Hip fractures in South Africa: mortality outcomes over 12 months post-fracture.

With increased urbanisation and longevity in sub-Saharan Africa, the burden of osteoporosis and resultant hip fractures (HF) has increased. This study shows that 1 in 3 subjects dies post-HF, and that there are significant delays and barriers to surgery, reflecting the need to prioritise HF care in South Africa. PURPOSE: The outcomes following hip fractures are unknown in sub-Saharan Africa. This study aimed to quantify the mortality rate (MR) following hip fractures and to identify predictors of mortality over 1 year. METHODS: In this cohort study, demographic, clinical, and biochemical characteristics of consecutive patients with low trauma hip fractures, admitted to the five public sector hospitals in eThekwini (formerly Durban), were recorded. Cox regression analyses identified predictors of mortality at 30 days and 1 year. RESULTS: In the 200 hip fracture patients studied, the mean age was 74.3 years (SD ± 8.8) and 72% were female. Hospital presentation was often delayed, only 15.5% presented on the day of fracture. At admission, 69.5% were anaemic, 42% had hyponatraemia, 34.5% raised creatinine, and 58.5% hypoalbuminaemia. All received skin traction before 173 (86.5%) underwent surgical fixation. Median time from admission to surgery was 19.0 days (IQR 12.3-25.0). Median hospital stay was 9.0 days (IQR 12.3-25.0). Mortality rates were 13% and 33.5% at 30 and 365 days, respectively. Over 1 year, African patients were more likely to die than Indian patients (40.9 versus 30%, HR 11.5 [95% CI 1.51, 2.57]; p = 0.012); delays to surgery predicted death (HR 1.02 [95% CI (1.00, 1.04)]; p = 0.022). In multivariate analyses, death at 1 year was most strongly predicted by an elevated serum creatinine (HR 2.43, 95% CI (1.02, 5.76), p = 0.044]. CONCLUSION: Hip fractures are associated with high MRs, in part explained by insufficient surgical capacity, highlighting the need for national efforts to improve hip fracture service provision.

Investigating the spatial variation and risk factors of childhood anaemia in four sub-Saharan African countries.

BACKGROUND: The causes of childhood anaemia are multifactorial, interrelated and complex. Such causes vary from country to country, and within a country. Thus, strategies for anaemia control should be tailored to local conditions and take into account the specific etiology and prevalence of anaemia in a given setting and sub-population. In addition, policies and programmes for anaemia control that do not account for the spatial heterogeneity of anaemia in children may result in certain sub-populations being excluded, limiting the effectiveness of the programmes. This study investigated the demographic and socio-economic determinants as well as the spatial variation of anaemia in children aged 6 to 59 months in Kenya, Malawi, Tanzania and Uganda. METHODS: The study made use of data collected from nationally representative Malaria Indicator Surveys (MIS) and Demographic and Health Surveys (DHS) conducted in all four countries between 2015 and 2017. During these surveys, all children under the age of five years old in the sampled households were tested for malaria and anaemia. A child's anaemia status was based on the World Health Organization's cut-off points where a child was considered anaemic if their altitude adjusted haemoglobin (Hb) level was less than 11 g/dL. The explanatory variables considered comprised of individual, household and cluster level factors, including the child's malaria status. A multivariable hierarchical Bayesian geoadditive model was used which included a spatial effect for district of child's residence. RESULTS: Prevalence of childhood anaemia ranged from 36.4% to 61.9% across the four countries. Children with a positive malaria result had a significantly higher odds of anaemia [AOR = 4.401; 95% CrI: (3.979, 4.871)]. After adjusting for a child's malaria status and other demographic, socio-economic and environmental factors, the study revealed distinct spatial variation in childhood anaemia within and between Malawi, Uganda and Tanzania. The spatial variation appeared predominantly due to unmeasured district-specific factors that do not transcend boundaries. CONCLUSIONS: Anaemia control measures in Malawi, Tanzania and Uganda need to account for internal spatial heterogeneity evident in these countries. Efforts in assessing the local district-specific causes of childhood anaemia within each country should be focused on.

Predictors of Trypanosoma lewisi in Rattus norvegicus from Durban, South Africa.

This study investigated associations between Trypanosoma lewisi and Xenopsylla cheopis, a common cyclical vector of T. lewisi; Polyplax spinulosa, a reported mechanical vector; and Laelaps echidnina and Laelaps lamborni, 2 rodent mites of Rattus norvegicus in Durban, South Africa. In total, 379 R. norvegicus individuals were live-trapped at 48 sites in 4 locality types around Durban during a 1-yr period. Rats were euthanized, cardiac blood was taken to check for hemoparasites, and ectoparasites were removed for identification. Parasite species richness was higher in pups (2.11) and juveniles (1.02) than adults (0.87). Most rats in the study harbored 1 or 2 of the 5 parasites surveyed. Rats with trypanosomes and fleas were more prevalent in the city center and harbor, where juveniles were most affected. Rats with lice were more prevalent in informal settlements and urban/peri-urban areas, where pups had the highest infestations. There was a significant positive association between rats with fleas and trypanosomes and a negative association between rats with lice and trypanosomes. Location and rat age were significant predictors of T. lewisi, X. cheopis, and P. spinulosa. Mites showed no strong association with trypanosomes. Ectoparasite associations are possibly habitat and life-cycle related. We conclude that Durban's city center, which offers rats harborage, an unsanitary environment, and availability of food, is a high-transmission area for fleas and trypanosomes, and consequently a potential public health risk.

Structural Equation Modeling of the Effects of Family, Preschool, and Stunting on the Cognitive Development of School Children.

