A collaborative and evolving response to the needs of frontline workers, patients and families during the COVID-19 pandemic at Tygerberg Hospital, Western Cape Province, South Africa.

The global devastation caused by the COVID-19 pandemic and its mental health impact is undeniable. The physical and psychological consequences are wide-ranging - affecting patients fighting the disease, frontline workers in the trenches with them, healthcare staff deployed in high-care settings, and families disconnected from their loved ones in their darkest hours. Within 6 weeks of the COVID-19 outbreak in South Africa, the Department of Psychiatry at Stellenbosch University established the TBH/SU COVID Resiliency Clinic to provide psychological support to frontline workers at Tygerberg Hospital. Identified barriers in healthcare workers accessing mental healthcare resulted in moving towards an on-site visibility to try to remove some of these barriers. This greater on-site presence enabled networking and building of relationships with frontline staff that over time highlighted other frontline needs, such as providing psychosocial and spiritual support to patients and their families. We share challenges, lessons learned and recommendations from two initiatives: the TBH/SU COVID-19 Resiliency Clinic, and an embedded COVID Care Team (CCT). We describe the establishment, roll-out and progress of the Clinic and the subsequent CCT.

Distance to treatment as a factor for loss to follow up of hepatitis C patients in North East England.

BACKGROUND: A large proportion of the 200 000 HCV-infected individuals in the UK are undiagnosed or lost to follow-up. Engaging known infected individuals in treatment is essential for elimination. METHODS: Using PHE surveillance data and HCV treatment registers from North East of England (NE) treatment centres for 1997-2016, we estimated the number of HCV cases not linked to treatment and the proportion with active infection. We compared distances of treated and untreated cases to treatment services, and assessed the effect of expanding HCV treatment into existing drug and alcohol treatment centres in the NEE on treatment accessibility. RESULTS: The odds of being treated was associated with distance to treatment services. Confirmatory results for ~50% were not reported to PHE NE. Overall, 3385 patients reported to PHE NE had no record of treatment; we estimated 1621 of these may have been lost to follow-up after confirmation of active infection. CONCLUSIONS: Poor access to healthcare services may contribute to under-diagnosis or loss to follow-up. Expanding HCV treatment delivery into NEE drug and alcohol treatment centres would improve the accessibility of treatment services to people infected with/at risk of HCV. This may increase the proportion receiving treatment and support progress towards elimination.

Secondhand smoke transfer and reductions by air sealing and ventilation in multiunit buildings: PFT and nicotine verification.

UNLABELLED: Surveys suggest that transfer of secondhand smoke (SHS) between units in multiunit residential buildings is common, but measured data are rare. This study was undertaken to quantify bulk air transfer between units and document transfer of SHS species before and after treatments that sealed boundaries between units and provided a minimum amount of continuous exhaust ventilation of each unit. Six buildings in Minnesota were studied. Treatments were performed in clusters of up to eight units in each building, including zero to two units occupied by smokers. Bulk air transfer was quantified through passive perfluorocarbon tracer (PFT) gas tests. SHS transfer was evaluated using passive nicotine sampling. The median fraction of air entering a unit that came from other units tagged with PFTs ranged from 0.021 in a new condominium building to 0.353 in a 1930s duplex, with an overall median of 0.041. Treatments provided a median decrease of 29% in the fraction of transferred air and reduced PFT concentrations by about 40%, because of increased ventilation of both source and target apartments. Nicotine was transferred at only one-sixth the rate of PFTs. Involuntary exposure to SHS can be reduced but not eliminated by modifying existing, occupied multiunit buildings. PRACTICAL IMPLICATIONS: Recent studies of secondhand smoke exposure in multiunit housing indicate transmission of SHS constituents from smokers' units to those occupied by nonsmokers. A straightforward solution for this problem is to eliminate air leakage transfer between these units. This study describes a 2-year investigation of air sealing and ventilation improvements in six multiunit buildings located in a heating-dominated climate region of the US. The results quantify the reduction in interunit transfer of air between smokers' and nonsmokers' units. While it is possible to reduce the transfer when done with care, it is extremely difficult to eliminate these flows unless the buildings are vacated and extensively rebuilt. Eliminating air leakage between smokers' and nonsmokers' units is not a practical means of solving SHS transmission in an existing building.

Pioneers in ethnopharmacology: the Dutch East India Company (VOC) at the Cape from 1650 to 1800.

