Radiotherapy teaching during COVID-19: An emergency teaching response

One Size Does Not Fit All: Implementation of an Equitable and Inclusive Strategic Response to Address Needs of Pediatric Resident Physicians during the Coronavirus Disease 2019 (COVID-19) Crisis

Background: Adverse pregnancy outcomes significantly contribute to maternal morbidity and mortality. Despite substantial global evidence, data on the effects of coronavirus disease 2019 (COVID-19) on maternal and neonatal outcomes in South Africa remain limited. Aim: To investigate the association between COVID-19 and adverse pregnancy outcomes. Setting: Tygerberg Hospital, Cape Town, South Africa. Methods: We performed a retrospective analysis of pregnant women tested for COVID-19 (categorised as positive or negative), admitted to Tygerberg Hospital between 01 March 2020 and 31 March 2021. The primary outcome was a composite of stillbirth, preterm birth, neonatal death, low birth weight, and maternal death. Binary logistic regression models were used to evaluate predictors of adverse pregnancy outcomes. Variables with p < 0.1 in the univariate model, along with clinically relevant covariates (maternal age, parity, COVID-19, human immunodeficiency virus [HIV], and preeclampsia), were included in the final multivariable model. Statistical analyses were performed via Stata/SE® (version 17.0) at α = 0.05. Results: Of 350 pregnant women (mean age: 29.8 years, [standard deviation {s.d.}: 6.99]), majority were in the third trimester (77.4%) and nulliparous (51.4%). Adverse outcomes occurred in 167 (47.7%) participants, with a higher prevalence among those without COVID-19 (51.4% vs. 43.6%) and those with preeclampsia (68.3% vs. 33.3%) compared to their counterparts. Preeclampsia was significantly associated with a higher risk of adverse pregnancy outcomes (adjusted odds ratio [AOR]: 2.87; 95% confidence interval [CI]: 1.62–5.09), whereas COVID-19 was not (AOR: 0.79; 95% CI: 0.42–1.46). Conclusion: COVID-19 was not associated with increased risk of adverse pregnancy outcomes. Conversely, preeclampsia significantly predicted adverse outcomes. Contribution: These findings underscore the importance of targeted antenatal interventions to mitigate maternal and neonatal morbidity during future pandemics.

Although literature globally indicates varied neurological and/or neuropsychiatric manifestations (NNM) and complications associated with coronavirus disease 2019 (COVID-19), information about NNM in infected hospitalised patients on the African continent remains limited. To describe the presentation of NNM and compare patients with and without NNM considering demographic and clinical profiles, treatment, and outcomes. Tygerberg Hospital, Cape Town, South Africa. Retrospective medical record review of the first 100 consecutively admitted COVID-19 patients (64 females, mean age 47.6 years) between March and June 2020. Of the 98 patients included in the analysis, 56.1% had at least one NNM. The most common NNM were myalgia (32.7%), headache (21.4%), loss of smell and/or taste (15.3%), and delirium (10.2%). Patients with and without NNM did not differ with respect to demographic characteristics. Patients with NNM had significantly more constitutional symptoms (p = 0.017) and were more likely to have neurological and/or neuropsychiatric comorbid conditions (10.9% vs. 0.0%, p = 0.033) than those without NNM. Patients without documented NNM were more likely to have abnormalities on chest X-ray (p = 0.009) than those with NNM. Coronavirus disease 2019 related treatment and mortality did not differ between the groups. Neurological and/or neuropsychiatric manifestations were common in hospitalised patients with COVID-19. The results suggest that while COVID-19 patients with NNM may have less of a respiratory phenotype they nonetheless have equivalent mortality rates. This study highlights the common NNM in patients with COVID-19 admitted to Tygerberg Hospital early in the pandemic and adds to the growing evidence of COVID-19 NNM.

