Differential management and associations of dyslipidaemia and hypertension by glycaemic status in urban South Africans.

BACKGROUND: Dyslipidaemia and hypertension care have not been reported in large samples of community-based participants with known diabetes (KD) nor compared with individuals at high risk for diabetes. OBJECTIVES: To describe the management and associations of dyslipidaemia and hypertension in adults with KD, newly diagnosed diabetes (NDD) and normoglycaemia. METHODS: This urban population-based cross-sectional study comprised participants with KD, NDD and normoglycaemia. Participants at high risk for diabetes but without KD underwent oral glucose tolerance tests; those who were subsequently classified as NDD or normoglycaemic were included in this study. Data collection comprised administered questionnaires, clinical measurements and biochemical analyses. Multivariable logistic regressions determined the associations with hypertension and dyslipidaemia management in separate models. RESULTS: Among 618 participants (82% women), aged median 58 years, there were 339 participants with KD, 70 with NDD and 209 with normoglycaemia. Prevalence of hypertension (BP ≥140/90 mmHg or on treatment) and dyslipidaemia (raised low-density lipoprotein cholesterol >3 mmol/L or on treatment) was highest in KD (89% and 83%) compared with NDD (64% and 74%) and normoglycaemia (66% for both) (p<0.001). Detected or known hypertension was highest in KD (97.4%), followed by NDD (88.9%) and normoglycaemia (80.3%). Among participants with known or detected hypertension, those with KD were most likely to be treated (90.2%) compared with NDD (77.5%) and normoglycaemia (74.5.%). Hypertension control among participants on treatment was highest in KD (69.5%) compared with NDD (51.6%) and normoglycaemia (61.0%). Participants with KD had significantly higher rates of previously detected dyslipidaemia (85.1%) compared with NDD (36.5%) and normoglycaemia (35.5%). KD participants were also more likely to be treated for their previously detected dyslipidaemia (85.4%) and to be controlled when on treatment (56.3%) compared with their counterparts (NDD: 63.2% and 33.3%, normoglycaemia: 61.2% and 43.3%, respectively). Diabetes control was poor; only 20% of those with KD had HbA1c <7%. In the regression models, compared with normoglycaemia, KD was associated with hypertension detection (odds ratio (OR) 6.91, 95% confidence interval (CI) 2.25 - 21.22) and control (OR 2.05, 95% CI 1.04 - 4.02). KD compared with normoglycaemia was associated with dyslipidaemia detection (OR 10.29, 95% CI 5.21 - 20.32) and treatment (OR 3.94, 95% CI 1.68 - 9.27). Sociodemographic and cardiovascular disease risk factors were generally not associated with hypertension or dyslipidaemia management. CONCLUSION: Albeit that diabetes control was poor and required better management, dyslipidaemia and hypertension prevalence were higher and better managed in KD than NDD and normoglycaemia. Different approaches are required to improve glucose control in KD, better identify NDD and monitor and prevent diabetes in high-risk individuals. Also important would be to improve care of hypertension and dyslipidaemia in those without KD.

Depression and post-traumatic stress symptoms two years post-rape and the role of early counselling: Rape Impact Cohort Evaluation (RICE) study.

Background: Survivors of sexual violence are at higher risk of adverse mental health outcomes compared to those exposed to other interpersonal traumas.Objective: To examine the trajectory of both post-traumatic stress disorder (PTSD) and depression as well as the role of early counselling over 24 months among rape survivors.Method: The South African Rape Impact Cohort Evaluation (RICE) study enrolled women aged 16-40 years attending post-rape care services within 20 days of a rape incident (n = 734), and a comparison group (n = 786) was recruited from primary health care. Women were followed for 24 months; the main study outcomes were depression and PTSD. Reports of early supportive counselling by the exposed group were also included. The analysis included an adjusted joint mixed model with linear splines to account for correlated observations between the outcomes.Results: At 24 months, 45.2% of the rape-exposed women met the cut-off for depression and 32.7% for PTSD. This was significantly higher than levels found among the unexposed. Although a decline in depression and PTSD was seen at 3 months among the women who reported a rape, mean scores remained stable thereafter. At 24 months mean depression scores remained above the depression cut-off (17.1) while mean PTSD scores declined below the PTSD cut-off (14.5). Early counselling was not associated with the trajectory of either depression or PTSD scores over the two years in rape-exposed women with both depression and PTSD persisting regardless of early counselling.Conclusion: The study findings highlight the importance to find and provide effective mental health interventions post-rape in South Africa.

