuropsychological test predict prolonged recovery in concussed children presenting to the ED?

Computerized neuropsychological tests (CNTs) are widely used internationally in concussion management. Their prognostic value for predicting recovery post-concussion is poorly understood, particularly in pediatric populations. The aim of the present study was to examine whether cognitive functioning (measured by CogSport) has prognostic value for predicting rapid versus slow recovery. This is a prospective longitudinal observational cohort study conducted at a state-wide tertiary pediatric hospital. Data were collected at 1-4, 14, and 90 days post-injury. Eligible children were aged ≥5 and <18 years presenting to the Emergency Department having sustained a concussion within 48 h. Concussion was defined according to the Zurich/Berlin Consensus Statement on Concussion in Sport. Dependent variables were reaction times and error rates on the CogSport Brief Battery. In total, 220 cases were analyzed; 98 in a rapid recovery group (asymptomatic at 14 days post-injury, mean age 11.5 [3.2], 73.5% male) and 122 in a slow recovery group (symptomatic at 14 days post-injury, mean age 12.0 [3.1], 69.7% male). Longitudinal GEE analyses modeled the trajectories of both mean log₁₀-transformed reaction time and error rates between groups over time (1-4, 14 and 90 days). Both group main and interaction (time by group) terms for all models were non-significant (p > .05). Cognitive functioning, measured by CogSport and assessed within 1-4 days of concussion, does not predict prolonged recovery in a pediatric sample. Further, there were no significant group differences at any time point. Considering the widespread use and promotion of CNTs, it is important that clinicians understand the significant limitations of the CogSport battery.

The preterm gut microbiota: changes associated with necrotizing enterocolitis and infection

AIM

To describe gut colonization in preterm infants using standard culture and 16S gene rRNA profiling, exploring differences in healthy infants and those who developed NEC/late onset sepsis (LOS).

METHODS

Ninety-nine stools from 38 infants of median 27-week gestation were cultured; 44 stools from 27 infants had their microbial profiles determined by 16S. Ordination analyses explored effects of patient variables on gut communities.

RESULTS

Standard microbiological culture identified a mean of two organisms (range 0-7), DGGE 12 (range 3-18) per patient. Enterococcus faecalis and coagulase negative staphylococci (CONS) were most common by culture (40% and 39% of specimens). Meconium was not sterile. No fungi were cultured. Bacterial community structures in infants with NEC and LOS differed from healthy infants. Infants who developed NEC carried more CONS (45% vs 30%) and less Enterococcus faecalis (31% vs 57%). 16S identified Enterobacter and Staphylococcus presence associated with NEC/LOS, respectively.

CONCLUSIONS

Important differences were found in the gut microbiota of preterm infants who develop NEC/LOS. The relationship of these changes to current practices in neonatal intensive care requires further exploration.

The molecular diversity of the methanogenic community in a hypereutrophic freshwater lake determined by PCR-RFLP

AIMS

To combine database-held sequence information with a programme of experimental molecular ecology to define the methanogenic community of a hypereutrophic lake by a PCR-restriction fragment length polymorphism (RFLP) analysis.

METHODS AND RESULTS

Methanogen diversity in a hypereutrophic freshwater lake was analysed using 16S rDNA PCR-RFLP. Database-held 16S rRNA gene sequences for 76 diverse methanogens were analysed for specific restriction sites that permitted unequivocal differentiation of methanogens. Restriction digestion and agarose gel electrophoresis of the 16S rDNA from selected methanogen pure cultures generated observed restriction profiles that corroborated the expected patterns. This method was then tested by analysing methanogen diversity in samples obtained over 1 year from sediment and water samples taken from the same sampling site.

CONCLUSIONS

Restriction analysis of the 16S rRNA gene sequences from 157 methanogen clones generated from lakewater and sediment samples showed that over 50% were similar to Methanoculleus spp. Furthermore, a total of 16 RFLP types (1-16) were identified, eight of which contained no cultured representative archaeal 16S rRNA gene sequences.

SIGNIFICANCE AND IMPACT OF THE STUDY

This RFLP strategy provides a robust and reliable means to rapidly identify methanogens in the environment.