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1.
Lancet ; 400(10360): 1321-1333, 2022 10 15.
Artigo em Inglês | MEDLINE | ID: mdl-36244383

RESUMO

BACKGROUND: Community health workers (CHWs) are increasingly providing task-shared psychological interventions for depression and alcohol use in primary health care in low-income and middle-income countries. We aimed to compare the effectiveness of CHWs dedicated to deliver care with CHWs designated to deliver care over and above their existing responsibilities and with treatment as usual for patients with a chronic physical disease. METHODS: We did a three-arm, cluster randomised, multicentre, open-label trial done in 24 primary health-care clinics (clusters) within the Western Cape province of South Africa. Clinics were randomly assigned (1:1:1) to implement dedicated care, designated care, or treatment as usual, stratified by urban-rural status. Patients with HIV or type 1 or type 2 diabetes were eligible if they were 18 years old or older, taking antiretroviral therapy for HIV or medication to manage their diabetes, had an Alcohol Use Disorders Identification Test (AUDIT) score of eight or more or a Center for Epidemiologic Studies Depression Scale score of 16 or more, and were not receiving mental health treatment. In the intervention arms, all participants were offered three sessions of an evidence-based psychological intervention, based on motivational interviewing and problem-solving therapy, delivered by CHWs. Our primary outcomes were depression symptom severity and alcohol use severity, which we assessed separately for the intention-to-treat populations of people with HIV and people with diabetes cohorts and in a pooled cohort, at 12 months after enrolment. The Benjamini-Hochberg procedure was used to adjust for multiple testing. The trial was prospectively registered with the Pan African Clinical Trials Registry, PACTR201610001825403. FINDINGS: Between May 1, 2017, and March 31, 2019, 1340 participants were recruited: 457 (34·1%) assigned to the dedicated group, 438 (32·7%) assigned to the designated group, and 445 (33·2%) assigned to the treatment as usual group. 1174 (87·6%) participants completed the 12 month assessment. Compared with treatment as usual, the dedicated group (people with HIV adjusted mean difference -5·02 [95% CI -7·51 to -2·54], p<0·0001; people with diabetes -4·20 [-6·68 to -1·72], p<0·0001) and designated group (people with HIV -6·38 [-8·89 to -3·88], p<0·0001; people with diabetes -4·80 [-7·21 to -2·39], p<0·0001) showed greater improvement on depression scores at 12 months. By contrast, reductions in AUDIT scores were similar across study groups, with no intervention effects noted. INTERPRETATION: The dedicated and designated approaches to delivering CHW-led psychological interventions were equally effective for reducing depression, but enhancements are required to support alcohol reduction. This trial extends evidence for CHW-delivered psychological interventions, offering insights into how different delivery approaches affect patient outcomes. FUNDING: British Medical Research Council, Wellcome Trust, UK Department for International Development, the Economic and Social Research Council, and the Global Challenges Research Fund.


Assuntos
Alcoolismo , Diabetes Mellitus Tipo 2 , Infecções por HIV , Adolescente , Adulto , Doença Crônica , Análise Custo-Benefício , Infecções por HIV/terapia , Humanos , Intervenção Psicossocial , África do Sul , Resultado do Tratamento
2.
Nutr Cancer ; 75(7): 1551-1559, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-37227249

RESUMO

Many South African children live in poverty and food insecurity; therefore, malnutrition within the context of childhood cancer should be examined. Parents/caregivers completed the Poverty-Assessment Tool (divided into poverty risk groups) and the Household Hunger Scale questionnaire in five pediatric oncology units. Height, weight, and mid-upper arm circumference assessments classified malnutrition. Regression analysis evaluated the association of poverty and food insecurity with nutritional status, abandonment of treatment, and one-year overall survival (OS). Nearly a third (27.8%) of 320 patients had a high poverty risk, associated significantly with stunting (p = 0.009), food insecurity (p < 0.001) and residential province (p < 0.001) (multinomial regression). Stunting was independently and significantly associated with one-year OS on univariate analysis. The hunger scale was significant predictor of OS, as patients living with hunger at home had an increased odds ratio for treatment abandonment (OR 4.5; 95% CI 1.0; 19.4; p = 0.045) and hazard for death (HR 3.2; 95% CI 1.02, 9.9; p = 0.046) compared to those with food security. Evaluating sociodemographic factors such as poverty and food insecurity at diagnosis is essential among South African children to identify at-risk children and implement adequate nutritional support during cancer treatment.


Assuntos
Desnutrição , Neoplasias , Criança , Humanos , África do Sul/epidemiologia , Fome , Prevalência , Abastecimento de Alimentos , Desnutrição/complicações , Desnutrição/diagnóstico , Desnutrição/epidemiologia , Pobreza , Transtornos do Crescimento/epidemiologia , Neoplasias/diagnóstico , Neoplasias/epidemiologia
3.
Pediatr Hematol Oncol ; 40(8): 752-765, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-36940097

RESUMO

This study investigates the prevalence of vitamin and iron deficiencies at cancer diagnosis. Newly diagnosed children between October 2018 and December 2020 at two South African pediatric oncology units (POUs) were assessed for nutritional and micronutrient status (Vit A, Vit B12, Vit D, folate, and iron). A structured interview with caregivers provided information regarding hunger and poverty risks. There were 261 patients enrolled with a median age of 5.5 years and a male-to-female ratio of 1:0.8. Nearly half had iron deficiency (47.6%), while a third had either Vit A (30.6%), Vit D (32.6%), or folate (29.7%) deficiencies. Significant associations existed between moderate acute malnutrition (MAM) and low levels of Vit A (48.4%; p = .005), Vit B12 (29.6%; p < .001), and folate (47.3%; p = .003), while Vit D deficiency was associated with wasting (63.6%) (p < .001). Males had significantly lower Vit D levels (respectively, 40.9%; p = .004). Folate deficiency was significantly associated with patients born at full term (33.5%; p = .017), age older than five years (39.8%; p = .002), residing in provinces Mpumalanga (40.9%) and Gauteng (31.5%) (P = .032); as well as having food insecurity (46.3%; p < .001), or hematological malignancies (41.3%; p = .004). This study documents the high prevalence of Vit A, Vit D, Vit B12, folate, and iron deficiency in South African pediatric cancer patients, demonstrating the need to include micronutrient assessment at diagnosis to ensure optimal nutritional support for macro-and micronutrients.


