Clinical associates and access to healthcare in the Eastern Cape province of South Africa.

BACKGROUND:  Clinical associates (ClinAs) were introduced into South Africa as part of the remedy for the severe shortage of healthcare workers in rural areas. Walter Sisulu University (WSU) graduated 100 ClinAs between 2011 and 2014. These ClinAs were expected to be based at district hospitals where they would work under the supervision of doctors, reduce the workload of doctors and increase access to healthcare in the Eastern Cape. AIM:  This study aimed to examine the role played by ClinAs in healthcare delivery in Eastern Cape district hospitals, and to determine whether the training of ClinAs adequately prepared them for this role. SETTING:  The study was conducted in the Eastern Cape province of South Africa amongst ClinAs who graduated from WSU between 2011 and 2014, and healthcare workers from Madzikane KaZulu Memorial Hospital. METHODS:  This was an exploratory cross-sectional mixed methods study with a convergent design. Surveys and in-depth interviews were conducted amongst ClinAs, nurses, doctors and one pharmacist. Both qualitative and quantitative data were analysed and reported. RESULTS:  Clinical associates are seen to improve the workload of doctors, and to increase access to healthcare. Thirty-four percent of ClinAs were no longer contributing to healthcare in the Eastern Cape. CONCLUSION:  Clinical associates are making a significant contribution to access to healthcare in the Eastern Cape. Their supervision regimen needs to be revisited and factors that contribute to the attrition of ClinAs in the Eastern Cape need to be addressed.

Preceptors' perceptions of assessing clinical associate students at district hospital sites.

BACKGROUND: Preceptors are key stakeholders in distributed health professions' education. They supervise students in the clinical setting to enable them to have a practical experience with patients, and they assess students' skills at the highest tier of clinical assessment. The university where this study was done conducts a distributed Bachelor of Clinical Medical Practice course on a distributed platform which is dependent on preceptors at the training sites. Understanding the perceptions of preceptors, as major stakeholders, regarding the student assessment they do will assist the faculty to provide better support and development that might be needed and assist in maximising the benefits of distributed training. AIM: The aim of this study was to explore the perceptions of preceptors regarding assessing clinical associate students at district hospitals in the Bachelor of Clinical Medical Practice programme. SETTING: The study was conducted at a rural university in the Eastern Cape province of South Africa. METHODS: This was a qualitative study involving nine preceptors who were purposively selected from three district hospital training sites based on their involvement in assessing clinical associate students. Semi-structured interviews were conducted, recorded, transcribed and thematically analysed. RESULTS: Four themes emerged from thematic analysis: assessment issues, preceptor issues, student issues and university support issues. Preceptors are committed and enthusiastic in training and assessing the clinical associate students but require input from the university in terms of training and ongoing support. CONCLUSION: Lack of training threatens the validity of preceptor assessment. Academic institutions should train and support preceptors to enable them better to fulfil their roles.

A systematic review of the efficacy and safety of intrapericardial fibrinolysis in patients with pericardial effusion.

Pericardial effusion is the abnormal accumulation of fluid in the pericardial space. The complications of pericardial effusion can either be acute (e.g., cardiac tamponade) or chronic (e.g., constrictive pericarditis). We have conducted a systematic review of the scientific literature to evaluate the efficacy and safety of intrapericardial fibrinolysis in preventing complications of pericardial effusion. We searched for both published and unpublished studies. 29 studies, with a total of 109 patients were included in this review; 17 case reports, 11 case series, and one randomised controlled trial (RCT). All included studies had a high risk of bias. The most common causes of pericardial effusion were Staphylococcus aureus (12 studies with 23 cases) and Mycobacterium tuberculosis (2 studies with 19 cases). The most common fibrinolytic agents used were streptokinase (15 studies) and urokinase (5 studies). Intrapericardial fibrinolysis prevented complications in 94 (86.2%) patients. Non-fatal procedure-related complications were reported 21 (19.2%) patients. No patient died following intrapericardial fibrinolysis. There is very low certainty of the efficiency and safety of intrapericardial fibrinolysis in preventing the complications of pericardial effusion. High quality RCTs are required to address this question.