Pathways to adverse pregnancy outcomes: exploring the mediating role of intimate partner violence and depression: results from a South African rape cohort study.

Adverse pregnancy outcomes (APOs) are common occurrences that contribute to negative maternal and child health outcomes. Our aim was to test the hypothesis that trauma exposure and depression are drivers of the better-recognised risk factors for miscarriage, abortion and stillbirths. Our comparative cohort study based in Durban, South Africa recruited women who reported a recent rape (n = 852) and those who had never experienced rape (n = 853), with follow-up for 36 months. We explored APOs (miscarriage, abortion or stillbirth) among those having a pregnancy during follow-up (n = 453). Potential mediators were baseline depression, post-traumatic stress symptoms, substance abuse, HbA1C, BMI, hypertension and smoking. A structural equation model (SEM) was used to determine direct and indirect paths to APO. Overall, 26.6% of the women had a pregnancy in the follow-up period and 29.4% ended in an APO, with miscarriage (19.9%) the most common outcome, followed by abortion (6.6%) and stillbirths (2.9%). The SEM showed two direct pathways from exposure to childhood trauma, rape and other trauma, to APO which were ultimately mediated by hypertension and/or BMI, but all paths to BMI were mediated by depression and IPV-mediated pathways from childhood and other trauma to hypertension. Food insecurity mediated a pathway from experiences of trauma in childhood to depression. Our study confirms the important role of trauma exposure, including rape, and depression on APOs, through their impact on hypertension and BMI. It is critical that violence against women and mental health are more systematically addressed in antenatal, pregnancy and postnatal care.

Estimating the changing burden of disease attributable to high systolic blood pressure in South Africa for 2000, 2006 and 2012.

BACKGROUND: Ongoing quantification of trends in high blood pressure and the consequent disease impact are crucial for monitoring and decision-making. This is particularly relevant in South Africa (SA) where hypertension is well-established. OBJECTIVE: To quantify the burden of disease related to high systolic blood pressure (SBP) in SA for 2000, 2006 and 2012, and describe age, sex and population group differences. METHODS: Using a comparative risk assessment methodology, the disease burden attributable to raised SBP was estimated according to age, se, and population group for adults aged ≥25 years in SA in the years 2000, 2006 and 2012. We conducted a meta-regression on data from nine national surveys (N=124 350) to estimate the mean and standard deviation of SBP for the selected years (1998 - 2017). Population attributable fractions were calculated from the estimated SBP distribution and relative risk, corrected for regression dilution bias for selected health outcomes associated with a raised SBP, above a theoretical minimum of 110 - 115 mmHg. The attributable burden was calculated based on the estimated total number of deaths and disability-adjusted life years (DALYs). RESULTS: Mean SBP (mmHg) between 2000 and 2012 showed a slight increase for adults aged ≥25 years (127.3 - 128.3 for men; 124.5 - 125.2 for women), with a more noticeable increase in the prevalence of hypertension (31% - 39% in men; 34% - 40% in women). In both men and women, age-standardised rates (ASRs) for deaths and DALYs associated with raised SBP increased between 2000 and 2006 and then decreased in 2012. In 2000 and 2012, for men, the death ASR (339/100 000 v. 334/100 000) and DALYs (5 542/100 000 v. 5 423/100 000) were similar, whereas for women the death ASR decreased (318/100 000 v. 277/100 000) as did age-standardised DALYs (5 405/100 000 v. 4 778/100 000). In 2012, high SBP caused an estimated 62 314 deaths (95% uncertainty interval 62 519 - 63 608), accounting for 12.4% of all deaths. Stroke (haemorrhagic and ischaemic), hypertensive heart disease and ischaemic heart disease accounted for >80% of the disease burden attributable to raised SBP over the period. CONCLUSION: From 2000 to 2012, a stable mean SBP was found despite an increase in hypertension prevalence, ascribed to an improvement in the treatment of hypertension. Nevertheless, the high mortality burden attributable to high SBP underscores the need for improved care for hypertension and cardiovascular diseases, particularly stroke, to prevent morbidity and mortality.

