The exceptional potential in extending primary care exposure for South African medical interns.

No abstract available.

The views of family physicians on National Health Insurance in Gauteng Province, South Africa.

BACKGROUND:  Universal health coverage (UHC) improves national health outcomes while addressing social inequalities in access to quality healthcare services. The district health system (DHS) is critical to the success of UHC in South Africa through the National Health Insurance (NHI) scheme. Family physicians (FPs), as champions of primary care, are central to the DHS operation and implementation of NHI. METHODS:  This was a qualitative exploratory study that used semi-structured interviews to explore FPs views and engagement on NHI policy and implementation in their districts. Ten FPs were included through purposive sampling. RESULTS:  Most of the FPs interviewed were not engaged in either policy formulation or strategic planning. The NHI bill was seen as a theoretical ideology that lacked any clear plan. Family physicians expressed several concerns around corruption in governmental structures that could play out in NHI implementation. Family physicians felt unsupported within their district structures and disempowered to engage in rollout strategies. The FPs were able to provide useful solutions to health system challenges because of the design of their training programmes, as well as their experience at the primary care level. CONCLUSION:  Healthcare governance in South Africa remains located in national and provincial structures. Devolution of governance to the DHS is required if NHI implementation is to succeed. The FPs need to be engaged in NHI strategies, to translate plans into actionable objectives at the primary care level.Contribution: This study highlights the need to involve FPs as key actors in implementing NHI strategies at a decentralised DHS governance level.

Myriad untold stories unfolding daily: South Africa's pursuit of quality primary health care.

No abstract available.

COPD Exposed to Air Pollution: A Path to Understand and Protect a Susceptible Population.

TOPIC IMPORTANCE: Air pollution poses a risk to the respiratory health of individuals with COPD. Long- and short-term exposures to higher levels of particulate-rich air pollution are associated with increased COPD exacerbation, hospitalization, and mortality, collectively implicating air pollution as a cause of adverse COPD-related outcomes. REVIEW FINDINGS: This review summarizes the evidence for COPD as a phenotype that confers susceptibility for adverse health outcomes in the face of common air pollution. We highlight how typical contributors to compromised urban air quality, including that from traffic, wildfire smoke, and indoor biomass combustion, adversely affect the COPD patient population. Evidence underscoring the burden of ongoing air pollution exposure on patients with COPD is discussed. We then detail the detrimental impact of that exposure on COPD pathophysiology, which in turn increases the patient's susceptibility. We specifically propose that indoor air is a particularly rational target for increased monitoring and remediation to protect patients with COPD. Because COPD is a heterogeneous disease with several endotypes, future intervention studies need to better include control populations, to highlight COPD-specific risks and identify subpopulations within patients with COPD who will benefit the most from improved indoor air quality. SUMMARY: Regulatory efforts must continue to broadly lower emission standards to protect this susceptible population from the negative health impacts of air pollution.

Transit and treatment: Aligning systems to address substance use in Connecticut.

OBJECTIVE: Test hypotheses that proximity to new transit improves substance use disorder treatment provider cost efficiency (i.e., economies of scale and scope). DATA SOURCES AND STUDY SETTING: Connecticut substance uses disorder treatment providers/programs. A 2015 rapid transit line opening with 10 stations, near some providers/programs. Providers' annual operating costs from publicly available federal tax forms (2013-2018). Annual client counts, service-type (including substance use disorder and/or mental health, among others), and location data, for 50 providers and their programs, from Department of Mental Health and Addiction Services, with an unbalanced panel of 285 provider-years. STUDY DESIGN: Economies of scale occur when the percent change in operating costs is less than the percentage change in clients. Economies of scope occur when operating costs fall as providers treat clients with multiple service needs. With our quasi-experimental, multivariate regressions approach, we test hypotheses that proximity to a new transit line enhances economies of scale and scope (i.e., lowers unit operating costs). DATA COLLECTION/EXTRACTION METHODS: Annual provider-level operating costs merged with new transit station locations and Department of Mental Health and Addiction Services program/provider-level secondary data (locations, client counts/completions/dates, service types, and average demographics). PRINCIPAL FINDINGS: For providers with programs within 1-mile of new transit (compared with a "control" sample beyond 1-mile of new transit), (i) a 10% increase in clients leads to a 0.12% lower operating costs per client; (ii) a 10% increase in clients completing treatment results in a 1.5% decrease in operating costs per client; (iii) a 10% increase in clients receiving treatment for multiple services causes a 0.81% lower operating costs per client; (iv) offering multiple services leads to 6.3% lower operating costs. CONCLUSIONS: New transit proximity causes operating cost savings for substance use disorder/mental health treatment providers. System alignment may benefit transit and health care sectors.