Assuntos
Deficiências de Ferro , Neoplasias , Criança , Humanos , Masculino , Feminino , Pré-Escolar , Vitaminas , África do Sul/epidemiologia , Prevalência , Ácido Fólico , Micronutrientes , Vitamina D , Estado Nutricional , Neoplasias/epidemiologia
4.
Mov Disord ; 37(1): 230-232, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34676912

RESUMO

Parkinson's disease (PD) incidence is increasing in sub-Saharan Africa. We recruited 687 individuals with PD from different ancestral groups across South Africa. More Afrikaner Europeans had early-onset PD than other ancestral groups. More men had PD than women, with a younger age at onset for men (56 years).


Assuntos
Doença de Parkinson , Idade de Início , Feminino , Humanos , Masculino , Doença de Parkinson/epidemiologia , África do Sul/epidemiologia , População Branca
5.
J Cardiovasc Magn Reson ; 24(1): 72, 2022 12 19.
Artigo em Inglês | MEDLINE | ID: mdl-36529806

RESUMO

BACKGROUND: Human immunodeficiency virus (HIV) infected persons on antiretroviral therapy (ART) have been shown to have functionally and structurally altered ventricles and may be related to cardiovascular inflammation. Mounting evidence suggests that the myocardium of HIV infected individuals may be abnormal before ART is initiated and may represent subclinical HIV-associated cardiomyopathy (HIVAC). The influence of ART on subclinical HIVAC is not known. METHODS: Newly diagnosed, ART naïve persons with HIV infection were enrolled along with HIV uninfected, age- and sex-matched controls. All participants underwent comprehensive cardiovascular assessment, including contrasted cardiovascular magnetic resonance (CMR) with multiparametric mapping on a 1.5T CMR system. The HIV group was started on ART (tenofovir/lamivudine/dolutegravir) and prospectively evaluated 9 months later. Cardiac tissue characterisation was compared in, and between groups using the appropriate statistical tests for the cross sectional data and the paired, prospective data respectively. RESULTS: Seventy-three ART naïve HIV infected individuals (32 ± 7 years, 45% female) and 22 healthy non-HIV subjects (33 ± 7 years, 50% female) were enrolled. Compared with non-HIV healthy subjects, the global native T1 (1008 ± 31 ms vs 1032 ± 44 ms, p = 0.02), global T2 (46 ± 2 vs 48 ± 3 ms, p = 0.006), and the prevalence of pericardial effusion (18% vs 67%, p < 0.001) were significantly higher in the HIV infected group at diagnosis. Global native T1 (1032 ± 44 to 1014 ± 34 ms, p < 0.001) and extracellular volume (ECV) (26 ± 4% to 25 ± 3%, p = 0.001) decreased significantly after 9 months on ART and were significantly associated with a decrease in the HIV viral load, decreased high sensitivity C-reactive protein, and improvement in the CD4 count (p < 0.001). Replacement fibrosis was significantly higher in the HIV infected group than controls (49% vs 10%, p = 0.02). The prevalence of late gadolinium enhancement did not change significantly over the 9-month study period (49% vs 55%, p = 0.4). CONCLUSION: Subclinical HIVAC may already be present at the time of HIV diagnosis, as suggested by the combination of subclinical myocardial oedema and fibrosis found to be present before administration of ART. Markers of myocardial oedema on tissue characterization improved on ART in the short term, however, it is unclear if the underlying pathological mechanism is halted, or merely slowed by ART. Mid- to long term prospective studies are needed to evaluate subtle myocardial changes over time and to assess the significance of subclinical myocardial fibrosis.


Assuntos
Cardiomiopatias , Infecções por HIV , Feminino , Humanos , Masculino , Estudos Prospectivos , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Imagem Cinética por Ressonância Magnética , HIV , Meios de Contraste , Estudos Transversais , Gadolínio , Valor Preditivo dos Testes , Miocárdio/patologia , Fibrose , Cardiomiopatias/patologia , Edema , Espectroscopia de Ressonância Magnética
6.
J Clin Monit Comput ; 36(3): 861-870, 2022 06.
Artigo em Inglês | MEDLINE | ID: mdl-33983533

RESUMO

Bioreactance (BR) is a novel, non-invasive technology that is able to provide minute-to-minute monitoring of cardiac output and additional haemodynamic variables. This study aimed to determine the values for BR-derived haemodynamic variables in stable preterm neonates during the transitional period. A prospective observational study was performed in a group of stable preterm (< 37 weeks) infants in the neonatal service of Tygerberg Children's Hospital, Cape Town, South Africa. All infants underwent continuous bioreactance (BR) monitoring until 72 h of life. Sixty three preterm infants with a mean gestational age of 31 weeks and mean birth weight of 1563 g were enrolled. Summary data and time series graphs were drawn for BR-derived heart rate, non-invasive blood pressure, stroke volume, cardiac output and total peripheral resistance index. All haemodynamic parameters were significantly associated with postnatal age, after correction for clinical variables (gestational age, birth weight, respiratory support mode). To our knowledge, this is the first paper to present longitudinal BR-derived haemodynamic variable data in a cohort of stable preterm infants, not requiring invasive ventilation or inotropic support, during the first 72 h of life. Bioreactance-derived haemodynamic monitoring is non-invasive and offers the ability to simultaneously monitor numerous haemodynamic parameters of global systemic blood flow. Moreover, it may provide insight into transitional physiology and its pathophysiology.


