Healthcare-associated infections among neonates and children in Pakistan: findings and the implications from a point prevalence survey.

BACKGROUND: Healthcare-associated infections (HAIs) increase morbidity, mortality and costs. The overall prevalence of HAIs is greater in low- and middle-income countries due to poor resources and infrastructure, with the incidence of HAIs greater among neonates and children. There is a need to understand the current situation in Pakistan including key drivers to improve future care. METHODS: Point prevalence survey (PPS) of HAIs in the children's wards of 19 public sector secondary- and tertiary-care hospitals of Pakistan and associated key drivers. RESULTS: A total of 1147 children were included in the PPS. 35.7% were neonates with 32.8% aged >1-5 years. 35.2% were admitted to the intensive care units (ICUs). Peripheral, central venous and urinary catheters were present in 48%, 2.9% and 5.6% of the patients, respectively. A total of 161 HAIs from various pathogens were observed in 153 cases, giving a prevalence of 13.3%. The majority of HAIs were caused by Staphylococcus aureus (31.7%) followed by Klebsiella pneumoniae (22.9%) and Escherichia coli (17.4%). Bloodstream infections were identified in 42 cases followed by lower-respiratory-tract infections in 35. Increased length of hospital stays and being admitted to the ICU, 'rapidly fatal' patients under the McCabe and Jackson criteria, central and peripheral catheterization, and invasive mechanical ventilation were, associated with higher HAIs (P<0.001). 99.7% of HAI patients fully recovered and were discharged from the hospital. CONCLUSION: There is a high prevalence of HAIs among neonates and children admitted to health facilities in Pakistan. Infection prevention and control measures should be implemented to help prevent future HAIs.

The assessment of haematologic and serum chemistry parameters in canine pyometra: a systematic review and meta-analysis.

OBJECTIVES: Pyometra is common in non-spayed adult female dogs requiring early diagnosis and treatment to increase the survival rate. The diagnosis of pyometra is mainly based on clinical examination and anamnesis. Radiography, ultrasonography and laboratory analyses are recommended to support a diagnosis. The aim of this study was to assess blood parameters associated with pyometra by performing a systematic review and meta-analysis. MATERIALS AND METHODS: The review was conducted in accordance with PRISMA guidelines. A search of three databases (PubMed, Google Scholar and CAB abstracts) was performed in July 2022. Studies providing information about laboratory parameters for both the pyometra group and healthy control group dogs were eligible for inclusion. Data extraction included the first author's name, publication year, country, number of participants in both groups, mean values of selected studies, standard deviation values, and blood parameters. The risk of bias for each study was evaluated, and a random-effects meta-analysis was performed. RESULTS: We included 44 studies which investigated 12 blood parameters. High heterogeneity was detected in all parameters in these meta-analyses. The following blood parameters were increased in dogs with pyometra: white blood cell (mean=27.75×109 L-1 , mean difference (MD)=17.16, 95% confidence interval (CI) 14.85 to 19.47), monocytes (mean=2.06×1012 /L, MD=1.37, 95% CI 0.99 to 1.74), blood urea nitrogen (mean=41.42 mg/dL MD=18.06, 95% CI 12.26 to 23.85), alkaline phosphatase (mean=212.78 IU/L, MD=137.51, 95% CI 81.81 to 88.62), and aspartate aminotransferase (mean=48.31 IU/L, MD=16.96, 95% CI 10.61 to 23.30). The following parameters were reduced: red blood cell (mean=5.42 1012 /L, MD=-1.37, 95% CI -1.68 to -1.05), haemoglobin (mean=121.20 g/L, MD=-30.57, 95% CI -39.70 to 21.45), albumin (mean=23.71 g/L, MD = -8.16, 95% CI -11.46 to -4.86). Lymphocyte, creatinine, urea, and alanine transaminase parameters were increased in some studies and decreased in others. CLINICAL SIGNIFICANCE: In canine pyometra, some blood parameters are consistently increased, some consistently decreased, and some increased or decreased depending on the study.

A national, multicentre, web-based point prevalence survey of antimicrobial use and quality indices among hospitalised paediatric patients across South Africa.

