Continuous workplace-based assessment as an indication of clinical competence in paediatric dentistry

An authentic workplace setting provides the ideal opportunity for assessment of students’ clinical competence at the ‘does’ level of performance. Final-year dental students in the Department of Paediatric Dentistry at the University of the Western Cape are evaluated in the clinical environment on a daily basis through multiple clinical evaluations which assess clinical and diagnostic skills over a year. An additional end-of-module clinical assessment in the form of a single blinded patient case (BPC) determines if students have reached the expected level of clinical competence in terms of patient evaluation and diagnosis. However, the reliability and feasibility of this single end-of-module clinical case have been questioned in this setting. This study aimed to determine if the current continuous workplace-based assessment (WPBA) results could be used as an indication of final-year students’ clinical competence at the end of the module. A retrospective, quantitative, cross-sectional study was conducted of all complete assessment records. The correlation between the continuous WPBA components was analysed together with an evaluation of the reliability and validity of the assessment results. The continuous formative WPBA practices were found to be both valid and reliable when using Kane’s (2013) and Royal’s (2017) frameworks for analysis. However, the BPC should be reconsidered due to feasibility and reliability concerns. Key words: Dental education, Paediatric Dentistry, clinical skills, workplace, summative, formative, continuous assessmen

Evaluation of an undergraduate psychiatric clinical rotation : exploring student perceptions

CITATION: Smit, I. M., Volschenk, M. & Koen, L. 2021. Evaluation of an undergraduate psychiatric clinical rotation : exploring student perceptions. South African Journal of Psychiatry, 27:a15,83, doi:10.4102/sajpsychiatry.v27i0.1583.The original publication is available at https://sajp.org.zaBackground: Globally, the appropriate transformation of medical training is critical to ensure the graduation of competent physicians who can address the growing health needs. Aim: To explore medical students’ perceptions of their learning experience during the undergraduate psychiatry late clinical rotation (PLCR) at Stellenbosch University (SU) and to use the findings to make possible recommendations regarding curriculum renewal. Setting: In recognition of this, the Department of Psychiatry at the Faculty of Medicine and Health Sciences of SU is reviewing its current teaching and learning practices. Methods: Data were collected from two focus groups. Results: Three main themes emerged: ‘learning in the clinical context’, ‘gaining knowledge’ and ‘generational needs’. Whilst several suggestions were made for potential improvement, the participants still endorsed that the PLCR does provide them with a good learning experience in psychiatry. Conclusions: Considering that these perceptions are from a group of millennials, the insights arising from the ‘generational needs’ theme were especially valuable. To bridge the generational gap and develop a curriculum that will not only meet the standards expected by educators but also achieve acceptance from learners, future research with a specific focus on clinical teachers’ perceptions is needed.https://sajp.org.za/index.php/sajp/article/view/1583Publisher's veriso

Digit ratio as an endophenotype in a schizophrenia population

CITATION: Nieuwoudt, W. D. B. et al. 2021. Digit ratio as an endophenotype in a schizophrenia population. South African Journal of Psychiatry, 27:a1587, doi:10.4102/sajpsychiatry.v27i0.1587.The original publication is available at https://sajp.org.zaBackground: Schizophrenia is a debilitating mental health condition affecting the lives of many South Africans. The origins of the heterogeneity in the presentation of the illness remain uncertain. Aim: This cross-sectional study performed a retrospective data analysis to determine the usefulness of digit ratio as an endophenotype in a South African schizophrenia population. Setting: A large genetic study in a South African schizophrenia population recruited patients from services in the Western and Eastern Cape. Methods: Complete clinical histories were captured for participants, including sets of images of the face and extremities. Software was utilised to measure the lengths of participants’ digits from said images and digit ratios (2D:4D) were calculated. Descriptive analyses were performed on the ratios and statistical differences in digit ratio means were calculated between groups characterised by sex, age of onset and the presence vs absence of positive symptoms. Linear modelling was utilised to assess for correlates between 2D:4D and positive and negative symptom severity using scores obtained from the Positive and Negative Syndrome Scale (PANSS) and Scale for the Assessment of Negative Symptoms (SANS). Results: 2D:4D in male participants did not significantly differ from female participants as in healthy populations. 2D:4D did not significantly correlate with the severity of positive or negative symptoms and 2D:4D means between groups did not significantly relate to age of onset. Conclusion: 2D:4D appears to be a possible endophenotype in schizophrenia in this population. 2D:4D, however, may not be as readily identifiable as certain minor physical anomalies and neurological soft signs significantly associated with schizophrenia in this population.https://sajp.org.za/index.php/sajp/article/view/1587Publisher's versio

