The Universitas Hospital NHLS Laboratory received a query from a paediatrician regarding the “delayed” laboratory results for baby H, a 1-month-old infant. The laboratory had received nine specimens from that same unit but none for baby H. Upon investigation, using standard laboratory procedures of checking traceability and delta-checking of consecutive chemistry test results over a few days, results were found for a baby whose blood had not been sampled that day (baby M). Review of baby M’s results appeared to better match the clinical findings of baby H mainly because he was jaundiced (on phototherapy) and baby H was not. A further complication was that 10 sample collection tubes had been pre-labelled in preparation for the phlebotomy procedure. However, because blood had not been collected from baby M there was the added possibility of a serial error in sample-patient linking in 8 of the remaining 9 samples. Most laboratory errors occur in the pre-analytical phase, and many of these involve mislabelling of specimen tubes. Morning group pre-labelling is a common Universitas hospital practice prior to actual phlebotomy and is designed to speed up the sample collection process, so that results are available in time for the morning consultant ward round. This report serves to act as an alert of the possible dangers of serial error and possible disastrous effect on patient care.

Lesotho faces a catastrophic syndemic of HIV and tuberculosis (TB). In 2011, the government of Lesotho launched isoniazid preventive therapy (IPT) as a once-off intervention to reduce the occurrence of TB in HIV-positive people. This study evaluated the effectiveness of IPT and the durability of its effectiveness based on Cox’s proportional hazards regression analysis of 2 955 records randomly sampled from six districts of Lesotho. The overall TB incidence rate was 2.0 per 100 person-years in 12 208 person-years. Thirty-nine (15.9%, n=246) patients developed TB after IPT. TB incidences per 100 person-years by timing of IPT were as follows: (a) IPT before ART (1.7); (b) IPT after ART (1.8); (c) no IPT (2.6); (d) IPT within one year of ART commencement (1.3) and (e) IPT 3-5 years after ART initiation (2.3). Gender, baseline World Health Organisation (WHO) clinical staging, district category and time to IPT relative to ART commencement emerged as significant predictors of TB occurrence. Increasing time to IPT by one six-month interval increased the risk of contracting TB by between 6% and 59. Further, IPT effectiveness rapidly deteriorated after four years. This indicates that delayed IPT after ART commencement significantly affects the effectiveness of this intervention. The need to consider booster doses of IPT cannot be overemphasised.

As such, medical technology, serves the purpose of seeking to enhance the quality of human life. In recent times, the effects of societal and ethical as well as legal aspects of technologies in medicine have come under the spotlight. Clinicians invariably use a wide assortment of technologies within the spectrum of laboratory medicine in diagnosing, treating and assessing the care of patients. These assortments of technologies play a pivotal role in healthcare and one could argue that medical practice is now fundamentally dependent on these technologies. While medical technology should be reducing the overall cost of treating patients due to its ability to enhance prevention by deriving custom-made therapies, this is not the case. Medical technology is conversely becoming more expensive, and as it is use increases, so does the cost of healthcare for patients at all levels of the socio-economic spectrum. The increasing use of high-end technology is very expensive, thereby increasing the cost of for example, laboratory testing. These ever increasing costs are beyond the reach of the average South African citizen who cannot afford the exorbitant costs of medical aid. This article addresses the ethicality of what is seemingly an unjust practice. It asserts that there should be greater efforts not only by the industry to develop suitable affordable technologies, but also by the various pathology laboratory sectors in accordance with the various medical needs and priorities of South African society. The local healthcare market is undergoing substantial cost constraints. If any new offerings are to be adopted by all healthcare providers, they first need to validate the cost in contrast to the assessable improvement such offerings can provide to improve or stabilise patient healthcare. The ever increasing cost of healthcare is unaffordable for the majority of South African citizens. All this can be construed as unethical practice since it increases medical costs for other citizens, as medical aid schemes are obliged to pass on these exorbitant costs incurred by them, to their members.

