Hybrid electronic record: An error reduction strategy for diverse medical prescription formats.

BACKGROUND:  This project is part of a broader effort to develop a new electronic registry for ophthalmology in the KwaZulu-Natal (KZN) province in South Africa. The registry should include a clinical decision support system that reduces the potential for human error and should be applicable for our diversity of hospitals, whether electronic health record (EHR) or paper-based. METHODS:  Post-operative prescriptions of consecutive cataract surgery discharges were included for 2019 and 2020. Comparisons were facilitated by the four chosen state hospitals in KZN each having a different system for prescribing medications: Electronic, tick sheet, ink stamp and handwritten health records. Error types were compared to hospital systems to identify easily-correctable errors. Potential error remedies were sought by a four-step process. RESULTS:  There were 1307 individual errors in 1661 prescriptions, categorised into 20 error types. Increasing levels of technology did not decrease error rates but did decrease the variety of error types. High technology scripts had the most errors but when easily correctable errors were removed, EHRs had the lowest error rates and handwritten the highest. CONCLUSION:  Increasing technology, by itself, does not seem to reduce prescription error. Technology does, however, seem to decrease the variability of potential error types, which make many of the errors simpler to correct.Contribution: Regular audits are an effective tool to greatly reduce prescription errors, and the higher the technology level, the more effective these audit interventions become. This advantage can be transferred to paper-based notes by utilising a hybrid electronic registry to print the formal medical record.

A New Gramicidin S Analogue with Potent Antibacterial Activity and Negligible Hemolytic Toxicity.

Antibiotic resistance is an urgent threat to global health, with the decreasing efficacy of conventional drugs underscoring the urgency for innovative therapeutic strategies. Antimicrobial peptides present as promising alternatives to conventional antibiotics. Gramicidin S is one such naturally occurring antimicrobial peptide that is effective against Staphylococcus aureus, with a minimum inhibitory concentration (MIC) of 4 µg/mL (3.6 µM). Despite this potent activity, its significant hemolytic toxicity restricts its clinical use to topical applications. Herein, we present rational modifications to the key ß-strand and ß-turn regions of gramicidin S to concurrently mitigate hemolytic effects, while maintaining potency. Critically, peptide 9 displayed negligible hemolytic toxicity, while possessing significant antibacterial potency against a panel of methicillin-sensitive and methicillin-resistant S. aureus clinical isolates (MIC of 8 µg/mL, 7.2 µM). Given the substantial antibacterial activity and near absence of cytotoxicity, 9 presents as a potential candidate for systemic administration in the treatment of S. aureus bacteremia/sepsis.

Implementation of Laparoscopic Nissen Fundoplications in a Developing South African Pediatric Surgical Service.

Introduction: Pediatric laparoscopic Nissen fundoplication (LNF) has become the standard approach at many centers. We developed a minimal access surgery (MAS) training curriculum to enhance the delivery of MAS for pediatric patients in a resource-limited setting. We reviewed our 10-year experience in implementing and performing LNF at our institution. Methods: We described the challenges of implementing MAS training for LNF and how we addressed them. Beneficial technical considerations were described. A retrospective review was performed on all pediatric LNFs performed. Results: We performed 268 LNFs. Specialists or trainees under supervision performed all LNFs. The trainee group performed 43 LNFs (16%). The median operative time for the specialists was 94 min (interquartile range [IQR] 50), and the trainee group was 140 min (IQR 62.5). The median number of cases performed until we improved operative time amongst the trainees was nine (IQR 3). There were seven repeat LNFs, and 11 cases were converted to open. The overall complication rate was 8.9%. A reduction in complications among specialists occurred over the years. The 30-day mortality post-LNF was 0.7%. Conclusion: LNF can be successfully introduced at a tertiary training centre in South Africa with good outcomes. A comprehensive quality improvement program, including MAS training, supported this.

Polyurea/Aminopropyl Isobutyl Polyhedral Oligomeric Silsesquioxane-Functionalized Graphene Nanoplatelet Nanocomposites for Force Protection Applications.