A review of published research in the South African Family Practice - A clarion call to action.

No abstract available.

Estimating time-dependent contact: a multi-strain epidemiological model of SARS-CoV-2 on the island of Ireland.

Mathematical modelling plays a key role in understanding and predicting the epidemiological dynamics of infectious diseases. We construct a flexible discrete-time model that incorporates multiple viral strains with different transmissibilities to estimate the changing patterns of human contact that generates new infections. Using a Bayesian approach, we fit the model to longitudinal data on hospitalisation with COVID-19 from the Republic of Ireland and Northern Ireland during the first year of the pandemic. We describe the estimated change in human contact in the context of government-mandated non-pharmaceutical interventions in the two jurisdictions on the island of Ireland. We take advantage of the fitted model to conduct counterfactual analyses exploring the impact of lockdown timing and introducing a novel, more transmissible variant. We found substantial differences in human contact between the two jurisdictions during periods of varied restriction easing and December holidays. Our counterfactual analyses reveal that implementing lockdowns earlier would have decreased subsequent hospitalisation substantially in most, but not all cases, and that an introduction of a more transmissible variant - without necessarily being more severe - can cause a large impact on the health care burden.

Vertiginous dizziness: A primary care approach.

Dizziness is an extremely common, yet complex neurological symptom that reflects a disturbance of normal balance perception and spatial orientation. Dizziness is a non-specific, catch-all term commonly used by patients to describe a wide array of symptoms, including a sensation of motion, weakness, light-headedness, unsteadiness, emotional upset and depression. The national 1-year prevalence of dizziness is around 50%, accounting for 4% of emergency department presentations and 1% of primary care consultations in South Africa. This article will focus on a diagnostic approach to the most common cause of dizziness (vertigo).

The family physician's guide to the private sector galaxy.

No abstract available.

One World, One Health: A growing need for an integrated global health approach.

No abstract available.

Guiding the emerging primary care researcher: A report of research capacity-building workshop.

There is an escalating interest in research capacity building across the globe. Research is an integral part of the continuous improvement process, clinical decision making and health system strengthening and should be embedded into the health system. The South African Family Practice Journal editorial team held a workshop on 19 August 2022 at the 24th National Family Practitioners Congress in Cape Town, with the aim of supporting primary care clinicians in their development from early-career researchers to established clinician-scientists. Small group and plenary discussions yielded valuable insights into the lived experiences of early career researchers and highlighted critical action areas to build the landscape of clinician-led research in the South African context.Contribution: This article contributes to current literature by providing insight into the lived experiences of early-career researchers and explores opportunities for research capacity-building.

Artificial intelligence: A strategic opportunity for enhancing primary care in South Africa.

No abstract available.

Creep-dilatancy development at a transform plate boundary.

How tectonic plates slip slowly and episodically along their boundaries, is a major, open question in earthquake science. Here, we use offshore in-situ sediment pore-pressure acquired in the proximity of the active offshore Main Marmara Fault and onshore geodetic time-series data set from a single GPS station to demonstrate the pore-pressure/deformation coupling during a 10-month slow-slip event. We show that pore pressure fluctuations are the expression of hydro-mechanical process affecting the deep seismogenic zone and indicate that small disturbances in geodetic data may have important meaning in terms of transient deformations. These results have major implications in understanding the spatial impact of slow-slip processes and their role in earthquake cycles. We demonstrate that piezometers measuring along a transform fault can help define the time scale regulating the coupling between slow-slip events and earthquake nucleation process.

The use of vagal manoeuvres in narrow complex tachyarrhythmias in primary care.

Supraventricular tachydysrhythmias (SVTs) are a common presenting complaint, with a national prevalence of 3/1000 persons. While most commonly stable, prolonged paroxysms can deteriorate into haemodynamically unstable subtypes or ventricular dysrhythmias. Early recognition with appropriate management is critical to reducing the morbidity associated with this condition. The American Heart Association holds that vagal manoeuvres are a first-line therapy in the management algorithm of stable SVTs. However, they state that no clear recommendations can be made around which manoeuvre to use, highlighting that future research should examine the efficacy and safety profiles of the various manoeuvres. In the South African primary care setting, clinicians must be at the forefront of pragmatic management strategies in the face of resource limitations, such as the unavailability of adenosine - a second-line therapy when vagal manoeuvres fail. In this article, we begin with a case study and review the literature around vagal manoeuvres.

