Further evidence of misclassification of the injury deaths in South Africa: When will the barriers to accurate injury death statistics be removed?

BACKGROUND: Contrary to the World Health Organization's internationally recommended medical certificate of cause of death, the South African (SA) death notification form (DNF) does not allow for the reporting of the manner of death to permit accurate coding of external causes of injury deaths. OBJECTIVES: To describe the injury cause-of-death profile from forensic pathology records collected for the National Cause-of-Death Validation (NCoDV) Project and compare it with profiles from other sources of injury mortality data. In particular, the recording of firearm use in homicides is compared between sources. METHODS: The NCoDV Project was a cross-sectional study of deaths that occurred during a fixed period in 2017 and 2018, from a nationally representative sample of 27 health subdistricts in SA. Trained fieldworkers scanned forensic records for all deaths investigated at the forensic mortuaries serving the sampled subdistricts during the study period. Forensic practitioners reviewed the records and completed a medical certificate of cause of death for each decedent. Causes of death were coded to the International Statistical Classification of Diseases, 10th revision (ICD-10), using Iris automated coding software. Cause-specific mortality fractions for injury deaths were compared with Injury Mortality Survey 2017 (IMS 2017) and Statistics South Africa 2017 (Stats SA 2017) datasets. The cause profile for all firearm-related deaths was compared between the three datasets. RESULTS: A total of 5 315 records were available for analysis. Males accounted for 77.6% of cases, and most decedents were aged between 25 and 44 years. Homicide was the leading cause of death (34.7%), followed by transport injuries (32.6%) and suicide (14.7%). This injury cause profile was similar to IMS 2017 but differed markedly from the official statistics, which showed markedly lower proportions of these three causes (15.0%, 11.6% and 0.7%, respectively), and a much higher proportion of other unintentional causes. Investigation of firearm-related deaths revealed that most were homicides in NCoDV 2017/18 (88.5%) and IMS 2017 (93.1%), while in the Stats SA 2017 data, 98.7% of firearm deaths were classified as accidental. Approximately 7% of firearm-related deaths were suicides in NCoDV 2017/18 and IMS 2017, with only 0.3% in Stats SA 2017. CONCLUSION: The official cause-of-death data for injuries in SA in 2017 differed substantially from findings from the NCoDV 2017/18 study and IMS 2017. Accurate data sources would ensure that public health interventions are designed to reduce the high injury burden. Inclusion of the manner of death on the DNF, as is recommended internationally, is critically important to enable more accurate, reliable and valid reporting of the injury profile.

Out-of-hospital cardiac arrest: Causes according to autopsy and electrocardiography - Analysis of 781 patients with neither hospital care nor prescribed medication during the preceding two years.

BACKGROUND: There is a knowledge gap regarding aetiology of and potential for predicting out-of-hospital cardiac arrest (OHCA) among individuals who are healthy before the event. AIM: To describe causes of OHCA and the potential for predicting OHCA in apparently healthy patients. METHODS: Patients were recruited from the Swedish Register of Cardiopulmonary Resuscitation from November 2007 to January 2011. Inclusion criteria were: OHCA with attempted CPR but neither dispensed prescription medication nor hospital care two years before the event The register includes the majority of patients suffering OHCA in Sweden where cardiopulmonary resuscitation (CPR) was attempted. Medication status was defined by linkage to the Swedish Prescribed Drug Register. Cause of death was assessed based on autopsy and the Swedish Cause of Death Register. Prediction of OHCA was attempted based on available electrocardiograms (ECG) before the OHCA event. RESULTS: Altogether 781 individuals (16% women) fulfilled the inclusion criteria. Survival to 30 days was 16%. Autopsy rate was 72%. Based on autopsy, 70% had a cardiovascular aetiology and 59% a cardiac aetiology. An ECG recording before the event was found in 23% of cases. The ECG was abnormal in 22% of them. CONCLUSION: Among OHCA victims who appeared to be healthy prior to the event, the cause was cardiovascular in the great majority according to autopsy findings. A minority had a preceding abnormal ECG that could have been helpful in avoiding the event.

Fluoride in drinking water in Madagascar and the development of a strategy for salt fluoridation.

