Increased Access to Antiretroviral Therapy Is Associated with Reduced Maternal Mortality in Johannesburg, South Africa: An Audit from 2003-2012.

OBJECTIVE: To assess the impact of expanded access to antiretroviral treatment (ART) on maternal mortality in Johannesburg, South Africa between 2003 and 2012. METHODS: Audit of patient files, birth registers and death certificates at a tertiary level referral hospital. Cause of death was assigned independently, by two reviewers. We compared causes of deaths and the maternal mortality ratios (MMR, deaths/100,000 live births) over three periods corresponding to changes in government policy on ART provision: period one, 2003-2004 (pre-ART); period two, 2005-2009 (ART eligibility with CD4 count <200cells/µL or WHO stage 4 disease); and period three, 2010-2012 (eligibility with CD4 count <350 cells/µL). RESULTS: There were 232 deaths and 80,376 deliveries in the three periods. The proportion of pregnant women tested for HIV rose from 43.4% in 2003 to 94.6% in 2012. MMR was 301, 327 and 232 in the three periods, (p = 0.10). The third period MMR was lower than the first and second combined (p = 0.03). Among HIV-positive women, the MMR fell from 836 in the first time period to 431 in the third (p = 0.008) but among HIV negative women it remained unchanged over the three periods, averaging 148. Even in the third period, however, the MMR among HIV-infected women was 3-fold higher than in other women. Mortality from direct obstetric causes such as hemorrhage did not decline over time, but deaths from tuberculosis and HIV-associated malignancy did. In 38.3% of deaths, women had not attended antenatal care. CONCLUSION: Higher coverage of HIV testing and ART has substantially reduced MMR in this hospital setting. Though the gap in MMR between women with and without HIV narrowed, a third of deaths still remain attributable to HIV. Lowering overall MMR will require further strengthening of HIV services, increased antenatal care coverage, and improved care for obstetric emergencies at all levels of care.

Non-infectious mimics of community-acquired pneumonia.

Community-acquired pneumonia (CAP) is a common cause of presentation to healthcare facilities. The diagnosis of CAP is usually made in patients with suggestive symptoms, signs, and radiological features. A number of non-infectious conditions, including neoplastic lesions, pulmonary oedema, pulmonary embolism, drug-induced pneumonitis, diffuse alveolar haemorrhage syndromes, cryptogenic organising pneumonia and acute eosinophilic pneumonia, may present in a similar way and mimic CAP. These other conditions are often only thought of after patients that are being treated as CAP fail to respond to therapy. The non-infectious mimics of CAP require early diagnosis and appropriate treatment to decrease patient morbidity and mortality. This article is intended to create an awareness of the non-infectious mimics of CAP and highlight some of the more frequent conditions as well as those that require early diagnosis and treatment to prevent a poor outcome.

Reduction of protein adsorption and macrophage and astrocyte adhesion on ventricular catheters by polyethylene glycol and N-acetyl-L-cysteine.

Cellular obstruction of poly(dimethyl)siloxane (PDMS) catheters is one of the most prevalent causes of shunt failure in the treatment of hydrocephalus. By modifying PDMS using short- and long-chain mono-functional polyethylene glycol (PEG604 and PEG5K, respectively) and N-acetyl-L-cysteine via adsorption and covalent binding (NAC and NAC/EDC/NHS, respectively), we increased surface wettability. We hypothesized that these surface modifications would inhibit protein adsorption and decrease host macrophage and astrocyte adhesion. Tested in a bioreactor set to mimic physiological flow, all modified surfaces significantly decreased albumin adsorption compared with PDMS (p < 0.05) except for PEG604-modified PDMS (p = 0.14). All four modification strategies significantly reduced (p < 0.01) fibronectin adsorption. PEG604, PEG5K, NAC, and NAC/EDC/NHS reduced the average level of macrophage adhesion by 53%, 63%, 40%, and 58% (p <.0.05 except when comparing PDMS with NAC) and astrocyte adhesion by 47%, 83%, 91%, and 72% (p < 0.05 except when comparing PDMS with PEG604), respectively. Combined with saline soak results which suggest that the surface wettability is stable over 30 days for each modification, our results are consistent with the hypothesis that these modifications decrease cell adhesion on catheters in vitro for the treatment of hydrocephalus.

Effects of surface wettability, flow, and protein concentration on macrophage and astrocyte adhesion in an in vitro model of central nervous system catheter obstruction.

While silicone devices have vastly improved an array of medical treatments, reactions at the tissue-substrate interface often impede their functionality. Insertion of a poly(dimethyl)siloxane (PDMS) catheter into the cerebral ventricles to drain excess cerebrospinal fluid (CSF) is the most common treatment of hydrocephalus, but shunting often fails because inflammatory tissue, choroid plexus cells, and debris grow into these central nervous system catheters and obstruct flow. We hypothesized that plasma oxidation of PDMS would inhibit macrophage and astrocyte adhesion under flow (0 to 0.3 mL/min) and protein (20.8 to 240 mg/dL) conditions similar to those observed in the physiological state. Oxidation (to increase wettability) had an inhibitory effect on macrophage cell binding (yielding a significant 88% change) that was generally more pronounced than the effect of flow (22% change) or protein concentration (3% change). In contrast, greater flow increased binding of astrocytes in most cases (yielding a significant 97% change); plasma oxidation (19% change), and protein concentration (60% change) had less pronounced effects. This study is the initial indicator that plasma oxidation of PDMS catheters may inhibit macrophage adhesion during CSF outflow but may not be as effective at inhibiting astrocyte binding.