From idea to systems solution: enhancing access to primary care in Malawi.

Malawi, like many other countries, faces challenges in providing accessible, affordable, and quality health services to all people. The Malawian policy framework recognizes the value of communities and citizens, as co-creators of health and leaders of localized and innovative initiatives, such as social innovations.Social innovations involve and include communities and citizens, as well as bring about changes in the institutions responsible for care delivery. In this article, we describe the institutionalization process of a citizen-initiated primary care social innovation, named Chipatala Cha Pa Foni, focused on extending access to health information and appropriate service-seeking behavior.An interdisciplinary multi-method qualitative case study design was adopted, drawing on data collected from key informant interviews, observations, and documents over an 18-month period. A composite social innovation framework, informed by institutional theory and positive organizational scholarship, guided the thematic content analysis. Institutional-level changes were analyzed in five key dimensions as well as the role of actors, operating as institutional entrepreneurs, in this process.A subset of actors matched the definition of operating as Institutional Entrepreneurs. They worked in close collaboration to bring about changes in five institutional dimensions: roles, resource flows, authority flows, social identities and meanings. We highlight the changing role of nurses; redistribution and decentralization of health information; shared decision-making, and greater integration of different technical service areas.From this study, the social innovation brought about key institutional and socio-cultural changes in the Malawi health system. These changes supported strengthening the system's integrity for achieving Universal Health Coverage by unlocking and cultivating dormant human-based resources. As a fully institutionalized social innovation, Chipatala Cha Pa Foni has enhanced access to primary care and especially as part of the Covid-19 response.

Examining the associations between self and body compassion and health related quality of life in people diagnosed with endometriosis.

OBJECTIVE: An understanding of the role that self and body compassion may play as protective mechanisms in the context of psychological and physical health conditions is steadily increasing. The availability of research pertaining to their role in mitigating the health-related quality of life (HRQoL) impacts associated with endometriosis is limited. The current study examined the influence of self and body compassion on HRQoL in people diagnosed with endometriosis. METHODS: Individuals aged 18+ years (n = 318), assigned female at birth, with a self-reported diagnosis of symptomatic endometriosis completed an online cross-sectional survey. Participant demographics and endometriosis-related data was collected in addition to self and body compassion and HRQoL. Standard multiple regression analyses (MRA) were conducted to estimate the proportion of variance in HRQoL that can be accounted for by self and body compassion in endometriosis. RESULTS: Self and body compassion were both associated with higher HRQoL across all domains. However, when both self and body compassion were entered into a regression, only body compassion was significantly associated with HRQoL domains of physical wellbeing, bodily pain, vitality, social engagement and general HRQoL; self-compassion explained no unique variance. In the domain of emotional wellbeing, when both self and body compassion were entered into a regression, both were significantly associated, and explained unique variance. CONCLUSIONS: It is suggested that future psychological interventions for individuals living with endometriosis should emphasise building general self-compassionate abilities with a subsequent specific focus on strategies designed to improve body compassion.

Blue carbon sinks in South Africa and the need for restoration to enhance carbon sequestration.

Blue carbon ecosystems (mangroves, salt marshes, and seagrasses) contribute towards climate change mitigation because they are efficient at sequestering atmospheric CO2 into long-term total ecosystem carbon stocks. Destruction or disturbance therefore reduces sink capacity and leads to significant CO2 emissions. This study reports the first national estimates of: 1) total carbon storage, 2) CO2 emissions from anthropogenic activities, 3) the potential for restoration to enhance carbon sequestration for blue carbon ecosystems in South Africa. Mangrove ecosystems have the greatest carbon storage per unit area (253-534 Mg C ha-1), followed by salt marshes (100-199 Mg C ha-1) and seagrasses (45-144 Mg C ha-1). Salt marshes are the most extensive and contribute 67 % to the national carbon stock of 4000 Gg C. Since 1930, 6500 ha has been lost across all blue carbon ecosystems (26 % of the natural extent), equivalent to losing 1086 Gg C from the national carbon stock. Historic CO2 emissions were estimated at an average rate of 30,266 t CO2e yr-1. Despite losses, a total of 3998 ha could be restored to increase carbon sequestration and CO2 removals of 14,845 tCO2e.yr-1. Extractive activities have declined rapidly in recent decades, but abiotic pressures on estuarine ecosystems (flow modification, reduced water quality, and artificial breaching) have been increasing. There is an urgent need to quantify the potential impact of these pressures and include them in estuarine management and restoration plans. Blue carbon ecosystems cover a relatively small area in South Africa, but they are valued for their multiple ecosystem services that contribute towards climate change adaptation and biodiversity co-benefits. These ecosystems need to be included in national policies driving climate change response in the Agriculture, Forestry and Other Land-Use (AFOLU) sector, such as incorporating them into the wetland subcategory of the national GHG inventory.