High mobility group box 1 in human cancer

High mobility group box 1 (HMGB1) is an extremely versatile protein that is located predominantly in the nucleus of quiescent eukaryotic cells, where it is critically involved in maintaining genomic structure and function. During cellular stress, however, this multifaceted, cytokine-like protein undergoes posttranslational modifications that promote its translocation to the cytosol, from where it is released extracellularly, either actively or passively, according to cell type and stressor. In the extracellular milieu, HMGB1 triggers innate inflammatory responses that may be beneficial or harmful, depending on the magnitude and duration of release of this pro-inflammatory protein at sites of tissue injury. Heightened awareness of the potentially harmful activities of HMGB1, together with a considerable body of innovative, recent research, have revealed that excessive production of HMGB1, resulting from misdirected, chronic inflammatory responses, appears to contribute to all the stages of tumorigenesis. In the setting of established cancers, the production of HMGB1 by tumor cells per se may also exacerbate inflammation-related immunosuppression. These pro-inflammatory mechanisms of HMGB1-orchestrated tumorigenesis, as well as the prognostic potential of detection of elevated expression of this protein in the tumor microenvironment, represent the major thrusts of this review.http://www.mdpi.com/journal/cellspm2020Immunolog

Systemic immune dysregulation in early breast cancer is associated with decreased plasma levels of both soluble co-inhibitory and co-stimulatory immune checkpoint molecules

Breast cancer cells exploit the up-regulation or down-regulation of immune checkpoint proteins to evade anti-tumor immune responses. To explore the possible involvement of this mechanism in promoting systemic immunosuppression, the pre-treatment levels of soluble co-inhibitory and co-stimulatory immune checkpoint molecules, as well as those of cytokines, chemokines, and growth factors were measured in 98 newly diagnosed breast cancer patients and compared with those of 45 healthy controls using multiplex bead array and ELISA technologies. Plasma concentrations of the co-stimulatory immune checkpoints, GITR, GITRL, CD27, CD28, CD40, CD80, CD86 and ICOS, as well as the co-inhibitory molecules, PD-L1, CTLA-4 and TIM-3, were all significantly lower in early breast cancer patients compared to healthy controls, as were those of HVEM and sTLR-2, whereas the plasma concentrations of CX3CL1 (fractalkine), CCL5 (RANTES) and those of the growth factors, M-CSF, FGF-21 and GDF-15 were significantly increased. However, when analyzed according to the patients’ breast cancer characteristics, these being triple negative breast cancer (TNBC) vs. non-TNBC, tumor size, stage, nodal status and age, no significant differences were detected between the plasma levels of the various immune checkpoint molecules, cytokines, chemokines and growth factors. Additionally, none of these biomarkers correlated with pathological complete response. This study has identified low plasma levels of soluble co-stimulatory and co-inhibitory immune checkpoint molecules in newly diagnosed, non-metastatic breast cancer patients compared to healthy controls, which is a novel finding seemingly consistent with a state of systemic immune dysregulation. Plausible mechanisms include an association with elevated levels of M-CSF and CCL5, implicating the involvement of immune suppressor cells of the M2-macrophage/monocyte phenotype as possible drivers of this state of systemic immune quiescence/dysregulation.The Cancer Association of South Africa (CANSA).https://www.frontiersin.org/journals/immunologydm2022Immunolog

A prospective, real‑world, multinational study of febrile neutropenia (FN) occurrence in oncology patients receiving chemotherapy with intermediate risk of FN : a MASCC neutropenia, infection, and myelosuppression study group initiative