OBJECTIVES: Data on antimicrobial consumption among the paediatric population in public hospitals in South Africa are limited. This needs to be addressed to improve future antimicrobial use and reduce antimicrobial resistance rates. This study aimed to quantify antimicrobial usage and to identify and classify which antimicrobials are used in the paediatric population in public sector hospitals in South Africa according to the World Health Organization (WHO) AWaRe list of antimicrobials. METHODS: A point prevalence survey was conducted among 18 public sector hospitals from nine provinces using a newly developed web-based application. Data were analysed according to the WHO AWaRe list to guide future quality improvement programmes. RESULTS: A total of 1261 paediatric patient files were reviewed, with 49.7% (627/1261) receiving at least one antimicrobial and with 1013 antimicrobial prescriptions overall. The top five antimicrobials included ampicillin (16.4%), gentamicin (10.0%), amoxicillin/enzyme inhibitor (9.6%), ceftriaxone (7.4%) and amikacin (6.3%). Antimicrobials from the 'Access' classification were the most used (55.9%), with only 3.1% being from the 'Reserve' classification. The most common infectious conditions for which an antimicrobial was prescribed were pneumonia (14.6%; 148/1013) and clinical sepsis (11.0%; 111/1013). Parenteral administration (75.6%; 766/1013) and prolonged surgical prophylaxis (66.7%; 10/15) were common concerns. Only 28.0% (284/1013) of prescribed antimicrobials had cultures requested; of which only 38.7% (110/284) of culture results were available in the files. CONCLUSION: Overall, antimicrobial prescribing is common among paediatric patients in South Africa. Interventions should be targeted at improving antimicrobial prescribing, including surgical prophylaxis, and encouraging greater use of oral antibiotics.

A point prevalence survey of antimicrobial utilisation patterns and quality indices amongst hospitals in South Africa; findings and implications.

Objectives: Antimicrobial use is growing, driven mainly by rising demands in developing countries. Knowing how antimicrobials are prescribed is important. Consequently, we undertook a point prevalence survey (PPS) quantifying antimicrobial consumption among 18 public sector hospitals across South Africa.Method: A purpose-built web-based application was used to collect PPS data.Results: Out of 4407 adult patients surveyed, 33.6% were treated with an antimicrobial. The most frequently prescribed groups were a combination of penicillins including ß-lactamase inhibitors. Amoxicillin combined with an enzyme inhibitor accounted for 21.4% total DDDs. In the medical and surgical wards, Access antimicrobials (54.1%) were mostly used, while in the ICU, Watch antimicrobials (51.5%) were mostly used. Compliance with the South African Standard Treatment Guidelines and Essential Medicines List was 90.2%; however, concerns with extended use of antimicrobials for surgical prophylaxis (73.2% of patients).Conclusion: The web-based PPS tool was easy to use and successful in capturing PPS data since the results were comparable to other PPS studies across Africa. High use of amoxicillin combined with an enzyme inhibitor, possibly because it was among the broad-spectrum antimicrobials in the Access group. The findings will assist with future targets to improve antimicrobial prescribing among public sector hospitals in South Africa.

Development of a web-based application to improve data collection of antimicrobial utilization in the public health care system in South Africa.

OBJECTIVE: Determining antimicrobial utilization patterns in hospitals can be a challenge given personnel and resource constraints with paper-based systems. A web-based application (APP) was developed in South Africa to address this, building on a recent point prevalence survey (PPS) using a paper-based system. Consequently, there was a need to test and evaluate the ease of use of a newly developed app and potential time saving versus paper-based methods for PPS. The findings can be used to further refine the APP. METHODS: The developed app was tested in a large academic public hospital in a PPS in South Africa. During data collection, the app was evaluated for functionality on 35 variables and subsequently refined. After data collection, the app was evaluated in terms of its time-saving potential and ease of use. RESULTS: 181 patient's files were surveyed across 13 wards in the hospital, with the antimicrobial usage findings similar to the previous paper-based study in the same hospital. The median age for males was 45.5 years and 42 years for females. Overall 80 out of 181 (44%) patients received antibiotics. Whilst 38% (12 out of 31) of patients in the adult surgical ward received antimicrobials, the prevalence was the highest (78%) in the pediatric medical wards. All the data collectors were confident in using the app after training and found the tool is not complex at all to use. In addition, the time taken to plan for the study and to collect data was considerably reduced. Reduced time spent in data collection and analysis is important for timely instigation of quality improvement programs in resource limited settings. CONCLUSIONS: All data collectors would recommend the app for future PPSs. Several concerns with data entry were identified, which have now been addressed. The app development has been successful and is now being deployed across South Africa as part of a national PPS as well as wider.