BackgroundThere is still a paucity of evidence on the outcomes of coronavirus disease 2019 (COVID-19) among people living with human immunodeficiency virus (PWH) and those co-infected with tuberculosis (TB), particularly in areas where these conditions are common. We describe the clinical features, laboratory findings and outcome of hospitalised PWH and human immunodeficiency virus (HIV)-uninfected COVID-19 patients as well as those co-infected with tuberculosis (TB).MethodsWe conducted a multicentre cohort study across three hospitals in Cape Town, South Africa. All adults requiring hospitalisation with confirmed COVID-19 pneumonia from March to July 2020 were analysed.ResultsPWH comprised 270 (19%) of 1434 admissions. There were 47 patients with active tuberculosis (3.3%), of whom 29 (62%) were PWH. Three-hundred and seventy-three patients (26%) died. The mortality in PWH (n = 71, 26%) and HIV-uninfected patients (n = 296, 25%) was comparable. In patients with TB, PWH had a higher mortality than HIV-uninfected patients (n = 11, 38% vs n = 3, 20%; p = 0.001). In multivariable survival analysis a higher risk of death was associated with older age (Adjusted Hazard Ratio (AHR) 1.03 95%CI 1.02–1.03, p < 0.001), male sex (AHR1.38 (95%CI 1.12–1.72, p = 0.003) and being “overweight or obese” (AHR 1.30 95%CI 1.03–1.61 p = 0.024). HIV (AHR 1.28 95%CI 0.95–1.72, p 0.11) and active TB (AHR 1.50 95%CI 0.84–2.67, p = 0.17) were not independently associated with increased risk of COVID-19 death. Risk factors for inpatient mortality in PWH included CD4 cell count < 200 cells/mm3, higher admission oxygen requirements, absolute white cell counts, neutrophil/lymphocyte ratios, C-reactive protein, and creatinine levels.ConclusionIn a population with high prevalence of HIV and TB, being overweight/obese was associated with increased risk of mortality in COVID-19 hospital admissions, emphasising the need for public health interventions in this patient population.

BackgroundHigh-risk people living with diabetes (PLWD) have increased risk for morbidity and mortality. During the first coronavirus disease 2019 (COVID-19) wave in 2020 in Cape Town, South Africa, high-risk PLWD with COVID-19 were fast-tracked into a field hospital and managed aggressively. This study evaluated the effects of this intervention by assessing the impact of this intervention on clinical outcomes in this cohort.MethodsA retrospective quasi-experimental study design compared patients admitted pre- and post-intervention.ResultsA total of 183 participants were enrolled, with the two groups having similar demographic and clinical pre-Covid-19 baselines. Glucose control on admission was better in the experimental group (8.1% vs 9.3% [p = 0.013]). The experimental group needed less oxygen (p < 0.001), fewer antibiotics (p < 0.001) and fewer steroids (p = 0.003), while the control group had a higher incidence of acute kidney injury during admission (p = 0.046). The median glucose control was better in the experimental group (8.3 vs 10.0; p = 0.006). The two groups had similar clinical outcomes for discharge home (94% vs 89%), escalation in care (2% vs 3%) and inpatient death (4% vs 8%).ConclusionThis study demonstrated that a risk-based approach to high-risk PLWD with COVID-19 may yield good clinical outcomes while making financial savings and preventing emotional distress.ContributionWe propose a risk-based approach to guide clinical management of high risk patients, which departs significantly from the current disease-based model. More research using randomised control trial methodology should explore this hypothesis.

