Entry Points to the Health System: a review of the emerging community models for management of non-life threatening urgent conditions relevant to Australia

Problem: The number of presentations to Emergency Departments (EDs) is increasing at levels above population growth rates and these increases are becoming unsustainable. Objective: To review evidence for emerging entry points to the health system for patients with non-life threatening urgent conditions (NLTUC) in order to consider more effective healthcare services in Australia. Methods: An in-depth review of the Emerald, Medline, CINAHL, Web of Science, Proquest Business and Medical databases from January 2005 to April 2016 matching ‘acute care’ or ‘urgent care’ with general practice andother health providers found thirteen entry point models with five currently relevant to Australia. Results: Studies examining five emerging entry points were found including urgent care community pharmacy, new prehospital practitioner community care, advanced nurse enhancement of primary care, designated urgent care clinics and integrated primary care centers. Evidence for these emerging models of community healthcare is presented including emerging initiatives, cost implications, subsequent admission to hospital, satisfaction, mortality, care, treatment time, subsequent referrals, testing and health outcomes. Conclusion: These emerging models of community healthcare need to be trialed and studied in the Australian context to evaluate whether they provide patients with NLTUC with a safe cost-effective option with similar outcomes to EDs. Implementation of these models can be examined further to determine their effectiveness in potentially reducing the increasing rate of presentation to EDs. Abbreviations: APCN – Advanced Primary Care Nurse; ECP – Emergency Care Practitioners; ED – Emergency Department; GP – General Practitioner; IPCC – Integrated Primary Care Centre; PP – Paramedic Practitioners; NLTUC – Non-Life Threatening Urgent Conditions; UCC – Urgent Care Clinics; UCCP – Urgent Care Community Pharmacy

The epidemiology of major incidents in the Western Cape Province, South Africa

Background. Major incidents put pressure on any health system. There are currently no studies describing the epidemiology of major incidents in South Africa (SA). The lack of data makes planning for major incidents and exercising of major incident plans difficult.Objective. To describe the epidemiology of major incidents in the Western Cape Province, SA.Methods. A retrospective analysis of the Western Cape Major Incident database was conducted for the period 1 December 2008 - 30 June 2014. Variables collected related to patient demographics and incident details. Summary statistics were used to describe all variables.Results. Seven hundred and seventy-seven major incidents were reviewed (median n=11 per month). Most major incidents occurred in the City of Cape Town (57.8%, n=449), but the Central Karoo district had the highest incidence (11.97/10 000 population). Transport-related incidents occurred most frequently (94.0%, n=730). Minibus taxis were involved in 312 major incidents (40.2%). There was no significant difference between times of day when incidents occurred. A total of 8 732 patients were injured (median n=8 per incident); ten incidents involved 50 or more victims. Most patients were adults (80.0%, n=6 986) and male (51.0%, n=4 455). Of 8 440 patients, 630 (7.5%) were severely injured. More than half of the patients sustained minor injuries (54.6%, n=4 605).Conclusion. Major incidents occurred more often than would have been expected compared with other countries, with road traffic crashes the biggest contributor. A national database will provide a better perspective of the burden of major incidents

Admission factors associated with the in-hospital mortality of burns patients in resource-constrained settings : a two-year retrospective investigation in a South African adult burns centre

CITATION: Boissin, C., et al. 2019. Admission factors associated with the in-hospital mortality of burns patients in resource-constrained settings : a two-year retrospective investigation in a South African adult burns centre. Burns, 45(6):1462-1470, doi:10.1016/j.burns.2019.03.005.The original publication is available at https://www.sciencedirect.comObjective: Little is known concerning the factors associated with in-hospital mortality of trauma patients in resource-constrained settings, not least in burns centres. We investigated this question in the adult burns centre at Tygerberg Hospital in Cape Town. We further assessed whether the Abbreviated Burn Severity Index (ABSI) is an accurate predictive score of mortality in this setting. Methods: Medical records of all patients admitted with fresh burns over a two-year period (2015 and 2016) were scrutinized to obtain data on patient, injury and admission-related characteristics. Association with in-hospital mortality was investigated for flame burns using logistic regressions and expressed as odds ratios (ORs). The mortality prediction of the ABSI score was assessed using sensitivity and specificity analyses. Results: Overall the in-hospital mortality was 20.4%. For the 263 flame burns, while crude ORs suggested gender, burn depth, burn size, inhalation injury, and referral status were all individually significantly associated with mortality, only the association with female gender, not being referred and burn size remained significant after adjustments (adjusted ORs = 3.79, 2.86 and 1.11 (per percentage increase in size) respectively). For the ABSI score, sensitivity and specificity were 84% and 86% respectively. Conclusion: In this specialised centre, mortality occurs in one in five patients. It is associated with a few clinical parameters, and can be predicted using the ABSI score.https://www.sciencedirect.com/science/article/pii/S030541791830874XPublisher's versio

