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Phenomenon: Tertiary education in post-apartheid South Africa has faced many challenges regarding class, language, and race. Even though previously white Afrikaans-rooted universities now have a diverse student population, recent student protests have highlighted the ongoing need for decolonization in higher education. In addition, the majority of public hospitals in the country function under significant staffing, infrastructure, and equipment shortages. Although the mistreatment of medical students has been well described internationally, to date no South African data exists. The aim of this study was to identify experiences of mistreatment of medical students by clinicians and academics at a South African university and to describe the type of mistreatment experienced, the perceived mental health effects, and the influence on academic performance, resilience, and students' knowledge of current reporting systems. Approach: A cross-sectional study was conducted through a locally developed online survey of 443 medical students at a South African university in May to June 2018, comprising of both open and closed ended questions. Levels of psychological distress (K10) and resilience (CD-RISC -10) were measured. Chi-square and student t-tests were used for the analysis of associations, and linear regressions were used to assess predictors of psychological distress. Qualitative data were analyzed thematically using the approach described by Braun and Clarke. Findings: Of 800 eligible medical students at Stellenbosch University, 443 students (55.4%) completed the survey. Mistreatment, comprising of being ignored/excluded (83.4%), offensive gestures (75.0%), verbal abuse (65.1%) and discrimination (64.4%), was prevalent and pervasive, and was perpetrated mainly by registrars (46.7%) and other medical staff (43.8%). Mistreatment was associated with psychological distress, which was generally high and more severe for females. Resilience, which was higher for males, moderated the effects of gender and perpetrator type on distress. Only 15% of students who had experienced mistreatment, either directly or indirectly, reported it, of which more than half (52.8%) were not happy with the outcome. Most students (80.9%) were not aware of the systems in place to report mistreatment. Insights: Student mistreatment is more highly prevalent among medical students at a South African university compared with studies conducted internationally. Despite over 20 years of democracy in South Africa, high rates of racial and gender discrimination were reported and descriptions of racial, language and gender discrimination were particularly concerning. Since the findings of this study, an anti-bullying poster-campaign has been initiated at the university as well as an online reporting system.

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OBJECTIVE: This prospective study assessed the risk of developing rotator cuff syndrome (RCS) with separate or specific combinations of biomechanical exposures measures, controlling for individual confounders. BACKGROUND: Compared with other musculoskeletal disorders, rates of work-related shoulder musculoskeletal disorders have been declining more slowly. METHOD: We conducted up to 2 years of individual, annual assessments of covariates, exposures, and health outcomes for 393 U.S. manufacturing and healthcare workers without RCS at baseline. Task-level biomechanical exposures assessed exposure to forceful exertions (level, exertion rates, duty cycles), vibration, and upper arm postures (flexion, abduction). Hazard ratios (HRs) were calculated with Cox proportional hazard models. RESULTS: We observed 39 incident RCS cases in 694 person-years (incidence rate = 5.62 per 100 person-years). Adjusting for confounders, we found increased risk of incident RCS associated with forceful hand exertions per minute for three upper arm posture tertiles: flexion ≥45° (≥28.2% time, HR = 1.11, CI [1.01, 1.22]), abduction ≥30° (11.9-21.2%-time, HR = 1.18, CI [1.04, 1.34]), and abduction >60° (≥4.8% time, HR = 1.16, CI [1.04, 1.29]). We failed to observe statistically significant effects for other interactions or any separate measures of biomechanical exposure. CONCLUSION: This study highlights the importance of assessing combinations of exposure to forceful repetition and upper arm elevation when developing interventions for preventing RCS. APPLICATION: Based on these results, interventions that reduce exposure to forceful repetition (i.e., lower force levels and/or slower exertion rates) may reduce the risk of RCS, especially when upper arm elevation cannot be avoided.

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BACKGROUND: Clostridioides difficile infection (CDI) contributes the global threats of drug resistant infections, healthcare acquired infections and antimicrobial resistance. Yet CDI knowledge among healthcare providers in low-resource settings is limited and CDI testing, treatment, and infection prevention measures are often delayed. OBJECTIVES: to develop a CDI intervention informed by the local context within South African public district level hospitals, and analyze the CDI intervention and implementation process. METHODS: A CDI checklist intervention was designed and implemented at three district level hospitals in the Western Cape, South Africa that volunteered to participate. Data collection included a retrospective medical records review of patients hospitalized with C. difficile test orders during the 90 days post-implementation. Patient outcomes and checklist components (e.g. antibiotics) were collected. Qualitative interviews (n = 14) and focus groups (n = 6) were conducted with healthcare providers on-site. The Consolidated Framework for Implementation Research (CFIR) and the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) were applied to collected data and observations in order to identify drivers and barriers to implementation and understand differences in uptake. RESULTS: One of the three hospitals displayed high intervention uptake. Highly relevant CFIR constructs linked to intervention uptake included tension for change, strong peer intervention champions, champions in influential leadership positions, and the intervention's simplicity (CFIR construct: complexity). Tension for change, a recognized need to improve CDI identification and treatment, at the high uptake hospital was also supported by an academic partnership for antimicrobial stewardship. CONCLUSIONS: This research provides a straight-forward health systems strengthening intervention for CDI that is both needed and uncomplicated, in an understudied low resource setting. Intervention uptake was highest in the hospital with tension for change, influential champions, and existing academic partnerships. Implementation in settings with fewer academic connections requires further testing of collaborative implementation strategies and proactive adaptations.

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BACKGROUND: South Africa (SA) currently performs the most peritoneal dialysis (PD) in Africa. Yet outcome data on PD programs on the continent are limited. With the escalating need for renal replacement, PD remains a life-saving modality especially as hemodialysis is limited in the public sector. This study aims to evaluate and report the outcomes of a PD-First program performed in a resource-limited setting and identify factors linked to poor outcomes. METHODS: This observational cohort study was performed at Groote Schuur Hospital, analyzing all PD patients retrospectively from January 2008 to June 2014 and thereafter prospectively until June 2015. Variables included demographics, adequacy, modality, fluid status, cardiovascular disease, and diabetes. The influence of these variables on peritonitis rate, technique survival, and patient survival was assessed. RESULTS: In total, 230 patients were initiated on PD, 31 of whom excluded as they were on PD for < 90 days. The mean age was 39.7 ± 10.4 years (standard deviation [SD]), 49.8% were male, 63.8% were mixed ancestry and 9.8 % were diabetic at dialysis initiation. The average length of time on PD was 17 months (interquartile range [IQR] 8 - 32). The peritonitis rate was 0.87 (confidence interval [CI] 7.8 - 9.7) events per patient year. The 1-, 2- and 5-year patient and technique survival was 91.3%, 79.6%, 50.2% and 85.0%, 75.2%, 45.0%, respectively. Diabetes subdistribution hazard ratio (SHR) 3.16 (95% CI 1.34 - 7.45, p = 0.009) strongly predicted an increased cumulative incidence for death when accounting for competing risks. African ethnicity SHR 2.16 (95% CI 1.26 - 3.71, p = 0.005) was a strong predictor of increased cumulative incidence for technique failure. CONCLUSIONS: In our PD-First program the results are encouraging, despite the lack of home visits due to safety, resource limitations, and a high disease burden. Technique failure in the African race needs further evaluation. Peritoneal dialysis remains a viable, life-saving alternative in an African setting.

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