A recent study based on a sample of 1,580 children from five adjacent geographical locations in KwaZulu-Natal, South Africa, was carried out to examine the association of nutrition, family influence, preschool education, and disadvantages in geographical location with the cognitive development of school children. Data were collected on the children from 2009 to 2011 for this developmental study and included cognitive scores and information on the health and nutrition of the children. The current study analyzed the association of demographic variables (geographical location (site)), child variables (sex, preschool education and socioeconomic status), parental level of education (maternal and paternal), child's health (HIV status and hemoglobin level) and anthropometric measures of nutritional status (height-for-age) with children's cognitive outcomes. The hypothesis is that the nutritional status of children is a pathway through which the indirect effects of the variables of interest exert influence on their cognitive outcomes. Factor analysis based on principal components was used to create a variable based on the cognitive measures, correlations were used to examine the bivariate association between the variables of interest in the preliminary analysis and a path analysis was constructed, which was used for the disaggregation of the direct and indirect effects of the predictors for each cognitive test in a structural equation model. The results revealed that nutritional status directly predicts cognitive test scores and is a path through which other variables indirectly influence children's cognitive outcome and development.

Factors associated with the health and cognition of 6-year-old to 8-year-old children in KwaZulu-Natal, South Africa.

OBJECTIVE: To investigate 6-year-old to 8-year-old children's health, nutritional status and cognitive development in a predominantly rural area of KwaZulu-Natal, South Africa. METHODS: Cohort study of 1383 children investigating the association of demographic variables (area of residence, sex, pre-school education, HIV status, height for age and haemoglobin level) and family variables (socioeconomic status, maternal and paternal level of education), with children's cognitive performance. The latter was measured using the Grover-Counter Scale of Cognitive Development and subtests of the Kaufman Assessment Battery for Children, second edition (KABC-II). General linear models were used to determine the effect of these predictors. RESULTS: Area of residence and height-for-age were the statistically significant factors affecting cognitive test scores, regardless of attending pre-school. Paternal level of education was also significantly associated with the cognitive test scores of the children for all three cognitive test results, whereas HIV status, sex and their socioeconomic status were not. CONCLUSION: Children with low cognitive scores tended to be stunted (low height-for-age scores), lacked pre-school education and were younger. Area of residence and their parents' educational level also influenced their cognition.

Risk factors of malaria in children under the age of five years old in Uganda.

BACKGROUND: Malaria is the leading cause of morbidity in Uganda with 90-95 % of the population at risk and it contributing to approximately 13 % of under-five mortality. The aim of this study was to investigate the relationship between the malaria status of children under the age of 5 years old in Uganda and selected socio-economic, demographic and environmental factors, as well as to identify significant risk factors associated with malaria. METHODS: This study made use of data collected from the 2014 Malaria Indicator Survey conducted in Uganda. Two test procedures for malaria in children under the age of 5 years old were carried out. Due to the complex survey design, a generalized linear mixed model was used to test for associations between several independent variables and the response variable, which was whether a child tested positive or negative for malaria according to the microscopy test. RESULTS: The sample in this study was made up of 4939 children. Of those children, 974 tested positive for malaria, resulting in an observed malaria prevalence of 19.7 %. The socio-economic factors closely related to the risk of malaria were main floor material, main wall material and availability of electricity in the household. The event of indoor residual spraying (IRS) significantly reduced a child's risk of malaria. An older child was associated with a higher risk of malaria, however their risk decreased with an increase in cluster altitude and an increase in their caregiver's education level. CONCLUSION: Although there has been a significant increase in the use of mosquito nets since the previous Malaria Indicator Survey done in 2009, particularly in the use of insecticide-treated nets (ITNs) and long-lasting insecticidal nets (LLINs), these control measures alone may not be sufficient. IRS will be a key strategy in reaching the malaria goals set by the government of Uganda. Supplementing these control measures with education of appropriate and consistent use of ITNs and LLINs, as well as education of practicing safe living habits, such as reducing outdoor activities during peak biting hours of a mosquito, can go a long way in aiding the reduction of the burden of malaria in Uganda.

The impact of missing data on clinical trials: a re-analysis of a placebo controlled trial of Hypericum perforatum (St Johns wort) and sertraline in major depressive disorder.

RATIONALE AND OBJECTIVE: Hypericum perforatum (St John's wort) is used to treat depression, but the effectiveness has not been established. Recent guidelines described the analysis of clinical trials with missing data, inspiring the reanalysis of this trial using proper missing data methods. The objective was to determine whether hypericum was superior to placebo in treating major depression. METHODS: A placebo-controlled, randomized clinical trial was conducted for 8 weeks to determine the effectiveness of hypericum or sertraline in reducing depression, measured using the Hamilton depression scale.We performed sensitivity analyses under different assumptions about the missing data process. RESULTS: Three hundred forty participants were randomized, with 28 % lost to follow-up. The missing data mechanism was not missing completely at random. Under missing at random assumptions, some sensitivity analyses found no difference between either treatment armand placebo, while some sensitivity analyses found a significant difference from baseline to week 8 between sertraline and placebo (-1.28, 95 % credible interval [-2.48; -0.08]), but not between hypericum and placebo (0.56, [-0.64;1.76]). The results were similar when the missing data process was assumed to be missing not at random. CONCLUSIONS: There is no difference between hypericum and placebo, regardless of the assumption about the missing data process. There is a significant difference between sertraline and placebo with some statistical-methods used. It is important to conduct an analysis that takes account of missing data using valid statistically principled methods. The assumptions about the missing data process could influence the results.