Herein, the development of new nanocomposite systems is reported based on one-part polyurea (PU) and aminopropyl isobutyl polyhedral oligomeric silsesquioxane (POSS)-functionalized graphene nanoplatelets (GNP-POSS) as compatible nanoreinforcements with the PU resin. GNP-POSS was effectively synthesized via a two-step synthesis protocol, including ultrasonication-assisted reaction and precipitation, and carefully characterized with respect to its chemical and crystalline structure, morphology, and thermal stability. FTIR and XPS spectroscopy analyses revealed that POSS interacts with the residual oxygen moieties of the GNPs through both covalent and noncovalent bonding. The X-ray diffraction pattern of GNP-POSS further revealed that the crystallinity of the GNPs was not altered after their functionalization with POSS. GNP-POSS was successfully incorporated in PU at contents of 1, 3, 5, and 10 wt % to yield PU/GNP-POSS nanocomposite films. An ATR-FTIR analysis of these films confirmed the presence of strong interfacial interactions between the urea groups of PU and the GNP-POSS functionalities. Moreover, the PU/GNP-POSS nanocomposite films exhibited enhanced thermal stability and mechanical properties compared to those of the neat PU film. The quasi-static tensile testing of the PU/GNP-POSS samples revealed remarkable enhancements in the tensile strength (from 7.9 for the neat PU to 25.1 MPa for PU/GNP-POSS) and Young's modulus (238-617 MPa), while elongation at break and toughness also showed 14 and 125% improvements, respectively. Finally, the effects of GNP-POSS content on the morphological, quasistatic tensile, and high-strain-rate dynamic behavior of the PU/GNP-POSS nanocomposite films were also investigated. Overall, the tests performed using a split-Hopkinson pressure bar setup revealed a large increase in the film strength (from 147.6 for the neat PU film to 199 MPa for the PU/GNP-POSS film) and a marginal increase in the energy density of the film (38.1-40.8 kJ/m3). These findings support the suitability of the PU/GNP-POSS nanocomposite films for force protection applications.

AAST grade of liver injury is not the single most important consideration in decision making for liver trauma.

BACKGROUND: The liver is one of the most injured organs in both blunt and penetrating trauma. The aim of this study was to identify whether the AAST liver injury grade is predictive of need for intervention, risk of complications and mortality in our patient population, and whether this differs between blunt and penetrating-trauma mechanisms. METHODS: Retrospective review of all liver injuries from a single high-volume metropolitan trauma centre in South Africa from December 2012 to January 2022. Inclusion criteria were all adults who had sustained traumatic liver injury. Patients were excluded if they were under 15 years of age or had died prior to operation or assessment. Statistical analysis was undertaken using both univariate and multivariate models. RESULTS: 709 patients were included, of which 351 sustained penetrating and 358 blunt trauma. Only 24.3 % of blunt compared to 76.4 % of penetrating trauma patients underwent laparotomy (p< 0.001). In blunt trauma, increasing AAST grade correlated directly with rates of laparotomy with an odds ratio of 1.7 (p < 0.001). In penetrating trauma, there was no statistical significance between increasing AAST grade and the rate of laparotomy. The rate of bile leak was 4.5 % (32/709) and of rebleed was 0.7 % (5/709). Five patients underwent ERCP and endoscopic sphincterotomy for bile leak, and three required angio-embolization for rebleeding. Increasing AAST grades were significantly associated with the odds of bile leak in both blunt and penetrating trauma. There was a statistically significant increase in the odds of a rebleed with increasing AAST grade in penetrating trauma. Five patients rebled, of which three died. Seven patients developed hepatic necrosis. Seventy-six patients died (10 %). There were 34/358 (9 %) deaths in the blunt cohort and 42 /351 (11 %) deaths in the penetrating trauma cohort. CONCLUSION: AAST grade in isolation is not a good predictor of the need for operation in hepatic trauma. Increasing AAST grade was not found to correlate with increased risk of mortality for both blunt and penetrating hepatic trauma. In both blunt and penetrating trauma, increasing AAST grade is significantly associated with increased bile leak. The need for ERCP and endoscopic sphincterotomy to manage bile leak in our setting is low. Similarly, the rate of rebleeding and of angioembolization was low.