Correlates of health-related quality of life: The influence of endometriosis, body image and psychological wellbeing.

OBJECTIVE: The understanding as to how people with endometriosis view and relate to their bodies is limited but important given the physical and psychological symptoms associated with the condition. The current study explored the differences in HRQoL (general, physical, emotional) and body image in an endometriosis and control sample. The current study also examined the influence of disease status (+Endo, -Endo), psychological wellbeing, and body image on HRQoL. METHODS: Data was collected via an international online cross-sectional survey examining HRQoL, body image factors (negative appreciation of body size, lack of body familiarity, general body dissatisfaction), and psychological wellbeing (depression, anxiety, somatic concern) in adults. RESULTS: Participants were grouped by disease status (endometriosis: +Endo n = 318; control: -Endo n = 420). As hypothesised, the +Endo group reported significantly lower HRQoL and poorer body image than those in the -Endo group. Hierarchical multiple regression analyses (MRA) indicated that disease status and somatic concern are significant correlates of general HRQoL, and that disease status and lack of body familiarity are significant correlates of physical and emotional HRQoL. CONCLUSION: Endometriosis has a negative impact on HRQoL and body familiarity, with those diagnosed with the condition reporting significantly lower levels of HRQoL. Assessment and treatment of poor body familiarity in people diagnosed with endometriosis is recommended as part of psychological treatment pathways.

Predictors of self-compassion in endometriosis: the role of psychological health and endometriosis symptom burden.

STUDY QUESTION: What is the relationship between self-compassion, endometriosis-related symptoms and psychological health in women with symptomatic endometriosis? SUMMARY ANSWER: Decreased self-compassion is associated with increased psychological distress, extended diagnostic delay and varies according to individual endometriosis-symptom profile. WHAT IS KNOWN ALREADY: Existing research indicates that endometriosis is associated with reduced psychological health and varied endometriosis-related symptom profiles. Examining the level of self-compassion reported by women with endometriosis is important as greater self-compassion has been found to improve psychological well-being in several chronic health populations. STUDY DESIGN, SIZE, DURATION: This study utilized a cross-sectional survey design to explore the relationship between self-compassion, psychological health and endometriosis-related symptoms (n = 318). PARTICIPANTS/MATERIALS, SETTING, METHODS: Women with a self-reported diagnosis of endometriosis were recruited via online advertising through social media platforms. Demographic and endometriosis-specific information (e.g. disease stage, diagnostic delay, symptom experience) was collected in addition to psychological health and self-compassion. Psychological health was measured by the PROMIS Emotional Distress and Anxiety short forms and the Patient Health Questionnaire (PHQ-15). Self-compassion was measured by the Self-Compassion Scale (26-item). Independent t-tests, bivariate correlations and linear regression analyses explored the relationship between specific endometriosis-related symptoms, psychological health and self-compassion. MAIN RESULTS AND THE ROLE OF CHANCE: Hierarchical multiple regression indicated that psychological symptoms accounted for the greatest variance in levels of self-compassion in the current sample. Depression and anxiety were found to be significant negative predictors of self-compassion. Notable symptoms that were significant in the final model were the presence of dysmenorrhea, lower back pain, dyspareunia, pain after sexual intercourse, fatigue and nausea. LIMITATIONS, REASONS FOR CAUTION: The cross-sectional nature of the findings prevents direct findings of causality. The information pertaining to endometriosis was self-report in nature and was not medically verified. WIDER IMPLICATIONS OF THE FINDINGS: These preliminary findings indicate the importance of clinical interventions aimed at enhancing self-compassion and the importance of individual case conceptualization and treatment planning based on endometriosis-related symptomatic profiles. STUDY FUNDING/COMPETING INTEREST(S): The study was not associated with research funding. Author L.V.N. is a member of the Endometriosis Australia Clinical Advisory Committee. TRIAL REGISTRATION NUMBER: N/A.