The efficacy and safety of complete pericardial drainage by means of intrapericardial fibrinolysis for the prevention of complications of pericardial effusion: a systematic review protocol.

INTRODUCTION: Intrapericardial fibrinolysis has been proposed as a means of preventing complications of pericardial effusion such as cardiac tamponade, persistent and recurrent pericardial effusion, and pericardial constriction. There is a need to understand the efficacy and safety of this procedure because it shows promise. METHODS AND ANALYSIS: We aim to assess the effects of intrapericardial fibrinolysis in the treatment of pericardial effusion. We will search PubMed, the Cochrane Library, African Journals online, Cumulative Index to Nursing and Allied Health Literature, Trip database, Clinical trials.gov and the WHO International Clinical Trials Registry Platform for studies that evaluate the efficacy and/or safety of complete pericardial fluid drainage by intrapericardial fibrinolysis irrespective of study design, geographical location, language, age of participants, aetiology of pericarditis or types of fibrinolytics. Two authors will do the search independently, screen the search outputs for potentially eligible studies and assess whether the studies meet the inclusion criteria. Discrepancies between the two authors will be resolved through discussion and arbitration by a third author. Data from the selected studies shall be extracted using a standardised data collection form which will be piloted before use. The methodological quality of studies will be assessed using the Cochrane Collaboration's tools for assessing risk of bias for experimental studies and non-randomised studies, respectively. The primary meta-analysis will use random effects models due to expected interstudy heterogeneity. Dichotomous data will be analysed using relative risk and continuous with data mean differences, both with 95% CIs. ETHICS AND DISSEMINATION: Approval by an ethics committee is not required for this study as it is a protocol for a systematic review of published studies. The results will be disseminated through a conference presentation and peer-reviewed publication. REVIEW REGISTRATION NUMBER: PROSPERO, CRD42014015238.

Antiretroviral prophylaxis for HIV prevention in heterosexual men and women.

BACKGROUND: Antiretroviral preexposure prophylaxis is a promising approach for preventing human immunodeficiency virus type 1 (HIV-1) infection in heterosexual populations. METHODS: We conducted a randomized trial of oral antiretroviral therapy for use as preexposure prophylaxis among HIV-1-serodiscordant heterosexual couples from Kenya and Uganda. The HIV-1-seronegative partner in each couple was randomly assigned to one of three study regimens--once-daily tenofovir (TDF), combination tenofovir-emtricitabine (TDF-FTC), or matching placebo--and followed monthly for up to 36 months. At enrollment, the HIV-1-seropositive partners were not eligible for antiretroviral therapy, according to national guidelines. All couples received standard HIV-1 treatment and prevention services. RESULTS: We enrolled 4758 couples, of whom 4747 were followed: 1584 randomly assigned to TDF, 1579 to TDF-FTC, and 1584 to placebo. For 62% of the couples followed, the HIV-1-seronegative partner was male. Among HIV-1-seropositive participants, the median CD4 count was 495 cells per cubic millimeter (interquartile range, 375 to 662). A total of 82 HIV-1 infections occurred in seronegative participants during the study, 17 in the TDF group (incidence, 0.65 per 100 person-years), 13 in the TDF-FTC group (incidence, 0.50 per 100 person-years), and 52 in the placebo group (incidence, 1.99 per 100 person-years), indicating a relative reduction of 67% in the incidence of HIV-1 with TDF (95% confidence interval [CI], 44 to 81; P<0.001) and of 75% with TDF-FTC (95% CI, 55 to 87; P<0.001). Protective effects of TDF-FTC and TDF alone against HIV-1 were not significantly different (P=0.23), and both study medications significantly reduced the HIV-1 incidence among both men and women. The rate of serious adverse events was similar across the study groups. Eight participants receiving active treatment were found to have been infected with HIV-1 at baseline, and among these eight, antiretroviral resistance developed in two during the study. CONCLUSIONS: Oral TDF and TDF-FTC both protect against HIV-1 infection in heterosexual men and women. (Funded by the Bill and Melinda Gates Foundation; Partners PrEP ClinicalTrials.gov number, NCT00557245.).