Clinical and molecular effects of oral CCR4 antagonist RPT193 in atopic dermatitis: A Phase 1 study.

BACKGROUND: RPT193 is an orally administered small molecule antagonist of the human C-C motif chemokine receptor 4 (CCR4) that inhibits the migration and downstream activation of T-helper Type 2 (Th2) cells. We investigated single- and multiple-ascending doses of RPT193 in healthy subjects, and multiple doses of RPT193 in subjects with moderate-to-severe atopic dermatitis (AD). METHODS: This was a first-in-human randomized, placebo-controlled Phase 1a/1b monotherapy study (NCT04271514) to evaluate the safety, tolerability, pharmacokinetics, pharmacodynamics, and CCR4 surface receptor occupancy in eligible healthy subjects and subjects with moderate-to-severe AD. Clinical efficacy and skin biomarker effects of RPT193 monotherapy were assessed as exploratory endpoints in AD subjects. RESULTS: In healthy (n = 72) and AD subjects (n = 31), once-daily RPT193 treatment was generally well tolerated, with no serious adverse events reported and all treatment-emergent adverse events reported as mild/moderate. In AD subjects, numerically greater improvements in clinical efficacy endpoints were observed with RPT193 monotherapy versus placebo up to the end of the treatment period (Day 29), with statistically significant improvement, compared to Day 29 and placebo, observed 2 weeks after the end of treatment (Day 43) on several endpoints (p < .05). Moreover, significant changes in the transcriptional profile were seen in skin biopsies of RPT193-treated versus placebo-treated subjects at Day 29, which were also significantly correlated with improvements in clinical efficacy measures. CONCLUSIONS: To our knowledge, this is the first clinical study with an oral CCR4 antagonist that showed clinical improvement coupled with modulation of the cutaneous transcriptomic profile in an inflammatory skin disease.

An international consensus on gaps in mechanisms of forced-based manipulation research: findings from a nominal group technique.

Force-Based Manipulation (FBM) including light touch, pressure, massage, mobilization, thrust manipulation, and needling techniques are utilized across several disciplines to provide clinical analgesia. These commonly used techniques demonstrate the ability to improve pain-related outcomes; however, mechanisms behind why analgesia occurs with these hands-on interventions has been understudied. Neurological, neuroimmune, biomechanical, neurovascular, neurotransmitter, and contextual factor interactions have been proposed to influence response; however, the specific relationships to clinical pain outcomes has not been well established. The purpose of this study was to identify gaps present within mechanism-based research as it relates to FBM. An international multidisciplinary nominal group technique (NGT) was performed and identified 37 proposed gaps across eight domains. Twenty-three of these gaps met consensus across domains supporting the complex multisystem mechanistic response to FBM. The strength of support for gaps within the biomechanical domain had less overall support than the others. Gaps assessing the influence of contextual factors had strong support as did those associating mechanisms with clinical outcomes (translational studies). The importance of literature investigating how FBM differs with individuals of different pain phenotypes (pain mechanism phenotypes and clinical phenotypes) was also presented aligning with other analgesic techniques trending toward patient-specific pain management (precision medicine) through the use of pain phenotyping.

Hybrid electronic record: An error reduction strategy for diverse medical prescription formats

Background: This project is part of a broader effort to develop a new electronic registry for ophthalmology in the KwaZulu-Natal (KZN) province in South Africa. The registry should include a clinical decision support system that reduces the potential for human error and should be applicable for our diversity of hospitals, whether electronic health record (EHR) or paper-based. Methods: Post-operative prescriptions of consecutive cataract surgery discharges were included for 2019 and 2020. Comparisons were facilitated by the four chosen state hospitals in KZN each having a different system for prescribing medications: Electronic, tick sheet, ink stamp and handwritten health records. Error types were compared to hospital systems to identify easily-correctable errors. Potential error remedies were sought by a four-step process. Results: There were 1307 individual errors in 1661 prescriptions, categorised into 20 error types. Increasing levels of technology did not decrease error rates but did decrease the variety of error types. High technology scripts had the most errors but when easily correctable errors were removed, EHRs had the lowest error rates and handwritten the highest. Conclusion: Increasing technology, by itself, does not seem to reduce prescription error. Technology does, however, seem to decrease the variability of potential error types, which make many of the errors simpler to correct. Contribution: Regular audits are an effective tool to greatly reduce prescription errors, and the higher the technology level, the more effective these audit interventions become. This advantage can be transferred to paper-based notes by utilising a hybrid electronic registry to print the formal medical record.

