Driver intoxication and risk for fatal crashes in South Africa: A 3-year review.

BACKGROUND:  Globally, alcohol intoxication has been shown to be significantly associated with increased risk for road traffic crash morbidity and mortality for all road users (drivers, passengers and pedestrians). This association relates to the diminished capacity of drivers while intoxicated to operate motor vehicles and the increased propensity for risk-taking behaviours. The overall prevalence of alcohol-related fatal crashes contributes significantly to the burden of disease in many countries. In South Africa, research into the relationship between alcohol intoxication and other driver risk behaviours is limited and variable, constraining appropriate and effective policy and programmatic options and interventions. OBJECTIVES:  To examine the risk for fatal crashes attributed to driver alcohol intoxication relative to speeding and other driver risk behaviours across a range of key crash and vehicle characteristics and temporal variables. METHODS:  The study used a sample of fatal crashes drawn from the Road Traffic Management Corporation database for the period 2016 - 2018, comprising 13 074 fatal crashes. An overview of the sample data is provided using descriptive statistics. Following this, logistic regression modelling was undertaken to examine and clarify the risk for alcohol-attributed fatal crashes against that for speeding and a combined category of all other driver risks using variables relating to crash complexity, vehicle characteristics and regulation, and temporal variables for day/night, weekday/weekend and vacation/non-vacation periods. RESULTS:  Compared with fatal crashes involving only the driver, the study revealed a significantly greater risk for alcohol-attributed fatal crashes in instances involving more complexity as measured by involvement of other road users (pedestrians and other drivers). Additionally, the risk for alcohol-attributed fatal crashes was significantly greater for light vehicles and buses/midibuses compared with trucks. Road users were also at greater risk for such crashes at night, over long and regular weekends, and during non-vacation periods of the year. CONCLUSIONS:  Improved enforcement to prevent alcohol intoxication using roadblocks is required in a focused manner during specific temporal periods (at night, over weekends and during non-vacation periods), while enforcement to prevent speeding and other driver risks should be prioritised during other periods using speed monitoring and mobile visible policing, respectively. There is an urgent need to improve the current measurement of alcohol attribution in fatal crashes, to ensure more accurate estimation of prevalence, and to improve analysis and understanding of the compound impact of alcohol intoxication on all other driver risk behaviours and associated fatal crashes.

Chronic kidney disease in patients at high risk of cardiovascular disease in the United Arab Emirates: A population-based study.

Chronic kidney disease has become an increasingly significant clinical and public health issue, accounting for 1.1 million deaths worldwide. Information on the epidemiology of chronic kidney disease and associated risk factors is limited in the United Arab Emirates. Therefore, this study aimed to evaluate the incidence and causes of chronic kidney disease stages 3-5 in adult United Arab Emirates nationals with or at high risk of cardiovascular disease. This retrospective study included 491 adults with or at high risk of cardiovascular disease (diabetes mellitus or associated clinical disease) who attended outpatient clinics at a tertiary care hospital in Al-Ain, United Arab Emirates. Estimated glomerular filtration rate was assessed every 3 months from baseline to June 30, 2017. Chronic kidney disease stages 3-5 were defined as an estimated glomerular filtration rate < 60 mL/min/1.73 m2 for ≥ 3 months. Multivariable Cox's proportional hazards analysis was used to determine the independent risk factors associated with developing chronic kidney disease stages 3-5. The cumulative incidence of chronic kidney disease stages 3-5 over a 9-year period was 11.4% (95% confidence interval 8.6, 14.0). The incidence rate of these disease stages was 164.8 (95% confidence interval 121.6, 207.9) per 10,000 person-years. The independent risk factors for developing chronic kidney disease stages 3-5 were older age, history of coronary heart disease, history of diabetes mellitus, and history of smoking. These data may be useful to develop effective strategies to prevent chronic kidney disease development in high-risk United Arab Emirates nationals.

A review of patients with glutaric aciduria type 1 at Inkosi Albert Luthuli Central Hospital, Durban, South Africa.