One-year mortality after hospital admission as an indicator of palliative care need: A retrospective cohort study.

BACKGROUND: Globally there is increasing awareness of the need for end-of-life care and palliative care in hospitalised patients who are in their final year of life. Limited data are available on palliative care requirements in low- and middle-income countries, hindering the design and implementation of effective policies and health services for these patients. OBJECTIVES: To determine the proportion of patients who die within 1 year of their date of admission to public hospitals in South Africa (SA), as a proxy for palliative care need in SA. METHODS: This was a retrospective cohort study using record linkage of admission and mortality data. The setting was 46 acute-care public hospitals in Western Cape Province, SA. RESULTS: Of 10 761 patients (median (interquartile range (IQR)) age 44 (31 - 60) years) admitted to the 46 hospitals over a 2-week period in March 2012, 1 570 (14.6%) died within 1 year, the majority within the first 3 months. Mortality rose steeply with age. The median (IQR) age of death was 57.5 (45 - 70) years. A greater proportion of patients admitted to medical beds died within 1 year (21.3%) compared with those admitted to surgical beds (7.7%). CONCLUSIONS: Despite a median age <60 years at admission, a substantial percentage of patients admitted to public sector hospitals in SA are in the final year of their lives. This finding should be seen in the context of SA's high communicable and non-communicable disease burden and resource-limited public health system, and highlights the need for policy development, planning and implementation of end-of-life and palliative care strategies for hospitals and patients.

ADAMTS-4 activity in synovial fluid as a biomarker of inflammation and effusion.

OBJECTIVE: To evaluate the potential of ADAMTS-4 (aggrecanase -1) activity in synovial fluid (SF) as a biomarker of knee injury and joint disease. DESIGN: We have measured ADAMTS-4 activity in the synovial fluid of 170 orthopaedic patients with different degrees of joint pathology, using a commercial ADAMTS-4 fluorescence resonance energy transfer (FRET) substrate assay. Patients were classified at arthroscopy as (i) macroscopically normal, (ii) with an injury of the meniscus, anterior cruciate ligament or chondral/osteochondral defects or (iii) with osteoarthritis, and the influence of independent factors (age, patient group, effusion and synovial inflammation) on ADAMTS-4 activity levels was assessed. RESULTS: In most patients (106/170) ADAMTS-4 activity was undetectable; ADAMTS-4 ranged from 0 to 2.8 ng/mL in synovial fluid from patients with an injury, 0-4.1 ng/mL in osteoarthritic patients and 4.0-12.3 ng/mL in patients with large effusions. Four independent variables each significantly influenced ADAMTS-4 activity in synovial fluid (all P < 0.001): age (concordance = 0.69), presence of osteoarthritis (OA) (concordance = 0.66), level of effusion (concordance = 0.78) and inflammation (concordance = 0.68). Not only did effusion influence the amount of ADAMTS-4 activity most strongly, but it also did this in an ordered manner (P < 0.001). CONCLUSIONS: The main finding of this study is that ADAMTS-4 levels in synovial fluid are most strongly correlated with inflammation and severity of effusion in the knee. Further study is required to determine if it could provide a useful tool to aid clinical diagnoses, indicate treatment, to monitor progression of joint degeneration or OA or alternatively the success of treatment.

Albumin concentration significantly impacts on free teicoplanin plasma concentrations in non-critically ill patients with chronic bone sepsis.