BackgroundThe emergence of genetic variants of SARS-CoV-2 was associated with changing epidemiological characteristics throughout coronavirus disease 2019 (COVID-19) pandemic in population-based studies. Individual-level data on the clinical characteristics of infection with different SARS-CoV-2 variants in African countries is less well documented.ObjectivesTo describe the evolving clinical differences observed with the various SARS-CoV-2 variants of concern and compare the Omicron-driven wave in infections to the previous Delta-driven wave.MethodWe performed a retrospective observational cohort study among patients admitted to a South African referral hospital with COVID-19 pneumonia. Patients were stratified by epidemiological wave period, and in a subset, the variants associated with each wave were confirmed by genomic sequencing. Outcomes were analysed by Cox proportional hazard models.ResultsWe included 1689 patients were included, representing infection waves driven predominantly by ancestral, Beta, Delta and Omicron BA1/BA2 & BA4/BA5 variants. Crude 28-day mortality was 25.8% (34/133) in the Omicron wave period versus 37.1% (138/374) in the Delta wave period (hazard ratio [HR] 0.68 [95% CI 0.47–1.00] p = 0.049); this effect persisted after adjustment for age, gender, HIV status and presence of cardiovascular disease (adjusted HR [aHR] 0.43 [95% CI 0.28–0.67] p < 0.001). Hospital-wide SARS-CoV-2 admissions and deaths were highest during the Delta wave period, with a decoupling of SARS-CoV-2 deaths and overall deaths thereafter.ConclusionThere was lower in-hospital mortality during Omicron-driven waves compared with the prior Delta wave, despite patients admitted during the Omicron wave being at higher risk.ContributionThis study summarises clinical characteristics associated with SARS-CoV-2 variants during the COVID-19 pandemic at a South African tertiary hospital, demonstrating a waning impact of COVID-19 on healthcare services over time despite epidemic waves driven by new variants. Findings suggest the absence of increasing virulence from later variants and protection from population and individual-level immunity.

Background: The coronavirus disease−2019 (COVID-19) pandemic has halted in-person medical education worldwide. Limited studies have reported on the mental health status of medical students during this public health emergency. This study aimed to explore the association of personal virus exposure, regional epidemic condition, and social support with medical students' depressive and anxiety symptoms during the COVID-19 outbreak in China.Methods: In February 2020, 5,982 medical students (60.0% females, Meanage = 21.7 years, Medianage = 22 years) completed an online survey consisting of demographics, personal virus exposure, the Patient Health Questionnaire, the Generalized Anxiety Disorder Scale, and the Social Support Rating Scale.Results: The prevalence rates of mild to severe depressive symptoms and anxiety symptoms were 35.2 and 22.8%, respectively. Multivariate linear regression showed that students with low- or medium-level social support had a higher risk of experiencing depressive or anxiety symptoms than those with high-level social support. COVID-19 exposure was positively associated with mild to severe depressive or anxiety symptoms. Respondents living in provinces with 500–1,000 confirmed COVID-19 cases had an increased risk of experiencing mild to severe depressive symptoms compared with those living in provinces with <100 cases. Other related factors were gender and years of training.Conclusions: Some medical students suffered from a poor psychological status during the COVID-19 outbreak. Low social support was a stronger factor related to poor mental status compared with COVID-19 exposure or the provincial epidemic condition. Thus, we suggest that colleges or universities provide social support and mental health screening.

The aim of this study was to identify arterial blood gas (ABG) abnormalities, with a focus on a high anion gap (AG) metabolic acidosis and evaluate outcomes in coronavirus disease 2019 (COVID-19) patients admitted to the ICU. A retrospective, observational study was conducted in a tertiary hospital in Cape Town during the first and second COVID-19 waves. Age, gender, sodium (Na), potassium (K), chloride (Cl), bicarbonate (HCO3std), pH, partial pressure of carbon dioxide (pCO2), creatinine, estimated glomerular filtration rate (eGFR), lactate levels and ABG results were obtained. The Pearson χ2 test or Fisher exact test and the Wilcoxon rank-sum test were used to compare mortality and survival. To identify factors associated with non-survival, a multivariable model was developed. This study included 465 patients, 226 (48%) of whom were female. The sample population's median (IQR) age was 54.2 (46.1-61.3) years, and 63% of the patients died. ABG analyses found that 283 (61%) of the 465 patients had alkalosis (pH ≥ 7.45), 65 (14%) had acidosis (pH ≤ 7.35) and 117 (25%) had normal pH (7.35-7.45). In the group with alkalosis, 199 (70.3%) had a metabolic alkalosis and in the group with acidosis, 42 (64%) had a metabolic acidosis with an increased AG of more than 17. Non-survivors were older than survivors (56.4years versus 50.3years, p < .001). Most of the COVID-19 patients admitted to the ICU had an alkalosis, and those with acidosis had a much worse prognosis. Higher AG metabolic acidosis was not associated with patients' characteristics.