Assuntos
Hemodinâmica , Recém-Nascido Prematuro , Peso ao Nascer , Criança , Humanos , Lactente , Recém-Nascido , Estudos Longitudinais , África do Sul
7.
Echocardiography ; 38(5): 729-736, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33847025

RESUMO

INTRODUCTION: The World Heart Federation (WHF) screening criteria do not incorporate a strict, reproducible definition of anterior mitral valve leaflet (AMVL) restriction. Using a novel definition, we have identified two distinct AMVL restriction configurations. The first, called "distal tip" AMVL restriction is associated with additional morphological features of rheumatic heart disease (RHD), while the second, "gradual bowing" AMVL restriction is not. This "arch-like" leaflet configuration involves the base to tip of the medial MV in isolation. We hypothesize that this configuration is a normal variant. METHODOLOGY: The prevalence and associated leaflet configurations of AMVL restriction were assessed in schoolchildren with an established "very low" (VLP), "high" (HP), and "very high" prevalence (VHP) of RHD. RESULTS: 936 studies were evaluated (HP 577 cases; VLP 359 cases). Sixty-five cases of "gradual bowing" AMVL restriction were identified in the HP cohort (11.3%, 95% CI 8.9-14.1) and 35 cases (9.7%, 95% CI 7-13.2) in the VLP cohort (P = .47). In the second analyses, an enriched cohort of 43 studies with proven definite RHD were evaluated. "Distal tip" AMVL restriction was identified in all 43 VHP cases (100%) and affected the central portion of the AMVL in all cases. CONCLUSION: "Gradual bowing" AMVL restriction appears to be a normal, benign variant of the MV, not associated with RHD risk nor with any other morphological features of RHD. Conversely, "Distal tip" AMVL restriction was present in all cases in the VHP cohort with no cases exhibiting a straight, nonrestricted central portion of the AMVL. This novel finding requires further investigation as a potential RHD rule-out test of the MV.


Assuntos
Insuficiência da Valva Mitral , Cardiopatia Reumática , Criança , Humanos , Programas de Rastreamento , Valva Mitral/diagnóstico por imagem , Prevalência , Cardiopatia Reumática/diagnóstico
8.
Echocardiography ; 37(6): 808-814, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32524654

RESUMO

BACKGROUND: Studies determining the reliability of the World Heart Federation (WHF) anterior mitral valve leaflet (AMVL) measurement are limited by the introduction of bias in their test-retest analyses. This study sought to determine the reliability of the current AMVL measurement while controlling for systematic bias. METHODS: Retrospective analysis of echocardiographic data from 16 patients with previous acute rheumatic fever was performed. Included in this study was an optimized cine loop of the mitral valve (MV) [reader-optimized measurement (ROM]) in the parasternal long-axis view and an optimized still image of the MV obtained from the same cine loop [specialist-optimized image (SOI)]. Each still image and associated cine loop was quadruplicated and randomized to determine intra- and inter-rater agreement and quantify the impact of zoom on AMVL measurement. RESULTS: Specialist-optimized image without zoom reflected the highest degree of agreement in both cohorts with an ICC of 0.29 and 0.46. The agreement in ROM images without zoom was ICC of 0.23 and 0.45. The addition of zoom to SOI decreased agreement further to an ICC of 0.20 and 0.36. The setting associated with the poorest agreement profile was ROI with zoom with an ICC of 0.13 and 0.34, respectively. The intra-rater agreement between readers in both cohorts was moderate across all settings with an ICC ranging between 0.64 and 0.86. CONCLUSIONS: The WHF AMVL measurement is only moderately repeatable within readers and demonstrates poor reproducibility that was not improved by the addition of a zoom-optimized protocol. Given our study findings, we cannot advocate the current WHF AMVL measurement as a reliable assessment for RHD.


Assuntos
Insuficiência da Valva Mitral , Cardiopatia Reumática , Humanos , Valva Mitral/diagnóstico por imagem , Reprodutibilidade dos Testes , Estudos Retrospectivos , Cardiopatia Reumática/diagnóstico por imagem
9.
BMC Infect Dis ; 19(Suppl 1): 784, 2019 Sep 16.
Artigo em Inglês | MEDLINE | ID: mdl-31526367

RESUMO

BACKGROUND: Eliminating mother-to-child transmission of HIV is a global public health target. Robust, feasible methodologies to measure population level impact of programmes to prevent mother-to-child transmission of HIV (PMTCT) are needed in high HIV prevalence settings. We present a summary of the protocol of the South African PMTCT Evaluation (SAPMTCTE) with its revision over three repeated rounds of the survey, 2010-2014. METHODS: Three cross sectional surveys (2010, 2011-2012 and 2012-2013) were conducted in 580 primary health care immunisation service points randomly selected after stratified multistage probability proportional to size sampling. All infants aged 4-8 weeks receiving their six-week immunisation at a sampled facility on the day of the visit were eligible to participate. Trained research nurses conducted interviews and took infant dried blood spot (iDBS) samples for HIV enzyme immunoassay (EIA) and total nucleic acid polymerase chain reaction (PCR) testing. Interviews were conducted using mobile phones and iDBS were sent to the National Health Laboratory for testing. All findings were adjusted for study design, non-response, and weighted for number of South African live-birth in each study round. In 2012 a national closed cohort of these 4 to 8-week old infants testing EIA positive (HIV Exposed Infants) from the 2012-2013 cross-sectional survey was established to estimate longer-term PMTCT impact to 18 months. Follow-up analyses were to estimate weighted cumulative MTCT until 18 months, postnatal MTCT from 6 weeks until 18 months and a combined outcome of MTCT-or-death, using a competing risks model, with death as a competing risk. HIV-free survival was defined as a child surviving and HIV-negative up to 18 months or last visit seen. A weighted cumulative incidence analysis was conducted, adjusting for survey design effects. DISCUSSION: In the absence of robust high-quality routine medical recording systems, in the context of a generalised HIV epidemic, national surveys can be used to monitor PMTCT effectiveness; however, monitoring long-term outcomes nationally is difficult due to poor retention in care.