OBJECTIVE: To update current knowledge of the distribution of drinking water fluoride content in Madagascar, in an effort to develop a strategy for the distribution of fluoridated salt to prevent tooth decay. BASIC RESEARCH DESIGN: In accordance with a strict protocol, water samples were collected from all the country's 22 regions. Fluoride concentration in ppm fluoride (F) was determined by use of a F ionselective electrode coupled with a pH/ion meter. RESULTS: A total of 651 sources of drinking water were sampled, of which 94% were found to have fluoride concentrations ≤ 0.7 ppm. The two regions with the highest number of water supplies with fluoride concentrations ⟩ 0.7 ppm are situated in the south and south-west of Madagascar. 87% of thermal springs have fluoride levels ⟩ 0.7 ppm, with a mean value of 2.21 ± 1.64 ppm. CONCLUSIONS: These findings confirm that, with the exception of certain districts in the extreme south of Madagascar, fluoridated salt distribution would be appropriate for most regions in the country. This could be achieved by encouraging salt producers in the north and west of Madagascar, who are responsible for over 88% of national salt production, to fluoridate their salt. Most of this salt is distributed throughout the north and centre of the country, whereas very little is distributed to the extreme south.

Fluoride content of toothpastes available in South Africa.

A high dental caries burden coupled with a lack of water or salt fluoridation make it imperative that toothpastes available to the South African consumer demonstrate adequate potential for caries control and contain between 1000ppm and 1500ppm total fluoride (TF), with at least 1000ppm F in free available/soluble form. METHODS: The objective was to determine TF, total soluble fluoride (TSF) and insoluble fluoride (IF) concentrations in 22 fluoride toothpastes commercially available in South Africa. Samples were purchased from a major pharmaceutical and food retailer located in the two metropolitan areas in South Africa. TF and TSF concentrations were determined potentiometrically, in quadruplicate, following acid hydrolysis of the samples using a calibrated Combination Fluoride Ion Selective Electrode. IF was calculated by subtracting TSF from TF. RESULTS: Although TF content was found to be statistically significantly lower than manufacturer declaration (3.2x10-7; p≤0.05), 77.3% of the samples still contained adequate free, available/soluble F levels. Relative mean TSF content for toothpastes formulated with a calcium-based abrasive was 85% (sd ±14.5; n=6) as opposed to 98.6% (sd ±2.6; n=16) for those containing silica. CONCLUSIONS: The total fluoride concentration of all the toothpastes was lower than that declared by the manufacturers, with one in four having TSF concentrations of less than 1000ppm F. The relative TSF concentrations for the calcium-containing toothpastes were lower than for the silica-based products, reducing their preventive and protective potential. The results call for strengthened regulation and quality control of fluoride toothpastes in South Africa, as well as international efforts to improve related norms.

PKC activation sensitizes basal-like breast cancer cell lines to Smac mimetics.

There is a need for novel strategies to initiate cancer cell death. One approach is the use of Smac mimetics, which antagonize inhibitor of apoptosis proteins (IAPs). Recent studies have shown that combinations of Smac mimetics such as LBW242 or LCL161 in combination with chemotherapeutic agents increase cancer cell death. Here we show that the protein kinase C (PKC) activator TPA together with the Smac mimetic LBW242 induces cell death in two basal breast cancer cell lines (MDA-MB-468 and BT-549) that are resistant to Smac mimetic as single agent. Ten other LBW242-insensitive cancer cell lines were not influenced by the TPA+LBW242 combination. The TPA+LBW242 effect was suppressed by the PKC inhibitor GF109203X, indicating dependence on PKC enzymatic activity. The PKC effect was mediated via increased synthesis and release of TNFα, which can induce death in the presence of Smac mimetics. The cell death, coinciding with caspase-3 cleavage, was suppressed by caspase inhibition and preceded by the association of RIP1 with caspase-8, as seen in complex II formation. Smac mimetics, but not TPA, induced the non-canonical NF-κB pathway in both MDA-MB-231 and MDA-MB-468 cells. Blocking the canonical NF-κB pathway suppressed TPA induction of TNFα in MDA-MB-468 cells whereas isolated downregulation of either the canonical or non-canonical pathways did not abolish the Smac mimetic induction of the NF-κB driven genes TNFα and BIRC3 in MDA-MB-231 cells although the absolute levels were suppressed. A combined downregulation of the canonical and non-canonical pathways further suppressed TNFα levels and inhibited Smac mimetic-mediated cell death. Our data suggest that in certain basal breast cancer cell lines co-treatment of TPA with a Smac mimetic induces cell death highlighting the potential of using these pathways as molecular targets for basal-like breast cancers.

