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Objectives: To evaluate the rate of tuberculosis (TB) in biologic users for rheumatic diseases in South Africa, the effectiveness of our latent TB infection (LTBI) programme, risk factors and outcome., Methods: TB cases were collected from the South African Biologics Registry (SABIO), rheumatologists and pharmaceutical companies. Demographics, LTBI screening and treatment, biological and disease modifying antirheumatic drug (DMARD) therapies, TB diagnosis and outcomes were recorded., Results: 96 TB cases were collected from 1999 to June 2017: rheumatoid arthritis 55, ankylosing spondylitis 27, psoriatic arthritis 4, and juvenile inflammatory arthritis 10. The TB rate was 1240/100 000 person years for biologic users (n=96) versus the biologic naive cohort of 0/100 000 years with an incidence rate difference of 0.0124 (p<0.0001). 60/96 had pulmonary and 36/96 had extra-pulmonary TB. Reactivation TB occurred in 45/96 cases. TB occurred in all biologics licenced in South Africa, the majority in monoclonal inhibitors (1683/100 000 person years) compared with etanercept (861/100 000 person years) and non-tumour necrosis factor (TNF) inhibitors (681/100 000 person years). The incidence rate ratio for monoclonal inhibitors compared with etanercept was 1.96 (p=0.005) and 2.47 (p=0.002) compared with non-TNF inhibitors with no significant difference between non-TNF inhibitors and etanercept (p=0.336). From those (12.9%) who screened LTBI positive, 14 developed TB, while the majority (77) screened LTBI negative. Black race, male sex, younger age and residence in the Western Cape were statistical risk factors. Two drug resistant TB cases and six deaths occurred., Conclusion: Reactivation and new onset TB is a significant risk for all biologics users in SA. Screening for LTBI is an imperative preventative strategy., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To quantify primary and secondary anti-tumour necrosis factor inadequate response (aTNF-IR) and intolerance in South Africans with rheumatoid arthritis (RA) over 1 year., Methods: Rheumatologists from nine independent private practices monitored RA patients commencing on aTNF therapy (incident cases) or already on aTNF therapy (prevalent cases). Observations at baseline and quarterly intervals recorded discontinuation of therapy for either lack of response or adverse effects., Results: Of the 98 patients screened, 86 were eligible to participate. Mean time from onset of symptoms of RA to start of aTNF treatment was 9.7 years (range: 0.5-32 years). Only 58 (67.4%) continued on aTNF therapy at 12 months, including five judged to have an aTNF-IR. Overall 12 patients had a secondary aTNF-IR with seven discontinuing for this reason. Seven patients discontinued due to adverse events, four due to funding problems and 10 were lost to follow-up. Infections were the most common adverse events, but only two stopped treatment as a result. No cases of active tuberculosis (TB) were recorded, despite nine patients having a positive tuberculin skin test and one, a past history of pulmonary TB., Conclusions: Almost a third of patients discontinued aTNF therapy over the 1-year period, with infections and inadequate response to treatment being the main reasons for discontinuation. The study highlights the need for biologics with alternative modes of action for patients with moderate to severe RA in South Africa., (© 2014 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd.)

Updated treatment recommendations for the therapy of rheumatoid arthritis (RA) in South Africa advocate early diagnosis, prompt initiation of disease-modifying anti-rheumatic drugs (DMARDs), and an intense treatment strategy where disease activity is assessed with a composite score such as the Simplified Disease Activity Index (SDAI). Frequent assessments and escalation of therapy are necessary until low disease activity (LDA) (SDAI ≤11) or ideally remission (SDAI ≤3.3) is achieved. Synthetic DMARDs may be used as monotherapy or in combination, and can be co-prescribed with low-dose corticosteroids if necessary. Biologic DMARD therapy should be considered for patients who have failed a 6-month trial of at least 3 synthetic DMARDs. All RA patients in SA are at increased risk of tuberculosis (TB), in particular patients using anti-tumour necrosis factor (TNF) biologic therapy. These recommendations provide practical suggestions for the screening and management of TB and other comorbidities, and offer an approach to monitoring of RA patients.

In a sample of 100 hospitalized human immunodeficiency virus-seropositive black South African patients with CD4 cell counts of <100 cells/mm(3), the point prevalence of disseminated Mycobacterium avium complex infection was 10%, in contrast with other African studies that report that the infection is uncommon. The point prevalence of Mycobacterium tuberculosis was 54%. The clinical and laboratory features of these patients were largely unhelpful in detecting M. avium complex; the BACTEC blood culture (Becton Dickinson) was the only reliable method.

The trend towards community living for people with learning disabilities puts pressure on traditional hierarchical lines of resource management. A sample of 150 community residential facilities is surveyed in order to describe the systems used to manage resources in the community and to assess the impact they have on the quality of service provided. There are marked differences amongst provider agencies in the degree to which responsibility for resource management is devolved to facility managers and this has a direct effect on the quality of care. Residential homes which operate under centralised management systems are more institutional in their care practices and less responsive to individual clients' needs. In contrast, homes in which responsibility is delegated to the facility manager provide a service more in keeping with current philosophies of care. The results of this survey suggest that more responsibility for resource management can be delegated to facility managers without losing control of expenditure and with improvements in the efficiency and effectiveness of care.

The increase in community care provision for people with a mental handicap makes an understanding of the attitudes and motivations of staff caring for them an urgent priority. Norma Raynes and colleagues describe a Department of Health-sponsored study which investigated the quality of care delivered in four key sectors of community residential care. Their findings reveal the positive attitudes of staff in all four settings and suggest that local authorities have a potential source of highly motivated recruits among those working in the health, voluntary and private sectors.