Estimating the changing disease burden attributable to raised low-density lipoprotein cholesterol in South Africa for 2000, 2006 and 2012.

BACKGROUND: Low-density lipoprotein cholesterol (LDL-C) is the most important contributor to atherosclerosis, a causal factor for ischaemic heart disease (IHD) and ischaemic stroke. Although raised LDL-C is a key contributor to cardiovascular disease (CVD), the exact attributable disease risk in South Africa (SA) is unknown. The the first SA comparative risk assessment (SACRA1) study assessed the attributable burden of raised total cholesterol, and not specifically LDL-C. OBJECTIVES: To estimate the national mean serum LDL-C by age, year and sex and to quantify the burden of disease attributable to LDL-C in SA for 2000, 2006 and 2012. METHODS: The comparative risk assessment (CRA) method was used. Estimates of the national mean of LDL-C, representing the 3 different years, were derived from 14 small observational studies using a meta-regression model. A theoretical minimum risk exposure level (TMREL) of 0.7 - 1.3 mmol/L was used. LDL-C estimates together with the relative risks from the Global Burden of Disease Study 2017 were used to calculate a potential impact fraction (PIF). This was applied to IHD and ischaemic stroke estimates sourced from the Second National Burden of Disease Study. Attributable deaths, years of life lost, years lived with disability and disability-adjusted life years (DALYs) were calculated. Uncertainty analysis was performed using Monte Carlo simulation. RESULTS: LDL-C declined from 2.74 mmol/L in 2000 to 2.58 mmol/L in 2012 for males, while in females it declined from 3.05 mmol/L in 2000 to 2.91 mmol/L in 2012. The PIFs for LDL-C showed a slight decline over time, owing to the slight decrease in LDL-C levels. Attributable DALYs increased between 2000 (n=286 712) and 2006 (n=315 125), but decreased thereafter in 2012 (n=270 829). Attributable age-standardised death rates declined between 2000 and 2012 in both sexes: in males from 98 per 100 000 members of the population in 2000 to 78 per 100 000 in 2012, and in females from 81 per 100 000 in 2000 to 58 per 100 000 in 2012. CONCLUSIONS: Mean LDL-C levels were close to 3 mmol/L, which is the recommended level at which cholesterol-lowering treatment should be initiated for people at low and moderate risk for cardiovascular outcomes. The decreasing trend in the age-standardised attributable burden due to LDL-C is encouraging, but it can be lowered further with the introduction of additional population-based CVD prevention strategies. This study highlights the fact that high LDL-C concentration in relation to the TMREL in SA is responsible for a large proportion of the emerging CVD, and should be targeted by health planners to reduce disease burden.

Overview.