BackgroundSince early December 2019, the 2019 novel coronavirus disease (COVID-19) has caused pneumonia epidemic in Wuhan, Hubei province of China. This study aimed to investigate the factors affecting the progression of pneumonia in COVID-19 patients. Associated results will be used to evaluate the prognosis and to find the optimal treatment regimens for COVID-19 pneumonia.MethodsPatients tested positive for the COVID-19 based on nucleic acid detection were included in this study. Patients were admitted to 3 tertiary hospitals in Wuhan between December 30, 2019, and January 15, 2020. Individual data, laboratory indices, imaging characteristics, and clinical data were collected, and statistical analysis was performed. Based on clinical typing results, the patients were divided into a progression group or an improvement/stabilization group. Continuous variables were analyzed using independent samples t-test or Mann-Whitney U test. Categorical variables were analyzed using Chi-squared test or Fisher's exact test. Logistic regression analysis was performed to explore the risk factors for disease progression.ResultsSeventy-eight patients with COVID-19-induced pneumonia met the inclusion criteria and were included in this study. Efficacy evaluation at 2 weeks after hospitalization indicated that 11 patients (14.1%) had deteriorated, and 67 patients (85.9%) had improved/stabilized. The patients in the progression group were significantly older than those in the disease improvement/stabilization group (66 [51, 70] vs. 37 [32, 41] years, U = 4.932, P = 0.001). The progression group had a significantly higher proportion of patients with a history of smoking than the improvement/stabilization group (27.3% vs. 3.0%, χ2 = 9.291, P = 0.018). For all the 78 patients, fever was the most common initial symptom, and the maximum body temperature at admission was significantly higher in the progression group than in the improvement/stabilization group (38.2 [37.8, 38.6] vs. 37.5 [37.0, 38.4]°C, U = 2.057, P = 0.027). Moreover, the proportion of patients with respiratory failure (54.5% vs. 20.9%, χ2 = 5.611, P = 0.028) and respiratory rate (34 [18, 48] vs. 24 [16, 60] breaths/min, U = 4.030, P = 0.004) were significantly higher in the progression group than in the improvement/stabilization group. C-reactive protein was significantly elevated in the progression group compared to the improvement/stabilization group (38.9 [14.3, 64.8] vs. 10.6 [1.9, 33.1] mg/L, U = 1.315, P = 0.024). Albumin was significantly lower in the progression group than in the improvement/stabilization group (36.62 ± 6.60 vs. 41.27 ± 4.55 g/L, U = 2.843, P = 0.006). Patients in the progression group were more likely to receive high-level respiratory support than in the improvement/stabilization group (χ2 = 16.01, P = 0.001). Multivariate logistic analysis indicated that age (odds ratio [OR], 8.546; 95% confidence interval [CI]: 1.628–44.864; P = 0.011), history of smoking (OR, 14.285; 95% CI: 1.577–25.000; P = 0.018), maximum body temperature at admission (OR, 8.999; 95% CI: 1.036–78.147, P = 0.046), respiratory failure (OR, 8.772, 95% CI: 1.942–40.000; P = 0.016), albumin (OR, 7.353, 95% CI: 1.098–50.000; P = 0.003), and C-reactive protein (OR, 10.530; 95% CI: 1.224−34.701, P = 0.028) were risk factors for disease progression.ConclusionsSeveral factors that led to the progression of COVID-19 pneumonia were identified, including age, history of smoking, maximum body temperature at admission, respiratory failure, albumin, and C-reactive protein. These results can be used to further enhance the ability of management of COVID-19 pneumonia.