Glutaric aciduria type 1 (GA1) is an organic acidaemia. The objective of this study was to describe the profile of patients diagnosed with GA1 at Inkosi Albert Luthuli Central Hospital, Durban, South Africa from 2007 to 2015. We identified 6 children (4 girls, 2 boys) in a retrospective review. The mean age at diagnosis was 12 months. Clinical findings on presentation were encephalopathic crises (n=4), hypotonia (n=4) and macrocephaly (n=5). Other complications included seizures (n=4), dystonia (n=3) and bulbar dysfunction (n=4). Urine organic acid screens showed elevated glutaric acid levels (n=6). Five patients tested positive for the A293T mutation on the glutarylco-enzyme A (CoA) dehydrogenase gene. Abnormalities on magnetic resonance imaging screening included hyperintense basal ganglia (n=6), widened perisylvian fissures (n=6), and an abnormal signal in the cerebral peduncles (n=5) and central tegmental tract (n=4). All patients were treated with L-carnitine and dietary modification. Two patients had a static clinical course, 1 patient gained milestones, and 3 have shown further neuroregression.

Readiness to adopt a performance measurement system for substance abuse treatment: Findings from the Service Quality Measures initiative.

BACKGROUND: A performance measurement system - the Service Quality Measures (SQM) initiative - has been developed to monitor the quality of South Africa (SA)'s substance abuse treatment services. Identifying factors associated with readiness to adopt this system may inform strategies to facilitate its robust implementation. OBJECTIVE: To examine factors associated with readiness to adopt a performance measurement system among SA substance abuse treatment providers. METHODS: We surveyed 81 treatment providers from 13 treatment sites in the Western Cape, SA. The survey examined awareness, resources, organisational climate, leadership support and readiness to adopt the SQM system. Regression analysis was used to identify factors associated with readiness to adopt this system. RESULTS: Readiness to adopt the SQM initiative was high (M=5.64, standard deviation 1.63). In bivariate analyses, caseload size (F=3.73 (degrees of freedom (df)=3.70), p=0.015), awareness (r=0.78, p<0.0001), leadership support (r=0.70, p<0.0001), resources (r=0.65, p<0.0001), openness to change (r=0.372, p=0.001), and external pressure to change were associated with readiness to adopt the SQM. In multivariate analyses, only awareness of the SQM initiative (B=0.34, standard error (SE) 0.08, t=4.4, p<0.0001) and leadership support (B=0.45, SE 0.11, t=4.0, p<0.0001) were significantly associated with readiness to adopt this system. CONCLUSION: While treatment providers report high levels of readiness to adopt the SQM system, findings show that the likelihood of adoption can be further increased through improved provider awareness and enhanced leadership support for this health innovation.

Household and caregiver characteristics and behaviours as predictors of unsafe exposure of children to paraffin appliances.

This study examines adult safety knowledge and practices regarding the use of paraffin cooking appliances. The use of these is common in South Africa with injury risks that are poorly understood. This cross-sectional study was in an informal settlement in Johannesburg, South Africa, where children were reportedly at high risk for burns. This study sought to clarify relationships between key risks and developed individual and composite variables from theoretical constructs and operational definitions of risks for burns. Risks included Child Use of Paraffin Appliances, Child Proximity to Cooking, Risky Stove Use, Caregiver's Burn Treatment Knowledge, Children Locked in House, Children Alone in House. Number of children remains as in proof as this was not a composite scale. Child Proximity to Cooking was associated with more children in the home. Households where children were in greater proximity to cooking were 6 times more likely to be left alone at home, with caregivers with no education over 100 times more likely to lock their children at home. Children locked in were often from homes where caregivers used appliances unsafely. In settings with hazardous energy use, compressed household configurations, and families with multiple children, Risky Stove Use and the practice of locking children in the home may be catastrophic.

Readiness to adopt a performance measurement system for substance abuse treatment: Findings from the Service Quality Measures initiative

Background. A performance measurement system ­ the Service Quality Measures (SQM) initiative ­ has been developed to monitor the quality of South Africa (SA)'s substance abuse treatment services. Identifying factors associated with readiness to adopt this system may inform strategies to facilitate its robust implementation.Objective. To examine factors associated with readiness to adopt a performance measurement system among SA substance abuse treatment providers.Methods. We surveyed 81 treatment providers from 13 treatment sites in the Western Cape, SA. The survey examined awareness, resources, organisational climate, leadership support and readiness to adopt the SQM system. Regression analysis was used to identify factors associated with readiness to adopt this system.Results. Readiness to adopt the SQM initiative was high (M=5.64, standard deviation 1.63). In bivariate analyses, caseload size (F=3.73 (degrees of freedom (df)=3.70), p=0.015), awareness (r=0.78, p<0.0001), leadership support (r=0.70, p<0.0001), resources (r=0.65, p<0.0001), openness to change (r=0.372, p=0.001), and external pressure to change were associated with readiness to adopt the SQM. In multivariate analyses, only awareness of the SQM initiative (B=0.34, standard error (SE) 0.08, t=4.4, p<0.0001) and leadership support (B=0.45, SE 0.11, t=4.0, p<0.0001) were significantly associated with readiness to adopt this system.Conclusion. While treatment providers report high levels of readiness to adopt the SQM system, findings show that the likelihood of adoption can be further increased through improved provider awareness and enhanced leadership support for this health innovation

Elevated Risk of Suicidal Ideation in HIV-Positive Persons.