Assuntos
Países em Desenvolvimento/economia , Infecções por HIV/epidemiologia , HIV/imunologia , Renda , Transmissão Vertical de Doenças Infecciosas/economia , Complicações Infecciosas na Gravidez/epidemiologia , Saúde da Criança/economia , Estudos Transversais , Intervalo Livre de Doença , Diagnóstico Precoce , Feminino , Seguimentos , Infecções por HIV/sangue , Infecções por HIV/mortalidade , Soropositividade para HIV , Humanos , Lactente , Recém-Nascido , Estudos Longitudinais , Masculino , Prontuários Médicos/economia , Gravidez , Prevalência , Estudos Prospectivos , África do Sul/epidemiologia , Inquéritos e Questionários
10.
Anesth Analg ; 129(4): 1137-1143, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31219915

RESUMO

BACKGROUND: It is unknown whether the implementation of an information video on spinal anesthesia for cesarean delivery, narrated in a patient's first language, reduces anxiety, increases satisfaction, and improves doctor-patient communication if there is a language barrier. In South Africa, most doctors speak English, and patients speak Xhosa, with educational and cultural disparities existing in many doctor-patient interactions. METHODS: One hundred seventy-five Xhosa patients scheduled for elective cesarean delivery were enrolled in the study. The first 92 patients received "usual care" verbal explanations of the spinal anesthesia procedure (control group); the next 83 patients watched a spinal anesthesia information video (intervention group), narrated in Xhosa. Videos were displayed using smartphones. Maternal anxiety was assessed before and after spinal explanation, using a Numerical Visual Analog Anxiety Scale (NVAAS). A difference in postexplanation NVAAS score of 1.5 points between intervention and control groups was regarded as clinically significant. Patient satisfaction was assessed using the Maternal Satisfaction Scale for Cesarean Section (MSSCS). RESULTS: The mean (standard deviation [SD]) age (31.5 years [5.2 years] and 32.1 years [5.4 years]) and preexplanation NVAAS score (4.2 [3.2] and 4.0 [3.0]) of the intervention and control groups, respectively, showed no difference at baseline. The mean (SD) postexplanation decrease in NVAAS score was greater in the intervention than in the control group (1.6 [3.5] vs 0.7 [2.3]; P = .046; unadjusted mean difference, 0.9 points [95% confidence interval {CI}, 0.02-1.8]). A linear regression model for the postexplanation NVAAS score showed that the intervention effect was significantly associated with the preexplanation score (P = .002), adjusted for age and English fluency. Patients with preexplanation NVAAS scores ≥5 showed a statistically significant intervention effect. There was no significant difference in patient satisfaction between the intervention and control groups. The smartphone was an accessible and convenient display medium for the video. Ninety-nine percent of patients exposed to the intervention would recommend watching the video before the procedure. CONCLUSIONS: In this pilot study, lower NVAAS scores were observed in anxious patients, when a Xhosa information video was used to ameliorate challenges posed by a doctor-patient language barrier. It is easily implemented and demonstrates a novel use of mobile health technology. The study provides baseline data to inform sample size calculations for future studies. A high level of patient recommendation for the video suggests that this is an agreeable practice.


Assuntos
Anestesia Obstétrica , Raquianestesia , Ansiedade/prevenção & controle , Cesárea , Barreiras de Comunicação , Idioma , Mães/psicologia , Educação de Pacientes como Assunto/métodos , Telemedicina/métodos , Gravação em Vídeo , Adulto , Anestesia Obstétrica/efeitos adversos , Anestesia Obstétrica/psicologia , Raquianestesia/efeitos adversos , Raquianestesia/psicologia , Ansiedade/diagnóstico , Ansiedade/psicologia , Cesárea/efeitos adversos , Cesárea/psicologia , Compreensão , Feminino , Humanos , Relações Médico-Paciente , Projetos Piloto , Gravidez , Fatores de Risco , Smartphone , África do Sul , Telemedicina/instrumentação
11.
Anesth Analg ; 129(2): 444-449, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-29878938

RESUMO

BACKGROUND: The increasing prevalence of obesity worldwide is a major threat to global health. Cardiac structural and functional changes are well documented for obesity as well as for pregnancy, but there is limited literature on morbidly obese parturients. We hypothesized that there are both cardiac structural and functional differences between morbidly obese pregnant women and pregnant women of normal body mass index (BMI). METHODS: This prospective cross-sectional study was performed in 2 referral maternity units in Cape Town, South Africa, over a 3-month period. Forty morbidly obese pregnant women of BMI ≥40 kg·m (group O) were compared to 45 pregnant women of BMI ≤30 kg·m (group N). Cardiac structure and function were assessed by transthoracic echocardiography, according to the recommendations of the British Society of Echocardiography. The 2-sample t-test with unequal variances was used for the comparison of the mean values between the groups. RESULTS: Acceptable echocardiographic images were obtained in all obese women. Statistical significance was defined as P < .0225 after applying the Benjamini-Hochberg correction for multiple testing. Mean (standard deviation) mean arterial pressure was higher in group O (91 [8.42] vs 84 [9.49] mm Hg, P < .001). There were no between-group differences in heart rate, stroke volume, or cardiac index (84 [12] vs 79 [13] beats·minute, P = .103; 64.4 [9.7] vs 59.5 [13.5] mL, P = .069; 2551 [474] vs 2729 [623] mL·minute·m, P = .156, for groups O and N, respectively). Stroke volume index was lower, and left ventricular mass was higher in group O (30.14 [4.51] vs 34.25 [7.00] mL·m, P = .003; 152 [24] vs 115 [29] g, P < .001). S' septal was lower in group O (8.43 [1.20] vs 9.25 [1.64] cm·second, P = .012). Considering diastolic function, isovolumetric relaxation time was significantly prolonged in group O (73 [15] vs 61 [15] milliseconds, P < .001). The septal tissue Doppler index E' septal was lower in group O (9.08 [1.69] vs 11.28 [3.18], P < .001). There were no between-group differences in E' average (10.7 [2.3] vs 12.0 [2.7], P = .018, O versus N) or E/E' average (7.85 [1.77] vs 7.27 [1.68], P = .137, O versus N). Right ventricular E'/A' was lower in group O (1.07 [0.47] vs 1.29 [0.32], P = .016). CONCLUSIONS: Cardiac index did not differ between obese pregnant women and those with normal BMI. Their increased left ventricular mass and lower stroke volume index could indicate a limited adaptive reserve. Obese women had minor decreases in septal left ventricular tissue Doppler velocity, but the E/E' average values did not suggest clinically significant diastolic dysfunction.


