Daniel Jacobus Van Hoving

Acute poisoning places a substantial burden on health systems in low- and middle-income countries, where limited medical toxicology capacity can constrain timely diagnosis, treatment, and prevention. However, little is known about healthcare workers’ perspectives on medical toxicology needs in Nigerian tertiary healthcare settings. This study explored healthcare workers’ perspectives on poisoning management and medical toxicology needs at a tertiary referral hospital in Abuja, Nigeria. A qualitative descriptive study was conducted at the National Hospital, Abuja. Fourteen purposively selected healthcare professionals completed a pre-interview survey and participated in face-to-face semi-structured interviews. Data were analyzed using Braun and Clarke’s reflexive thematic analysis. Two overarching themes emerged: factors influencing poisoning and its management, and opportunities to strengthen poisoning management. Participants described socioeconomic vulnerability, environmental and occupational exposures, cultural health practices, and limited medical toxicology training as important challenges. They also identified inadequate antidote availability, limited access to specialist toxicology advice, lack of poison information services, and the need for improved surveillance, clinical decision-support tools, and continuing professional development. The findings identify key priorities for strengthening poisoning management, including medical toxicology training, antidote availability, poison information services, and surveillance, which may be relevant to similar tertiary healthcare settings in Nigeria and sub-Saharan Africa.

Background: Improved, rapid, non-sputum-based tuberculosis tests for people with HIV are needed. We aimed to summarise the diagnostic accuracy and yield of urine Xpert Ultra (Cepheid, USA; Xpert-Ultra) for tuberculosis diagnosis, in inpatients and outpatients with HIV.Methods: We conducted a systematic review and individual participant data meta-analysis of cross-sectional and cohort studies that performed urine Xpert-Ultra or urine Xpert-MTB/RIF and an adequate microbiological reference standard, in adults with HIV. We searched PubMed, Web of Science and Scopus from 2005, in any language. An adapted QUADAS-2 tool summarized quality. Primary outcomes were urine Xpert-Ultra diagnostic accuracy and yield. Urine Xpert-MTB/RIF and urine Determine TB Lipoarabinomannan (Abbott, USA; Determine-LAM) were index comparators for accuracy. The harmonised microbiological reference standard (hMRS) classified participants with a positive Xpert or culture as hMRS-positive, and hMRS-negative if none were positive, and at least one Xpert or culture was negative. Diagnostic yield was compared with sputum Xpert and Determine-LAM. This review was registered on PROSPERO (CRD42024527648).Findings: After screening 1654 studies, 16 cohorts (7951 participants) were included. Four cohorts had no bias or applicability concerns. Sensitivity of urine Xpert-Ultra was 52% (95%CI: 40-64%) in inpatients and 23% (95%CI: 19-28) in outpatients. Specificity was ≥96% in both settings. Heterogeneity was substantially reduced after adjusting for CD4 variance. Sensitivity increased, without impacting specificity, at lower CD4 counts. For inpatients with CD4 counts at the median (~130 cells/mL), adding urine Xpert-Ultra to sputum Xpert and Determine-LAM was predicted to increase diagnostic yield from 70.8% (95%CI: 64.3-77.2) to 85.0% (95%CI: 78.2-89.5). For outpatients with CD4 counts at the median (~295 cells/mL) urine Xpert-Ultra was predicted to increase yield from 74.5% (95%CI: 69.2-81.1) to 77.9% (95%CI: 72.3-83.4).Interpretation: Urine Xpert-Ultra had suboptimal sensitivity, but high specificity. Despite its sensitivity, incremental diagnostic yield was still seen beyond Determine-LAM and sputum Xpert, particularly in inpatients.

Background: Penetrating neck injuries (PNIs) are common, yet imaging protocols for asymptomatic patients remain debated in resource-limited settings. Objectives: Describe the clinical course, imaging findings and outcomes of asymptomatic PNI patients who underwent CT angiography and oesophagography (CTA&O) at a tertiary hospital in the Western Cape, South Africa. Method: A retrospective review of asymptomatic PNI patients who underwent CTA&O at Tygerberg Hospital between 01 January 2021 and 30 June 2022. Demographics, mechanism, imaging findings and outcomes were extracted from electronic hospital systems. Results: Ninety-one patients were included (median age 30 years; 88 [97%] males; 84 [92%] stab wounds). Sixty (66%) had a normal CTA&O; 31 (34%) had 40 abnormalities (aerodigestive tract: n = 28 [70%]; vascular: n = 7 [17.5%]; orthopaedic n = 5 [12.5%]). Of these, 18/31 (58%) had no further investigation and 13/31 (42%) had 14 investigations. Most 17/18 (94%) suspected aerodigestive injury investigations were negative. One (3%) required facial artery embolization. There were no complications or deaths. Conclusion: CTA&O identified PNI-related radiological abnormalities in one-third of the asymptomatic PNI patients. Although most did not represent clinically important injuries requiring intervention, CTA&O is valuable for screening. These findings may improve CTA&O interpretation and reduce downstream investigations while ensuring safety. Contribution: This study provides context-specific evidence on CTA&O findings in asymptomatic PNI patients. Distinguishing common PNI-related radiological abnormalities from clinically important findings may improve CTA&O interpretation and improve resource use.