Globally, suicide and HIV/AIDS remain two of the greatest healthcare issues, particularly in low- and middle-income countries. Several studies have observed a relationship between suicidal behaviour and HIV/AIDS. Materials and Methods. The main objective of this research was to determine the prevalence of elevated risk of suicidal ideation in HIV-positive persons immediately following voluntary HIV counselling and testing (VCT). The study sample consisted of adult volunteers attending the VCT clinic at a university-affiliated, general state hospital. Participants completed a sociodemographic questionnaire, Beck's Hopeless Scale, and Beck's Depression Inventory. Results. A significantly elevated risk of suicidal ideation was found in 83.1% of the patients who tested seropositive. Despite a wide age range in the cohort studied, the majority of patients with suicidal ideation were males in the younger age group (age < 30 years), consistent with the age-related spread of the disease and an increase in suicidal behaviour in younger people. Relevant associated variables are discussed. Conclusion. The results serve as important markers that could alert healthcare professionals to underlying suicide risks in HIV-positive patients. It is recommended that screening for elevated risk of suicidal ideation and prevention of suicidal behaviour should form a routine aspect of comprehensive patient care at VCT clinics.

Hazardous and harmful use of alcohol and/or other drugs and health status among South African patients attending HIV clinics.

There is growing recognition of the influence of substance use, particularly alcohol use, on HIV disease progression. This study investigated how hazardous/harmful use of alcohol and drugs impacts the health status of 1503 patients attending HIV clinics. Of the sample, 37 % indicated hazardous/harmful drinking and 13 % indicated a drug problem. Hazardous/harmful use of alcohol and drugs was significantly related to health status, with participants using substances more likely to have TB-positive status (χ(2) = 4.30, p < 0.05), less likely to be on ARVs (χ(2) = 9.87, p < 0.05) and having lower CD4 counts (t = 4.01, p < 0.05). Structural equation modelling confirmed the centrality of hazardous/harmful use of alcohol as a direct and indirect determinant of disease progression. Based on these findings it is recommended that patients attending HIV clinics be routinely screened for problematic alcohol and/or drug use, with strong emphasis on ensuring ARV adherence in those with problematic alcohol use.

Guideline for the diagnosis and management of multiple sclerosis: a Southern African perspective.

Before making a diagnosis of multiple sclerosis (MS), it is imperative that alternative diagnoses are considered and excluded. This is particularly important in South Africa, which is a moderate prevalence MS area, has a high burden of neurological infections and where the majority of the people are black - an ethnic group that has a very low frequency of MS. Before applying diagnostic criteria, there should be no better explanation for the patient's presentation. This guideline, written on behalf of the Multiple Sclerosis Society of South Africa, aims to assist in the diagnosis and treatment of MS in Southern Africa. 

Development and preliminary validation of a patient-reported outcome measure for swallowing after total laryngectomy (SOAL questionnaire).

OBJECTIVES: To develop and validate a laryngectomee-specific questionnaire to investigate swallowing function. This paper describes the generation of questionnaire items, pretesting with laryngectomees and a preliminary validation. DESIGN: This study employed 2 phases: questionnaire development and questionnaire validation. Items were developed from patient (n = 10) and clinician (n = 6) focus groups. Content checking, acceptability and face validity were determined through pretesting with 10 laryngectomees and via consensus feedback from 35 speech and language therapists. During preliminary validation, the 17-item final questionnaire was administered to 3 different groups. Discrimination amongst groups was established by comparing questionnaire responses of a laryngectomee group (n = 19) with known dysphagic (n = 19) and non-dysphagic groups (n = 20). Questionnaire responses from the reference dysphagic group were compared with an instrumental assessment of swallowing, the modified barium swallow (MBS). SETTING: Large urban teaching hospital. PARTICIPANTS: Speech and language therapists, laryngectomees, non-dysphagic volunteers, post-radiotherapy dysphagic patients. MAIN OUTCOME MEASURE: Preliminary validation of SOAL questionnaire. RESULTS: Normal, laryngectomee and dysphagic groups had significantly different SOAL scores, as did laryngectomees with different degrees of swallowing impairment (Kruskall Wallis, P << 0.001). The subjective SOAL score had a strong positive correlation with the reference measure of ratings on the MBS (r = 0.5; P = 0.03). CONCLUSIONS: The swallowing outcome after laryngectomy (SOAL) questionnaire is a simple, self-administered tool to assess swallowing function post-total laryngectomy. Further specific testing with a laryngectomy cohort is necessary for full validation. Its potential value lies in screening for dysphagia in clinics or during long-term follow-up of laryngectomees.