Actualización de las recomendaciones sobre sueño seguro / Update on safe sleep recommendatios

La muerte súbita de un lactante puede ser de causa explicada, indeterminada ­si no se investigó en forma suficiente­ o inexplicada ­cuando una investigación completa no permite determinar su causa­. La muerte súbita inexplicada, o síndrome de muerte súbita infantil, afecta en particular a las poblaciones más vulnerables. La muerte de estos niños que nacen con alteraciones del neurodesarrollo es la parte visible de una problemática que se origina en el embarazo. Disminuir la cantidad de niños vulnerables depende de políticas de salud y, sobre todo, de lograr mejorar las condiciones de vida de la población. Son acciones a largo plazo. Conocer a fondo los factores de riesgo que pueden desencadenar la muerte inesperada es lo que se puede hacer ya. La actualización de las recomendaciones sobre sueño seguro refleja nuevos conocimientos basados en la evidencia científica y un enfoque integral de los aspectos socioculturales relacionados con esta problemática.

Sudden unexpected infant death may be explained, cause by an etiology, unexplained but insufficiently investigated, or unexplained when a full investigation fails to determine the cause. Unexplained sudden death in infancy or sudden infant death syndrome particularly affects the most vulnerable populations. The death of these children who are born with alterations in their neurodevelopment is the visible part of a problem that originates in pregnancy. Reducing the number of vulnerable children depends on health policies and, above all, on improving the living conditions of the population. These are long-term actions. Knowing in depth the risk factors that can trigger unexpected death is what can be done now. The update of the recommendations on safe sleep reflects new knowledge based on scientific evidence and a comprehensive approach to the sociocultural aspects related to this problem.

Actualización de las recomendaciones sobre sueño seguroUpdate on safe sleep recommendatios

RESUMEN La muerte súbita de un lactante puede ser de causa explicada, indeterminada -si no se investigó en forma suficiente- o inexplicada -cuando una investigación completa no permite determinar su causa-. La muerte súbita inexplicada, o síndrome de muerte súbita infantil, afecta en particular a las poblaciones más vulnerables. La muerte de estos niños que nacen con alteraciones del neurodesarrollo es la parte visible de una problemática que se origina en el embarazo. Disminuir la cantidad de niños vulnerables depende de políticas de salud y, sobre todo, de lograr mejorar las condiciones de vida de la población. Son acciones a largo plazo. Conocer a fondo los factores de riesgo que pueden desencadenar la muerte inesperada es lo que se puede hacer ya. La actualización de las recomendaciones sobre sueño seguro refleja nuevos conocimientos basados en la evidencia científica y un enfoque integral de los aspectos socioculturales relacionados con esta problemática.

ABSTRACT Sudden unexpected infant death may be explained, cause by an etiology, unexplained but insufficiently investigated, or unexplained when a full investigation fails to determine the cause. Unexplained sudden death in infancy or sudden infant death syndrome particularly affects the most vulnerable populations. The death of these children who are born with alterations in their neurodevelopment is the visible part of a problem that originates in pregnancy. Reducing the number of vulnerable children depends on health policies and, above all, on improving the living conditions of the population. These are long-term actions. Knowing in depth the risk factors that can trigger unexpected death is what can be done now. The update of the recommendations on safe sleep reflects new knowledge based on scientific evidence and a comprehensive approach to the sociocultural aspects related to this problem.

[Update on safe sleep recommendatios]. / Actualización de las recomendaciones sobre sueño seguro.