Assuntos
Ecocardiografia Doppler , Coração/diagnóstico por imagem , Hemodinâmica , Obesidade Mórbida/complicações , Parto , Complicações Cardiovasculares na Gravidez/diagnóstico por imagem , Função Ventricular , Adaptação Fisiológica , Adulto , Índice de Massa Corporal , Estudos Transversais , Feminino , Coração/fisiopatologia , Humanos , Obesidade Mórbida/diagnóstico , Obesidade Mórbida/fisiopatologia , Valor Preditivo dos Testes , Gravidez , Complicações Cardiovasculares na Gravidez/etiologia , Complicações Cardiovasculares na Gravidez/fisiopatologia , Estudos Prospectivos , África do Sul , Volume Sistólico , Função Ventricular Esquerda , Função Ventricular Direita , Remodelação Ventricular , Adulto Jovem
12.
J Digit Imaging ; 32(3): 396-400, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30298437

RESUMO

Time-critical management is of particular significance in the trauma and emergency setting, where intervals from patient arrival to diagnostic imaging and from imaging to radiology report are key determinants of outcome. This study, based in the Trauma and Emergency Unit of a large, tertiary-level African hospital with a fully digital radiology department, assessed the impact of increased workload on computerised tomography (CT) efficiency. Sequential, customised searches of the institutional radiology information system (RIS) were conducted to define two weekends in 2016 with the lowest and highest emergency CT workloads, respectively. The electronic RIS timestamps defining the intervals between key steps in the CT workflow were extracted and analysed for each weekend. With the exception of radiologist reporting time, workflow steps were significantly prolonged by increased workload. This study highlights the potential role of the integrated digital radiology system in enabling a detailed analysis of imaging workflow, thereby facilitating the identification and appropriate management of bottlenecks.


Assuntos
Eficiência Organizacional , Serviço Hospitalar de Emergência/organização & administração , Avaliação de Processos em Cuidados de Saúde , Sistemas de Informação em Radiologia/organização & administração , Tomografia Computadorizada por Raios X , Carga de Trabalho/estatística & dados numéricos , Humanos , Estudos Retrospectivos , África do Sul , Centros de Atenção Terciária
13.
Anesth Analg ; 126(1): 190-195, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28799968

RESUMO

BACKGROUND: Perioperative hypothermia may affect maternal and neonatal outcomes after obstetric spinal anesthesia. Core temperature is often poorly monitored during spinal anesthesia, due to the lack of an accurate noninvasive core temperature monitor. The aim of this study was to describe core temperature changes and temperature recovery during spinal anesthesia for elective cesarean delivery. We expected that obstetric spinal anesthesia would be associated with a clinically relevant thermoregulatory insult (core temperature decrease >1.0°C). METHODS: A descriptive study was conducted in 28 women. An ingestible telemetric temperature sensor was used to record core temperature over time (measured every 10 seconds). The primary outcome was the maximum core temperature decrease after spinal anesthetic injection. The secondary outcomes were lowest absolute core temperature, time to lowest temperature, time to recovery of core temperature, hypothermic exposure (degree-hours below 37.0°C), and the time-weighted hypothermic exposure (median number of degrees below 37.0°C per hour). Basic descriptive statistics, median spline smooth, and integration of the area below the 37.0°C line of the temperature-over-time curve were utilized to analyze the data. RESULTS: Intestinal temperature decreased by a mean (standard deviation) of 1.30°C (0.31); 99% confidence interval (CI), 1.14 to 1.46 after spinal anesthetic injection. The median (interquartile range [IQR]) time to temperature nadir was 0.96 (0.73-1.32) hours (95% CI, 0.88-1.22). Fourteen of the 28 participants experienced intestinal temperatures below 36.0°C after spinal injection. Temperature was monitored for a minimum of 8 hours after spinal injection. In 8 of 28 participants, intestinal temperature did not recover to baseline during the monitored period. A median (IQR) of 4.59 (3.38-5.92) hours (95% CI, 3.45-5.90) was required for recovery to baseline intestinal temperature in the remaining 20 patients. Participants experienced a median (IQR) of 1.97 (1.00-2.68) degree-hours of hypothermic exposure (95% CI, 1.23-2.45). The median (IQR) number of degrees below 37.0°C per hour was 0.45 (0.35-0.60) (95% CI, 0.36-0.58). CONCLUSIONS: During cesarean delivery under spinal anesthesia, women experienced a rapid decrease in core temperature. Using an intestinal telemetric sensor, the perioperative thermal insult and recovery were documented with high resolution. Fifty percent of participants in this study became hypothermic. Although the surgical procedure is typically of short duration, women undergoing spinal anesthesia for cesarean delivery experience significant hypothermic exposure and compromised thermoregulation for several hours.