The earliest inhabitants of South Africa are believed to be the Khoi-Khoi and San peoples, whose knowledge of economic botany is extensive. Their ethnomedical practice, based on the plant species indigenous to the region, is an oral tradition and particularly susceptible to disruption. The culture of both peoples has during the past 350 years come under increasing threat of extinction, resulting in the likely loss to science of important ethnomedical knowledge. While written records of Khoi-San traditional medical practice are preserved in English, they mainly cover the period from 1800 onward. Earlier written records do exist, but do not appear to have been adequately screened. The present study was undertaken in order to complete the historical written record by critically examining all potential sources of Khoi and San ethnomedical information, for the years 1650-1800. These sources comprised journals of exploratory expeditions, herbarium specimens, published academic works and archival records associated with the activities of the former Dutch East India Company (VOC) at the Cape. The results of the search show that the VOC had a great interest in Khoi and San traditional medicines and attempted to record this knowledge. The VOC archives in particular represent a largely untapped source of ethnomedical information with potential application in health care, new drug development and intellectual property protection.

Managing chronic hepatitis C acquired through intravenous drug use.

We retrospectively reviewed the provision and uptake of hospital services for 253 current and ex-intravenous drug users with hepatitis C virus (HCV). Overall, 237 attended at least one clinic (mean age 32 years, 70% male, 43% on maintenance methadone); 81% had evidence of active viral replication and 137 agreed to a liver biopsy to assess disease severity. Of these 137, 24% had mild chronic hepatitis with a low risk of progression to cirrhosis, but 9% had cirrhosis (mean age 40 years, mean time since initial intravenous drug use 15.8 years). Only 50 of the 100 patients in whom antiviral therapy was indicated, commenced treatment; 18 (36%) have had a sustained virological response. The natural history or response to treatment of chronic HCV in those who acquire it through intravenous drug use is not different to that previously reported for post-transfusion HCV. However, a substantial proportion default from follow-up or decline further intervention. As intravenous drug use is now the main risk factor for acquisition of HCV, these data have implications for future delivery of care aimed at limiting the morbidity of chronic HCV, and limiting the spread of hepatitis C virus infection amongst intravenous drug users.

Harry E. Bacon Oration. Comparison of the functional results of restorative proctocolectomy for ulcerative colitis between the J and W configuration ileal pouches with sutured ileoanal anastomosis.

PURPOSE: This study was designed to compare function of patients who had undergone reconstruction following proctocolectomy for ulcerative colitis using the J or W configuration ileoanal pouch. METHODS: Of 126 patients who underwent restorative proctocolectomy between January 1981 and March 1993, 101 had surgery for ulcerative colitis. Eighty-seven of these patients were available for review by personal or postal interview. All operative procedures were performed by one surgeon. The group comprised 35 W-pouches and 52 J-pouches. RESULTS: More patients with a J-pouch had a stool frequency of greater than 8 per 24 hours (P = 0.044), and they were also more likely to use a perineal pad (P = 0.019). No difference in the rates of nocturnal stool frequency, fecal incontinence, or use of constipating agents between the two pouch designs was found. Significantly more patients with a J-pouch have had episodes of pouchitis (P = 0.001). Of the total patient group 91.9 percent felt that restorative proctocolectomy had improved their quality of life. CONCLUSION: Minor differences in the function of the W configuration ileoanal pouch and the J configuration ileoanal pouch are demonstrated in this study.

Effect of exogenous arginine vasopressin on adrenocorticotropin and cortisol release in myotonie dystrophy patients: delayed responses of normal magnitude.

Abstract We administered intramuscular arginine vasopressin (AVP) to ten normal controls and eight myotonic dystrophy patients. By measuring plasma AVP levels in five of the myotonics and all the normals, we showed that absorption and distribution of AVP was not delayed or significantly reduced in myotonics. The magnitude of the mean plasma adrenocorticotropin (ACTH) response to AVP in the myotonics was not different from that of normals, although it was significantly delayed (mean peak time, 37.5+/-4.9 versus 17.0 +/- 3.2 min). We propose that this delay was caused by a significantly reduced ACTH secretion rate in myotonics, because the maximum rate of detection of ACTH in plasma is reduced in myotonics (0.6 +/- 0.2 versus 1.7 +/- 0.5 pmol/L/min), whose corticotropes, while having the same capacity to respond to the AVP stimulus, are slower to attain that capacity. The mean integrated cortisol response (AUC) was significantly smaller for myotonics (8072 +/- 2017 versus 13049+/-1630 nmol.min/L). This may be due to the slower rate of ACTH delivery to the adrenal in myotonics. The timing of the adrenal response does not appear to be impaired in myotonic dystrophy, with the cortisol peak following the ACTH peak by approximately 15 min in both groups. The normal magnitude ACTH response to AVP in myotonics is in contrast to that seen to ACTH secretagogues acting via corticotropin- releasing hormone-initiated pathways, where a rapid hypersecretion is seen. We propose a mechanism of defective calcium transport to account for these observations.