BackgroundCoronavirus disease 2019 (COVID‐19) is associated with hematological abnormalities of variable severity. The full blood count (FBC) and leukocyte differential count (DIFF) could facilitate the prediction of disease severity and outcome in COVID‐19. This study aimed to assess the hematological parameters in early severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection and their correlation with disease outcome.MethodsA retrospective cross‐sectional descriptive study was performed. Adults with a FBC and positive SARS‐CoV‐2 polymerase chain reaction results between March 1, and June 31, 2020 were reviewed. Basic hematological parameters (FBC, DIFF) and human immunodeficiency virus (HIV) status were recorded. Outcome measures were admission to a general ward or intensive care unit (ICU), recovery or death.ResultsSix hundred and eighty‐five cases median age 51 years, were analyzed. Forty‐four percent were males and fourteen percent were HIV‐positive with no association between death and/or ICU admission (p = 0.522 and p = 0.830, respectively). Leucocytosis was predictive of ICU admission (odds ratio [OR]: 2.4, confidence interval [CI]: 1.77–3.8186) and neutrophilia, of both mortality (OR: 1.5, CI: 1.0440–2.0899) and ICU admission (OR: 4, CI: 2.5933–6.475). Median lymphocyte count was decreased and d‐dimer raised, showing no significant association with outcome. Raised neutrophil‐to‐lymphocyte‐ratio (NLR) was associated with increased odds of mortality (OR: 2.5, CI: 1.3556–3.2503) and ICU admission (OR: 4.8, CI: 2.4307–9.5430) as was monocyte‐to‐lymphocyte‐ratio (MLR) (OR: 2, CI: 1.3132–2.9064) and (OR: 2.3, CI: 1.0608–1.9935), respectively. Hospital admission and older age were significantly associated with mortality (p = 0.0008 and p < 0.0001), respectively.ConclusionEvidence‐based interpretation of routine laboratory parameters, readily available in resource‐constrained settings, may identify patients at increased risk of mortality. The FBC, DIFF, NLR, and MLR should form part of the early COVID‐19 investigation.

The role of radiotherapy (RT) in cancer care is well described, with a clear correlation between access to radiotherapy and overall survival. Cancer mortality rates in Africa are substantially higher than those of the rest of the world, which may be partly attributed to lack of RT access and insufficient human resources. The Access to Care (A2C) Cape Town RT training programme was created in 2014 with the aim of supplementing practical RT training in the region, focusing on clinics moving from 2 to 3D conformal radiotherapy (3DCRT). The programme makes use of hybrid teaching methods, including pre-course e-learning followed by 17 on-site days of free-thinking design exercises, didactic learning, hands-on treatment planning computer sessions (39% of total teaching time), virtual simulation training and departmental demonstration sessions. Email support is offered to all teams for 3 months after each course to develop clinical protocols. Thirteen teams (radiation oncologist, medical physicist and radiation therapy technologist) from Africa attended the course between 2015 and 2019, with additional participants from seven South African and four international centres. E-learning done on the LäraNära training platform was only successful once formal progress tracking was introduced in 2019 (34% vs. 76% test completion rate). Delays between course attendance and initial clinical use of equipment proved to be detrimental to knowledge retention, with some centres having to send a second team for training. The course will be modified for remote teaching in 2021, to make provision for the global changes in travel due to Covid-19.

Variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are continuously emerging, highlighting the importance of regular surveillance of SARS-CoV-2 and other epidemiologically significant pathogenic viruses in the current context. Reverse transcription-quantitative PCR (RT-qPCR) is expensive, time-consuming, labor-intensive, requires a large reagent volume, and only tests a few targets in a single run. High-throughput qPCR (HT-qPCR) utilizing the Biomark HD system (Fluidigm) can be used as an alternative. This study applied an HT-qPCR to simultaneously detect SARS-CoV-2, SARS-CoV-2 nucleotide substituted RNA, and other pathogenic viruses in wastewater. Wastewater samples were collected from the coronavirus disease 2019 (COVID-19) quarantine facility between October 2020 and February 2021 (n = 4) and from the combined and separated sewer lines of a wastewater treatment plant (WWTP) in Yokkaichi, Mie Prefecture, Japan, between March and August 2021 (n = 23 each). The samples were analyzed by HT-qPCR using five SARS-CoV-2, nine SARS-CoV-2 spike gene nucleotide substitution-specific, five pathogenic viruses, and three process control assays. All samples from the quarantine facility tested positive for SARS-CoV-2 and the nucleotide substitutions N501Y and S69-70 del (Alpha variant) were detected in the December 2020 sample, coinciding with the first clinical case in Japan. Only three WWTP samples were positive when tested with a single SARS-CoV-2 assay, whereas more than eight samples were positive when tested with all assays, indicating that using multiple assays increases the likelihood of detection. The nucleotide substitution L452R (Delta variant) was detected in the WWTP samples of Mie Prefecture in April 2021, but the detection of Delta variant from patients had not been reported until May 2021. Aichi virus 1 and norovirus GII were prevalent in WWTP samples. This study demonstrated that HT-qPCR may be the most time- and cost-efficient method for tracking COVID-19 and broadly monitoring community health.