BACKGROUND: South Africa (SA) faces multiple health challenges. Quantifying the contribution of modifiable risk factors can be used to identify and prioritise areas of concern for population health and opportunities for health promotion and disease prevention interventions. OBJECTIVE: To estimate the attributable burden of 18 modifiable risk factors for 2000, 2006 and 2012. METHODS: Comparative risk assessment (CRA), a standardised and systematic approach, was used to estimate the attributable burden of 18 risk factors. Risk exposure estimates were sourced from local data, and meta-regressions were used to model the parameters, depending on the availability of data. Risk-outcome pairs meeting the criteria for convincing or probable evidence were assessed using relative risks against a theoretical minimum risk exposure level to calculate either a potential impact fraction or population attributable fraction (PAF). Relative risks were sourced from the Global Burden of Disease, Injuries, and Risk Factors (GBD) study as well as published cohort and intervention studies. Attributable burden was calculated for each risk factor for 2000, 2006 and 2012 by applying the PAF to estimates of deaths and years of life lost from the Second South African National Burden of Disease Study (SANBD2). Uncertainty analyses were performed using Monte Carlo simulation, and age-standardised rates were calculated using the World Health Organization standard population. RESULTS: Unsafe sex was the leading risk factor across all years, accounting for one in four DALYs (26.6%) of the estimated 20.6 million DALYs in 2012. The top five leading risk factors for males and females remained the same between 2000 and 2012. For males, the leading risks were (in order of descending rank): unsafe sex; alcohol consumption; interpersonal violence; tobacco smoking; and high systolic blood pressure; while for females the leading risks were unsafe sex; interpersonal violence; high systolic blood pressure; high body mass index; and high fasting plasma glucose. Since 2000, the attributable age-standardised death rates decreased for most risk factors. The largest decrease was for household air pollution (-41.8%). However, there was a notable increase in the age-standardised death rate for high fasting plasma glucose (44.1%), followed by ambient air pollution (7%). CONCLUSION: This study reflects the continued dominance of unsafe sex and interpersonal violence during the study period, as well as the combined effects of poverty and underdevelopment with the emergence of cardiometabolic-related risk factors and ambient air pollution as key modifiable risk factors in SA. Despite reductions in the attributable burden of many risk factors, the study reveals significant scope for health promotion and disease prevention initiatives and provides an important tool for policy makers to influence policy and programme interventions in the country.

Elevated resting heart rate is associated with several cardiovascular disease risk factors in urban-dwelling black South Africans.

This study determined the associations of resting heart rate (RHR) with cardiovascular disease risk factors (CVDRF) in 25-74-year-old black South Africans. This cross-sectional study determined CVDRF by administered questionnaires, clinical measurements and biochemical analyses, including oral glucose tolerance tests. Multivariable linear regression models determined the associations of rising RHR with CVDRF. The basic model comprised age, gender, urbanisation, problematic alcohol use, daily cigarette smoking, physical activity and waist circumference. Glucose, blood pressure and cholesterol variables were entered separately and individually in the above model. Among the 1054 participants (382 men and 672 women, mean age 42.8 years), mean RHR was 70.6 beats per minute (bpm) and significantly higher in women (73.6 bpm) compared with men (65.3 bpm). RHR peaked in 45-54-year-old men (69.3 bpm) and 25-34-year-old women (75.3 bpm). Prevalence of RHR < 60 bpm and ≥90 bpm was 24.3% and 6.2%. In the regression model, female gender, problematic alcohol use, decreasing physical activity and increasing waist circumference were significantly associated with rising RHR. All glycaemic variables (diabetes, fasting glucose and 2-hour glucose) and diastolic blood pressure were significantly associated with RHR. The use of RHR in daily primary healthcare settings to identify increased risk for CVDRF should perhaps be encouraged.

Peripheral adiponectin levels in anxiety, mood, trauma- and stressor-related disorders: A systematic review and meta-analysis.