Sudden unexpected infant death may be explained, cause by an etiology, unexplained but insufficiently investigated, or unexplained when a full investigation fails to determine the cause. Unexplained sudden death in infancy or sudden infant death syndrome particularly affects the most vulnerable populations. The death of these children who are born with alterations in their neurodevelopment is the visible part of a problem that originates in pregnancy. Reducing the number of vulnerable children depends on health policies and, above all, on improving the living conditions of the population. These are long-term actions. Knowing in depth the risk factors that can trigger unexpected death is what can be done now. The update of the recommendations on safe sleep reflects new knowledge based on scientific evidence and a comprehensive approach to the sociocultural aspects related to this problem.

La muerte súbita de un lactante puede ser de causa explicada, indeterminada ­si no se investigó en forma suficiente­ o inexplicada ­cuando una investigación completa no permite determinar su causa­. La muerte súbita inexplicada, o síndrome de muerte súbita infantil, afecta en particular a las poblaciones más vulnerables. La muerte de estos niños que nacen con alteraciones del neurodesarrollo es la parte visible de una problemática que se origina en el embarazo. Disminuir la cantidad de niños vulnerables depende de políticas de salud y, sobre todo, de lograr mejorar las condiciones de vida de la población. Son acciones a largo plazo. Conocer a fondo los factores de riesgo que pueden desencadenar la muerte inesperada es lo que se puede hacer ya. La actualización de las recomendaciones sobre sueño seguro refleja nuevos conocimientos basados en la evidencia científica y un enfoque integral de los aspectos socioculturales relacionados con esta problemática.

The Influence of HIV Status on Acute Appendicitis: A Retrospective Study from South Africa.

BACKGROUND: Despite the human immunodeficiency virus (HIV) being the most common comorbidity in South African surgical patients, its impact on appendicitis has not been well-described. We aimed to determine HIV status' influence on patients' presentation, assessment, management and outcomes with acute appendicitis. METHODS: The retrospective chart review included all patients aged 12 years and older who were HIV-positive or HIV-negative and presented with acute appendicitis between 1 January 2013 and 31 December 2019. The primary outcome measure was survival to discharge. Secondary outcomes included analysis of the presentation (vital signs), assessment (biochemical, inflammatory markers) and management (intraoperative anatomical severity grading, length of hospital stay). RESULTS: Of the 1096 patients with appendicitis, 196 (17.9%) were HIV-positive, and CD4 counts were available for 159. The median age was 23 years, with the HIV-positive patients being older and HIV-negative group having more males (58.7%). While the HIV-positive patients had a longer median length of hospital stay, there was no statistically significant difference in the two groups' incidence of high-grade appendicitis (p = 0.670). The HIV-positive patients had a higher median shock index (OR 7.65; 95% [CI 2.042-28.64]) than their HIV-negative counterparts. HIV-positivity had a significant association with mortality (OR 9.56; 95% CI [1.68-179.39]), and of the seven HIV-positive patients who died, 66.7% (n = 4) had a CD4 < 200 cells/mm3 (OR 8.6; 95% CI [1.6-63.9]). CONCLUSION: HIV-positive patients, those with CD4 < 200 cells/mm3 or not on ART, have increased mortality risk and may benefit from increased perioperative surveillance. Patients with an unknown HIV status in a high-prevalence population should be offered HIV testing to risk stratify more accurately.

Excitonic Coupling in Fluorene-Based Bichromophoric Systems: Vibrational Quenching and the Transition from Weak to Intermediate Coupling.