Success rates of manual restorative treatment (MRT) with amalgam in permanent teeth in high caries-risk Filipino children.

OBJECTIVES: The objective of the study is to evaluate the success rate of amalgam restorations in manually prepared cavities under field conditions within a comprehensive school-based oral health-care program in high caries-risk children. MATERIALS AND METHODS: A total of 1322 restorations were placed in the permanent teeth of 619 high caries risk Filipino children by two dentists and two trained health-care workers. Only hand instruments and an encapsulated amalgam, mixed with a manually powered amalgamator, were used. The restorations were evaluated after a service time of 1 to 5 years using modified atraumatic restorative treatment (ART) criteria. RESULTS: The overall success rate of the amalgam restorations was 95.3% (n = 1260) after a mean service time of 2.7 years (SD = 1.4). Multiple-surface restorations showed significantly higher failure rates (11.4%) than single-surface occlusal (4.7%) and single-surface non-occlusal (2.1%) restorations; 93.6% of large restorations was performed successfully, but had a risk of failure twice to that of small restorations (odds ratio (OR) = 2.141). The score of the decayed, missing, and filled teeth (DMFT) index had significant influence on the success rate. The risk of restoration failure increased by 11.5% for each unit increase in DMFT (OR = 1.148). Neither the operator nor age nor gender of the patient had a significant effect on the success rate of the restorations. CONCLUSION: Amalgam was performed satisfactorily as a filling material when placed under field conditions in manually prepared cavities in the permanent dentition of high caries-risk children. Success of the restorations was influenced by the patient's caries experience (DMFT), restoration size, and service time. CLINICAL RELEVANCE: Manual restorative treatment (MRT) amalgam restorations were performed satisfactorily, but higher dental caries experience and large cavities contribute to lower success rates.

Minimal intervention dentistry II: part 3. Management of non-cavitated (initial) occlusal caries lesions--non-invasive approaches through remineralisation and therapeutic sealants.

Epidemiological data on dental caries show that prevention and treatment needs have evolved significantly over the past two decades. In younger patients the distribution of caries lesions is mainly found on the occlusal surfaces. The treatment approaches utilised by dentists must evolve to integrate preventive and treatment solutions tailored to the care needs, which are straightforward to implement in the dental office and whose effectiveness is underpinned by scientific evidence. This article aims to describe the principles of non-invasive management of non-cavitated (initial) occlusal caries lesions, based on evidence from recent studies published in the international literature.

A risk stratification model to predict adverse neonatal outcome in labor.

OBJECTIVE: The development and evaluation of a labor risk model consisting of a combination of antepartum risk factors and intrapartum fetal heart rate (FHR) characteristics that can reliably identify those infants at risk for adverse neonatal outcome in labor. STUDY DESIGN: A nested case-control study of term singleton deliveries at the nine hospitals between March 2007 and December 2009. Eligibility criteria included: gestational age ≥ 37.0 weeks; singleton pregnancy; documented continuous FHR monitoring for ≥ 2 h before delivery; assessment of FHR tracing at least every 20 min; and, available maternal and neonatal outcomes. Adverse neonatal outcome was defined as nonanomalous infants admitted to the newborn intensive care unit with either a 5 minute Apgar score <7 or an umbilical artery pH<7.1. Initial risk score was determined using data available at 1 h after admission. Patients with an initial risk score between 7 and 15 were considered high risk. Intrapartum risk scores were then created for these patients using FHR tracing data and labor characteristics. RESULT: A total of 51 244 patients were identified meeting study criteria. Of the antepartum variables evaluated (n=31), 10 were associated with an adverse outcome. The high-risk group made up 28% of the population and accounted for 59.8% of the adverse outcomes. Intrapartum characteristics were then evaluated in this high-risk group. Intrapartum evaluation identified the highest risk group with a C/S rate of 40% and adverse outcome rate of 11.3%. CONCLUSION: Incorporation of maternal and antepartum risk factors with FHR analysis can improve the ability to identify the fetus at risk in labor.