The impact of decreased serum albumin concentrations on free antibiotic concentrations in non-critically ill patients is poorly described. This study aimed to describe the pharmacokinetics of a high-dose regimen of teicoplanin, a highly protein-bound antibiotic, in non-critically ill patients with hypoalbuminaemia. Ten patients with chronic bone sepsis and decreased serum albumin concentrations (<35 g/L) receiving teicoplanin 12 mg/kg 12-hourly intravenously for 48 h followed by 12 mg/kg once daily were enrolled. Surgical debridement was performed on Day 3. Samples of venous blood were collected pre-infusion and post-infusion during the first 4 days of therapy. Total and free teicoplanin concentrations were assayed using validated chromatographic methods. The median serum albumin concentration for the cohort was 18 (IQR 15-24) g/L. After 48 h, the median (IQR) free trough (fC(min)) and total trough (tC(min)) concentrations were 2.90 (2.67-3.47) mg/L and 15.54 (10.28-19.12) mg/L, respectively, although trough concentrations declined thereafter. Clearance of the free concentrations was significantly high relative to the total fraction at 38.6 (IQR 29.9-47.8) L/h and 7.0 (IQR 6.8-9.8) L/h, respectively (P<0.001). Multiple linear regression analysis demonstrated that whereas total teicoplanin concentration did not impact on free concentrations (P=0.174), albumin concentration did (P<0.001). This study confirms the significant impact of hypoalbuminaemia on free concentrations of teicoplanin in non-critically ill patients, similar to that in critically ill patients. Furthermore, the poor correlation with total teicoplanin concentration suggests that therapeutic drug monitoring of free concentrations should be used in these patients.

A point-prevalence survey of public hospital inpatients with palliative care needs in Cape Town, South Africa.

OBJECTIVES: To assess the need for palliative care among inpatients occupying acute beds in the public sector hospitals of the Cape Town Metropole. METHODS: A cross-sectional, contemporaneous, point-prevalence study was performed at 11 public sector hospitals in the Cape Town Metropole using a standardised palliative care identification tool. Data were collected on the socio-demographic characteristics, diagnoses, and prior and current care planning of patients. RESULTS: The case notes of 1 443 hospital inpatients were surveyed, and 16.6% were found to have an active life-limiting disease. The mean age of the group was 56 years. The diagnoses were cancer in 50.8%, organ failure in 32.5%, and HIV/tuberculosis in 9.6%. The greatest burden of disease was in the general medical wards, to which an overall 54.8% of patients meeting the requirements for palliative care were admitted. CONCLUSIONS: This study provides evidence for the need for palliative care services in public sector hospitals and in the health system as a whole. The young age of patients and the high prevalences of end-stage renal failure and HIV are unique, and the burden in the general medical wards suggests a focus for initial inpatient programmes.

Suicidal ideation and attempt among South African medical students.

International data reveal that medical students are at higher risk of attempting suicide than the general population. We aimed to determine the prevalence of suicidal ideation and attempt among South African medical students from three universities and identify key predisposing risk factors. Data were collected via a questionnaire to medical students on demographics, mental health history, depressive symptoms, suicidal ideation and attempt. A total of 874 medical students from three universities were enrolled. We found a high prevalence of suicidal ideation (32.3%) and suicidal attempt (6.9%), which is three times higher than the general age-appropriate South African population. Simple screening questionnaires can identify such students, enabling universities to provide targeted and improved support for at-risk students.

Twelve-month outcomes of patients admitted to the acute general medical service at Groote Schuur Hospital.

OBJECTIVES: Hospitalisation for medical illness has ongoing impact on individuals, healthcare services and society beyond discharge. This study's objective was to determine the 12-month mortality and functional outcomes of patients admitted to the acute medical service at Groote Schuur Hospital (GSH). METHODS: Follow-up, using the hospital records system and provincial death registry, together with telephonic interviews or home visits, was attempted for 465 medical inpatients admitted to GSH between 14 September and 16 November 2009. Functional outcomes were assessed using the Katz activities of daily living (ADL) score and Barthel index (BI). Outcome measures. The major study outcomes included: 12-month mortality (overall and unexpected), changes in functional status and pre- and post-admission employment rates. RESULTS: Inpatient mortality was 11%. At 12-month follow-up, 35% (145/415) were deceased and 30% (125/415) could not be traced; 38% (55/145) of deaths were considered expected and unexpected mortality was associated with age >40 years (p=0.02) and an admission urea >7.0 mmol/l (p=0.004). Katz ADL deteriorated in 15% (21/143) of interviewed patients and was associated with age >50 years (p=0.005); 23% (33/143) had improved Katz ADL associated with admission human immunodeficiency virus (HIV) (p=0.01), tuberculosis (TB) infection (p=0.05) and sepsis (p=0.02). Employment rates declined from 41% (59/145) pre-admission to 18% (26/145) at 12 months (p<0.001), with little increase in the number of persons receiving disability grants. Twenty per cent (29/145) of patients required hospital readmission and this was associated with ADL functional decline (p=0.01). CONCLUSIONS: There was a very high overall mortality of 42% in patients admitted to the general medical wards. Significant employment decline and readmission rates highlight the additional economic and societal burdens of hospitalisation due to medical illness in the survivors.