Continence level following radical prostatectomy.

The relationship of the urethral anastomosis and postoperative continence following radical prostatectomy is uncertain. The objective of this study was to determine radiographically the functional level of continence following radical prostatectomy relative to the site of the intraoperative urethral anastomosis. In 8 patients having a radical prostatectomy, an intraoperative hemoclip was placed at the site of the urethral anastomosis and the postoperative functional level of continence was determined using a standing lateral cystogram. The functional level of continence was 9 mm (SD = 3.0) distal to the site of the urethral anastomosis. The level in the urethra that continence occurs may be a function of the intrinsic continence parameters of each individual patient.

Low subcutaneous degradation and slow absorption of insulin in insulin-dependent diabetic patients during continuous subcutaneous insulin infusion at basal rate.

As information on the absorption kinetics and local degradation of infused insulin is relevant to programming strategies for continuous subcutaneous insulin infusion, we examined the time relationship of systemic insulin appearance and quantitated subcutaneous degradation during a near-basal rate of continuous subcutaneous insulin infusion in five insulin-dependent diabetic patients. Plasma free insulin was monitored for 8 h during and 3 h after a subcutaneous (abdominal wall) infusion of neutral insulin at 2.4 U/h. An identical intravenous infusion (2-4 h) was given on a separate occasion. Plateau levels of free insulin were not significantly different during the subcutaneous (37 +/- 8 mU/l) and intravenous (40 +/- 7 mU/l) infusions. Fitting of the free insulin data to our two-pool model of the subcutaneous space gave a mean estimate of 9.2 units insulin (= 3.8 h infusion) for the subcutaneous depot after 8 h. Model estimates of systemic insulin appearance, as a percentage of subcutaneous infusion rate, were 59% and 93% after 4 and 8 h respectively, and 76% 2 h after cessation of infusion. In insulin-dependent diabetic patients subcutaneous degradation of infused insulin is negligible but local accumulation in the subcutaneous space is considerable. The delay in absorption has important clinical implications for interruption and resumption of continuous subcutaneous insulin infusion and also for programming of variable basal rates.

Hypoglycemic episodes during continuous subcutaneous insulin infusion: decreased frequency but increased susceptibility.

There has been concern regarding the susceptibility of patients on continuous subcutaneous insulin infusion (CSII) to hypoglycemic episodes. This study has examined glycemic control, the frequency of hypoglycemic reactions and the counterregulatory response to an IV insulin infusion fo 2.4 units per hour in five brittle insulin-dependent diabetics before and during CSII. CSII was associated a significant reduction in glycosylated hemoglobin, standard deviation of blood glucose estimations and daily insulin dosage. The frequency of symptomatic hypoglycemic reactions was reduced (mean 14/4 weeks pre CSII, 5/4 weeks post CSII, p less than 0.05). However, after CSII the IV insulin caused a more rapid fall in blood glucose from the physiological to the hypoglycemic range while growth hormone and cortisol responses were both reduced (p less than 0.05) and the deficient glucagon response was not improved. Thus, although the frequency of reported hypoglycemic reactions was reduced by CSII, susceptibility to hypoglycemia due to excess insulin delivery was enhanced, owing to increased insulin sensitivity and/or additional impairment of the counterregulatory response.

Comparison of potency of porcine insulin and semisynthetic human insulin at 3 dose levels using the euglycaemic clamp.

The relative potency of porcine insulin and semisynthetic human insulin has been examined in humans using the euglycaemic glucose clamp technique. Three 90 minute consecutive infusions at 2.4, 4.8 and 7.2 units/hr were administered to 7 normal subjects. The rate of glucose infusion (mg/min, mean +/- SEM) required to maintain euglycaemia during the last 40 minutes of each insulin infusion for porcine (P) and human (H) insulin was not significantly different. However, when the glucose infusion rate was expressed as a function of the mean serum insulin level (mU/l) over the same period of time the values for P and H at 4.8 and 7.2 U/hr were not significantly different but H was greater than P (13.6 +/- 1.9, v 10.8 +/- 1.9, p less than .05) at 2.4 U/hr. Mean serum insulin levels did not differ significantly for human or porcine insulin infusion. This study confirms the similarity in potency between human and porcine insulin in the human. However, delivery at 2.4 U/hr, which would predominantly affect hepatic glucose output, suggests that semisynthetic human insulin is more potent than porcine insulin with respect to the liver.

