Living conditions and respiratory health in Walmer Township and Wells Estate, Port Elizabeth, South Africa.

BACKGROUND: Many impoverished communities in South Africa (SA) simultaneously face multiple preventable socioenvironmental hazards associated with elevated burdens of ill health. One such hazard is failure to institute effective buffer zones between human settlements and point sources of pollution such as airports and industrial zones. OBJECTIVES: To gather information on living conditions, housing quality and health status in two poor communities in the SA coastal industrial city of Port Elizabeth. METHODS: The study was undertaken in Walmer Township, situated in close proximity to Port Elizabeth International Airport, and Wells Estate, which borders two industrial sites. Approximately 120 households were randomly selected from each study site. Following written informed consent, information on the neighbourhood environment and housing conditions was collected through administration of a structured questionnaire. RESULTS: The two study sites were similar in respect of household language, income, education, high levels of debt servicing and high reliance on social grants. Relative to Walmer Township, higher levels of indoor dust and bad odours in the neighbourhood were reported in Wells Estate, as were higher rates of selected respiratory ill-health symptoms. Upper respiratory tract symptoms were significantly associated with reports of high levels of indoor dust, while lower respiratory tract symptoms were significantly associated with low income, overcrowding, and having a young child in the household. CONCLUSIONS: The study highlights a scenario of a triple environmental hazard to health in the study communities: (i) poverty; (ii) poor-quality housing; and (iii) lack of an effective buffer zone between the study communities and local point sources of pollution. Respiratory ill-health conditions were significantly associated with poverty, household composition and living conditions.

Outcomes of severe traumatic brain injury at time of discharge from tertiary academic hospitals in Bloemfontein.

BACKGROUND: Despite the condition being a major public health concern, limited data are available regarding survival rates and the requirement for post-hospitalisation support of patients with traumatic brain injury (TBI) in South Africa (SA). OBJECTIVES: To describe the clinical profile and in-hospital outcomes of patients with TBI at intensive care units (ICUs) of tertiary referral hospitals in the Free State Province, SA, between 2013 and 2017. METHODS: This retrospective descriptive study of patients with TBI was conducted at Pelonomi Tertiary and Universitas Academic Hospitals. Patients' demographic information and variables such as mechanism and type of injury, Glasgow Coma Scale (GCS) prior to ICU admission, neurosurgical intervention, duration of stay in ICU and hospital, GCS and final outcome at discharge were recorded. RESULTS: The 138 patients included in the final data analysis had a median (range) age of 30.5 (13 - 70) years, with a male predominance of 82.6%. The median lengths of stay in ICU and hospital were 6 and 16 days, respectively. Outcomes data showed that 65.9% of patients survived until discharge from hospital. Of patients whose GCS could be determined at discharge, 52.8% were deceased, 7.9% were in a persistently vegetative state, 11.2% had severe and 13.5% moderate disability, and 14.6% had a good recovery. CONCLUSION: TBI is associated with high mortality and morbidity. The lack of post-hospitalisation rehabilitation, and support for patients and their caregivers, requires urgent redress.

Global perspectives on operative vaginal deliveries.

Operative vaginal delivery (OVD) refers to the use of an instrument (forceps or vacuum device) to assist with the delivery of the fetus from the vagina. This can help improve maternal and fetal outcomes and has to be weighed up against the risks and benefits of performing second-stage cesarean deliveries. OVD forms an integral part of basic emergency obstetric care and a skilled birth attendant's duties. Outlet forceps and vacuum extraction should be used to shorten the second stage of labor and to improve maternal and fetal outcomes associated with delayed second stage. Despite the known benefit of OVD, available data on the use of OVDs in low- and middle-income countries show very low rates, mostly due to the lack of skilled healthcare workers and equipment shortages. Increased use of OVD can safely reduce the number of second-stage cesarean deliveries with its associated morbidity and mortality. We recommend implementing training programs to increase the number of skilled healthcare workers and strengthening health systems to provide birthing facilities with the equipment required to perform OVD.

New-onset diabetes after transplant: Incidence, risk factors and outcome.

BACKGROUND: The outcome of renal transplantation depends on achieving effective immunosuppression while minimising the consequences of such treatment. The occurrence of new-onset diabetes in the post-transplant period has been associated with several risk factors including some immunosuppressive medication. Better understanding of the clinical and genetic risk factors associated with new-onset diabetes after transplant (NODAT) could enable risk stratification of patients in the pre-transplant period, with the goal of applying measures that will reduce the incidence. OBJECTIVES: To ascertain the incidence of and clinical and genetic risk factors that predispose to NODAT, and to examine its effect on the outcome of renal transplantation. METHODS: We performed a retrospective cohort review of all renal transplants at Groote Schuur Hospital, Cape Town, South Africa, between 2004 and 2008. Patients who were lost to follow-up or had pre-transplant diabetes or primary non-function were excluded. A subset of the cohort who gave informed consent was enlisted for genetic tests. RESULTS: We identified 111 patients who met the inclusion criteria. The incidence of NODAT was 18.0% (n=20 patients). Risk factors for NODAT included age at transplant (p=0.03), body weight (p=0.04), treatment for acute cellular rejection (p=0.02) and polycystic kidney disease as the cause of renal failure (p=0.005). None of the genes investigated (TCF7L2 rs11196205, rs12255372 and rs7903146 and HNF1ß rs1800575, rs121918671 and rs121918672) was found to be significantly associated with the risk of NODAT. The genotype frequencies for the single-nucleotide polymorphisms studied were closer (although not identical) to those reported for Caucasians than to those reported for the Yoruba (black) population in West Africa. Overall patient survival was 78% at five years, while graft survival was 72%. There was no significant difference in patient or graft survival between the group with NODAT and the group without. CONCLUSIONS: NODAT was common in renal transplant recipients. Some risk factors predate transplant and could be used to risk-stratify patients to determine appropriate risk-reduction strategies. The genetic determinants for NODAT in this population may differ from those reported elsewhere. NODAT had no impact on patient or graft survival in this cohort.