Abnormal glucose metabolism in non-diabetic patients presenting with an acute stroke: prospective study and systematic review.

BACKGROUND: Non-diabetic patients presenting with an acute stroke often have hyperglycaemia. In most populations it is unknown whether the hyperglycaemia is transient and due to the acute stress response or whether it represents undiagnosed abnormal glucose metabolism. AIM: To evaluate the prevalence and predictors of persistent hyperglycaemia in non-diabetic patients with an acute stroke. DESIGN: Prospective observational study. METHODS: Non-diabetic patients over 40 years old with an acute stroke were enrolled over a 2-year period. On admission patients were evaluated with an HbA(1c) and a 75 g oral glucose tolerance test (OGTT). The OGTT was repeated 3 months later. A meta-analysis was performed to interpret our results in the context of published data. RESULTS: One hundred and seven patients were analysed. On admission 26 (24%) patients had diabetes, 39 (37%) had impaired glucose tolerance and 42 (39%) had normal glucose tolerance. Forty-four (68%) patients with hyperglycaemia on admission were re-investigated at least 3 months after discharge. Of these, 6 (14%) had diabetes, 12 (27%) had impaired glucose tolerance and 26 (59%) had normal glucose tolerance. A 2-h post-load glucose value >or=10 mmol/l predicted persistent hyperglycaemia with 72.2% sensitivity, 65.4% specificity and a positive predictive value and negative predictive value of 59.1 and 77.3%, respectively. A meta-analysis of prevalence data of impaired glucose metabolism in non-diabetic individuals 3 months after having had an acute stroke revealed a combined prevalence of 58% (95% confidence interval 25.4-90.5%). CONCLUSION: In this study hyperglycaemia in the setting of an acute stroke was transient in the majority of patients.

MPFL reconstruction for recurrent patella dislocation: a new surgical technique and review of the literature.

Recurrent dislocation, subluxation and functional instability due to patellofemoral pain might be present in 30 % to 60 % of patients managed non-operatively for posttraumatic patella instability. Disruption of the capsule, medial patella retinaculum and/or vastus medialis obliquus have been associated with recurrent patella instability but recently the medial patellofemoral ligament (MPFL) has been recognised as the most important ligamentous stabiliser preventing lateral dislocation of the patella. Many nonanatomical surgical techniques for the treatment of recurrent patellar dislocation have been described in the literature. These procedures alter the pre-morbid patella mechanics by several principles, including the release of tight lateral ligaments, tensioning of loose medial structures and distal realignment of the extensor mechanism or a combination of these. Very few address the principle site of pathology in patella dislocation, i.e., the torn MPFL. The outcomes are inconsistent and many studies have reported recurrent dislocations and patellofemoral pain and arthritis in up to 40 %. We describe a simple technique of MPFL reconstruction using a single hamstring tendon graft which is passed through the medial intermuscular septum at the adductor's magnus insertion and is fixed to the superomedial pole of the patella. A comprehensive review of the existing techniques of MPFL reconstruction using semitendinosus tendon autografts is also provided.

Economic empowerment and black disabled entrepreneurs: negotiating partnerships in Cape Town, South Africa.

PURPOSE: This paper presents a second part reporting on Community Disability Entrepreneurship Project (CoDEP) which was initiated in order to contribute to the development of entrepreneurial skills of disabled people living in informal settlements around Cape Town, South Africa. The aim of CoDEP has been the upliftment and economic empowerment of disabled people. This paper describes the point of departure, the theoretical framework of participatory action research (PAR), the development of research parameters, and continued focus. METHOD: A participatory action research (PAR) approach was initiated in order to monitor and inform the effective development of CoDEP. This cyclic methodology allowed all participants to engage in decision-making and development of the programme. RESULTS: While negotiating partnerships with disabled entrepreneurs, the six spheres within which optimal interaction could take place emerged as: (i) the choice of occupation; (ii) changing a culture of receiving; (iii) nurturing teamwork by negotiating roles and responsibilities; (iv) a focus on ability; (v) understanding the research process; and (vi) organizational development dynamics. Committed interaction emerged as the quintessence of these partnerships.