Assuntos
Anestesia Obstétrica/métodos , Raquianestesia/métodos , Cesárea/métodos , Hipotermia/prevenção & controle , Monitorização Intraoperatória/métodos , Telemetria/métodos , Adulto , Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Temperatura Corporal/fisiologia , Feminino , Humanos , Hipotermia/etiologia , Hipotermia/fisiopatologia , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/fisiopatologia , Complicações Intraoperatórias/prevenção & controle , Monitorização Intraoperatória/instrumentação , Gravidez , Telemetria/instrumentação , Adulto Jovem
14.
Lancet ; 387(10024): 1187-97, 2016 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-26970721

RESUMO

BACKGROUND: HIV-associated tuberculosis is difficult to diagnose and results in high mortality. Frequent extra-pulmonary presentation, inability to obtain sputum, and paucibacillary samples limits the usefulness of nucleic-acid amplification tests and smear microscopy. We therefore assessed a urine-based, lateral flow, point-of-care, lipoarabinomannan assay (LAM) and the effect of a LAM-guided anti-tuberculosis treatment initiation strategy on mortality. METHODS: We did a pragmatic, randomised, parallel-group, multicentre trial in ten hospitals in Africa--four in South Africa, two in Tanzania, two in Zambia, and two in Zimbabwe. Eligible patients were HIV-positive adults aged at least 18 years with at least one of the following symptoms of tuberculosis (fever, cough, night sweats, or self-reported weightloss) and illness severity necessitating admission to hospital. Exclusion criteria included receipt of any anti-tuberculosis medicine in the 60 days before enrolment. We randomly assigned patients (1:1) to either LAM plus routine diagnostic tests for tuberculosis (smear microscopy, Xpert-MTB/RIF, and culture; LAM group) or routine diagnostic tests alone (no LAM group) using computer-generated allocation lists in blocks of ten. All patients were asked to provide a urine sample of at least 30 mL at enrolment, and trained research nurses did the LAM test in patients allocated to this group using the Alere Determine tuberculosis LAM Ag lateral flow strip test (Alere, USA) at the bedside on enrolment. On the basis of a positive test result, the nurses made a recommendation for initiating anti-tuberculosis treatment. The attending physician made an independent decision about whether to start treatment or not. Neither patients nor health-care workers were masked to group allocation and test results. The primary endpoint was 8-week all-cause mortality assessed in the modified intention-to-treat population (those who received their allocated intervention). This trial is registered with ClinicalTrials.gov, number NCT01770730. FINDINGS: Between Jan 1, 2013, and Oct 2, 2014, we screened 8728 patients and randomly assigned 2659 to treatment (1336 to LAM, 1323 to no LAM). 108 patients did not receive their allocated treatment, mainly because they did not meet the inclusion criteria, and 23 were excluded from analysis, leaving 2528 in the final modified intention-to-treat analysis (1257 in the LAM group, 1271 in the no LAM group). Overall all-cause 8-week mortality occurred in 578 (23%) patients, 261 (21%) in LAM and 317 (25%) in no LAM, an absolute reduction of 4% (95% CI 1-7). The risk ratio adjusted for country was 0·83 (95% CI 0·73-0·96), p=0·012, with a relative risk reduction of 17% (95% CI 4-28). With the time-to-event analysis, there were 159 deaths per 100 person-years in LAM and 196 per 100 person-years in no LAM (hazard ratio adjusted for country 0·82 [95% CI 0·70-0·96], p=0·015). No adverse events were associated with LAM testing. INTERPRETATION: Bedside LAM-guided initiation of anti-tuberculosis treatment in HIV-positive hospital inpatients with suspected tuberculosis was associated with reduced 8-week mortality. The implementation of LAM testing is likely to offer the greatest benefit in hospitals where diagnostic resources are most scarce and where patients present with severe illness, advanced immunosuppression, and an inability to self-expectorate sputum. FUNDING: European Developing Clinical Trials Partnership, the South African Medical Research Council, and the South African National Research Foundation.


Assuntos
Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Lipopolissacarídeos/urina , Sistemas Automatizados de Assistência Junto ao Leito , Tuberculose/diagnóstico , Infecções Oportunistas Relacionadas com a AIDS/tratamento farmacológico , Infecções Oportunistas Relacionadas com a AIDS/imunologia , Infecções Oportunistas Relacionadas com a AIDS/mortalidade , Adulto , África/epidemiologia , Antituberculosos/uso terapêutico , Biomarcadores/urina , Contagem de Linfócito CD4 , Testes Diagnósticos de Rotina , Feminino , Hospitalização , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Sensibilidade e Especificidade , Resultado do Tratamento , Tuberculose/tratamento farmacológico , Tuberculose/imunologia , Tuberculose/mortalidade
15.
Matern Child Nutr ; 13(1)2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-26564246

RESUMO

Serum retinol was assessed in mothers and newborns from an impoverished South African community where liver is frequently eaten and vitamin A deficiency known to be absent. Paired cord and maternal blood (n = 201) were collected after delivery and analysed for serum retinol and C-reactive protein (CRP). Liver intake during pregnancy and intention to breastfeed were also assessed. Mean serum retinol was 1.03 µmol/L ± 0.40 in mothers and 0.73 ± 0.24 µmol/L in newborns, with 21.4% and 49.3% having serum retinol <0.70 µmol/L (<20 µg/dL), respectively. Raised CRP was found in 59.9% of mothers, with a significant negative correlation between serum retinol and CRP (r = -0.273; p < 0.0001). Liver was eaten by 87.6% of mothers, and 99% indicated their intention to breastfeed. Despite consumption of liver, serum retinol was low in both the mother and the newborn. The conventional cut-off for serum retinol, i.e. <0.70 µmol/L may therefore not apply for the mother and newborn in the period immediately after delivery. Serum retinol may be influenced by factors other than vitamin A status, e.g. the haemodilution of pregnancy, as well as the acute phase response induced by the birth process, as suggested by raised CRP in 60% of mothers. In the newborns, the low serum retinol is likely to increase rapidly, as liver is frequently eaten by mothers and practically all of them intended to breastfeed. Our results confirm the need for better indicators of vitamin A status or alternative cut-off values during this period.