BACKGROUND: Anxiety, mood, trauma- and stressor-related disorders confer increased risk for metabolic disease. Adiponectin, a cytokine released by adipose tissue is associated with these disorders and obesity via inflammatory processes. Available data describing associations with mental disorders remain limited and conflicted. METHODS: A systematic search was conducted for English, peer-reviewed articles from inception until February 2019 that assessed for serum or plasma adiponectin levels in adults with an anxiety, mood or trauma-related disorder. Diagnoses were determined by psychiatric interview, based on DSM-IV, DSM-5 or ICD-10 criteria. Analyses were performed using STATA 15 and Standardized mean difference (SMD) with 95% confidence interval was applied to pool the effect size of meta-analysis studies. RESULTS: In total 65 eligible studies were included in the systematic review and 30 studies in this meta-analysis. 19,178 participants (11,262 females and 7916 males), comprising healthy adults and adults with anxiety, mood and trauma-related disorders, were included. Overall results indicated an inverse association between adiponectin levels and examined mental disorders. Specifically, patients with an anxiety disorder (SMD  = -1.18 µg/mL, 95% CI, -2.34; -0.01, p â€Š= 0.047); trauma or stressor-related disorder (SMD â€Š= â€Š-0.34 µg/mL, 95% CI, -0.52; -0.17, p â€Š= 0.0000) or bipolar disorder (SMD  = â€Š-0.638 µg/mL, 95% CI, -1.16, -0.12, p â€Š= 0.017) had significant lower adiponectin levels compared to healthy adults. LIMITATIONS: Heterogeneity, potential publication bias, and lack of control for important potential confounders were significant limitations. CONCLUSION: Peripheral adiponectin levels appear to be inversely associated with anxiety, mood, trauma- and stressor related disorders and may be a promising biomarker for diagnosis and disease monitoring.

Increase in blood pressure over a 7-year period in a mixed-ancestry South African population.

BACKGROUND: An increase in the prevalence of high blood pressure (BP) has been reported globally and in the South African (SA) population. OBJECTIVES: To investigate temporal changes in absolute BP levels and hypertension prevalence in the mixed-ancestry South Africans. METHODS: Participants were from two independent cross-sectional surveys conducted during 2008/09 (N=928) and 2014/16 (N=1 969) in Bellville South, Cape Town, SA. Participants' eligibility was based on several criteria, including age >20 years and neither bedridden nor pregnant. Data were obtained by administered questionnaires, clinical measurements (BP and anthropometry) and biochemical assessments (oral glucose tolerance tests and cotinine levels). Known hypertension was based on a self-reported history of doctor-diagnosed hypertension and ongoing treatment. Comparison across years was based on the crude prevalence of hypertension as well as direct age-standardised prevalence, based on the SA 2011 mixed-ancestry population distribution, in 10-year age increments. RESULTS: In all, 708 participants (76.3%) in 2008/09 and 1 488 (75.6%) in 2014/16 were female. Between 2008/09 and 2014/16, mean systolic BP increased from 124 to 136 mmHg (absolute mean difference 15 mmHg) and mean diastolic BP from 75 to 85 mmHg (absolute mean difference 9 mmHg) in the overall sample. The prevalence of screen-detected hypertension increased from 11.6% to 24.8%, with a similar increase in males and females, while the prevalence of known cases remained stable. These changes remained significant after adjustment for age and gender. CONCLUSIONS: A rightward shift in absolute BP translated into a significant increase in the prevalence of hypertension over time in this population. The predominant increases in screen-detected hypertension suggest that the deteriorating profile was not matched by efforts to detect and manage individuals with higher-than-optimal BP levels.

Knowledge generation via publications on hypertension prevalence in population-based studies conducted in sub-Saharan Africa over 30 years: 1990 - 2019.

Hypertension prevalence in sub-Saharan Africa (SSA) is high, is rising and has emerged as the most prevalent cardiovascular disease risk factor. Research is required to provide evidence-based findings to prioritise hypertension prevention and control. This systematic review aims to describe the distribution of and trends in scientific outputs on hypertension prevalence in population-based studies in SSA over the last three decades. Relevant English-language articles documenting hypertension prevalence in population-based studies in SSA, published between 1 January 1990 and 25 April 2019, were identified through a comprehensive electronic search of MEDLINE. Of the 3 795 citations retrieved, 414 fulfilled the inclusion criteria. Scientific outputs increased incrementally per 10-year period: 1990 - 1999: n=32; 2000 - 2009: n=65; and 2010 - 2019: n=317. The greatest number of scientific outputs over the 30-year period originated from South Africa (n=81) and Nigeria (n=74). Increasing scientific outputs on hypertension prevalence in SSA have not translated into optimal hypertension management, which remains inadequate.