Haiti : the South African perspective

The original publication is available at http://www.samj.org.zaBackground and problem statement. The South African response to the Haitian earthquake consisted of two independent nongovernment organisations (NGOs) working separately with minimal contact. Both teams experienced problems during the deployment, mainly owing to not following the International Search and Rescue Advisory Group (INSARAG) guidelines. Critical areas identified. To improve future South African disaster responses, three functional deployment categories were identified: urban search and rescue, triage and initial stabilisation, and definitive care. To best achieve this, four critical components need to be taken into account: rapid deployment, intelligence from the site, government facilitation, and working under the auspices of recognized organisations such as the United Nations and the World Health Organization. Conclusion. The proposed way forward for South African medical teams responding to disasters is to be unified under a leading academic body, to have an up-to-date volunteer database, and for volunteers to be current with the international search and rescue course currently being developed by the Medical Working Group of INSARAG. An additional consideration is that South African rescue and relief personnel have a primary responsibility to the citizens of South Africa, then the Southern African Development Community region, then the rest of the African continent and finally further afield. The commitment of government, private and military health services as well as NGOs is paramount for a unified response.Publishers' versio

Understanding anti-tuberculosis drug efficacy: rethinking bacterial populations and how we model them

Tuberculosis still remains a global health emergency, claiming 1.5 million lives in 2013. The bacterium responsible for this disease, Mycobacterium tuberculosis (M.tb), has successfully survived within hostile host environments, adapting to immune defence mechanisms, for centuries. This has resulted in a disease that is challenging to treat, requiring lengthy chemotherapy with multi-drug regimens. One explanation for this difficulty in eliminating M.tb bacilli in vivo is the disparate action of antimicrobials on heterogeneous populations of M.tb, where mycobacterial physiological state may influence drug efficacy. In order to develop improved drug combinations that effectively target diverse mycobacterial phenotypes, it is important to understand how such subpopulations of M.tb are formed during human infection. We review here the in vitro and in vivo systems used to model M.tb subpopulations that may persist during drug therapy, and offer aspirations for future research in this field

Detectors for the James Webb Space Telescope Near-Infrared Spectrograph I: Readout Mode, Noise Model, and Calibration Considerations

We describe how the James Webb Space Telescope (JWST) Near-Infrared Spectrograph's (NIRSpec's) detectors will be read out, and present a model of how noise scales with the number of multiple non-destructive reads sampling-up-the-ramp. We believe that this noise model, which is validated using real and simulated test data, is applicable to most astronomical near-infrared instruments. We describe some non-ideal behaviors that have been observed in engineering grade NIRSpec detectors, and demonstrate that they are unlikely to affect NIRSpec sensitivity, operations, or calibration. These include a HAWAII-2RG reset anomaly and random telegraph noise (RTN). Using real test data, we show that the reset anomaly is: (1) very nearly noiseless and (2) can be easily calibrated out. Likewise, we show that large-amplitude RTN affects only a small and fixed population of pixels. It can therefore be tracked using standard pixel operability maps.Comment: 55 pages, 10 figure

13[C]-Urea Breath Test as a Novel Point-of-Care Biomarker for Tuberculosis Treatment and Diagnosis