Background: Research indicates an increase in drug resistance to pathogenic human bacteria, despite the increase in synthetic antimicrobial drugs. As a result, medicinal plants are proving to be rich resources of constituents which can be used in drug development and synthesis of antimicrobial agents and/or their derivatives. Many of therapeutic drugs e.g. antimicrobial, anti-cancer and antioxidants have compounds extracted from plants as their primary active ingredients or molecules of plant origin serve as blue prints for synthetic or partially synthetic drugs. Methods: The antimicrobial activity of the Asparagus laricinus aqueous extract was evaluated by determination of minimum inhibitory concentration against laboratory strains of both gram-positive ( Bacillus subtilis , Streptococcus pneumonia and Staphylococcus aureus ) and gram-negative bacteria ( Pseudomonas aeruginosa , Escherichia coli and Proteus vulgaris ). The micro-plate assays based on iodo-nitrotetrazolium violet indicator was used to evaluate cell viability. Antioxidative stress activity of the extract was determined using Saccharomyces cerevisiae (BY4742) as the model eukaryotic system, while constitutes of the plant extract were profiled using LC/MS. Results: This study reports on the anti-bacterial and antioxidative stress activity of Asparagus laricinus . It was observed that 50µg/ml of the plant extract was the (MIC) for the gram-positive bacteria Bacillus subtilis , Streptococcus pneumonia and Staphylococcus aureus . While100µg/ml that was required for other gram-negative strains, Pseudomonas aeruginosa , Escherichia coli and Proteus vulgaris and Staphylococcus aureus was inhibited by 25µg/ml of the plant extract. The plant extract protected Saccharomycescerevisiae (BY4742) cells from oxidative stress when the cells were incubated with 10mM (H 2 O 2 ) for 1.5 hours. The phyto constituents of the plant extract were profiled using LC/MS and four major peaks were assigned chemical formulae. Conclusions: Asparagus laricinus water extract showed antimicrobial and antioxidative stress activities. LC/MS profile of major constituents of the plant extract revealed the presence of an alkaloid similar to 4-thiazolidinones, known to have important biological activities.

Background: The automated fragmented red cell (FRC) is a promising diagnostic tool for the rapid diagnosis of patients with a suspected thrombotic micro-angiopathy (TMA). Aim: To evaluate the FRC in comparison to the microscopic schistocyte percentage in order to determine its diagnostic utility. Methods: Schistocytes were evaluated in 136 samples by microscopy by two competent morphologists according to International Council for Standardisation in Haematology (ICSH) recommendations. This was compared with the FRC on the Sysmex XN-9000 (Sysmex Corporation, Kobe, Japan). The degree of agreement was measured using the Bland and Altman method and Deming-regression statistical methods. Results: Schistocytes were observed in patients with TMA (8.82%), malignancies (11.03%), haemodialysis (34.56%), haemoglobinopathies (8.82%), nutritional anaemias (13.24%) and in neonates (1.47%). The correlation co-efficient between the two morphologists was 0.97 (CI, 0.92 to 1.01) and the mean of the differences was -0.02 (CI, -0.53 to 0.50). The Sysmex overestimated the schistocyte count (2.61, CI, 2.15 to 3.07) and revealed a poor correlation with microscopy (0.21 CI, 0.05 to 0.38). There was no correlation between the percentage of microcytic (%Micro-R) and hypochromic red cells (%Hypo-He) and the FRC. Conclusion: This study confirms that observer bias between morphologists can be reduced by implementing the ICSH guidelines. Measurement of the automated FRC by the Sysmex XN 9000 analyser overestimated the schistocyte percentage. The FRC requires confirmation by microscopy.

Nyaope is a novel psychoactive mixture of drugs unique to South Africa’s townships. A mixture of caffeine, paracetamol, opiates, sedatives, psychoactive drugs as well as antibiotics and antiretroviral drugs were identified using Time of Flight Mass Spectrometry. The Nyaope users frequently complained of severe chest and abdominal pain, excessive drowsiness, vomiting and diarrhoea with progressive weight loss. However, the effect of Nyaope on various body systems has not been verified. The purpose of this study was to investigate the status of liver, kidney, endocrine function, and haematological parameters in chronic Nyaope users. Ninety eight users participated for laboratory analyses of liver, kidney, thyroid and gonadal functions, blood counts and immunophenotyping. From these, 86.7% of users showed abnormalities in the laboratory tests performed, and 10.2% to 31.6% with possible specific organ dysfunctions. In conclusion, Nyaope users were found to have abnormal laboratory parameters that may be suggestive of organ dysfunctions, occult infections, and possible bone marrow suppression and would require further investigations.

Introduction: The frequency of serious bacterial infections has increased due to the high prevalence of HIV, contributing to the increasing rates of multi-drug organisms which include carbapenem-resistant Enterobacteriaceae (CRE). This has resulted in higher use of immunosuppressive and cytotoxic drugs to treat serious bacterial infections and optimal treatment for infections caused by CRE remains unknown. The benefits of azole antifungals and its derivatives have become very topical due to their diverse spectrum of pharmacological properties, but its efficacy has not been tested in the South African context. The aim of this study was to determine the antibacterial effects of azole antifungals against CRE. Method: Different concentrations of azole antifungals (ketoconazole, metronidazole and fluconazole) were used to prepare sensitivity discs and four pathogenic strains of CRE ( K. pneumoniae, E. coli, S. marcesens and C. freundii ). These were obtained from Lancet Laboratory in Durban and were used to determine the antibacterial activity of the selected azole antifungals, using: Disc Diffusion, Modified Agar Diffusion and Minimum Inhibition Concentration (MIC) method, as described by Bauer et al. 1966. Results: Antimicrobial Susceptibility Testing revealed that azoles have no inhibition activity against CRE test organisms and biochemical tests also demonstrated that azoles have no adverse effects on the CRE organisms. Conclusion: Although the results obtained in this study indicated no activity of azoles against CRE, clinical studies are still necessary for the modification of the azole substituents and synthesis of azole derived drugs to confirm and optimise the antibacterial efficacy of these compounds.

