The healthcare system costs of hip fracture care in South Africa.

Despite rapidly ageing populations, data on healthcare costs associated with hip fracture in Sub-Saharan Africa are limited. We estimated high direct medical costs for managing hip fracture within the public healthcare system in SA. These findings should support policy decisions on budgeting and planning of hip fracture services. PURPOSE: We estimated direct healthcare costs of hip fracture (HF) management in the South African (SA) public healthcare system. METHODS: We conducted a micro-costing study to estimate costs per patient treated for HF in five regional public sector hospitals in KwaZulu-Natal (KZN), SA. Two hundred consecutive, consenting patients presenting with a fragility HF were prospectively enrolled. Resources used including staff time, consumables, laboratory investigations, radiographs, operating theatre time, surgical implants, medicines, and inpatient days were collected from presentation to discharge. Counts of resources used were multiplied by unit costs, estimated from the KZN Department of Health hospital fees manual 2019/2020, in local currency (South African Rand, ZAR), and converted to 2020 US$ prices. Generalized linear models estimated total covariate-adjusted costs and cost predictors. RESULTS: The mean unadjusted cost for HF management was US$6935 (95% CI; US$6401-7620) [ZAR114,179 (95% CI; ZAR105,468-125,335)]. The major cost driver was orthopaedics/surgical ward costs US$5904 (95% CI; 5408-6535), contributing to 85% of total cost. The covariate-adjusted cost for HF management was US$6922 (95% CI; US$6743-7118) [ZAR113,976 (95% CI; ZAR111,031-117,197)]. After covariate adjustment, total costs were higher in patients operated under general anaesthesia [US$7251 (95% CI; US$6506-7901)] compared to surgery under spinal anaesthesia US$6880 (95% CI; US$6685-7092) and no surgery US$7032 (95% CI; US$6454-7651). CONCLUSION: Healthcare costs following a HF are high relative to the gross domestic product per capita and per capita spending on health in SA. As the population ages, this significant economic burden to the health system will increase.

Ethnic and gender-specific incidence rates for hip fractures in South Africa: A multi-centre study.

BACKGROUND: Limited data exist on the incidence of hip fractures in South Africa (SA). We report gender and ethnic specific incidence rates of hip fractures in SA. METHODS: In a multicentre prospective study, conducted in geographically defined municipalities of three provinces in SA, a structured questionnaire was administered to all subjects aged 40 years and over, presenting with a new atraumatic hip fracture, from 1 April 2017 to 31 March 2018. Gender and ethnic specific incidence rates (IR) of hip fractures were calculated using population statistics from Statistics SA. FINDINGS: Of the 2767 subjects enrolled, 1914 (69·2%) were women and 853 (30·8%) were men. The majority of subjects were from the White population (40·9%) followed by those from the African (26·4%), Coloured (18·7%) and Indian (13·9%) populations. Men with hip fractures were significantly younger than women in the total group (69 [IQR 59-79] versus 77 years [IQR 68-84], p < 0·001) and in each ethnic group. White subjects were significantly older (p < 0·0001) and Africans significantly younger (p < 0·0001) than the other ethnic groups. In women, the highest IR was noted in the White population (176·0 per 100,000), followed by that in the Indian (147·7 per 100,000), Coloured (73·2 per 100,000) and African populations (43·6 per 100,000). A similar pattern was seen in men albeit at lower rates, with the highest rate in White men at 76·5 per 100,000. In the total study population and the African population, the IR was higher in men compared to women in subjects under 60 years. In the White population, the IR was higher in men compared to women in the 40-44 years age group. While in the Coloured and Indian populations the IR was higher in men compared to women in the 40-49 years and 45-54 years age groups, respectively. There was an increase in the relative risk ratios with age in the total study population, and in all ethnic groups in both women and men. INTERPRETATION: Hip fractures occur in all ethnic groups in South Africa with higher IRs in the White and Indian populations compared to the Coloured and African populations. Consistent with the published literature, the overall hip fracture IR was higher in women than in men, except in the younger age groups, and increased with age. FUNDING: South African Medical Research Council and the University of KwaZulu-Natal Competitive Research Grant.

Osteoporotic hip fractures in Black South Africans: a regional study.