Current strategies are inadequate to curb the rise of tobacco use in Africa.

Recently, there have been significant advances in the battle against tobacco use in Africa, with achievements including ratification of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) and the passing of tobacco control legislation in several countries. Many African countries have achieved measured success, while Uganda, South Africa and Mauritius have accomplished significantly more in their efforts to curb tobacco use. Nevertheless, few African countries meet the standards of the individual WHO FCTC articles with regard to comprehensive implementation. Africa has lower rates of tobacco taxation, weaker smoke-free policies and fewer restrictions on tobacco advertising compared with other world regions. These shortcomings have enabled the tobacco industry to expand its markets on the continent by capitalising on economic growth, changing social norms and population demographics. Consequently, tobacco use is increasing in Africa, with smoking prevalence having risen 57% between 1990 and 2009 compared with western Europe, where it decreased substantially during the same period. Rapid smoking uptake in Africa has led to tobacco-related conditions emerging as increasingly important public health problems. African nations are unlikely to meet the 2025 goal of a 30% relative reduction in tobacco use, as advocated by the World Health Assembly in 2013 and identified as the 'most urgent and immediate priority' intervention to reduce non-communicable diseases (NCDs). While there has been some progress, the current commitment of most African countries to the WHO FCTC has not translated into effective delivery of tobacco control policies and programmes. Strong tobacco control policies, which are among the most effective population-based strategies for NCD prevention, are needed. These include introducing higher tobacco excise taxes, stronger smoke-free policies, graphic warnings on cigarette packages, bans on tobacco advertising, promotion and sponsorship, and anti-smoking mass media campaigns. Furthermore, tobacco industry interference needs to be actively addressed by monitoring its activities and exposing misconducts, thereby changing attitudes to the industry. Technical support, capacity building and adequate financing are needed in Africa to enable countries to competently manage legal challenges to tobacco control and deal with the subversive tactics of the industry. Civil society and the media - major players in holding governments accountable for responsible stewardship - need to educate and pressurise African politicians and governments to implement and enforce effective tobacco control policies. Otherwise, if unchecked, the widespread uptake of tobacco use will be a threat not only to health but also to sustainable human development in Africa.

Differential obesity indices identify the metabolic syndrome in Black men and women in Cape Town: the CRIBSA study.

AIMS: To determine the obesity indices, specifically waist circumference (WC), that identified ≥2 other metabolic syndrome (MS) components (2009 criteria) in 25- to 74-year-old Africans in Cape Town. METHODS: Data were collected from a cross-sectional sample by administered questionnaires, clinical measurements and biochemical analyses. The obesity cut points were estimated by the Youden Index. Logistic regression analyses determined whether obesity cut points identifying ≥2 MS components occurred at true inflection points. RESULTS: Among the 1099 participants, the calculated cut points and 95% confidence intervals (CI) were: men, WC 83.9 cm (81.6-86.2), waist-to-hip ratio (WHR) 0.89 (0.87-0.90), waist-to-height ratio (WHtR) 0.50 (0.48-0.52) and body mass index (BMI) 24.1 kg/m(2) (22.0-26.1); women, WC 94.0 cm (92.6-95.3), WHR 0.85 (0.83-0.87), WHtR 0.59 (0.57-0.60) and BMI 32.1 kg/m(2) (29.7-34.6). Raised WC was significantly associated with ≥2 MS components in men: WC 84.0-93.9 cm (odds ratio (OR): 3.19, 95% confidence interval (CI): 1.73-5.85) and WC ≥94.0 cm (OR: 8.50, 95% CI: 4.44-16.25) compared with WC <84.0 cm, and in women: WC 80.0-93.9 cm (OR: 2.93, 95% CI: 1.32-6.54) and WC ≥94.0 cm (OR: 5.33, 95% CI: 2.40-11.85) compared with WC <80.0 cm. In the logistic model with BMI for women, obesity (OR: 3.60, 95% CI: 1.82-7.10) but not overweight (P = 0.063) was significantly associated with ≥2 MS components. CONCLUSIONS: Obesity cut points for Africans should be re-evaluated and adjusted accordingly.

