First social impact bond for the SAMRC: A novel financing strategy to address the health and social challenges facing adolescent girls and young women in South Africa.

A social impact bond (SIB) is an innovative financing mechanism to attract investors to social programmes traditionally funded by governments. In this article, in celebration of the 50th anniversary of the South African Medical Research Council (SAMRC), the authors describe the SAMRC's first foray into this new world of financing through a SIB to improve the health and quality of life of adolescent girls and young women (AGYW). The AGYW SIB is in its preparatory phase and is scheduled for implementation in 2020. The authors describe the mechanism, including financial flows and the process of customising the SIB to meet the needs of AGYW, focusing on HIV prevention and treatment and the prevention and management of unintended pregnancies in schoolgoing AGYW. The authors outline an approach to designing the package of interventions, the metrics associated with such a programme and the business model. It is hypothesised that the proposed approach will lead to an improvement in programmatic outcomes, monitoring and evaluation tools and cost-effectiveness, and will develop key learning data for the future use of SIBs in health service delivery.

Son Preference of Immigrants to the United States: Data from U.S. Birth Certificates, 2004-2013.

Son preference has existed for centuries in many cultures and societies. In some Asian countries, including China and India, the sex ratio at birth (SRB, number of male infants divided by number of female infants times 100) is elevated above the worldwide biological norm of about 105. We investigate whether this ratio is elevated in the U.S. for immigrant women. We analyze U.S. birth certificates for 2004-2013 and categorize births by mother's and father's race/ethnicity; mother's place of birth, and birth order of the child. The SRB is elevated for two groups of women: Chinese women born in China for children of birth order 2 and higher, and Indian women born in India for children of birth order 3 and higher. The SRB is not elevated for Chinese and Indian women born in the U.S., nor for Mexican women, Black women, nor White women, regardless of place of birth. The race/ethnicity of the child's father does not appear to be a strong factor in the SRB. In the early twenty-first century the elevated SRB for Chinese and Indian women born in China and India respectively suggests sex selection for higher order births in the U.S.

Perineal resuturing versus expectant management following vaginal delivery complicated by a dehisced wound (PREVIEW): a pilot and feasibility randomised controlled trial.

OBJECTIVE: To establish the feasibility of conducting a definitive randomised controlled trial (RCT) comparing the effectiveness of resuturing versus expectant management for dehisced perineal wounds. DESIGN: A multicentre pilot and feasibility RCT. SETTING: Ten UK maternity units from July 2011 to July 2013. POPULATION: Eligible women with a dehisced perineal wound within 2 weeks of childbirth. METHODS: The interventions were resuturing or expectancy. Randomisation was via web or telephone, stratified by participating centre. Blinding was not possible due to the nature of the interventions. Analysis was by intention-to-treat. OUTCOME: The primary outcome measure was wound healing at 6-8 weeks. RESULTS: The study revealed a number of feasibility issues, particularly strong patient and clinician preference for treatment options at recruiting centres and the timing of the primary outcome measure. Thirty-four women were randomised (17 in each arm). Data from 33 women were analysed on an intention-to-treat analysis to obtain preliminary estimates of effect size. There was a difference in wound healing at 2 weeks favouring resuturing (OR 20.00, 95% CI 2.04 to 196.37, p=0.004). However, by 6-8 weeks all but one wound in both groups had healed. CONCLUSIONS: PREVIEW revealed a number of feasibility issues, which impacted on recruitment rate. These will have to be taken into account in the design of any future definitive study. In this feasibility study, resuturing was associated with quicker wound healing and women reported higher satisfaction rates with the outcome at 3 months. TRIAL REGISTRATION NUMBER: ISRCTN05754020.

Perineal resuturing versus expectant management following vaginal delivery complicated by a dehisced wound (PREVIEW): a nested qualitative study.