New-onset diabetes after transplant: Incidence, risk factors and outcome

Background. The outcome of renal transplantation depends on achieving effective immunosuppression while minimising the consequences of such treatment. The occurrence of new-onset diabetes in the post-transplant period has been associated with several risk factors including some immunosuppressive medication. Better understanding of the clinical and genetic risk factors associated with new-onset diabetes after transplant (NODAT) could enable risk stratification of patients in the pre-transplant period, with the goal of applying measures that will reduce the incidence.Objectives. To ascertain the incidence of and clinical and genetic risk factors that predispose to NODAT, and to examine its effect on the outcome of renal transplantation.Methods. We performed a retrospective cohort review of all renal transplants at Groote Schuur Hospital, Cape Town, South Africa, between 2004 and 2008. Patients who were lost to follow-up or had pre-transplant diabetes or primary non-function were excluded. A subset of the cohort who gave informed consent was enlisted for genetic tests.Results. We identified 111 patients who met the inclusion criteria. The incidence of NODAT was 18.0% (n=20 patients). Risk factors for NODAT included age at transplant (p=0.03), body weight (p=0.04), treatment for acute cellular rejection (p=0.02) and polycystic kidney disease as the cause of renal failure (p=0.005). None of the genes investigated (TCF7L2 rs11196205, rs12255372 and rs7903146 and HNF1ß rs1800575, rs121918671 and rs121918672) was found to be significantly associated with the risk of NODAT. The genotype frequencies for the single-nucleotide polymorphisms studied were closer (although not identical) to those reported for Caucasians than to those reported for the Yoruba (black) population in West Africa. Overall patient survival was 78% at five years, while graft survival was 72%. There was no significant difference in patient or graft survival between the group with NODAT and the group without.Conclusions. NODAT was common in renal transplant recipients. Some risk factors predate transplant and could be used to risk-stratify patients to determine appropriate risk-reduction strategies. The genetic determinants for NODAT in this population may differ from those reported elsewhere. NODAT had no impact on patient or graft survival in this cohort

Important complications of chronic kidney disease.

The complications of chronic kidney disease (CKD) are dyslipidaemia, hyperkalaemia, metabolic acidosis, anaemia, and bone and mineraldisorders. Dyslipidaemia may be treated with low-density lipoprotein-lowering agents. Statins are ineffective in stages 4 and 5 CKD, but areindicated for preventing the progression of disease in the earlier stages. Chronic acidosis has recently been shown to be a risk factor in theprogression of CKD renal dysfunction. Therefore, treatment is mandatory. Practically, this should consist of 1 - 2 heaped teaspoons of sodiumbicarbonate 2 - 3 times per day, which is an inexpensive and safe therapy that does not raise the blood pressure in spite of the increased sodiumlevel. Target levels of haemoglobin, according to international guidelines, are between 10 g/dL and 12 g/dL. The serum phosphate level is raisedin stage 4 CKD, and especially in stage 5 CKD, which is associated with coronary carotid and other vascular calcifications and may result inischaemic heart disease, myocardial infarction and stroke. A raised parathyroid hormone level (secondary hyperparathyroidism) is also a majorrisk factor for cardiovascular disease and is associated with increased hypertension and resistance to the treatment of CKD-associated anaemia.

Cervical squamous intraepithelial lesions and associated cervical infections in an HIV-positive population in Rural Mpumalanga, South Africa.