Introduction: Extracranial carotid artery aneurysms and pseudoaneurysms are rare, comprising less than 4% of all peripheral artery aneurysms. Rural primary health care facilities often face significant challenges because of limited access to formal imaging. Point-of-care ultrasound (PoCUS) has the potential to bridge this gap, accelerating timely diagnosis and management in remote settings. Patient presentation: A 19-year-old male presented to a rural primary health care clinic in the Western Cape of South Africa with a 3-week history of left-sided neck swelling and recent odynophagia. Physical examination revealed a firm, pulsatile mass with an audible bruit. Management and outcome: Formal imaging was unavailable for several months, delaying surgical advice. However, the clinic’s newly procured mobile ultrasound allowed for PoCUS, which identified a pulsatile vascular lesion consistent with a carotid pseudoaneurysm. Computed tomography angiography confirmed the diagnosis, and the patient was referred for tertiary care where the lesion was repaired. He had vasculitis on histology and exhibited inconclusive features of a connective tissue disorder, but a definitive cause was not found. Despite multiple attempts, he could not be contacted for follow-up. Conclusion: This case highlights how PoCUS can accelerate definitive management in resource-limited settings. Contribution: Point-of-care ultrasound is potentially an effective, cost-efficient diagnostic tool in rural healthcare settings but requires significant investment in equipment and training. Further research is needed to evaluate its feasibility in South African rural health systems.

Ultrasound is a useful diagnostic tool that can yield significant diagnostic data, but its optimized usage necessitates operators who are trained and experienced. Integrating ultrasound into anatomy education has been demonstrated to significantly enhance medical and health science students' understanding of living anatomy by providing real‐time, dynamic visualizations of anatomical structures. This study aimed to develop, implement, and evaluate a comprehensive program for anatomists, with a focus on enhancing training in ultrasound techniques and fostering motivation to integrate ultrasound into their teaching methodologies for effective anatomical instruction. This qualitative case study was conducted with thirteen lecturers and MSc Anatomy students at the Division of Clinical Anatomy, Stellenbosch University, after obtaining written informed consent prior to participation. The study employed a convenient sampling strategy, ensuring that all participants were willing and interested in the ultrasound training session. Participants received preparatory videos before engaging in practical training. The session involved a brief theoretical introduction followed by 90 min of hands‐on practice, where participants scanned anatomical structures under guidance. Out of the 13 participants, ten completed the open‐ended questionnaires. Thematic analysis of the data developed two themes. These are described as: (1) Strengths of Ultrasound Training; and (2) Challenges and Strategies for Improvement in Ultrasound Training. The training effectively engaged participants and highlighted areas for improvement to enhance the educational impact. The study was conducted at a single institutional setting, and as a result, the findings may have limited transferability to other institutions with different teaching methods and resources.

Background: Point-of-care ultrasound (PoCUS) is a core competency in emergency medicine, and its use in other primary healthcare settings is growing. The study investigates the PoCUS competency, training and qualifications of doctors working in public emergency departments. Methods: An online survey was distributed to doctors at five public Cape Town emergency departments, followed by a practical assessment of an Extended Focused Assessment with Sonography in Trauma (eFAST) and a basic cardiac ultrasound examination. Descriptive and inferential statistics are presented. Results: All participants had attended an in-person PoCUS course before, and 45 (83.3%) were trained by supervisors at work. Eleven participants (20.4%) were credentialled. In the practical assessment, 73.5% were rated as competent in eFAST and 55.9% in basic cardiac ultrasound. The median scores were 80.4% (eFAST) and 76.9% (cardiac ultrasound). Credentialled participants were more likely to achieve a pass mark (> 60%) in eFAST (p < 0.001) and cardiac ultrasound (p < 0.001). Conclusion: All the emergency department doctors who use PoCUS had received formal PoCUS training, and the majority of PoCUS providers had an adequate skill level in the applications tested. The credentialled providers performed better overall. There is a need for further research to investigate the persistently low credentialling rate and potential solutions, not only among practitioners in emergency departments but also generalists and primary care practitioners. Contribution: Our study provides a unique snapshot of the PoCUS skills of junior doctors and trainees in public Cape Town emergency departments.

Background: Non-urgent patients are frequently found in emergency centres (ECs) and contribute to prolonged waiting times, overcrowding, high workloads and reduced quality of care. The aim of this study was to explore the perspectives of lead clinicians regarding patient attendance at ECs with non-urgent conditions in Western Cape district, South Africa. Methods: An exploratory descriptive qualitative study in which semi-structured interviews with 19 family physicians and one emergency medicine specialist from 11 district hospitals and four community health centres were conducted. Results: Key reasons for non-urgent patients to attend the EC were a lack of access to primary care, poor understanding of emergencies and health services, issues related to work and transport, referral by general practitioners, being seen quicker, preference for a doctor, dissatisfaction with primary care and worries about confidentiality. The effects were seen as reduced quality of care for urgent and non-urgent patients, overcrowding, reduced staff morale, many complaints as well as abusive behaviour, manipulation of the triage system, longer triage and waiting times. Conclusion: Action should be taken to: strengthen the primary care platform through better access, coverage and quality of care; educate communities and general practitioners; harness digital technology and telehealth; change the way emergency medical services operate and ensure adequate staffing of ECs. Alternative methods for offering primary care should be evaluated. Contribution: This article discusses the reasons for, effects of, and possible solutions to the problem of non-urgent patients attending ECs. Further studies may explore the perspectives of patients and medical officers.