Suicidal ideation in seropositive patients seen at a South African HIV voluntary counselling and testing clinic.

OBJECTIVE: Suicidal behaviour and HIV/AIDS are significant public health concerns. The aim of this study was to investigate suicidal ideation in patients who were referred to a voluntary HIV counselling and testing (VCT) clinic and who were found to be seropositive. This in order to improve suicide prevention and intervention strategies amongst such patients. METHOD: The sample studied consisted of volunteer adult patients referred over a three-month period to a HIVVCT clinic based at a university-affiliated general state hospital. Patients completed a questionnaire on sociodemographic data. Suicidal ideation was measured using the Beck Hopelessness Scale and the Beck Depression Inventory (BDI), at two time points (within 72 hours after notification and again at a 6 week follow-up). All patients received extensive pre-and post-test counselling. RESULTS: HIV-test results were available for 189 (99.5%) of the original sample of 190 patients studied, with 157 (83.1%) testing positive. More females tested positive as did unemployed and single/divorced patients. The mean age for HIV-positive patients was 33.49 (SD = 9.449), and for HIV-negative patients it was 37.94 (SD = 15.238). Age was a significant factor in that for each year increase in age, the risk of testing HIV-positive decreased by 4.1%. Lower education and traditional beliefs were also significantly associated with testing HIV-positive. At 72 hours suicidal ideation was present in 17.1% (95% confidence interval 12.16% to 23.45%), and at 6 weeks in 24.1% (95% confidence interval 17.26% to 32.39%) of the seropositive patients. Their average BDI scores were 15.20 and 14.23 respectively at the two time points. CONCLUSION: Suicidal ideation was present in a significant number of the seropositive cohort studied and increased over a six week period among these patients. The average BDI scores at both time points imply a clinical depression. The findings also suggest an association between positive HIV-test results and certain socio-demographic variables that can act as indicators for suicidal ideation in HIV-infected persons, although this requires further research. Although the relationship between suicidal ideation and HIV-infection is complex, it is an important consideration when assessing patient suicide vulnerability at HIV VCT clinics and when implementing suicide prevention and management strategies.

Diagnostic outcome of patients referred to psychiatry with medically unexplained symptoms: a retrospective study.

OBJECTIVE: Medically unexplained symptoms (MUS) are commonly encountered in medical practice. In psychiatry, they are classified mostly as Somatoform Disorders and are often associated with anxiety and depression. The literature suggests that, in some cases, MUS may be ascribed to Somatoform Disorders when, fact, they are "organic" syndromes that are misdiagnosed. In developing countries, with fewer resources, MUS may be more difficult to assess. METHOD: We undertook a retrospective chart review to examine the demographics, referral pathway, management and diagnostic outcome of subjects (n = 50) referred to psychiatry with MUS over an 18 month period. RESULTS: Subjects with MUS accounted for only 4.5% of the total number of files reviewed. In only 38% of cases did the final diagnosis in psychiatry concur with the referral diagnosis. In 28% of cases a new "organic" diagnosis was made and in 72% of cases a new psychiatric diagnosis was made. Subjects who were diagnosed with "organic" illness were seen fewer times prior to referral to psychiatry and were significantly older than other subjects. CONCLUSION: In developing countries like SA, a significant number of patients with MUS may have underlying "organic" illness, and most may have psychiatric disorders. Patients with MUS, especially older patients, should be more extensively investigated. Psychiatric referral of these patients is very appropriate.