Although controversial, hyperglycaemia has been associated with immune dysregulation. We compared the expression of T-cell activation markers in Western Cape hyperglycaemic individuals with matched normoglycaemic controls. Sixty nine participants (86% being women) were included and screened for hyperglycaemia according to World Health Organisation (WHO) criteria. Standard multi-colour flow cytometry was used to measure expression of HLA-DR, CD38, CD95 and PD-1on T-cells at baseline and post incubation with 30mmol glucose. The results were compared and correlated with markers of glucose metabolism and inflammation. The 69 participants included 35 with normal glucose tolerance and 34 with hyperglycaemia. Antigen expression was similar between the two groups. However, after exposure to glucose the percentage of CD4 + T-cells expressing CD95 significantly decreased (p=0.03). There was no correlation with markers of glucose metabolism, but expression did correlate with C-reactive protein. This study in a modest sample group found no relationship between T-cell activation and glucose metabolism, suggesting that other factors such as obesity may be responsible for immune dysregulation. Further studies are required to confirm these findings.

Background: Medicinal plants contain components of therapeutic value and provide an alternative form of available antibiotics to multiple infections. Development of microbial resistance to the available antibiotics has further enhanced the investigation of the role of antimicrobial activity of medicinal plants. Method: Here we report the antimicrobial properties of Artemisia afra, Psidium guajava and Erythrina lysistemon extracts obtained by using two different extraction solvents. Extracts were subjected to tests using zones of inhibition, Thin Layer Chromatography and High Pressure Liquid Chromatography (HPLC). Results: Pronounced antimicrobial activity was observed against Staphylococcus aureus using the ethanol extraction technique. However, no statistical significance was observed between the results produced using extracts from both methods A (according to dilution factor) and B (method 3a of the German Homeopathic Pharmacopoeia). Conclusion: The potential for developing antimicrobials from plants in vivo provides a platform for phytomedicine and pharmacological studies.

Background: The National Health Laboratory Services (NHLS), Quality Assurance (QA) department’s responsibility is to ensure diagnostic supplies meet required standards. Of particular importance are in vitro diagnostic devices (IVD’s) such as: reagents, all controls including Quality Controls (QC), equipment and laboratory consumables. Applying the required standards ensures that they are ‘fit for purpose’. This process supports and enhances laboratory accreditation as well as strengthening all laboratory systems. Objectives: To assess: (i) the IVD’s acquisition processes within the NHLS; (ii) whether a health technology assessment (HTA) framework could be used and (iii) assessing the impact of implementing a health technology assessment unit in supporting accreditation and strengthening laboratory systems. Methods: The researchers planned a strategy meeting to review IVD acquisition processes within the selected organisation. The participants were multidisciplinary technical laboratory personal. The discussions at the HTA strategic workshop focused on Quality Assurance and laboratory accreditation in addressing the requirements of ISO15189:2012, which is important to ensure consistent adherence to accreditation and compliance measures across all the laboratories within the NHLS framework. Results: A workshop entitled: Health Technology Assessment Strategy was the first workshop held by the NHLS to stress the challenges faced when acquiring new technologies. The workshop participant’s described the present processes of IVD acquisition within the NHLS as incoherent. In particular, they emphasised the lack of clearly defined IVD evaluation and requisition procedures. The examples given were the following: the adoption of technologies on ad-hoc bases with limited consensus from all users, the lack or inadequate selection criteria for performance evaluations, the need to adopt standardised protocols and report templates and the absence of a national database to ensure monitoring and compliance of existing suppliers. Conclusions: The acquisition of IVD’s for pathology services is a universal requirement. The NHLS is unique as it provides pathology services to hospitals but is not incorporated as part of the hospital’s management system. However the impact of evaluating IVD’s is a requirement for developed and developing countries. The establishment of the HTA unit would provide an environment for the coordination and management all IVD requests. This unit would be a single port of entry at the NHLS for all IVD performance evaluations and in addition it would support laboratory accreditation as well as procurement decision making processes within the NHLS.