Minimal intervention dentistry: part 5. Atraumatic restorative treatment (ART)--a minimum intervention and minimally invasive approach for the management of dental caries.

While originally developed in response to a need to provide effective restorative and preventive treatment in underserved communities where running water and electricity might not always be available, over the past two decades, the atraumatic restorative treatment (ART) approach has become a worldwide phenomenon; used not only in some of the poorest developing countries but also in some of the most wealthy. The ART approach involves the removal of infected dentine with hand-instruments followed by the placement of a restoration where the adjacent pits and fissures are sealed simultaneously using high viscosity glass-ionomer inserted under finger pressure. Reliable results can only be obtained if the treatment protocol, as described in this article, is closely followed. ART should be considered as a therapeutic option especially in children, anxious patients and those with special needs.

Dental volunteering - a time for reflection and a time for change.

Dental volunteers and their NGOs may have the potential to make a significant and long-lasting contribution to global oral health. However, their traditional approach to volunteering in developing countries can be questioned as to its appropriateness and sustainability combined with potential harmful effects that it might bring to the local health system. This article reviews the positive and negative aspects of this approach to dental volunteering and examines possible changes that could be made to the prevailing volunteer paradigm.

Analysis of initial rhythm, witnessed status and delay to treatment among survivors of out-of-hospital cardiac arrest in Sweden.

BACKGROUND: The characteristics of patients who survive out-of-hospital cardiac arrest (OHCA) are incompletely known. The characteristics of survivors of OHCA during a period of 16 years in Sweden are described. METHODS: All the patients included in the Swedish Cardiac Arrest Registry between 1992 and 2007 in whom cardiopulmonary resuscitation was attempted and who were alive after 1 month were included in the survey. RESULTS: In all, 2432 survivors were registered. Information on initial rhythm at their first ECG recording was missing in 11%. Of the remaining 2165 survivors, 80% had a shockable rhythm and 20% had a non-shockable rhythm. Only a minority with a shockable rhythm among the bystander-witnessed cases were defibrillated within 5 min after cardiac arrest. This proportion did not change during the entry period. Among survivors found in a non-shockable rhythm, the majority were bystander-witnessed cases and a few had a delay from cardiac arrest to ambulance arrival of <5 min. Of all survivors, more women (27%) than men (18%) were found in a non-shockable rhythm (p<0.0001). During the 16 years in which the register was used for this study, the proportion of survivors found in a shockable rhythm did not change significantly. The cerebral performance categories score indicated better cerebral function among patients found in a shockable rhythm than in those found in a non-shockable rhythm. CONCLUSION: Among survivors of OHCA, a substantial proportion was found in a non-shockable rhythm and this occurred more frequently in women than in men. The proportion of survivors found in a shockable rhythm has not changed markedly over time. Survivors found in a shockable rhythm had a better cerebral performance than survivors found in a non-shockable rhythm. The proportion of survivors who were bystander-witnessed and found in a shockable rhythm and defibrillated early is still remarkably low.

PUFA--an index of clinical consequences of untreated dental caries.

RATIONALE: Dental caries is a global public health problem, especially in children. Most caries in developing countries remains untreated. Only limited data are available on the clinical consequences of untreated dental caries because there is no measure to quantify the prevalence and severity of oral conditions resulting from untreated dental caries. OBJECTIVES: To present a new index to evaluate the prevalence and severity of oral conditions resulting from untreated dental caries. To validate the index within the Philippines National Oral Health Survey, 2006. METHODS: The PUFA index records the presence of severely decayed teeth with visible pulpal involvement (P/p), ulceration caused by dislocated tooth fragments (U/u), fistula (F/f) and abscess (A/a). RESULTS: Good kappa values show the reliability of the index. The prevalence of PUFA/pufa >0 was 85% and 56% for 6- and 12-year-olds, respectively. The mean number of teeth affected (PUFA/pufa) was 3.5 and 1.2 for 6- and 12-year-olds, respectively. In 6- and 12-year-olds, 40% and 41% of decayed teeth had progressed to odontogenic infections. CONCLUSION: The PUFA index complements classical caries indices with relevant information for epidemiologists and health care planners.

Efficacy of silver diamine fluoride for Arresting Caries Treatment.