Differential associations of cardiovascular disease risk factors with relative wealth in urban-dwelling South Africans.

BACKGROUND: To examine the associations of cardiovascular disease risk factors (CVDRF) with wealth, defined by the asset index, in 25- to 74-year-old black Africans in Cape Town. METHODS: Assets, including consumer durable goods, and CVDRF were determined in a randomly selected cross-sectional sample. A principal component analysis of the pooled data, based on assets that defined wealth, was used to develop an asset index. Ordinal logistic regression analyses assessed the independent associations of CVDRF with wealth tertiles. RESULTS: Among the 1099 participants, the least poor compared with the poorest tertile had significantly higher prevalence of diabetes (16.3 versus 9.6%), hypercholesterolaemia (33.9 versus 21.4%), obesity (45.4 versus 26.3%) and fat intake ≥30% of diet (44.2 versus 29.3%). Daily smoking was highest in the poorest (35.8%) versus the least poor (26.4%). Psychosocial stress (low sense of coherence or locus of control) was significantly higher in poorer participants. In the regression analyses, wealth was associated with male gender [odds ratio (OR): 1.89, 95% confidence interval (CI): 1.37-2.60], urbanization (OR: 1.02, 95% CI: 1.01-1.02), high fat intake, obesity and hypercholesterolaemia. Daily smoking, problematic alcohol use (OR: 0.70, 95% CI: 0.52-0.94) and psychosocial stress were inversely related to wealth. CONCLUSIONS: Differential distribution of CVDRF by wealth mandates incorporating equity components when developing tailored interventions.

Factors associated with contraceptive use in a rural area in Western Cape Province.

BACKGROUND: Safe and effective contraceptive use can substantially improve women's reproductive health. Although the contraceptive prevalence rate (CPR) in South Africa is comparable to rates globally, inequalities in CPR affect poor and rural women. This study aimed to determine the CPR and factors associated with contraceptive use in a rural district of Western Cape Province. METHOD: Cross-sectional survey data based on 412 face-to-face interviews with female participants between 18 and 44 years of age were collected in 2006 for a primary fetal alcohol syndrome prevention study in a rural district in Western Cape Province. The study used effective contraception (ECC) as the outcome variable. ECC included use of oral contraceptives, condoms, injectables or sterilisation. Independent variables included socio-demographic factors, substance use, psychosocial factors, community factors, childbearing characteristics and partner characteristics. RESULTS: Women were more likely to use ECC if they reported high self-esteem (compared with low or moderate self-esteem (prevalence risk ratio (PRR)=1.23; 95% confidence interval (CI) 0.99 - 1.53); if they strongly or moderately agreed that their culture entitled men to make decisions regarding child-bearing compared with those who disagreed (PRR=1.28; 95% CI 0.96 - 1.71); and if they had one child or more compared with no children (PRR=1.62; 95% CI 1.24 - 2.11). CONCLUSION: The CPR for sexually active women in this study was low at 39.3%. To promote contraceptive use in similar rural populations, family planning programmes should focus on increasing men's approval of contraception, improving partner communication around family planning and bolstering women's confidence in their reproductive decision-making, and particularly their self-esteem. There should be greater focus on nulliparous women.

Intraoperative values of S-100 protein, myelin basic protein, lactate, and albumin in the CSF and serum of neurosurgical patients.