Opinion: The use of point-of-care sonography in primary care: An ethical perspective.

The use of point-of-care ultrasound (PoCUS) is fast becoming a global standard of care. World over, training programmes are embracing the use of PoCUS to improve patient care, reduce risks to patients and reduce the burden of unnecessary referrals and investigations. The South African setting is particularly amenable to the benefits of this diagnostic modality to improve healthcare delivery to rural and marginalised populations. However, as with any technological advancements, the use of PoCUS is also not immune to deleterious consequences and patient harm from overdependence and over-zealous uptake. Family physicians, as the champions of primary care, should take the lead to ensure the effective and proper use of PoCUS in rural and primary care settings through advocacy, training and accreditation of clinicians to safely harness the benefits of PoCUS and minimise harm.

Impact of Exposure to Diesel Exhaust on Inflammation Markers and Proteases in Former Smokers with Chronic Obstructive Pulmonary Disease: A Randomized, Double-blinded, Crossover Study.

Rationale: There is growing evidence that chronic obstructive pulmonary disease (COPD) can be caused and exacerbated by air pollution exposure. Objectives: To document the impact of short-term air pollution exposure on inflammation markers, proteases, and antiproteases in the lower airways of older adults with and without COPD. Methods: Thirty participants (10 ex-smokers with mild to moderate COPD and 20 healthy participants [9 ex-smokers and 11 never-smokers]), with an average age of 60 years, completed this double-blinded, controlled, human crossover exposure study. Each participant was exposed to filtered air (control) and diesel exhaust (DE), in washout-separated 2-hour periods, in a randomly assigned order. Bronchoscopy was performed 24 hours after exposure to collect lavage. Cell counts were performed on blood and airway samples. ELISAs were performed to measure acute inflammatory proteins, matrix proteinases, and antiproteases in the airway and blood samples. Measurements and Main Results: In former smokers with COPD, but not in the other participants, exposure to DE increased serum amyloid A (effect estimate, 1.67; 95% confidence interval [CI], 1.21-2.30; P = 0.04) and matrix metalloproteinase 10 (effect estimate, 2.61; 95% CI, 1.38-4.91; P = 0.04) in BAL. Circulating lymphocytes were increased after DE exposure (0.14 [95% CI, 0.05-0.24] cells × 109/L; P = 0.03), irrespective of COPD status. Conclusions: A controlled human crossover study of DE exposure reveals that former smokers with COPD may be susceptible to an inflammatory response compared with ex-smokers without COPD or never-smoking healthy control participants. Clinical trial registered with www.clinicaltrials.gov (NCT02236039).

Strides to Achieve a Stable Symmetry Index During Running.

CONTEXT: The quality of running mechanics is often characterized by limb pattern symmetry and used to support clinical decisions throughout the rehabilitation of lower-extremity injuries. It is valuable to ensure that gait analyses provide stable measures while not asking an individual to complete an excessive number of running strides. The present study aimed to determine the minimum number of strides required to establish a stable mean symmetry index (SMSI) of discrete-level measures of spatiotemporal parameters, joint kinematics, and joint kinetics. Further, the study aimed to determine if differences occurred between random and consecutive strides for directional and absolute symmetry indices. DESIGN: Descriptive laboratory study. METHODS: A sequential average was used to determine how many strides were required to achieve a SMSI within a 60-second trial. Multiple 2-factor repeated-measure analysis of variances were used to determine if differences between bins of strides and symmetry calculations were significantly different. RESULTS: A median SMSI was achieved in 15 strides for all biomechanical variables. There were no significant differences (P > .05) found between consecutive and random bins of 15 strides within a 60-second trial. Although there were significant differences between symmetry calculation values for most variables (P < .05), there appeared to be no systematic difference between the numbers of strides required for stable symmetry for either index. CONCLUSIONS: As 15 strides were sufficient to achieve a SMSI during running, a continued emphasis should be placed on the number of strides collected when examining interlimb symmetry.

Cannabinoids for the treatment of refractory neuropathic pruritus in amyotrophic lateral sclerosis: A case report.