BACKGROUND: The incidences of genital human papillomavirus (HPV) infection, associated squamous intraepithelial lesions and cervical squamous cell carcinoma are significantly increased in HIV-positive women. The role of other cervicovaginal infections in the acquisition of the HPV infection, cervical carcinogenesis and genital HIV infection remains largely speculative. METHODS: A retrospective study was conducted including 1087 HIV-positive women in rural Mpumalanga province, South Africa, for the period 1 May 2009 to 31 August 2010. For each patient, the age at first presentation, cervical cytological diagnosis, subsequent follow-up cytology and histology, and microscopically visible infections (including endemic Bilharzia) were tabulated and statistically analysed. RESULTS: The prevalence of low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL), squamous cell carcinoma, atypical squamous cells of undetermined significance (ASC-US) and atypical squamous cells, cannot exclude HSIL (ASC-H) in the study population were 22.1%, 30.9%, 0.6%, 13.5% and 4.0%, respectively. LSIL, HSIL and squamous cell carcinoma were diagnosed, respectively, at the average ages of 35.7, 37.9 and 37.2 years. Four patients with cervical intraepithelial neoplasia grade 1 (CIN1), 32 with CIN2/CIN3 and two with cervical squamous cell carcinoma were also diagnosed with Bilharzia. Of the other infections only bacterial vaginosis had a positive statistical correlation with HPV-induced cervical abnormalities (LSIL, HSIL or squamous cell carcinoma). CONCLUSION: This study confirms the high prevalence of progressive HPV-associated cervical disease in a rural Southern African HIV-positive population, which is at least equal to or worse than in other African HIV-positive studies. The high incidence of Bilharzia infection in those cases that underwent cervical cone excision suggests a possible relationship with progressive HPV disease and cervical carcinogenesis. Bacterial vaginosis (perhaps in combination with Bilharzia) may compromise the normal barriers against HPV and HIV infection.

Clinicopathological insights into lupus nephritis in South Africans: a study of 251 patients.

There are few published studies on biopsy proven lupus nephritis (LN) from sub-Sahara Africa, mainly due to lack of expertise and pathology back-up for performing and interpreting renal biopsies in many centres. The purpose of this study was to document factors associated with biopsy proven LN and to determine clinical and laboratory models that best predict proliferative LN in South Africans. Of the 251 patients studied, 84.1% were females and 79.3% were of mixed ancestry. There were more observed cases of proliferative LN (63%) than non-proliferative LN. Factors associated with proliferative LN were male gender (p = 0.049), haematuria on dipstix (p < 0.0001), proteinuria on dipstix (p = 0.042), low serum albumin (p = 0.032), low complement C3 (p < 0.0001), low complement C4 (p = 0.009) and positive double-stranded DNA (p = 0.039). Using four models designed from various combinations of the factors associated with proliferative LN, the specificity and positive predictive values were highest for the model that combined gender (male), presence of dipstix haematuria and proteinuria, hypoalbuminaemia, low C3 and low C4 and positive double-stranded DNA (100% respectively). Further study is recommended to identify the value of using these demographic and laboratory parameters in identifying patients with proliferative LN in resource limited centres where the performance of a biopsy is not possible.

Improvements in renal osteodystrophy in patients treated with lanthanum carbonate for two years.

AIMS: To investigate the evolution of renal osteodystrophy in patients on maintenance dialysis, treated with lanthanum carbonate (LC) vs. standard phosphate-binder therapy (Stx). MATERIALS AND METHODS: This was a 2-year, randomized, prospective, open-label study during which patients on dialysis received LC titrated to a maximum of 3,000 mg/day or their previous phosphate binder treatment with the aim to achieve target phosphorus levels of < or = 5.9 mg/dl. Paired bone biopsy samples for histomorphometric analysis were available at baseline and 1 year (LC 32, Stx 33), and at baseline and 2 years (LC 32, Stx 24). RESULTS: With similar phosphorus control, Stx was associated with numerically higher serum calcium levels at most visits. Results of osteocalcin and bone-specific alkaline phosphatase in LC patients were higher throughout the study and correlated with parameters of bone formation; however, the differences were not significant. Histological changes in bone turnover and volume were analyzed with respect to normal ranges. There was an improvement in bone turnover in the LC group, which was significant in the 1-year group, and an improvement in bone volume which was significant in the 2-year group. No significant changes in bone turnover or bone volume were observed in the Stx groups. In the 2-year LC group, 1 patient had osteomalacia at baseline and end of therapy, and a mineralization defect developed in 2 other patients. Several possible factors for a mineralization defect were present in these patients, but no single cause could be clearly identified. Histomorphometric parameters of bone, including formation and mineralization, did not correlate with bone lanthanum. No mineralization defect was observed in the Stx groups. CONCLUSION: These findings show that similar phosphorus control with Stx and LC results in higher bone turnover after 1 year and higher bone volume after 2 years with LC.

Short-course, low-dose oral betamethasone as an adjunct in the treatment of acute infective sinusitis : a comparative study with placebo.

OBJECTIVE: To assess the effect of a short course of low-dose oral corticosteroid used as an adjunct to antimicrobials in patients with acute infective sinusitis. STUDY DESIGN AND PATIENTS: Double-blind, randomised, placebo-controlled study including 42 patients with a clinical diagnosis of acute infective sinusitis. The study was performed at three primary healthcare sites in South Africa during the period January-November 2003. INTERVENTION: Two equal groups received either betamethasone 1mg orally (n = 21; the treatment group) or placebo tablets (n = 21; the placebo group) once a day in the morning for five consecutive days. All patients received amoxicillin-clavulanic acid 625mg orally, three times daily for 5 days. MAIN OUTCOME MEASURE: Patients rated symptoms on a daily symptom score card for 5 days and were examined by the investigator at diagnosis (day 0) and on the second visit (day 6). RESULTS: Headache, facial pain, nasal congestion and dizziness improved significantly from baseline in the treatment group compared with the placebo group over 5 days of treatment (p = 0.028, p