Knowledge, attitudes and practices of health care professionals towards adverse drug reaction reporting in public sector primary health care facilities in a South African district.

PURPOSE: Adverse drug reactions (ADRs) have an appreciable impact on patients' health. Little is known however about ADR reporting in ambulatory care environments especially in low- and middle-income countries. Consequently, our aim was to determine knowledge, attitudes and practices (KAP) among health care professionals (HCPs) towards ADR reporting in primary health care (PHC) facilities in South Africa. The findings will be used to direct future activities. METHODS: Descriptive, cross-sectional design using quantitative methodology among 8 public sector community health care centres and 40 PHC clinics in the Tshwane Health District, Gauteng Province. A self-administered questionnaire was distributed to 218 HCPs, including all key groups. RESULTS: A total of 200 responses were received (91.7%). Although an appropriate attitude towards ADR reporting existed, the actual frequency of ADR reporting was low (16.0%). Of the respondents, 60.5% did not know how to report, where to report or when to report an ADR and 51.5% said the level of their clinical knowledge made it difficult to decide whether or not an ADR had occurred. Over 97.5% stated they should be reporting ADRs with 89% feeling that ADR reporting is a professional obligation and over 70% that ADR reporting should be compulsory. When results were combined, the overall mean score in terms of positive or preferred practices for ADR reporting was 24.6% with pharmacists having the highest scores. CONCLUSION: Under-reporting of ADRs with gaps in KAP was evident. There is a serious and urgent need for education and training of HCPs on ADR reporting in South Africa.

Mental health care - a public health priority in South Africa

Mental health is an integral part of health and it includes an individual's emotional, psychological and social well-being. Mental illness remains underreported and underdiagnosed, particularly in low- and middle-income countries, including South Africa. South Africa carries a huge burden of mental illnesses with the most prevalent being anxiety disorders, substance abuse disorders, mood disorders and depression. People with mental health conditions often face neglect in the health system as well as stigma and discrimination. This has resulted in poor health outcomes, isolation and high suicide rates, including amongst adolescents. The South African National Mental Health Policy Framework and Strategic Plan (2013­2020) aims to integrate mental health into the health system to provide quality mental health services that are accessible, equitable and comprehensive, particularly for community-based mental health. This article provides an overview of mental health care in South Africa, highlighting its public health importance

Progress in structure recovery from low dose exposures: Mixed molecular adsorption, exploitation of symmetry and reconstruction from the minimum signal level.

We investigate the recovery of structures from large-area, low dose exposures that distribute the dose over many identical copies of an object. The reconstruction is done via a maximum likelihood approach that does neither require to identify nor align the individual particles. We also simulate small molecular adsorbates on graphene and demonstrate the retrieval of images with atomic resolution from large area and extremely low dose raw data. Doses as low as 5 e-/Å2 are sufficient if all symmetries (translations, rotations and mirrors) of the supporting membrane are exploited to retrieve the structure of individual adsorbed molecules. We compare different optimization schemes, consider mixed molecules and adsorption sites, and requirements on the amount of data. We further demonstrate that the maximum likelihood approach is only count limited by requiring at least three independent counts per entity. Finally, we demonstrate that the approach works with real experimental data and in the presence of aberrations.

Publication trends of clinical trials performed in South Africa.