Diagnostic outcome of patients referred to psychiatry with medically unexplained symptoms: a retrospective study

Objective: Medically unexplained symptoms (MUS) are commonly encountered in medical practice. In psychiatry; they are classified mostly as Somatoform Disorders and are often associated with anxiety and depression. The literature suggests that; in some cases; MUS may be ascribed to Somatoform Disorders when; fact; they are ""organic"" syndromes that are misdiagnosed. In developing countries; with fewer resources; MUS may be more difficult to assess. Method: We undertook a retrospective chart review to examine the demographics; referral pathway; management and diagnostic outcome of subjects (n = 50) referred to psychiatry with MUS over an 18 month period. Results: Subjects with MUS accounted for only 4.5of the total number of files reviewed. In only 38of cases did the final diagnosis in psychiatry concur with the referral diagnosis. In 28of cases a new ''organic"" diagnosis was made and in 72of cases a new psychiatric diagnosis was made. Subjects who were diagnosed with ""organic"" illness were seen fewer times prior to referral to psychiatry and were significantly older than other subjects. Conclusion: In developing countries like SA; a significant number of patients with MUS may have underlying ""organic"" illness; and most may have psychiatric disorders. Patients with MUS; especially older patients; should be more extensively investigated. Psychiatric referral of these patients is very appropriate."

Use of botulinum toxin in voice restoration after laryngectomy.

BACKGROUND: Following laryngectomy, a distinct population of patients fails to achieve successful tracheoesophageal voice. These patients' voices range from strained and effortful to none at all. Such patients may present with severe hypertonicity or spasm of the pharyngoesophageal segment. Botulinum toxin has been used to chemically denervate the pharyngeal musculature, and is an alternative to invasive surgical procedures. The aim of this article is to review the evidence for using botulinum toxin to achieve an improvement in post-laryngectomy voice. METHODS: A Medline literature review (1966 to January 2009) and a search of the Cochrane database were performed. Foreign language articles and those not pertaining to post-laryngectomy voice restoration were excluded. RESULTS: Nine articles reporting a total of 134 patients were identified. Although there were differences in the outcome measures used, objective improvement in voice production occurred in between 70 and 100 per cent of cases. CONCLUSION: Botulinum toxin can be used as a safe and cost-effective treatment in patients with confirmed pharyngoesophageal segment hypertonicity and/or spasm following laryngectomy, to obtain an improvement in voice quality.

Biological variation of ischaemia-modified albumin in healthy subjects.

AIM: Ischaemia-modified albumin (IMA), as measured by the albumin-cobalt binding (ACB) test, has been cleared by the US Food and Drug administration as a biomarker to exclude the presence of myocardial ischaemia in patients. Although there are a number of published studies detailing the clinical utility of IMA, data on the biological variation of IMA are still lacking. In this study we determined the analytical and biological variance components of ischaemia modified albumin, and compared the distribution of IMA values in our patient population to those provided by the kit manufacturer. METHODS: IMA was determined once a week for five consecutive weeks on a cohort of healthy subjects using a colorimetric method, the A CB test on a Roche modular analyser. RESULTS: The analytical coefficient of variation (CV(A)) was 5%, and the within-subject (CV(I)) and between-subject (CV(G)) biological variations were 3 and 7%, respectively. Analysis of the repeated measures with gender and race (black and Caucasian) as between-subject factors, and weeks (1-5) as the within-subject factor showed that gender had no significant effect on circulating IMA concentrations (p = 0.3146), whereas race did have a significant effect (p = 0.0062). A significant (p = 0.0185) interaction was observed between gender and race. CONCLUSION: The ACB test could bring a new dimension to the care and management of patients with acute coronary syndrome. Further studies for normal population distributions by gender and ethnicity, and an optimum cut-off value appear to be required.

Biological Variation of Ischaemia-Modified Albumin in Healthy Subjects : Cardiovascular Topic

Aim : Ischaemia-modified albumin (IMA); as measured by the albumin-cobalt binding (ACB) testr; has been cleared by the US Food and Drug administration as a biomarker to exclude the presence of myocardial ischaemia in patients. Although there are a number of published studies detailing the clinical utility of IMA; data on the biological variation of IMA are still lacking. In this study we determined the analytical and biological variance components of ischaemia-modified albumin; and compared the distribution of IMA values in our patient population to those provided by the kit manufacturer. Methods : IMA was determined once a week for five consecutive weeks on a cohort of healthy subjects using a colorimetric method; the ACB testr on a Roche modular analyser. Results : The analytical coefficient of variation (CVA) was 5; and the within-subject (CVI) and between-subject (CVG) biological variations were 3 and 7; respectively. Analysis of the repeated measures with gender and race (black and Caucasian) as between-subject factors; and weeks (1-5) as the within-subject factor showed that gender had no significant effect on circulating IMA concentrations (p = 0.3146); whereas race did have a significant effect (p = 0.0062). A significant (p = 0.0185) interaction was observed between gender and race. Conclusion : The ACB testr could bring a new dimension to the care and management of patients with acute coronary syndrome. Further studies for normal population distributions by gender and ethnicity; and an optimum cut-off value appear to be required