OBJECTIVES: To assess the concentrations of S-100 protein, myelin basic protein (MBP), and lactate, and the (CSF)/serum albumin ratio (Qalb) during intracranial neurosurgical procedures. METHODS: Samples of CSF from 91 patients with various CNS diseases were obtained by aspiration of cisternal CSF at the beginning of surgery (before starting surgical manipulation of the brain) and concentrations of S-100 protein, MBP, and lactate, and Qalb were determined. At the same time blood was sampled for determination of serum S-100 protein concentration. Patients were divided into three groups according to the aetiology of their CNS disease (intracranial haemorrhage, n=11; benign intracranial mass lesion, n=52; malignant neoplastic disease, n=28). Radiological and intraoperative characteristics were documented. RESULTS: In each of these three groups median values of all four CSF variables measured were raised. The occurrence of brain oedema and a midline shift correlated significantly with raised concentrations of MBP and Qalb. Breaching of the arachnoid layer, documented at surgery for benign lesions, correlated with higher concentrations of MBP, lactate, CSF S-100 protein, and Qalb. CONCLUSIONS: Intraoperative values of S-100 protein, MBP, lactate, and Qalb are increased in patients with intracranial haemorrhage, benign intracranial mass lesion, and malignant neoplastic disease. Breaching of the arachnoid layer and oedema is associated with higher concentrations of some of the aforementioned proteins. These biochemical data can serve as a basis for further research into CSF specific proteins.

Periodic follow-up after breast cancer and the effect on survival.

OBJECTIVE: To assess the role of routine follow-up in current management of breast cancer. DESIGN: Retrospective review. SETTING: Teaching hospital, The Netherlands. SUBJECTS: 270 patients who presented with recurrent breast cancer, 1974-90. MAIN OUTCOME MEASURE: Recurrence was coded as asymptomatic or symptomatic and related to survival. RESULTS: 170 (63%) of the recurrences were detected when they were symptomatic and 100 (37%) when they were not. The groups differed significantly according to the site of recurrence; 45/100 recurrences were local in the asymptomatic group compared with 23/170 (14%) in the symptomatic group. There was no significant difference in disease-free survival between the two groups. Overall 5-year survival after primary treatment for all recurrences (locoregional and distant) was significantly better (p=0.0003) in the asymptomatic group (62/100) than in the symptomatic group 79/170 (46%). However, when locoregional and distant recurrences were analysed separately no significant differences were found between both groups in overall survival after primary treatment or survival after detection of recurrence. The 5-year overall survival after primary treatment for distant recurrence was 26/47 (55%) in the asymptomatic group compared with 62/134 (46%) in the symptomatic group (p=0.13). For locoregional recurrence these figures were 35/45 (78%) and 14/23 (61%), respectively (p=0.34). Routine follow-up hardly affected the course of locoregional recurrence. Only five of 75 patients with local recurrence (7%) developed uncontrolled local disease, 2 of whom were initially detected during routine follow-up. CONCLUSIONS: We conclude that in the current management of breast cancer the medical impact of follow-up is low, so follow-up visits after treatment for breast cancer are hardly warranted.

Epidemiological aspects of psychiatric disorder in a Dutch health area.

A two-phase study of psychiatric prevalence has been carried out among the inhabitants (aged 18-64) of a Dutch health area (Nijmegen). In phase 1, a random sample of 3232 persons answered the GHQ-30 (response rate: 75%). In phase 2, 486 of the respondents were interviewed with the full PSE within two weeks. The relationship of PSE-'caseness' (ID greater than or equal to 5) and GHQ score was expressed in a logistic regression model, the parameters of which showed strong agreement with the Canberra results, for all socio-demographic variables examined, except for urbanization. By means of the logistic model the point-prevalence of PSE cases was calculated at 7.3% (range 5.5%-9.2%). Prevalence did not differ significantly in men and women. Higher case rates were found in the age category of 55-59 years, among divorced and widowed persons, the lower educational and occupational levels, the unemployed, chronically ill and unable to work, and with city people. This study adds further evidence to a growing body of epidemiological data suggesting similar rates and patterns of psychiatric disorder in populations in industrialized countries.