Arthroscopic assisted reduction and fixation of a juvenile Tillaux fracture.

We report a case of Tillaux fracture of the distal tibia in a 14-year-old patient. Reduction and fixation of the fracture was achieved arthroscopically through the anterolateral portal. The patient was able to participate in competitive athletic activities 3.5 months after surgery with an AOFAS score of 100. Arthroscopy is an expedient tool in the management of intra-articular fractures of the ankle providing anatomical reduction under direct visualization with minimum intervention.

Understanding partnerships in developing disabled entrepreneurs through participatory action research.

PURPOSE: The paper reports on a community disability entrepreneurship project in Khayelitsha and Nyanga, Cape Town, South Africa. Disabled people, Disabled People South Africa ( a national organization made up by disabled people's organizations), a non-governmental organisation and occupational therapists from the University of Cape Town collaborated with the focus to achieve economic empowerment of disabled people though the establishment of micro-enterprises. METHOD: Participatory Action Research strategies, which informed and monitored the effective development of the community disability entrepreneurship project, were carefully integrated with the existing principles of community development. RESULTS: The participatory action research process provided an opportunity for shared learning and development. This article reports on the challenges and strategies faced by disabled people in the quest to establish themselves as entrepreneurs. The challenges that were identified through analysis from the experiences of participants were starting with nothing, lack of capacity and complexity of establishing working relationships. The strategies used were building group identity and developing capacity together. Indicators of positive outcome that emerged from an inductive content analysis are presented and discussed.

A comparison of the surgical caseloads of selected companion animal hospitals and a veterinary academic hospital in South Africa.

Educational institutions should be aware of the frequency of surgical procedures in private practice, to assist both the student and the lecturer in evaluating the relative importance of procedures and to structure training programmes accordingly. The surgical caseload for 1 year at a veterinary academic hospital and 13 private companion animal hospitals registered with the South African Veterinary Council were compared. Surgical records were entered into a spreadsheet and sorted according to 96 selected surgical procedures to facilitate comparisons. Surgical procedures were in turn grouped according to date, species, degree of difficulty and frequency of occurrence. Feline procedures were more commonly performed in private hospitals. The academic hospital's caseload was dominated by major and advanced procedures while the private hospitals carried out more minor procedures. At the private hospitals more general surgery, and ear, nose and throat surgery as well as dental procedures were performed, while at the academic hospital more ophthalmic, orthopaedic, thoracic and neurosurgical procedures were carried out. The most commonly performed procedures at the academic hospital differed from those at the private hospitals. No seasonal trends were evident.

Major lower limb amputation following failed infrainguinal vascular bypass surgery: a prospective study on amputation levels and stump complications.

The effect of failed vascular bypass surgery on final amputation level and stump complications is the subject of debate. The aim of this prospective cohort study was to assess the influence of previous infrainguinal bypass surgery on amputees in the authors' centre. Over a three-year period, 234 amputations (219 patients) were performed for critical ischemia. The cause of ischemia was either peripheral obstructive arterial disease (POAD) or diabetes mellitus (DM). Forty-eight percent (48%) (113 amputations) had ipsilateral vascular bypass surgery prior to amputation and 52% (121 amputations) had not. Final amputation level and the post-operative complications of infection, significant stump pain and delayed wound healing were used as the outcome measures for this study. At the end of the study period these outcome measures were used to compare the influence of previous bypass surgery on the two groups of amputees. There was a significantly higher rate of transfemoral amputations (TFA) (32.7%) vs. 16.5%; p < 0.05) and stump infection rate (42% vs. 23%; p < 0.05) in the bypass group. Significant stump pain (p = 0.23) and delayed wound healing (p = 0.24) was more prevalent in the bypass group although statistical significance could not be demonstrated.