OBJECTIVE: To explore women's lived experiences of a dehisced perineal wound following childbirth and how they felt participating in a pilot and feasibility randomised controlled trial (RCT). DESIGN: A nested qualitative study using semistructured interviews, underpinned by descriptive phenomenology. PARTICIPANTS AND SETTING: A purposive sample of six women at 6-9 months postnatal who participated in the RCT were interviewed in their own homes. RESULTS: Following Giorgi's analytical framework the verbatim transcripts were analysed for key themes. Women's lived experiences revealed 4 emerging themes: (1) Physical impact, with sub-themes focusing upon avoiding infection, perineal pain and the impact of the wound dehiscence upon daily activities; (2) Psychosocial impact, with sub-themes of denial, sense of failure or self-blame, fear, isolation and altered body image; (3) Sexual impact; and (4) Satisfaction with wound healing. A fifth theme 'participating in the RCT' was 'a priori' with sub-themes centred upon understanding the randomisation process, completing the trial questionnaires, attending for hospital appointments and acceptability of the treatment options. CONCLUSIONS: To the best of our knowledge, this is the first qualitative study to grant women the opportunity to voice their personal experiences of a dehisced perineal wound and their views on the management offered. The powerful testimonies presented disclose the extent of morbidity experienced while also revealing a strong preference for a treatment option. TRIAL REGISTRATION NUMBER: ISRCTN05754020; results.

Treatment of a maxillary fibrosarcoma in an adult alpaca.

CASE DESCRIPTION: An approximately 5-year-old sexually intact male alpaca was evaluated because of a right-sided maxillary mass that had recurred after previous surgical debulking. CLINICAL FINDINGS: Clinical, radiographic, and CT examination revealed an approximately 1.5-cm-diameter soft tissue mass associated with expansile osteolysis of the maxillary alveolar bone, beginning at the level of the right maxillary third premolar tooth extending caudally to the level of the rostral roots of the second molar tooth. TREATMENT AND OUTCOME: Right partial maxillectomy was performed, and histologic examination revealed an incompletely excised fibrosarcoma with osseous metaplasia. External beam radiation therapy to the tumor bed was initiated 1 month after surgery. Computerized planning was performed, and a total radiation dose of 48 Gy was prescribed in eleven 4.4-Gy fractions. Follow-up CT evaluations 6 and 58 weeks after radiation therapy was completed revealed no evidence of tumor recurrence. No clinical evidence of tumor recurrence was detected through 110 weeks after radiation therapy. CLINICAL RELEVANCE: The oral fibrosarcoma in the alpaca described here was successfully treated with surgical excision and adjuvant radiation therapy, resulting in excellent quality of life of the treated animal.

Intermittent single-agent doxorubicin for the treatment of canine B-cell lymphoma.

Canine B-cell lymphoma is a highly treatable disease, but cost and logistical factors may hamper an owner's ability to pursue treatment of their pet with this disease. The authors evaluated the use of single-agent doxorubicin in an intermittent fashion for efficacy in the treatment of this disease. Morphologic and clinical data were analyzed for prognostic significance. Eighteen dogs with B-cell lymphoma, all with multicentric disease, were enrolled. The overall complete response (CR) rate was 78%, median total doxorubicin remission time (TDR) was 80.5 days, and median overall survival (OS) was 169.5 days. The median number of doxorubicin doses administered was 4.5. First remission times were significantly affected by clinical stage and substage of disease. Outcome for the dogs in this study were similar to those previously reported for single-agent doxorubicin treatment. Additionally, the intermittent nature of the treatments made the described protocol more feasible for the owners who enrolled their pets in this study. Intermittent single-agent doxorubicin is not a substitute for multiagent chemotherapy protocols in the treatment of canine lymphoma; however, it is a reasonable alternative if the cost and time commitments are limiting factors for an owner.

Re-launch of the South African Society of Medical Managers (previously known as the Medical Administrators Group).

Medical management is a recognised specialty in many developing and developed countries, including Australia, India, New Zealand, Pakistan and Sri Lanka. In South Africa it was recognised as a sub-specialty in the 1990s, but this is no longer the case. The South African Society of Medical Managers, in close collaboration with the Division of Medical Management of the College of Public Health Medicine of South Africa, has been working to re-establish the specialty of medical management in South Africa. Well-trained specialist medical managers would play a significant role in the effective and efficient implementation of National Health Insurance and primary healthcare re-engineering through the practice of evidence-based health care, clinical economics and administrative medicine.

Use of samarium Sm 153 lexidronam for the treatment of dogs with primary tumors of the skull: 20 cases (1986-2006).