Osteoporotic hip fractures are thought to be rare in Blacks however, this study from South Africa shows a significant increase in the number of hip fracture in Blacks. With the expected increase in older people, osteoporotic fractures will pose a major health problem and screening guidelines needed to be implemented. INTRODUCTION: Developing countries are predicted to bear the burden of osteoporosis in the coming decades. This study was undertaken to review earlier reports that osteoporotic hip fractures are rare in Black Africans. METHODS: In an observational study, the incidence rates and relative risk ratios (RRR) of osteoporotic hip fractures were calculated in the Black population, aged 60 years and older, residing in the eThekwini region of South Africa. All Black subjects, presenting with a minimal trauma hip fracture to five public hospitals in the region, entered the study. Descriptive statistics were applied to show differences in age and sex. RESULTS: Eighty-seven subjects were enrolled in the study with a mean age of 76.5 ± 10.5 years and the sex ratio of women to men was 2.5:1. Although men were younger than women, this was not significant (74.2 ± 12.3 vs. 77.4 ± 9.6 years, p = 0.189). The age-adjusted rate was 69.2 per 100,000 p.a. for women and 73.1 per 100,000 p.a. for men. There was a significant increase in the relative risk ratios for hip fractures after the age of 75 years in the total cohort and in women and men. Except for the 65-69-year age group, there was no significant difference in the age-adjusted RRR between women and men. CONCLUSION: This study represents the largest number of hip fractures recorded in Black Africans. Although the incidence rate is approximately tenfold higher than previously recorded, it remains amongst the lowest globally. A national registry inclusive of private and public sector is required to establish the true incidence rate of hip fractures in Black Africans.

High risk of malnutrition associated with depressive symptoms in older South Africans living in KwaZulu-Natal, South Africa: a cross-sectional survey.

BACKGROUND: Malnutrition contributes to functional and cognitive decline in older adults, which results in decreased quality of life and loss of independence. This study aimed to identify determinants of nutritional risk among community-dwelling adults in KwaZulu-Natal, South Africa. METHODS: A cross-sectional survey was undertaken in 1008 subjects aged 60 years and over who were randomly selected by systematic sampling. Demographics, socioeconomic data and self-reported history of medical conditions were recorded. The Mini Nutritional Assessment-Short Form (MNA-SF) was used to screen for nutritional risk, and the Centre for Epidemiologic Studies Depression scale was administered to all subjects. Descriptive statistics and the Pearson chi-square and Kruskal-Wallis tests were used for statistical analysis. Logistic regression modelling determined predictors of nutritional risk. RESULTS: Of the 984 participants (mean age = 68.8 ± 7.4 years; range 60-103 years) who completed the MNA-SF, 51% were classified as having a normal nutritional status, 43.4% at risk for malnutrition and 5.5% classified as malnourished. Men were more likely to be either at risk for malnutrition or be malnourished than women (p = 0.008), as were subjects with a monthly household income of ≤R1600 per month (~133 USD) (p = 0.003). In logistic regression models, depressed people were 2.803 (p < 0.001) times more likely to be at risk or be malnourished than those not depressed. CONCLUSION: A high prevalence of risk of malnutrition was identified in older South Africans living in an urban area with poor infrastructure. Further investigations are warranted to determine whether the higher prevalence of depressive symptomatology in nutritionally at risk individuals is a determinant or a consequence of malnutrition, in order to develop targeted nutritional interventions in this age group.

The safety of osteoporosis medication.

Osteoporosis is a common, costly and serious disease, which is still too often regarded as an inevitable part of the normal ageing process and therefore sub-optimally treated, especially in the elderly--in fact, only two out of every 10 patients who sustain a hip fracture receive any form of assessment or prophylactic therapy for osteoporosis. One out of five patients die within 1 year after a hip fracture, and < 50% are capable of leading an independent life. Yet very effective anti-fracture therapy, capable of reducing fracture risk by 35 - 60%, is available. A number of publications have recently questioned the safety of drugs routinely used to treat patients with osteoporosis. This paper attempts to put the situation into perspective and expresses the National Osteoporosis Foundation of South Africa's view on the safety of these drugs. Their efficacy in preventing skeletal fractures and their cost-effectiveness are not addressed in any detail. The paper emphasises the fact that all osteoporosis medications have side-effects, some of which are potentially life-threatening.

Promoting access to innovation for frail old persons. IAGG (International Association of Gerontology and Geriatrics), WHO (World Health Organization) and SFGG (Société Française de Gériatrie et de Gérontologie) Workshop--Athens January 20-21, 2012.