BACKGROUND: Pathogen-specific metabolic pathways may be detected by breath tests based on introduction of stable isotopically-labeled substrates and detection of labeled products in exhaled breath using portable infrared spectrometers. METHODOLOGY/PRINCIPAL FINDINGS: We tested whether mycobacterial urease activity could be utilized in such a breath test format as the basis of a novel biomarker and diagnostic for pulmonary TB. Sensitized New-Zealand White Rabbits underwent bronchoscopic infection with either Mycobacterium bovis or Mycobacterium tuberculosis. Rabbits were treated with 25 mg/kg of isoniazid (INH) approximately 2 months after infection when significant cavitary lung pathology was present. [(13)C] urea was instilled directly into the lungs of intubated rabbits at selected time points, exhaled air samples analyzed, and the kinetics of delta(13)CO(2) formation were determined. Samples obtained prior to inoculation served as control samples for background (13)CO(2) conversion in the rabbit model. (13)CO(2), from metabolic conversion of [(13)C]-urea by mycobacterial urease activity, was readily detectable in the exhaled breath of infected rabbits within 15 minutes of administration. Analyses showed a rapid increase in the rate of (13)CO(2) formation both early in disease and prior to treatment with INH. Following INH treatment, all evaluable rabbits showed a decrease in the rate of (13)CO(2) formation. CONCLUSIONS/SIGNIFICANCE: Urea breath testing may provide a useful diagnostic and biomarker assay for tuberculosis and for treatment response. Future work will test specificity for M. tuberculosis using lung-targeted dry powder inhalation formulations, combined with co-administering oral urease inhibitors together with a saturating oral dose of unlabeled urea, which would prevent the delta(13)CO(2) signal from urease-positive gastrointestinal organisms

The Evolution of Extracellular Fibrillins and Their Functional Domains

Fibrillins constitute the major backbone of multifunctional microfibrils in elastic and non-elastic extracellular matrices, and are known to interact with several binding partners including tropoelastin and integrins. Here, we study the evolution of fibrillin proteins. Following sequence collection from 39 organisms representative of the major evolutionary groups, molecular evolutionary genetics and phylogeny inference software were used to generate a series of evolutionary trees using distance-based and maximum likelihood methods. The resulting trees support the concept of gene duplication as a means of generating the three vertebrate fibrillins. Beginning with a single fibrillin sequence found in invertebrates and jawless fish, a gene duplication event, which coincides with the appearance of elastin, led to the creation of two genes. One of the genes significantly evolved to become the gene for present-day fibrillin-1, while the other underwent evolutionary changes, including a second duplication, to produce present-day fibrillin-2 and fibrillin-3. Detailed analysis of several sequences and domains within the fibrillins reveals distinct similarities and differences across various species. The RGD integrin-binding site in TB4 of all fibrillins is conserved in cephalochordates and vertebrates, while the integrin-binding site within cbEGF18 of fibrillin-3 is a recent evolutionary change. The proline-rich domain in fibrillin-1, glycine-rich domain in fibrillin-2 and proline-/glycine-rich domain in fibrillin-3 are found in all analyzed tetrapod species, whereas it is completely replaced with an EGF-like domain in cnidarians, arthropods, molluscs and urochordates. All collected sequences contain the first 9-cysteine hybrid domain, and the second 8-cysteine hybrid domain with exception of arthropods containing an atypical 10-cysteine hybrid domain 2. Furin cleavage sites within the N- and C-terminal unique domains were found for all analyzed fibrillin sequences, indicating an essential role for processing of the fibrillin pro-proteins. The four cysteines in the unique N-terminus and the two cysteines in the unique C-terminus are also highly conserved

Granulomas and inflammation: Host-Directed Therapies for Tuberculosis

Tuberculosis (TB) remains a leading global health problem that is aggravated by emergence of drug-resistant strains, which account for increasing number of treatment-refractory cases. Thus, eradication of this disease will strongly require better therapeutic strategies. Identification of host factors promoting disease progression may accelerate discovery of adjunct host-directed therapies (HDTs) that will boost current treatment protocols. HDTs focus on potentiating key components of host anti-mycobacterial effector mechanisms, and limiting inflammation and pathological damage in the lung. Granulomas represent a pathological hallmark of TB. They are comprised of impressive arrangement of immune cells that serve to contain the invading pathogen. However, granulomas can also undergo changes, developing caseums and cavities that facilitate bacterial spread and disease progression. Here, we review current concepts on the role of granulomas in pathogenesis and protective immunity against TB, drawing from recent clinical studies in humans and animal models. We also discuss therapeutic potential of inflammatory pathways that drive granuloma progression, with a focus on new and existing drugs that will likely improve TB treatment outcomes