Here at home (South Africa) the numbers were down almost 50% on last week’s 7-day average  (2 126 cases) with 1507 new cases recorded in our 7-day average ( 11th June)

Regarding our neighbours:  on the 12th of June  Namibia also recorded a significant lowering of cases, with 126 reported vs the 243 cases from last week; Botswana recorded slightly raised figures from last week, with 329 cases and Kenya 185 cases as of the 11th of June. Zimbabwe saw a slight drop, recording 109 cases on their 7-day average, and finally Nigeria on the 11th of June recording 25 cases. So again these are all 7-day averages, and the data comes from the data repository at Johns Hopkins University.

Our COVID story for the week is tangentially linked to the virus.  A recently published trial looked into whether the time of administration of a vaccine (morning vs afternoon), and psychosocial factors such as high-stress levels had any impact on the vaccine's efficacy. Previous studies had shown that vulnerable groups such as the elderly, had a differing antibody response and consequently less protection, depending on whether they were given a vaccination in the morning or afternoon. Psychosocial factors such as high-stress levels were also thought to play a part in this differing response. These studies related to thymus-independent vaccines such as those for influenza – hence the interest from a COVID perspective. It had been suggested in these previous studies that “manipulating the diurnal rhythms within the immune response”³ by administering the vaccines at different times of day, might improve the response and consequently the disease cover.

The study consisted of  two parts:

Study one considered 75 respondents: all were students, 41 were women and the mean age was 22.9 [SD of 3.89yrs]. The study set out to determine the efficacy of the vaccine in a lower-stress environment and to consider the time of administration. The participants were randomly assigned to receive a  polysaccharide pneumococcal vaccine either in the morning or in the afternoon. The participants provided a baseline blood sample prior to administration, then returned at 1 week, 4 and 8 weeks for repeat samples

The second study, which set out to determine the effect of high-stress (psychosocial factors) on vaccine efficacy, considered 61 parents, mostly women (43 participants) who had a mean age of 41.4 [SD= 5.3yrs], and who were parents of children aged between 3 and18 years. Of these parents, 32 had children who had developmental disabilities. The group was given a baseline blood test prior to the administration of the vaccine ( 32 in the morning, 29 in the afternoon) before the vaccine was administered. This group returned one month and six months later for follow-up testing.

And the findings? The data indicated that neither time of day of vaccination nor psychosocial factors consistently impacted antibody response to the thymus-independent pneumococcal vaccination, and therefore neither were a factor in the administration of  thymus-dependent vaccines.  

And that's our COVID round-up for the week. Links to all our source articles as always listed below

1. COVID-19 Data Repository by the Center for Systems Science and Engineering ( CSSE) at Johns Hopkins University

2. Latest confirmed cases of COVID-10 in South Africa ( 10 June 2022) (NICD)

3. Time of day of vaccination does not relate to antibody response to thymus-independent vaccinations 

Next up:  Infectious Disease Update

This week, there are no further alerts to report for the measles outbreak we reported on last week. We will keep watching and keep you up to date on any developments.

There is an interesting development regarding the Monkeypox outbreak, however. This week 30 prominent scientists wrote an article, published in the journal Virology, in which they stated that the continued referral to the disease as an ‘African’ phenomenon was misleading and discriminatory, given there is no clear link back to the continent in the current cases.  Most concerningly this discrimination is playing out in the media.

Specifically, they argued that the current classification of the MPXV genetic strain only recognises two variants – the West African and the Central African or Congo Basin clade - but there is no reference to the current global north strain. They put forward an alternative classification which the WHO is said to be considering. We’ll see what next week brings in relation to this debate.

In other matters infectious, there is a new TB testing strategy being rolled out in SA. The health news site Spotlight reported that the strategy will see people who are considered high-risk, offered molecular TB tests even if they are asymptomatic. The strategy is referred to as targeted universal testing or TUT, and is said to improve TB detection by 17%. Under the new strategy, these tests will routinely be offered to people living with HIV-AIDS, or those living in households where there are diagnosed cases of TB. Given that an estimated 150 000 people go undiagnosed with TB each year, it is hoped that by improving the rate of diagnosis, the tests will significantly improve the outcomes for such people, together with reducing the overall TB burden in the country. The original commentary in the Lancet and the article in Spotlight can be found below.