OBJECTIVE: To evaluate samarium Sm 153 lexidronam ((153)Sm-EDTMP) as a treatment option for dogs with bony tumors of the skull. DESIGN: Retrospective case series. ANIMALS: Dogs with multilobular osteochondrosarcoma (MLO) or osteosarcoma (OSA) of the skull. PROCEDURES: Veterinary Medical Teaching Hospital records from the Universities of Missouri and Florida from 1986 to 2006 were searched for dogs with primary skull tumors treated with (153)Sm-EDTMP. RESULTS: 25 dogs were initially evaluated, with 5 dogs subsequently excluded because of inadequate follow-up or unrelated death. Seven OSAs and 13 MLOs were diagnosed. Tumors involved the occipital and frontal bones (n = 10), zygomatic arch and maxilla region (6), palate (3), and mandible (1). No clinically important adverse effects related to (153)Sm-EDTMP treatment were documented. Of the 20 dogs evaluated 21 days after injection with (153)Sm-EDTMP, 4 had subjective improvement, 13 had progressive disease, and 3 had insufficient follow-up. On the basis of radiographic findings, metastasis was suspected in 1 dog; 16 dogs had no metastasis evident, and medical records were insufficient for 3 dogs. Survival time, defined as the (153)Sm-EDTMP injection date to the date of death, ranged from 3 to 1,314 days (median, 144 days). CONCLUSIONS AND CLINICAL RELEVANCE: The subjective improvement in 4 patients and lack of clinical evidence of adverse effects suggested that (153)Sm-EDTMP injection may be an option for the treatment of dogs with MLO or OSA of the skull when other treatments have failed or surgery is not possible.

The effect of climate on migration: United States, 1995-2000.

This paper examines the effect of climate on migration. We examine whether climate is an influential factor in internal migration. We assume that most persons tend to avoid exposure to bitter and cold winters, and excessively hot and humid summers, preferring climates between these extremes. When engaging in-migration decision-making, therefore, to the extent possible, considerations involving climate are believed to be brought into the calculus. There is a very limited demographic literature on the effects of climate on migration. In this paper, we undertake an aggregate-based analysis of the effect of climate on migration. We examine this relationship among the 50 states of the United States. We focus attention on the varying effects of climate on three migration measures for the 1995-2000 time period, namely, in-migration, out-migration, and net migration. We next evaluate the effect of climate on migration in the context of a broad application of human ecology. Here climate, a manifestation of the physical environment, is measured with three major independent variables. The other ecological predictors pertaining to organization, population, technology, and the social environment are used as controls. This enables us to examine the effects of climate on migration in the context of competing ecological hypotheses.

Photodynamic therapy for the treatment of periocular squamous cell carcinoma in horses: a pilot study.

OBJECTIVE: Local photodynamic therapy (PDT) is a novel cancer therapy in veterinary ophthalmology. A prospective pilot study seeking to demonstrate proof of principle and safety for the treatment of equine periocular squamous cell carcinoma (PSCC) was therefore conducted. We hypothesized that surgical excision with adjunctive local PDT is an effective and safe treatment for equine PSCC. PROCEDURES: Nine horses (10 eyes) with PSCC were treated with surgical resection, local infiltration of resulting wound beds with 2-[1-hexyloxyethyl]-2-devinylpyropheophorbide-a (HPPH) and irradiation with 665-nm wavelength diode laser. Regular follow-up ophthalmic examinations were performed. RESULTS: Surgical resection and PDT yielded disease-free intervals of 25-68 months in our study horses as of January, 2008. These results were obtained following a single treatment in seven horses and two treatments in one horse. In one horse, carcinoma in situ developed 2.5 months after partial surgical excision and PDT, requiring local excision under standing sedation. CONCLUSIONS: Preliminary results suggest that surgical resection and adjunctive local PDT is a safe and effective novel treatment for PSCC in horses. More research is needed before PDT for the treatment of equine PSCC can be adequately compared with other current modalities. Important to future investigations regarding PDT, tumor recurrence rate, length of hospitalization, number of treatment episodes required to effect tumor remission, and total treatment costs should be examined in a controlled manner. Our present results and experiences suggest that this treatment may be useful in the treatment of equine PSCC.

Repair of congenital heart disease: a primer--Part 2.

This review, the second of two parts, describes the repair of aortic arch anomalies, left-to-right shunts, valvular disease, tetralogy of Fallot, and truncus arteriosus. Cardiac transplantation is also discussed. Advances in the surgical management of congenital heart disease have led to improved patient survival and quality of life. Improvements in technology in computed tomography and magnetic resonance imaging have resulted in increasing utilization of cross-sectional imaging in these patients. Perioperative care necessitates that radiologists have a basic understanding of the surgical treatment and the resultant postoperative anatomy. Because many patients with treated congenital heart disease are being followed up into the 4th and 5th decades of life, this is information that will fall within the domain of all radiologists who interpret cross-sectional images of the thorax.