Purpose: While hearing care professions recently submitted commentary about proposed regulatory guidelines for over-the-counter (OTC) hearing aids, educational considerations were not highlighted much. This article examines audiology education regarding OTC devices, specifically addressing how graduate curricula may incorporate the topic and examining graduate audiology students' perspectives on proposed OTC regulations. Graduate audiology curricula include a wide breadth of core classes and several specialized courses. The topic of OTC devices may fit well within graduate coursework focused on Professional Issues, Public Health, or Practice Management. This article presents the curricular option implemented at a mid-Atlantic university, including a brief course description, module overview for the OTC topic, and two related assignments. Graduate audiology training with a public health focus will generally address the core functions, assessment, policy, and assurance, which facilitates a topic such as OTC devices. This educational framework also optimized the examination of graduate students' views by qualitative analysis of assignment responses ( n = 21) from audiology students. Thematic analysis of data revealed four themes with respective subthemes and categories. Major themes are examined in a discussion highlighting the perspectives of audiology graduate students. Conclusions: Regular teaching course audits facilitate curricular changes and may incorporate professional topics that are new, controversial, and/or in the development phase to optimize audiology curricular transformation. Analyzing student perspectives on current topics, such as OTC devices, provided an avenue for immersing public health audiology concepts into graduate training with an overall goal to improve equity and inclusion in clinical practice. The topic of OTC devices was appropriate for educating future audiologists.

This document, "RULES REGULATIONS OF THE SOUTH AFRICAN INSTITUTION," printed in Cape Town in 1830, formally establishes the rules and structure for a scientific and exploratory body founded on June 17, 1829. The primary objective of the Institution is to investigate the Geography, Natural History, and general Resources of South Africa. Key Rules and Organisational Structure Support and Membership: The Institution is funded by contributions, subscriptions, and other resources. It comprises several membership categories: Ordinary Members (who hold voting power), Privileged Members, Honorary Members (eminent scientists residing abroad), Corresponding Members (those promoting the Institution's objectives), and Annual Subscribers (both Resident and Non-Resident). Admission for Ordinary and Corresponding Members requires a recommendation and a ballot. Governance: The Institution is led by Office-Bearers elected annually from the Ordinary Members, including a Patron (optional Chairman), a President (Chairman in Patron's absence), Four Vice Presidents, a Treasurer, Two Secretaries, and Nine Members of Council. The Council is responsible for the sole charge of funds, making By-Laws, and managing Repositories, with major property sales or purchases requiring sanction from Ordinary Members. Activities and Meetings: General Monthly Meetings (last Wednesday of the month) are held for hearing approved Essays, Communications, and Committee Reports. General Annual Meetings (first Monday in June) include reports from officers, a discourse on the progress of knowledge, and the election of Office-Bearers. The Museum, Gardens, and other Repositories are to be open to the public under Council-fixed regulations. Initial Members: The document includes a list of initial Privileged Members (including His Excellency the Hon. Sir G. L. Cole) and numerous Ordinary Members (e.g., Rev. Dr Adamson, Rev. F. Fallows, Dr Smith), demonstrating immediate, high-level support within the Colony. In summary, the document outlines the foundational constitution of a significant early South African scientific society, detailing its purpose, funding, membership classifications, and a comprehensive governance framework.

Optimization of the 5-plex digital PCR workflow for simultaneous monitoring of SARS-CoV-2 and other pathogenic viruses in wastewater