DATA AVAILABILITY : Novartis supports the publication of scientifically rigorous analysis that is relevant to patient care, regardless of a positive or negative outcome. Qualified external researchers can request access to anonymized patient-level data, respecting patient-informed consent, through www. clini calst udyda tareq uest. com, according to requirements noted on the web portal.PURPOSE : Limited knowledge is available on the incidence of febrile neutropenia (FN) in intermediate-risk patients and the rationale for use of granulocyte colony-stimulating factor (G-CSF) in these patients. We aimed to estimate the rate at which patients associated with intermediate risk (10–20%) of FN would develop ≥ 1 episode of FN with a commonly used chemotherapy regimen in clinical practice. METHODS : This prospective, real-world, observational, multinational, multicenter study (December 2016–October 2019) recruited patients with solid tumors or Hodgkin’s/non-Hodgkin’s lymphoma. Patients receiving chemotherapy with intermediate risk of FN, but not G-CSF as primary prophylaxis were included and observed for the duration of the chemotherapy (≤ 6 cycles and ≤ 30 days after the last chemotherapy administration). RESULTS : In total, 364 patients (median age, 56 years) with 1601 cycles of chemotherapy were included in the analysis. The incidence of FN was 5% in cycle 1, 3% in cycles 2–3, and 1% in cycles 4–6. The rate of patients with ≥ 1 episode of FN was 9%, and 59% of FN events were reported during cycle 1. The rate of grade 4 neutropenia in cycle 1 was 11%, and 15% of patients experienced ≥ 1 episode of grade 4 neutropenia. CONCLUSIONS : Overall, the incidence of FN was low, with a high incidence in cycle 1 and a decrease in the subsequent cycles. These results provide the real FN risk for common chemotherapy regimens in patients generally excluded from clinical trials. Prophylactic G-CSF in intermediate-risk patients could be considered as per clinician’s judgement.Open access funding provided by University of Pretoria. This work was supported by research funding from Novartis Pharma AG, Basel, Switzerland.https://www.springer.com/journal/520am2024ImmunologySDG-03:Good heatlh and well-bein

Dysregulation of systemic soluble immune checkpoints in early breast cancer is attenuated following administration of neoadjuvant chemotherapy and is associated with recovery of CD27, CD28, CD40, CD80, ICOS and GITR and substantially increased levels of PD-L1, LAG-3 and TIM-3

Neoadjuvant chemotherapy (NAC) may alter the immune landscape of patients with early breast cancer (BC), potentially setting the scene for more effective implementation of checkpoint-targeted immunotherapy. This issue has been investigated in the current study in which alterations in the plasma concentrations of 16 soluble co-stimulatory and co-inhibitory, immune checkpoints were measured sequentially in a cohort of newly diagnosed, early BC patients (n=72), pre-treatment, post-NAC and post-surgery using a Multiplex® bead array platform. Relative to a group of healthy control subjects (n=45), the median pre-treatment levels of five co-stimulatory (CD27, CD40, GITRL, ICOS, GITR) and three co-inhibitory (TIM-3, CTLA-4, PD-L1) soluble checkpoints were significantly lower in the BC patients vs. controls (p<0.021-p<0.0001; and p<0.008-p<0.00001, respectively). Following NAC, the plasma levels of six soluble co-stimulatory checkpoints (CD28, CD40, ICOS, CD27, CD80, GITR), all involved in activation of CD8+ cytotoxic T cells, were significantly increased (p<0.04-p<0.00001), comparable with control values and remained at these levels post-surgery. Of the soluble co-inhibitory checkpoints, three (LAG-3, PD-L1, TIM-3) increased significantly post-NAC, reaching levels significantly greater than those of the control group. PD-1 remained unchanged, while BTLA and CTLA-4 decreased significantly (p<0.03 and p<0.00001, respectively). Normalization of soluble co-stimulatory immune checkpoints is seemingly indicative of reversal of systemic immune dysregulation following administration of NAC in early BC, while recovery of immune homeostasis may explain the increased levels of several negative checkpoint proteins, albeit with the exceptions of CTLA-4 and PD-1. Although a pathological complete response (pCR) was documented in 61% of patients (mostly triple-negative BC), surprisingly, none of the soluble immune checkpoints correlated with the pCR, either pre-treatment or post-NAC. Nevertheless, in the case of the co-stimulatory ICMs, these novel findings are indicative of the immune-restorative potential of NAC in early BC, while in the case of the co-inhibitory ICMs, elevated levels of soluble PD-L1, LAG-3 and TIM-3 post-NAC underscore the augmentative immunotherapeutic promise of targeting these molecules, either individually or in combination, as a strategy, which may contribute to the improved management of early BC