BACKGROUND: Neuropathic symptoms have a wide variety of manifestations, ranging from pain to pruritus. Neuropathic pruritus is a type of chronic pruritus related to damaged small fibers. Cannabinoids have evidence to manage neuropathic symptoms. We present a case of refractory neuropathic pruritus that was successfully managed with the use of oral cannabinoids. CASE PRESENTATION: A 60-year-old male with amyotrophic lateral sclerosis with ongoing pruritus despite the use of standard neuropathic therapies. POSSIBLE COURSE OF ACTION: Sodium channel and N-methyl-D-aspartate receptor antagonists have evidence for neuropathic symptoms but can cause significant gastrointestinal side effects. Prescription cannabinoids such as nabiximol can be cost prohibitive to use in practice. Synthetic tetrahydrocannabinol products are dose limited by psychoactive side effects. FORMULATION OF A PLAN: A balanced oral cannabinoid from a licensed producer was preferred as it has evidence for neuropathic symptoms and is generally well tolerated. OUTCOME: The patient showed improvement to his pruritus score from 7/10 to 3/10. There was initial increased sedation but tolerance developed quickly. LESSONS LEARNED FROM CASE: Cannabinoids are possibly safe and effective in management of neuropathic pruritus. VIEW ON RESEARCH PROBLEMS: Additional research is needed to establish efficacy and safety.

Enhancing Well-Being and Social Connectedness for Maori Elders Through a Peer Education (Tuakana-Teina) Programme: A Cross-Sectional Baseline Study.

Background: Maori kaumatua (elders) face stark health and social inequities compared to non-Maori New Zealanders. The tuakana-teina (older sibling-younger sibling) peer education programme is a strengths-based approach to enhance well-being and social connectedness. The purpose of this study is to present the baseline data from this programme and identify correlates of well-being outcomes. Method: Participants included 128 kaumatua who completed a self-report survey about health-related quality of life, spirituality, social connection and loneliness, life satisfaction, cultural identity and connection, elder abuse, health service utilisation and demographics. Findings: Multiple regression models illustrated the following correlates of outcomes: (a) self-rated health: needing more help with daily tasks (ß = -0.36) and housing problems (ß = -0.17); (b) health-related quality of life: needing more help with daily tasks (ß = -0.31), housing problems (ß = -0.21), and perceived autonomy (ß = 0.19); (c) spiritual well-being: understanding of tikanga (cultural protocols) (ß = 0.32) and perceived autonomy (ß = 0.23); (d) life satisfaction: social support (ß = 0.23), sense of purpose (ß = 0.23), cultural identity (ß = 0.24), trouble paying bills (ß = -0.16), and housing problems (ß = -0.16); (e) loneliness: elder abuse (ß = 0.27), social support (ß = -0.21), and missing pleasure of being with whanau (extended family) (ß = 0.19). Conclusions: Key correlates for outcomes centred on social support, housing problems, cultural connection and perceived autonomy. These correlates are largely addressed through the programme where tuakana/peer educators provide support and links to social and health services to teina/peer recipients in need. This study illustrates needs and challenges for kaumatua, whilst the larger programme represents a strengths-based and culturally-centred approach to address health issues related to ageing in an Indigenous population.

Do Athletes With a Reconstructed Anterior Cruciate Ligament Respond Differently Than Controls to Visual Challenges When Dynamic Postural Stability is Assessed?

Individuals returning to sport after anterior cruciate ligament reconstruction (ACLR) are at an increased risk of sustaining a subsequent ACL injury. It is suspected that increased reliance on visual information to maintain stability may factor into this increased risk. The connection between visual reliance and ACLR is not well understood during dynamic tasks. Examination of the proposed visual reliance may help improve returning to sport standards and reduce subsequent ACL injury risk. A total of 12 ACLR individuals and 12 age- and sex-matched controls completed several trials of a normalized dynamic hop task on both limbs under 3 different visual conditions (eyes open, low visual disruption, and high visual disruption). Stroboscopic eyewear were worn by each participant to disrupt vision during testing. Ground reaction force data were collected during landing. Dynamic postural stability was assessed using 2 separate calculations: dynamic postural stability index and time to stability. No significant statistical interactions or group differences were observed. The stroboscopic eyewear did increase the medial-lateral stability index from the eyes open to the low visual disruption condition (P < .05). These findings suggest that ACLR individuals do not rely on visual information more than controls during a dynamic hop task.