Assuntos
Carne , Mães , Período Pós-Parto/sangue , Deficiência de Vitamina A/epidemiologia , Vitamina A/sangue , Adulto , Aleitamento Materno , Proteína C-Reativa/metabolismo , Dieta , Feminino , Sangue Fetal/química , Humanos , Recém-Nascido , Fígado , Estado Nutricional , Fatores Socioeconômicos , África do Sul , Inquéritos e Questionários , Deficiência de Vitamina A/sangue , Deficiência de Vitamina A/diagnóstico , Adulto Jovem
16.
Thorax ; 70(9): 840-6, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26060256

RESUMO

BACKGROUND: There is limited knowledge of chest radiographic abnormalities over time in HIV-infected children in resource-limited settings. OBJECTIVE: To investigate the natural history of chest radiographic abnormalities in HIV-infected African children, and the impact of antiretroviral therapy (ART). METHODS: Prospective longitudinal study of the association of chest radiographic findings with clinical and immunological parameters. Chest radiographs were performed at enrolment, 6-monthly, when initiating ART and if indicated clinically. Radiographic abnormalities were classified as normal, mild or moderate severity and considered persistent if present for 6 consecutive months or longer. An ordinal multiple logistic regression model assessed the association of enrolment and time-dependent variables with temporal radiographic findings. RESULTS: 258 children (median (IQR) age: 28 (13-51) months; median CD4+%: 21 (15-24)) were followed for a median of 24 (18-42) months. 70 (27%) were on ART at enrolment; 130 (50%) (median age: 33 (18-56) months) commenced ART during the study. 154 (60%) had persistent severe radiographic abnormalities, with median duration 18 (6-24) months. Among children on ART, 69% of radiographic changes across all 6-month transition periods were improvements, compared with 45% in those not on ART. Radiographic severity was associated with previous radiographic severity (OR=120.80; 95% CI 68.71 to 212.38), lack of ART (OR=1.72; 95% CI 1.29 to 2.27), enrolment age <18 months (OR=1.39; 95% CI 1.06 to 1.83), diffuse, severe radiographic abnormality at enrolment (OR=2.18; 95% CI 1.33 to 3.56), hospitalisation for lower respiratory tract infection during the previous 6 months (OR=1.88; 95% CI 1.06 to 3.30) and length of follow-up: at 18-24 months (OR=0.66; 95% CI 0.49 to 0.90), and at 30-54 months (OR=0.42; 95% CI 0.32 to 0.56). CONCLUSIONS: Most children had severe radiographic abnormalities persisting for at least 18 months. ART was beneficial, reducing the risk of radiographic deterioration or increasing the likelihood of radiological improvement.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/complicações , Doenças Respiratórias/diagnóstico por imagem , População Negra , Criança , Pré-Escolar , Feminino , Seguimentos , Infecções por HIV/diagnóstico por imagem , Infecções por HIV/tratamento farmacológico , Humanos , Lactente , Modelos Logísticos , Estudos Longitudinais , Masculino , Estudos Prospectivos , Radiografia , Doenças Respiratórias/complicações , Doenças Respiratórias/epidemiologia , África do Sul/epidemiologia
17.
Public Health Nutr ; 17(12): 2798-805, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24476795

RESUMO

OBJECTIVE: To assess the contribution of liver to the vitamin A intake of 24-59-month-old children from an impoverished South African community where liver is frequently consumed and vitamin A deficiency previously shown to be absent. DESIGN: Cross-sectional. SETTING: Northern Cape Province, South Africa. SUBJECTS: Children aged 24-59 months (n 150). Vitamin A intake from liver was assessed using a single 24 h recall and a quantified liver frequency questionnaire. In addition, information on vitamin A intake via the national fortification programme was obtained from the 24 h recall and information on vitamin A supplementation from the Road-to-Health Chart. Height, weight and socio-economic data were also collected. RESULTS: Stunting, underweight and wasting were prevalent in 36·9 %, 25·5 % and 12·1 % of children. Mean daily vitamin A intake from liver was 537 and 325 µg retinol equivalents measured by the 24 h recall and liver frequency questionnaire, respectively. Liver was consumed in 92·7 % of households and by 84·7 % of children; liver intake was inversely related to socio-economic status (P < 0·05). The food fortification programme contributed 80 µg retinol equivalents and the vitamin A supplementation programme 122 µg retinol equivalents to daily vitamin A intake. CONCLUSIONS: The study showed that liver alone provided more than 100 % of the Estimated Average Requirement of the pre-school children in this impoverished community. The results also challenge the notion generally held by international health bodies that vitamin A deficiency, poor anthropometric status and poverty go together, and reinforces the fact that South Africa is a culturally diverse society for which targeted interventions are required.


Assuntos
Dieta , Fígado , Carne , Necessidades Nutricionais , Pobreza , Deficiência de Vitamina A/prevenção & controle , Vitamina A/administração & dosagem , Adulto , Pré-Escolar , Estudos Transversais , Suplementos Nutricionais , Características da Família , Feminino , Alimentos Fortificados , Transtornos do Crescimento/epidemiologia , Humanos , Masculino , Rememoração Mental , Avaliação Nutricional , Classe Social , África do Sul/epidemiologia , Inquéritos e Questionários , Magreza/epidemiologia , Síndrome de Emaciação/epidemiologia
18.
Int J Cardiovasc Imaging ; 39(1): 169-182, 2023 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-36598696