Repair of congenital heart disease: a primer-part 1.

Advances in the surgical management of congenital heart disease have led to enhanced patient survival and quality of life. Improvements in technology in computed tomography and magnetic resonance imaging have resulted in increasing use of cross-sectional imaging in these patients. Perioperative care in these patients requires that radiologists have an understanding of the surgical treatment and the resultant postoperative anatomy. Because many of these patients with treated congenital heart disease are being followed into the 4th and 5th decades of life, this is information that will fall within the domain of the radiologist who deals with adults. This review, which is presented in two parts, covers the major surgical procedures used for the treatment of congenital heart disease, and will be presented in two parts. In part 1, median sternotomy and its complications, palliative procedures, and complex repairs are discussed.

Evaluation of a novel immunomodulator composed of human chorionic gonadotropin and bacillus Calmette-Guerin for treatment of canine mast cell tumors in clinically affected dogs.

OBJECTIVE: To evaluate safety and efficacy of LDI-100, a preparation containing human chorionic gonadotropin (hCG) and bacillus Calmette-Guerin (BCG), in the treatment of dogs with mast cell tumors and to compare results with those from a control group receiving single-agent vinblastine. ANIMALS: 95 dogs with measurable grade II or III mast cell tumors. PROCEDURES: Dogs were randomized to receive either LDI-100 (1.35 ng of BCG and 2 units of hCG, SC, q 24 h) or vinblastine (2 mg/m(2), IV, q 1 wk) for 6 weeks. Tumors were measured at baseline and day 42, and dogs were monitored for signs of toxicosis. Clinical performance scores were recorded at each visit. Differences in host factors (sex, weight, and age), clinical performance score, tumor response, and adverse events were analyzed. RESULTS: 46 dogs received LDI-100, and 49 dogs received vinblastine. No significant differences were found between the 2 treatment groups with regard to host factors or clinical performance score. Tumor response (>or=50% reduction) rates were similar between the LDI-100 and vinblastine group (28.6% and 11.7%, respectively). Dogs in the LDI-100 group had significantly less neutropenia than the vinblastine group. CONCLUSIONS AND CLINICAL RELEVANCE: hCG and BCG have immunomodulatory and antitumor effects against a variety of malignancies in humans and dogs. In this study, LDI-100 provided clinical responses comparable to single-agent vinblastine chemotherapy but without myelosuppression. LDI-100 is a promising new agent that should be further investigated for multimodality therapy of mast cell tumors in dogs.

The joint evolution of mating system, floral traits and life history in Clarkia (Onagraceae): genetic constraints vs. independent evolution.

Genetic correlations caused by pleiotropy or linkage disequilibrium may influence the joint evolution of multiple traits as populations or taxa diverge. The evolutionary transition from outcrossing to selfing has occurred numerous times and is often accompanied by phenotypic and genetic changes in multiple traits such as flower size, pollen-ovule ratio, stigma and anther maturity and the age of reproductive maturity. Determining whether the recurring patterns of multitrait change are because of selection on each trait independently and/or the result of genetic correlations among traits can shed light on the mechanism that accounts for such convergence. Here, we evaluate whether floral traits are genetically correlated with each other and/or with whole-plant traits within- and between-populations and taxa. We report results from a greenhouse study conducted on two pairs of sister taxa with contrasting mating systems: the autogamously selfing Clarkia exilis and its predominantly outcrossing progenitor C. unguiculata and the autogamous Clarkia xantiana ssp. parviflora and its outcrossing progenitor C. xantiana ssp. xantiana. We examined variation within and covariation among maternal families in three populations of each taxon with respect to the age at first flower, the rate of successive flower production and the number of days between bud break and anther dehiscence and stigma receptivity within individual flowers. Based on phenotypic divergence between sister taxa, bivariate regressions, correlations among maternal family means and analysis of covariance (ancova), we did not find unilateral support indicating that genetic constraints govern the joint distribution of floral and whole-plant traits.

Proteomics of canine lymphoma identifies potential cancer-specific protein markers.