BACKGROUND: Investigators and sponsors of clinical trials have an ethical obligation to disseminate clinical trial results, whether positive or negative, in a timely manner. OBJECTIVES: To determine the publication rate and average time to reporting for clinical trials carried out in South Africa (SA) and to explore factors indicating whether a study is published or not. METHODS: A registry-based quantitative retrospective analysis of 79 SA clinical trials for new medicines registered between January 2008 and December 2010 was performed. The relevant trial identification number in the register was used to track all peer-reviewed publications subsequent to registration. Tracking of clinical trials was done through a systematic literature search of the electronic journal databases of the South African Medical Journal (SAMJ), the Cochrane Library, Public Library of Science Medical Journal (PLoS Medicine) and BioMed Central, all of which are indexed on MEDLINE via PubMed. In addition, a manual search of the Open Access Journal of Clinical Trials databases and reference lists on articles related to the trial medicine was performed. RESULTS: Of the 79 clinical trials surveyed, 72 were concluded by December 2014. Only 35 (48.6%) of them had the results published in a peer-reviewed journal, the current benchmark for dissemination of trial results. The majority (82.9%) of those published had a positive outcome. Of the 35 trials that were published, 77.1% were published within 2 years. The average time from completion to initial reporting was 22 months. Fewer than half (40.5%) of the clinical trials surveyed were placebo controlled. CONCLUSION: The absence of complete outcomes data from SA clinical trials warrants utmost attention. The study puts forward a case to the regulatory body and research ethics committees to compel all data from clinical trials to be made accessible to clinicians and the public in general by being published in an easily accessible form and in a timely manner.

Publication Trends of Clinical Trials Performed in South Africa

BACKGROUND:Investigators and sponsors of clinical trials have an ethical obligation to disseminate clinical trial results; whether positive or negative; in a timely manner.OBJECTIVES:To determine the publication rate and average time to reporting for clinical trials carried out in South Africa (SA) and to explore factors indicating whether a study is published or not.METHODS:A registry-based quantitative retrospective analysis of 79 SA clinical trials for new medicines registered between January 2008 and December 2010 was performed. The relevant trial identification number in the register was used to track all peer-reviewed publications subsequent to registration. Tracking of clinical trials was done through a systematic literature search of the electronic journal databases of the South African Medical Journal (SAMJ); the Cochrane Library; Public Library of Science Medical Journal (PLoS Medicine) and BioMed Central; all of which are indexed on MEDLINE via PubMed. In addition; a manual search of the Open Access Journal of Clinical Trials databases and reference lists on articles related to the trial medicine was performed. RESULTS:Of the 79 clinical trials surveyed; 72 were concluded by December 2014. Only 35 (48.6%) of them had the results published in a peer-reviewed journal; the current benchmark for dissemination of trial results. The majority (82.9%) of those published had a positive outcome. Of the 35 trials that were published; 77.1% were published within 2 years. The average time from completion to initial reporting was 22 months. Fewer than half (40.5%) of the clinical trials surveyed were placebo controlled.CONCLUSION:The absence of complete outcomes data from SA clinical trials warrants utmost attention. The study puts forward a case to the regulatory body and research ethics committees to compel all data from clinical trials to be made accessible to clinicians and the public in general by being published in an easily accessible form and in a timely manner

Well-posedness and qualitative behaviour of a semi-linear parabolic Cauchy problem arising from a generic model for fractional-order autocatalysis.

In this paper, we examine a semi-linear parabolic Cauchy problem with non-Lipschitz nonlinearity which arises as a generic form in a significant number of applications. Specifically, we obtain a well-posedness result and examine the qualitative structure of the solution in detail. The standard classical approach to establishing well-posedness is precluded owing to the lack of Lipschitz continuity for the nonlinearity. Here, existence and uniqueness of solutions is established via the recently developed generic approach to this class of problem (Meyer & Needham 2015 The Cauchy problem for non-Lipschitz semi-linear parabolic partial differential equations. London Mathematical Society Lecture Note Series, vol. 419) which examines the difference of the maximal and minimal solutions to the problem. From this uniqueness result, the approach of Meyer & Needham allows for development of a comparison result which is then used to exhibit global continuous dependence of solutions to the problem on a suitable initial dataset. The comparison and continuous dependence results obtained here are novel to this class of problem. This class of problem arises specifically in the study of a one-step autocatalytic reaction, which is schematically given by A→B at rate apbq (where a and b are the concentrations of A and B, respectively, with 0

Towards weighing individual atoms by high-angle scattering of electrons.