Excimeric systems (i.e., excited dimers) have well served as model compounds for the study of the delocalization of electronic energy over weakly interacting chromophores. However, there remain relatively few isolated systems in which such interactions can be studied experimentally at a level to afford detailed comparisons with theory. In this Article, we examine a series of covalently and noncovalently linked dimers of fluorene, as a model aromatic chromophore, where the formation of excimers requires a π-stacked, cofacial orientation at van der Waals contact. Building upon a series of seminal prior studies that examined vibronic quenching of the excitation interaction in van der Waals dimers, the key question that we sought to address here is whether a single quenching factor could reproduce experimental excitonic splittings across a series of covalently and noncovalently linked bichromophoric systems built from the same chromophore. In comparing experimentally measured excitonic splittings with calculated static splittings using time-dependent density functional methods, we find that all systems save one fall on a line with a slope of 0.080(8), reflecting a vibrational quenching of roughly 1 order of magnitude. The outlier, which shows a significantly reduced quenching factor, represents a cyclophane-linked system where the fluorene moieties are constrained in a cofacial arrangement. We argue that this system evidences the transition from the weak to intermediate coupling regime.

Systematic Review of Procedural Skill Simulation in Health Care in Low- and Middle-Income Countries.

ABSTRACT: Low- and middle-income countries (LMICs) have adopted procedural skill simulation, with researchers increasingly investigating simulation efforts in resource-strained settings. We aim to summarize the current state of procedural skill simulation research in LMICs focusing on methodology, clinical area, types of outcomes and cost, cost-effectiveness, and overall sustainability. We performed a comprehensive literature review of original articles that assessed procedural skill simulation from database inception until April 2022.From 5371 screened articles, 262 were included in this review. All included studies were in English. Most studies were observational cohort studies (72.9%) and focused on obstetrics and neonatal medicine (32.4%). Most measured outcome was the process of task performance (56.5%). Several studies mentioned cost (38.9%) or sustainability (29.8%). However, few articles included actual monetary cost information (11.1%); only 1 article assessed cost-effectiveness. Based on our review, future research of procedural skill simulation in LMICS should focus on more rigorous research, cost assessments, and on less studied areas.

Mapping spatial morbidity patterns for bronchiolitis related to socioeconomic estimators: A spatial epidemiology approach to identify health disparities in Puerto Madryn, Argentina.

OBJECTIVES: To describe the frequency of hospitalizations of infants under 1 year of age with bronchiolitis in Puerto Madryn, Argentina, and to study the spatial distribution of cases throughout the city in relation to socioeconomic indicators. To visualize and better understand the underlying processes behind the local manifestation of the disease by creating a vulnerability map of the city. METHODS: We performed a cross-sectional study of all patients discharged for bronchiolitis from the local public Hospital in 2017, considering length of hospital stay, readmission rate, patient age, home address and socioeconomic indicators (household overcrowding). To understand the local spatial distribution of the disease and its relationship to overcrowding, we used GIS and Moran's global and local spatial autocorrelation indices. RESULTS: The spatial distribution of bronchiolitis cases was not random, but significantly aggregated. Of the 120 hospitalized children, 100 infants (83.33%) live in areas identified as having at least one unsatisfied basic need (UBN). We found a positive and statistically significant relationship between frequency of cases and percentage of overcrowded housing by census radius. CONCLUSIONS: A clear association was found between bronchiolitis and neighborhoods with UBNs, and overcrowding is likely to be a particularly important explanatory factor in this association. By combining GIS tools, spatial statistics, geo-referenced epidemiological data, and population-level information, vulnerability maps can be created to facilitate visualization of priority areas for development and implementation of more effective health interventions. Incorporating the spatial and syndemic perspective into health studies makes important contributions to the understanding of local health-disease processes.

Smart Wearable Patches Using Light-Controlled Activation and Delivery of Photoswitchable Antimicrobial Peptides.

A novel strategy to treat Staphylococcus aureus (S. aureus) skin infections is presented, where UV light is used to facilitate concomitant light-controlled activation and delivery of an antimicrobial therapeutic agent. Specifically, a new photoswitchable gramicidin S analogue was immobilized onto a polymeric wearable patch via a photocleavable linker that undergoes photolysis at the same wavelength of light required for activation of the peptide. Unlike toxic gramicidin S, the liberated active photoswitchable peptide exhibits antimicrobial activity against S. aureus while being ostensibly non-haemolytic to red blood cells. Moreover, irradiation with visible light switches off the antimicrobial properties of the peptide within seconds, presenting an ideal strategy to regulate antibiotic activity for localized bacterial infections with the potential to mitigate resistance.