Comparison of plateau insulin levels achieved by intravenous or subcutaneous insulin infusion: evidence for low rates of subcutaneous degradation.

Continuous insulin infusion via the subcutaneous (s.c.) route is attractive for diabetes therapy because of its simplicity compared with other routes. Some insulin will be degraded locally before systemic absorption, although the magnitude of this degradation has not been established. We have performed in five normal subjects s.c. and intravenous (i.v.) insulin infusions (2.4 U/h) of sufficient duration to compare steady-state systemic appearance rates of exogenous insulin. A steady state was produced after 60-90 min (i.v.) and 6-8 h (s.c.). Blood glucose fell to approximately 2.7 mmol/L in both studies and a fall in C-peptide indicated suppression of endogenous insulin secretion. Plateau insulin levels attributable to systemic entry of exogenous insulin were 36 +/- 2.0 mU/L (i.v. route) and 29 +/- 1.8 mU/L (s.c. route). These indicate a rate of 2.c. degradation of insulin of 19 +/- 5% in the steady state. We conclude that there is a low rate of degradation of insulin during continuous s.c. infusion.

Atrial fibrillation and arterial embolism in hyperthyroidism.

Atrial fibrillation or flutter was present in 70 of 381 patients with uncontrolled hyperthyroidism; return to stable sinus rhythm occurred in 39 with antithyroid and antiarrhythmic treatment. One third of the patients who reverted did so in the first week of treatment while still hyperthyroid. As expected, reversion was more likely in younger patients, and in those with arrhythmia of recent onset, without evidence of other heart disease. Eight patients with arrhythmia had proven (five) or probable (three) major arterial embolic episodes. Four of these eight patients died. Embolism tended to occur at an early stage, during uncontrolled hyperthyroidism, in patients with both atrial fibrillation and cardiac failure. These findings suggest that prophylactic anticoagulation may be appropriate in this high risk group, although more extensive studies are necessary before effective prevention of embolism can be claimed.

Isolation of lipoteichoic acids from Butyrivibrio fibrisolvens.

Lipoteichoic acid (LTA) and deacylated lipoteichoic acid have been isolated from the bovine-rumen Gram-negative anaerobe Butyrivibrio fibrisolvens by phenol extraction. Lipoteichoic acid (21.8 mumol phosphorus/g cells) consisted of a conventional 1, 3-phosphodiester-linked chain of glycerol phosphate units joined covalently to a glycolipid. It was not substituted with glycosyl or D-alalyl ester groups. Deacylated lipoteichoic acid (57.5 mumol phosphorus/g cells) was similar in constitution but lacked fatty acid esters. Lipoteichoic acid reacted serologically with antisera to the glycerol phosphate backbone of known lipoteichoic acids. The presence of similar teichoic acid polymers has also been demonstrated in some other strains of B. fibrisolvens and this is of significance in demonstrating that teichoic acids can occur in Gram-negative bacteria.

Formation of extracellular lipoteichoic acid by oral streptococci and lactobacilli.

Examination of the culture fluids from a number of strains of oral streptococci and latobacilli has shown the presence of an erythrocyte-sensitizing antigen with the properties of lipoteichoic acid. The antigen was isolated from the culture fluids of Lactobacillus casei and Lactobacillus fermentum and characterized chemically and serologically, For other strains, serological evidence for the presence of lipoteichoic acid depends on the reactivity with antiserum specific for the glycerol phosphate backbone. The relative concentrations of the antigen in culture fluids from different organisms, in culture fluids from different stages of growth, and in extracts of organisms was estimated by determining the maximum dilution that fully sensitized erythrocytes; the culture fluid titer, which is the reciprocal of the dilution, varied from 4 to 320. Strains of Streptococcus mutans were generally characterized by a high level of extracellular lipoteichoic acid, the amount being greater than that detectable in cell extracts; this conclusion was confirmed by using the quantitative precipitin method. A high-molecular-weight fraction obtained from S. mutans BHT culture fluid was effective in sensitizing erythrocytes at a concentration of 1 mug/ml, compared with 2 mug/ml required for cellular lipoteichoic acid from L. casei. The detecting procedure depends on the teichoic acid sensitizing erythrocytes but, as shown with L. fermentum, low-molecular-weight nonsensitizing teichoic acid may also be present in culture fluid.