We consider theoretically the energy loss of electrons scattered to high angles when assuming that the primary beam can be limited to a single atom. We discuss the possibility of identifying the isotopes of light elements and of extracting information about phonons in this signal. The energy loss is related to the mass of the much heavier nucleus, and is spread out due to atomic vibrations. Importantly, while the width of the broadening is much larger than the energy separation of isotopes, only the shift in the peak positions must be detected if the beam is limited to a single atom. We conclude that the experimental case will be challenging but is not excluded by the physical principles as far as considered here. Moreover, the initial experiments demonstrate that the separation of gold and carbon based on a signal that is related to their mass, rather than their atomic number.

Atomic structure from large-area, low-dose exposures of materials: a new route to circumvent radiation damage.

Beam-induced structural modifications are a major nuisance in the study of materials by high-resolution electron microscopy. Here, we introduce a new approach to circumvent the radiation damage problem by a statistical treatment of large, noisy, low-dose data sets of non-periodic configurations (e.g. defects) in the material. We distribute the dose over a mixture of different defect structures at random positions and with random orientations, and recover representative model images via a maximum likelihood search. We demonstrate reconstructions from simulated images at such low doses that the location of individual entities is not possible. The approach may open a route to study currently inaccessible beam-sensitive configurations.

Optimum HRTEM image contrast at 20 kV and 80 kV--exemplified by graphene.

The dependence of high-resolution transmission electron microscopy (HRTEM) image contrast of graphene on the adjustable parameters of an aberration-corrected microscope operated at 80 and 20 kV has been calculated and, for 80 kV, compared with measurements. We used density functional theory to determine the projected atom potential and obtained the image intensity by averaging over the energy distribution of the imaging electrons, as derived from the electron energy loss spectroscopy measurements. Optimum image contrast has been determined as a function of energy spread of the imaging electrons and chromatic aberration coefficient, showing that significant improvement of contrast can be achieved at 80 kV with the help of a monochromator, however at 20 kV only with chromatic aberration correction and bright atom contrast conditions.

Transmission electron microscopy at 20 kV for imaging and spectroscopy.

The electron optical performance of a transmission electron microscope (TEM) is characterized for direct spatial imaging and spectroscopy using electrons with energies as low as 20 keV. The highly stable instrument is equipped with an electrostatic monochromator and a C(S)-corrector. At 20 kV it shows high image contrast even for single-layer graphene with a lattice transfer of 213 pm (tilted illumination). For 4 nm thick Si, the 200 reflections (271.5 pm) were directly transferred (axial illumination). We show at 20 kV that radiation-sensitive fullerenes (C(60)) within a carbon nanotube container withstand an about two orders of magnitude higher electron dose than at 80 kV. In spectroscopy mode, the monochromated low-energy electron beam enables the acquisition of EELS spectra up to very high energy losses with exceptionally low background noise. Using Si and Ge, we show that 20 kV TEM allows the determination of dielectric properties and narrow band gaps, which were not accessible by TEM so far. These very first results demonstrate that low kV TEM is an exciting new tool for determination of structural and electronic properties of different types of nano-materials.

From point defects in graphene to two-dimensional amorphous carbon.

While crystalline two-dimensional materials have become an experimental reality during the past few years, an amorphous 2D material has not been reported before. Here, using electron irradiation we create an sp2-hybridized one-atom-thick flat carbon membrane with a random arrangement of polygons, including four-membered carbon rings. We show how the transformation occurs step by step by nucleation and growth of low-energy multivacancy structures constructed of rotated hexagons and other polygons. Our observations, along with first-principles calculations, provide new insights to the bonding behavior of carbon and dynamics of defects in graphene. The created domains possess a band gap, which may open new possibilities for engineering graphene-based electronic devices.