Links
 
4. Urgent need for a non-discriminatory and non-stigmatizing nomenclature for monkeypox virus Virology virus
5. Positive Signs for new TB testing ( Spotlight)
6. Accelerate investment and action to find the missing patients with tuberculosis (The Lancet)
 

Matters Ageing

This week we decided to focus on an area of age care which is starting to receive more attention, and that is the management of trauma in the elderly. As our populations' age, it stands to reason that the number of elderly people coming through the doors of the ER will increase. Estimates are that the incidence of traumatic injury among this older age group could reach more than 40% by 2050.

Elderly patients admitted with trauma are more at risk of developing dementia and of having a poor outcome, even when the injury is classed as minor. In fact, the researchers of this study indicate that in 2019, unintentional injury was ranked the 7th cause of death in older adults in the US.  Despite this, not much work has been done in the area of management of the elderly and trauma.

In this study, the researchers introduced a multi-disciplinary approach to the care of older adults admitted to the ER with trauma. The pathway included measures such as an initial assessment by a geriatrician within 48 hours of admission, which looked at the patient’s daily living functionality, mini cognition screening for early dementia and for depression; a confusion assessment with each shift was conducted by the nursing team; physios and occupational therapists assessed the patient’s mobility and functional needs, and social workers assessed for any social barriers. 

The researchers reported that there was a significant improvement in clinical outcomes in patients with traumatic injury (who had not undergone a surgical procedure) when an age-friendly multidisciplinary care pathway was introduced. An important conclusion of the study is that communication between the specialities was key in the effective implementation of such an approach and that would require a concerted effort on the part of all involved. They further state that given the significant improvement evidenced in patients in the study, these pathways should be formalised into the operating practices of all trauma units.


Link

7. Association Between Implementation of a Geriatric Trauma Clinical Pathway and Changes in Rates of Delirium in Older Adults With Traumatic Injury? 

Focus on Paediatrics
 

A while ago we reported on a study that looked into the effect of point-of-care genome testing to prevent severe ototoxicity due to the administration of aminoglycosides. That particular study showed that there was a benefit to introducing this practice into neonatal ICUs.

The study we’ve chosen this week looked at whether there was any similar benefit to point-of-care testing for respiratory pathogens on antibiotic prescribing in paediatrics. Specifically, the researchers wanted to determine if point-of-care testing reduced the use of antibiotics in acutely ill children

1243 children were included in the unblinded randomised clinical trial which took place between May 2019 and March 2020. The children, aged between 0 and 17 years of age, were randomly assigned to undergo either multiplex PCR point-of-care testing on arrival at casualty or to receive routine care. The multiplex testing included testing for 18 viruses and 3 bacterial strains and was ready within 70 minutes of arrival at the ER. The children in the control group (routine care) were tested at the discretion of the clinician, and their results only arrived the following day.

 It was found that multiplex PCR point-of-care testing for respiratory pathogens did not reduce the overall rate of antibiotic scripting: targeted antibiotic therapy was commenced in only 1.4% of the children who underwent testing. The researchers further concluded that clinical decision-making remained the main determiner for scripting. 

Links

8. Effect of Point-of-Care Testing for Respiratory Pathogens on Antibiotic Use in Children (JAMA Pediatrics)
9.Rapid-point of care Genotyping to Avoid Aminoglycoside-Induced Ototoxicity in Neonatal Intensive Care ( JAMA Pediatrics) 

Ophthalmology Review
 

Onto matters ophthalmology and JAMA Ophthalmology has had a busy month with some very interesting studies published.

Last week we wrote a clinical summary of a study which looked at the link between retinal thickness and dementia. This week we reviewed a study which considered whether the use of marine fatty acid supplementation reduced the incidence of Dry Eye Disease (DED). 

The study was an ancillary trial to the Vitamin D and Omega-3 Trial (VITAL), which looked at the role of these supplements in the primary prevention of cancer and cardiovascular disease. The study reviewed data from 23 523 participants, all of whom had no recorded incidence of DED. 

A daily dose of one gram of  Marine ω-3 fatty acid was given to 11 757 participants and the results were compared to those who received a placebo (11 766 participants). Researchers found there was no difference in the incidence of DED between the placebo and the marine w-3 fatty acid group, nor was there any difference in the severity of DED in those participants who went on to develop the condition.