UNLABELLED: Frailty tends to be considered as a major risk for adverse outcomes in older persons, but some important aspects remain matter of debate. OBJECTIVES: The purpose of this paper is to present expert's positions on the main aspects of the frailty syndrome in the older persons. PARTICIPANTS: Workshop organized by International Association of Gerontology and Geriatrics (IAGG), World Health Organization (WHO) and Société Française de Gériatrie et de Gérontologie (SFGG). RESULTS: Frailty is widely recognized as an important risk factor for adverse health outcomes in older persons. This can be of particular value in evaluating non-disabled older persons with chronic diseases but today no operational definition has been established. Nutritional status, mobility, activity, strength, endurance, cognition, and mood have been proposed as markers of frailty. Another approach calculates a multidimensional score ranging from "very fit" to "severely frail", but it is difficult to apply into the medical practice. Frailty appears to be secondary to multiple conditions using multiple pathways leading to a vulnerability to a stressor. Biological (inflammation, loss of hormones), clinical (sarcopenia, osteoporosis etc.), as well as social factors (isolation, financial situation) are involved in the vulnerability process. In clinical practice, detection of frailty is of major interest in oncology because of the high prevalence of cancer in older persons and the bad tolerance of the drug therapies. Presence of frailty should also be taken into account in the definition of the cardiovascular risks in the older population. The experts of the workshop have listed the points reached an agreement and those must to be a priority for improving understanding and use of frailty syndrome in practice. CONCLUSION: Frailty in older adults is a syndrome corresponding to a vulnerability to a stressor. Diagnostic tools have been developed but none can integrate at the same time the large spectrum of factors and the simplicity asked by the clinical practice. An agreement with an international common definition is necessary to develop screening and to reduce the morbidity in older persons.

Experience with azathioprine in systemic sclerosis associated with interstitial lung disease.

The aim of this study was to evaluate the safety and efficacy of azathioprine in the treatment of interstitial lung disease (ILD) associated with systemic sclerosis (SSc). The records of patients with SSc with ILD who were treated with azathioprine were reviewed. Patients were treated with azathioprine and low-dose prednisone if they had progressive pulmonary symptoms (deterioration in the dyspnea score) or poor or deteriorating lung function. Response was classified as improved if the FVC increased more than 10% from baseline, and stable if it remained within 10% of baseline. Serial dyspnea scores were recorded. Eleven patients were treated with azathioprine, three of whom received treatment for 6 months or less owing to adverse effects (nausea, leukopenia and pulmonary tuberculosis in one patient each). The remaining eight patients received at least 12 months' treatment and the results suggested an improvement in the mean percent predicted FVC from a baseline value of 54.25+/-3.53 to 63.38+/-6.15 after 12 months ( p=0.101). Overall, five patients improved and three remained stable. The mean dyspnea score ( n=8) improved from a baseline of 1.55+/-0.19 to 0.50+/-0.19 at 12 months ( p=0.011). This is the first case series of patients with SSc-associated ILD treated with azathioprine. Our results suggest that azathioprine may have a role in stabilizing lung function and improving symptoms in SSc, although this needs confirmation by a randomized controlled trial.

Kallikrein and kinin receptor expression in inflammation and cancer.

The kallikrein family of serine proteases has been investigated in many inflammatory disorders as molecular mapping, gene characterisation and cloning of kinin receptor genes have unfolded experimentally. In the molecular events of the inflammatory response the kallikrein cascade plays a significant role, since it is considered to initiate and maintain systemic inflammatory responses and immune-modulated disorders. A primary event is the chemotactic attraction of neutrophils which deliver the kallikrein-kinin cascade to sites of cellular injury and carcinogenic transformation of cells. The present study establishes the casual involvement of the kallikrein cascade in infection, inflammatory joint disease, acute transplant rejection, renal glomerular diseases, angiogenesis and carcinoma. We provide strong evidence for new or enhanced expression of kinin B1 receptors in inflammation, and additionally the induction of kallikrein genes in angiogenesis and carcinoma. The results provide insights into possible roles of kallikrein inhibitors and kinin receptor antagonists.

Rheumatologic manifestations of gastrointestinal disorders.

Rheumatologic features are among the most common extraintestinal manifestations of gastrointestinal disorders. They are an important cause of morbidity and continue to generate interest among researchers. Over the past year, reports have focused attention on inflammatory bowel disease and coeliac disease. Among the hepatic disorders, cryoglobulinemia, Sjögren's syndrome, and other immunological disorders have been reported in association with hepatitis C virus infections. Rheumatologic manifestations are well-documented in association with pancreatic disorders. There are also a number of interesting and unusual case reports that are reviewed.

Immunolocalization of bradykinin receptors on human synovial tissue.

Kinins have been implicated in the pathogenesis of experimental and clinical inflammatory arthritis. Previous studies have reported increased amounts of plasma and tissue kallikreins in synovial fluid, raised kinin levels and an upregulation of kinin B2 receptors on synovial fluid neutrophils in rheumatoid arthritis. Bradykinin binding sites have been identified on human synovial cells by autoradiographic localization and Scatchard analysis. This study was undertaken to localize immunohistochemically kinin B1 and B2 receptors on human synovial tissue. Synovial tissue was obtained at the time of joint replacement surgery or arthroscopic synovectomy in six patients (two RA, two OA and two with avascular necrosis). Tissue sections were immunolabelled for kinin B1 and B2 receptors and viewed by light and confocal microscopy. No immunolabelling of the kinin receptors was observed in the method controls. In all patients labelling for kinin B2 receptors was observed in the synovial lining cells, fibroblasts and endothelial lining cells of blood vessels. There was no immunolabelling for kinin B1 receptors in all samples. These findings further support a role for the B2 receptors in joint diseases. There did not appear to be an induction of the kinin B1 receptor in human synovial tissue obtained from patients with chronic arthritis. However, further studies are required to assess the role of B1 receptors in active joint inflammation.