Clinical experience with severe acute respiratory syndrome Coronavirus 2-related illness in children : hospital experience in Cape Town, South Africa

CITATION: van der Zalm, M. M. et al. 2021. Clinical Experience With Severe Acute Respiratory Syndrome Coronavirus 2-Related Illness in Children: Hospital Experience in Cape Town, South Africa. Clinical infectious diseases, 72(12):e938–e944. doi:10.1093/cid/ciaa1666The original publication is available at https://academic.oup.com/cid/Background: Children seem relatively protected from serious severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related disease, but little is known about children living in settings with high tuberculosis and human immunodeficiency virus (HIV) burden. This study reflects clinical data on South African children with SARS-CoV-2. Methods: We collected clinical data of children aged <13 years with laboratory-confirmed SARS-CoV-2 presenting to Tygerberg Hospital, Cape Town, between 17 April and 24 July 2020. Results: One hundred fifty-nine children (median age, 48.0 months [interquartile range {IQR}, 12.0-106.0 months]) were included. Hospitalized children (n = 62), with a median age of 13.5 months (IQR, 1.8-43.5 months) were younger than children not admitted (n = 97; median age, 81.0 months [IQR, 34.5-120.5 months]; P < .01.). Thirty-three of 159 (20.8%) children had preexisting medical conditions. Fifty-one of 62 (82.3%) hospitalized children were symptomatic; lower respiratory tract infection was diagnosed in 21 of 51 (41.2%) children, and in 11 of 16 (68.8%) children <3 months of age. Respiratory support was required in 25 of 51 (49.0%) children; 13 of these (52.0%) were <3 months of age. One child was HIV infected and 11 of 51 (21.2%) were HIV exposed but uninfected, and 7 of 51 (13.7%) children had a recent or new diagnosis of tuberculosis. Conclusions: Children <1 year of age hospitalized with SARS-CoV-2 in Cape Town frequently required respiratory support. Access to oxygen may be limited in some low- and middle-income countries, which could potentially drive morbidity and mortality. HIV infection was uncommon but a relationship between HIV exposure, tuberculosis, and SARS-CoV-2 should be explored.https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciac266/6591403Publishers versio

The impact of a psychiatry clinical rotation on the attitude of South African final year medical students towards mental illness

Abstract Background Stigmatising attitudes of health care professionals towards mental illness can impede treatment provided for psychiatric patients. Many studies have reported undergraduate training to be a critical period for changing the attitudes of medical students, and one particularly valuable intervention strategy involves time spent in a clinical psychiatric rotation. In South Africa, medical students are exposed to a clinical rotation in psychiatry but there is no evidence to show whether this has an effect on attitudes toward mental illness. Methods This prospective cohort study involved a convenience sample of 112 South African medical students in their 5th or 6th year of undergraduate training. This sample attended a 7-week psychiatry rotation. The Attitudes to Mental Illness Questionnaire (AMIQ) was used to assess students’ attitudes toward mental illness before and after the clinical rotation which includes exposure to a number of psychiatric sub-divisions and limited didactic inputs. Results There was a significant improvement (p < 0.01, t-test) in the students’ attitude toward mental illness following the psychiatric rotation. Females displayed a more positive attitude towards mental illness at the end of the rotation compared to males. The participants’ attitude significantly deteriorated for the non-psychiatric vignette describing diabetes (< 0.01, t-test). Conclusions Our findings suggest that clinical training and exposure to a psychiatric setting impacts positively on medical students’ attitude towards mental illness, even when this training does not include any focused, didactic anti-stigma input