RESUMO

HIV associated cardiomyopathy (HIVAC) is a poorly understood entity that may progress along a continuum. We evaluated a group of persons newly diagnosed with HIV and studied the evolution of cardiac abnormalities after ART initiation. We recruited a group of newly diagnosed, ART naïve persons with HIV and a healthy, HIV uninfected group. Participants underwent comprehensive cardiovascular evaluation, including cardiovascular magnetic resonance imaging. The HIV group was started on ART and re-evaluated 9 months later. The cardiovascular parameters of the study groups were compared at diagnosis and after 9 months. The ART naïve group's (n = 66) left- and right end diastolic volume indexed for height were larger compared with controls (n = 22) (p < 0.03). The left ventricular mass indexed for height was larger in the naïve group compared with controls (p = 0.04). The ART naïve group had decreased left- and right ventricular ejection fraction (p < 0.03) and negative, non-linear associations with high HIV viral load (p = 0.02). The left ventricular size increased after 9 months (p = 0.04), while the systolic function remained unchanged. The HIV group had a high rate of non-resolving pericardial effusions. HIV infected persons demonstrate structurally and functionally altered ventricles at diagnosis. High HIV viral load was associated with left- and right ventricular dysfunction. Cardiac parameters and pericardial effusion prevalence did not show improvement with ART. Conversely, a concerning trend of increase was observed with left ventricular size. These subclinical cardiac abnormalities may represent a stage on the continuum of HIVAC that can progress to symptomatic disease if the causes are not identified and addressed.


Assuntos
Cardiomiopatias , Infecções por HIV , Derrame Pericárdico , Humanos , HIV , Volume Sistólico , Estudos Prospectivos , Função Ventricular Direita , Valor Preditivo dos Testes , Infecções por HIV/complicações , Infecções por HIV/diagnóstico , Infecções por HIV/tratamento farmacológico , Imageamento por Ressonância Magnética , Cardiomiopatias/complicações , Espectroscopia de Ressonância Magnética , Função Ventricular Esquerda
19.
Public Health Nutr ; 15(4): 716-24, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-21859509

RESUMO

OBJECTIVE: To assess serum retinol, liver intake patterns, breast-feeding history and anthropometric status in pre-school children of a low socio-economic community where liver is regularly consumed. DESIGN: Cross-sectional study. SETTING: Northern Cape Province, South Africa. SUBJECTS: Children aged 1-6 years (n 243) who attended the local primary health-care facility and had not received a vitamin A supplement in the 6 months preceding the study. Non-pregnant female caregivers (n 225), below 50 years of age, were also assessed. RESULTS: Despite stunting, underweight and wasting being prevalent in 40·5%, 23·1% and 8·4% of the children, only 5·8% had serum retinol concentrations < 20 µg/dl, which is in sharp contrast to the national prevalence of 63·6%. None of the caregivers were vitamin A deficient. Liver was eaten by 89·2% of children, with 87% of households eating liver at least once monthly and 30% eating it at least once weekly; liver was introduced into the diet of the children at a median age of 18 months. Ninety-three per cent of the children were being breast-fed or had been breast-fed in the past; children were breast-fed to a median age of 18 months. A significant negative correlation was found between educational level of the caregiver and frequency of liver intake (r = -0·143, P=0·032). There was no correlation between serum retinol and indicators of anthropometric or socio-economic status. CONCLUSIONS: The blanket approach in applying the national vitamin A supplementation programme may not be appropriate for all areas in the country, even though the community may be poor and undernourished.


Assuntos
Antropometria , Transtornos da Nutrição Infantil/epidemiologia , Fígado , Vitamina A/administração & dosagem , Vitamina A/sangue , Aleitamento Materno/estatística & dados numéricos , Criança , Transtornos da Nutrição Infantil/sangue , Pré-Escolar , Estudos Transversais , Suplementos Nutricionais , Feminino , Humanos , Lactente , Masculino , Fatores Socioeconômicos , África do Sul/epidemiologia , Deficiência de Vitamina A/sangue , Deficiência de Vitamina A/epidemiologia
20.
BMC Public Health ; 12: 503, 2012 Jul 04.
Artigo em Inglês | MEDLINE | ID: mdl-22762453

RESUMO

BACKGROUND: Due to a paucity of data regarding the availability and efficacy of equipment, health promotion methods and materials currently used by health professionals for the management of patients with non-communicable diseases (NCDs) at primary health care (PHC) facilities in Cape Town, an audit was undertaken. METHODS: A multi-centre cross-sectional study was undertaken to interview patients (n = 580) with NCDs at 30 PHC facilities. A questionnaire was used to obtain information on preferences for health promotion methods for lifestyle modification. Individual semi-structured interviews were conducted with selected health professionals (n = 14) and captured using a digital recorder. Data were transferred to the Atlas ti software programme and analysed using a thematic content analysis approach. RESULTS: Blood pressure measurement (97.6%) was the most common diagnostic test used, followed by weight measurement (88.3%), urine (85.7%) and blood glucose testing (80.9%). Individual lifestyle modification counselling was the preferred health education method of choice for the majority of patients. Of the 64% of patients that selected chronic clubs/support groups as a method of choice, only a third rated this as their first choice. Pamphlets, posters and workshops/group counselling sessions were the least preferred methods with only 9%, 13% and 11% of patients choosing these as their first choice, respectively. In an individual counselling setting 44.7% of patients reported that they would prefer to be counselled by a doctor, followed by a nurse (16.9%), health educator (8.8%) and nutrition advisor (4.8%). Health professionals identified numerous barriers to education and counselling. These can be summarised as a lack of resources, including time, space and equipment; staff-related barriers such as staff shortage and staff turnover; and patient-related barriers such as patient load and patient non-compliance. CONCLUSION: The majority of patients attending PHC facilities want to receive lifestyle modification education. There is not however, one specific method that can be regarded as the gold standard. Patients' preferences regarding health education methods differ, and they are more likely to be susceptible to methods that do not involve much reading. Health education materials such as posters, pamphlets and booklets should be used to supplement information received during counselling or support group sessions.


Assuntos
Atitude do Pessoal de Saúde , Doença Crônica/terapia , Pessoal de Saúde/psicologia , Promoção da Saúde/métodos , Estilo de Vida , Preferência do Paciente/estatística & dados numéricos , Atenção Primária à Saúde/organização & administração , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Pesquisa Qualitativa , África do Sul , Adulto Jovem
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