Arresting Caries Treatment (ACT) has been proposed to manage untreated dental caries in children. This prospective randomized clinical trial investigated the caries-arresting effectiveness of a single spot application of: (1) 38% silver diamine fluoride (SDF) with tannic acid as a reducing agent; (2) 38% SDF alone; (3) 12% SDF alone; and (4) no SDF application in primary teeth of 976 Nepalese schoolchildren. The a priori null hypothesis was that the different treatments have no effect in arresting active cavitated caries. Only the single application of 38% SDF with or without tannic acid was effective in arresting caries after 6 months (4.5 and 4.2 mean number of arrested surfaces; p < 0.001), after 1 year (4.1 and 3.4; p < 0.001), and after 2 years (2.2 and 2.1; p < 0.01). Tannic acid conferred no additional benefit. ACT with 38% SDF provides an alternative when restorative treatment for primary teeth is not an option.

Evaluation of the use of anti-TNF-alpha in an LPS-induced murine model.

OBJECTIVE: Tumor necrosis factor alpha (TNF-alpha) may play a critical role in inflammatory-mediated preterm labor. Medications blocking the activity of TNF-alpha have been shown to be effective in the treatment of conditions such as rheumatoid arthritis; however, the use of these medications for an event like preterm birth or fetal death is unknown. We hypothesized that treatment with anti-TNF-alpha may decrease the rate of fetal death and preterm birth in a LPS-induced murine model. METHODS: Pregnant C57BL/6J mice received intraperitoneal (IP) injections of either vehicle or 2mg anti-TNF-alpha. After 24h, 10 microg of LPS was administered IP. Mice were sacrificed 24h later and outcomes between groups were assessed. A second set of experiments utilizing RT-PCR was performed to determine the influence of anti-TNF-alpha on production of inflammatory cytokines in response to LPS. RESULTS: There were 72 resultant pups in the LPS+saline group, and 91 in the group receiving LPS+anti-TNF-alpha. Pretreatment with anti-TNF-alpha reduced the rate of fetal death and preterm birth after LPS administration (p<0.01). Expression of IL-6, IL-1beta, TLR-2, CD14 and COX-1 were found to be significantly reduced in mice treated with anti-TNF-alpha and LPS compared to LPS alone. CONCLUSION: The use of anti-TNF-alpha decreased fetal deaths and preterm deliveries in an LPS-induced model of preterm birth. In addition, there were critical gene expression alterations in the group receiving anti-TNF-alpha. Further evaluation of TNF-alpha blockade as a potential treatment for preterm labor is warranted.

Quality of life after tension-free vaginal tape surgery for female stress incontinence.

OBJECTIVE: To undertake a long-term follow-up evaluation of the quality of life (QOL) of women who had undergone a tension-free vaginal tape (TVT) procedure. MATERIAL AND METHODS: During the period 1995-2001, 970 women with urinary stress incontinence underwent TVT surgery at the Department of Obstetrics and Gynecology, Falun Hospital. A questionnaire was mailed on average 5.7 years after the TVT procedure. Two incontinence-specific QOL instruments--the Incontinence Impact Questionnaire-7 (IIQ-7) and the Urogenital Distress Inventory-6 (UDI-6)--were administered. An additional questionnaire included general questions and questions about chronic diseases that may be associated with urinary incontinence. RESULTS: The mean age at surgery was 58.7 years (range 29-89 years). Of 913 eligible women, 768 (78.9%) responded. Mean IIQ-7 and IDU-6 scores as estimated by the women improved dramatically at follow-up as compared to preoperative values: from 43.7 to 11.5 for the IIQ-7 and from 54.2 to 24.0 for the UDI-6 on a scale from 0 to 100 (p = 0.0001 for both). There were few differences in mean QOL scores even 8 years after TVT surgery, compared to those determined a shorter time after the operation. Women with diabetes, chronic constipation, chronic bronchitis and preoperative recurrent urinary infections had a relative improvement in QOL of the same magnitude as that of the remaining study population. Advanced age was negatively associated with an improvement in QOL scores. CONCLUSIONS: Improvements in measures of QOL after TVT surgery are dramatic and persist for years. Women with concomitant diseases that may be associated with urinary incontinence can be assured that there is a good chance of success with TVT surgery.