Immunocytochemical analysis of tissue kallikrein and the kinin moiety in rheumatoid synovial fluid neutrophils.

Polymorphonuclear leucocytes (PMNs) from the synovial fluid of patients with rheumatoid arthritis (RA) showed reduced tissue kallikrein and kinin immunoreactivity in comparison with blood PMNs from healthy individuals as judged visually using confocal microscopy. Similarly, synovial fluid PMNs exhibited reduced tissue kallikrein immunoreactivity as compared with blood PMNs from the same RA patients. Blood PMNs stimulated to degranulate in vitro also displayed less immunostaining for tissue kallikrein and kinin than non-stimulated PMNs. By contrast, no difference in kininogen immunostaining was detected between RA synovial fluid PMNs and blood PMNs from healthy people. It is considered that the results support the hypothesis that tissue kallikrein, released from the granules of RA synovial fluid PMNs, cleaves the kinin moiety from multifunctional kininogen protein on the surface of the PMNs.

Rheumatologic manifestations of malignancy.

The association of rheumatic syndromes and malignancy is highlighted in this review. The prevalence of malignancy in a series of patients with unclassified rheumatic syndromes is reported. The spectrum of arthropathies associated with malignancy includes bilateral knee effusions, sacroiliitis, and adult-onset Still's disease. There are further reports on the well-recognized association between dermatomyositis and malignancy. The importance of screening for malignancy in patients with classic dermatomyositis as well as dermatomyositis sine myositis is highlighted. The association of mixed cryoglobulinemia with hepatitis C virus infection, hepatocellular carcinoma, and non-Hodgkin's lymphoma is discussed. Finally, the association of miscellaneous rheumatic features such as autoantibodies, vasculitis, carpal tunnel syndrome, and multicentric reticulohistiocytosis with malignancy is described.

Rheumatologic features of hematologic disorders.

The rheumatologic manifestations of hemophilia and the hemoglobinopathies have been previously reviewed. Recent observations on the management and complications of these disorders are presented. Although rheumatologic manifestations are well recognized in leukemias and lymphomas, most of the observations have been based on small series of patients and case reports. This review focuses on leukemias and lymphomas, and brief reference is made to the myelodysplastic syndromes.

Gout in black South Africans: a clinical and genetic study.

OBJECTIVE: To define the clinical characteristics of gout and determine if there were any genetic associations with gout in black South Africans. METHODS: The records of 107 patients with gout seen over a five year period were retrospectively analysed. The HLA class I and class II antigens were studied in a prospective survey of 46 patients. RESULTS: The male to female ratio was 6.6:1. The diagnosis of gout was based on identification of monosodium urate crystals from the synovial fluid, synovial tissue or tophaceous material in 62 patients (58%) and on clinical criteria in the remaining 45 patients (42%). The mode of presentation was monoarthritis in 40 patients (37.4%), pauciarthritis in 30 (28%) and polyarthritis in 37 (34.6%). The joints which were most frequently involved were the knee in 91 patients (85%), the first metatarsophalangeal in 80 (74.8%) and the ankle in 66 (61.7%). A secondary cause was identified in 52 patients (48.6%) (diuretic therapy in 48 patients and chronic renal impairment in four); 55 patients (51.4%) had primary gout. The genetic study showed an increased frequency of HLA-B14 in patients with primary gout compared with controls. CONCLUSIONS: Gout is more common in black Africans than previously recognised and frequently presents with involvement of more than one joint. There was an increased frequency of HLA-B14 in patients with primary gout but the clinical significance of this is uncertain.

The prevalence of diffuse idiopathic skeletal hyperostosis in African blacks.

The prevalence of diffuse idiopathic skeletal hyperostosis (DISH) was studied in a hospital based population of African Blacks over the age of 40 years. The study was based on an analysis of the lateral chest radiographs of 1000 patients in a retrospective study and 500 consecutive medical admissions in a prospective study. The overall prevalence of DISH was 3.9% (males 3.8% and females 4.2%). There was a rise in the prevalence of DISH with increasing age from 1% in the 40-49 year age group to 13.6% in those over 70 years. The prevalence of diabetes was 52.4% in the 21 patients with DISH who were seen in the prospective analysis. Ankylosing spondylitis, which is associated with HLA-B27, is rare in African Blacks. However, DISH is not uncommon but its prevalence is lower than in a similar hospital based study of Jews in Israel.