Links

10. Efficacy of Marine ω-3 Fatty Acid Supplementation vs Placebo in Reducing Incidence of Dry Eye Disease in Healthy US Adults (JAMA Ophthalmology)
11. Vitamin D and Omega-3 Trial (VITAL) Clinical Trials.Gov)
12. Association Between Retinal Layer Thickness and Cognitive Decline in Older Adults (MedED Clinical Summary)

Tech Goes Robotic
 

This week Science Robotics published the results of a study which looked into a significant development in the wonderous field of biometric robotic skin. One of the challenges in the development of whole-body robotic skin has been the poor performance of soft tactile sensors – those that pick up physical sensations such as applied pressure.  The developers of this latest innovation point to issues such as "..complex structure, poor scalability and fragility"¹³, as limitations to the use of robotic skin to date.

This latest robotic skin innovation, constructed from hydrogel and a silicone elastomer, closely resembles the multi-layered structure of actual skin.  Embedded in the sensor structure is a system of electrodes and microphones which are able to measure vibration resulting from touch: the hydrogel layer depresses in response to the touch, and these impulses are sent to the electrodes where they are then measured; the microphones pick up any vibration that results from the tactile stimuli which help the skin determine where the stimuli are coming from, and what type of stimuli it is.

The data gathered from these two mechanisms is then converted via tomographic imaging and deep neural networks into what the researchers term multi-modal tactile information – replicating how human skin works. 

So in essence, this robotic skin is now capable of touching and feeling. If you are wondering what the application for this remarkable innovation is, without sounding too sci-fi, look no further than prosthetics. I would imagine that the sensors would be able to pick up areas of excessive pressure and the feedback loop would then be to adjust the gell that is placed in that pressure area, preventing pressure areas from developing and significantly improving the quality of the individual's experience. We’ll keep our eye on development in this space.

Link

13. A biomimetic elastomeric robot skin using electrical impedance and acoustic tomography for tactile sensing (science.org)
 

Ethics, Legalities and Medical Practice
 

This week there really was only one big story in South African healthcare, and that was the suspension of  Dr Tim de Maayer. If you don’t know the story - unlikely though that would be- Dr De Maayer was the paediatrician who sent a letter to the Gauteng Department of Health, outlining the horrendous state of affairs at Raheema Moosa hospital, and basically pleading for intervention. And then he was suspended. As one would expect.

What I don’t think was expected by the perpatrators of this lunacy, was the outrage of civic society and the public at large. An online petition calling for his re-instatement garnered 45,000 signatures in less than 24 hours – no mean feat in a public worn down by daily outrage. 

And so with due haste an intervention was made by the Gauteng DOH, and wallah -  Dr Tim de Maayer was re-instated. 

A good outcome for this situation, but I double the incident will encourage other practitioners to report incidence of incompetence, malfeasance and the host of other woes that beset our  failing healthcare system. And we – the public -  will be the poorer for it. 

We wish Dr de Mayer every ounce of strength in continuing to fight the good fight for the women and children at Raheema Moosa. South Africa owes you a debt that can never be repaid.

Links

14. Whistleblower paediatrician’s suspension lifted after massive public outcry (DM)
15. Paediatrician Dr Tim De Maayer's open letter to Health Department heads: 'How do you manage to come to work every day, fail at your job of ensuring basic healthcare for the people you serve and still sleep at night?(DM)

This week, we’re keeping with the theme of infectious disease, and given our story about TB testing, did you know that mycobacterium tuberculosis is thought to have been around as long as 3 million years?  

In ancient Greece it was referred to as phtisis; in ancient Rome “tabes”, and in Hebrew “schachepheth”.

According to our source article in the 1700s …"TB was called “the white plague” due to the paleness of the patients." ¹⁶  In 1834 Johann Schonlein named the disease 'tuberculosis' although it was commonly referred to as consumption well into the 19th century. It was also referred to as “Captain of all these men of death’¹⁶. And as we know it was Robert Koch who named the causative organism as mycobacterium tuberculosis on March 23, 1882.  

So if you didn't know – now you do.

16. History of World TB Day (CDC.gov)

And that is all for the Week in Review. 

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All that's left is to say, wherever you are, stay safe, stay sane, and join me next week where I review the week in medicine.

This has been a production on the Medical Education Network – delivering quality medical education and information to Southern Africa since 2008. All thoughts and comments on this podcast remain that of its creators. Every effort has been made to fact check the information contained here. Any errors or misstatements that may occur are unintentional.