PURPOSE: Early diagnosis of cancer is crucial for the success of treatment of the disease, and there is a need for markers whose differential expression between disease and normal tissue could be used as a diagnostic tool. Spontaneously occurring malignancies in pets provide a logical tool for translational research for human oncology. Lymphoma, one of the most common neoplasms in dogs, is similar to human non-Hodgkin's lymphoma and could serve as an experimental model system. EXPERIMENTAL DESIGN: Thirteen lymph nodes from normal dogs and 11 lymph nodes from dogs with B-cell lymphoma were subjected to proteomic analysis using two-dimensional PAGE separation and matrix-assisted laser desorption/ionization time-of-flight analysis. RESULTS: A total of 93 differentially expressed spots was subjected to matrix-assisted laser desorption/ionization time-of-flight tandem mass spectrometry analysis, and several proteins that showed differential expression were identified. Of these, prolidase (proline dipeptidase), triosephosphate isomerase, and glutathione S-transferase were down-regulated in lymphoma samples, whereas macrophage capping protein was up-regulated in the lymphoma samples. CONCLUSIONS: These proteins represent potential markers for the diagnosis of lymphoma and should be further investigated in human samples for validation of their utility as diagnostic markers.

Liquid chromatographic analysis of vitamin B6 in reconstituted infant formula: collaborative study.

A liquid chromatographic (LC) method was validated for the determination of total vitamin B6 in infant formula. Total vitamin B6 was quantified by converting the phosphorylated and free vitamers into pyridoxine. Pyridoxine was determined by ion pair reversed-phase LC with fluorescence detection. The method was subjected to an AOAC collaborative study involving a factory-manufactured, milk- and soy-based infant formula. Each was spiked at 3 concentrations in the range of 0-1 microg/g and sent as blind duplicate to participant laboratories. Nine laboratories returned valid data which were statistically analyzed for outliers and precision parameters. The repeatability relative standard deviation (RSD(r)) ranges were 2.0-4.0 and 3.5-5.9% for fortified milk- and soy-based formulas, respectively. The reproducibility relative standard deviation (RSD(R)) ranges were 8.2-8.4 and 6.7-11.2% for fortified milk- and soy-based formulas, respectively. HORRAT values ranged from 0.42 to 0.53, indicating that the precision of the method is acceptable. The mean RSD(r):RSD(R) values were 0.60 and 0.55 for milk- and soy-based formulas, respectively. As expected, RSDs for the unfortified samples were higher, but their HORRAT values (0.81 and 2.06) helped define a realistic limit of quantitation as 0.05 microg/g. Recovery data were quantitative and varied between 81.4 and 98.0% (mean = 89.8%) for each of 6 spiked materials.

Patterns of gay and lesbian partnering in the larger metropolitan areas of the United States.

This paper had two objectives. First, we developed for each large metropolitan area of the United States with a population of 500,000 or more in 1990 four indexes of gay partnering and four indexes of lesbian partnering. We compared and related these indexes and their variable measurements with one another. Second, using what we argue is the statistically and demographically preferred set of gay and lesbian partnering rates, we proposed and tested an assortment of ecological hypotheses relating characteristics of the metropolitan areas with the gay and lesbian partnering rates. Rates of gay and lesbian partnering, we show, are more influenced by such metropolitan characteristics as physical climate and the crime rate than by a religious characteristic such as the number of Southern Baptist adherents. Among the conclusions of the paper is our claim that there needs to be greater consideration of the methodological issues related to the use of government data for the development of rates of gay and lesbian partnering.

Evaluation of community contribution to tuberculosis control in Cape Town, South Africa.

SETTING: Low income, high density, urban settlements in Cape Town, South Africa. OBJECTIVES: To evaluate community treatment supervision as part of tuberculosis (TB) programme implementation. DESIGN: A non-randomised prospective study was conducted under programme conditions from January 1998 to December 1999, comparing TB programme performance in an area with (Guguletu), and an area without (Nyanga) the option of TB treatment supervision by community health workers. RESULTS: Data were collected for 2873 adult TB patients. For smear-positive TB patients, treatment cure rates were higher in the intervention area (Guguletu) than in the control area (Nyanga) (58% vs. 50%, P = 0.0378) and for retreatment cases (47% vs. 35%, P = 0.0791), treatment success rates were similar. CONCLUSIONS: Community health worker support contributed to better TB control programme performance than an approach based exclusively on health facilities. Clear government policy and support for lay health worker programmes in TB control is needed.

Cost and cost-effectiveness of community-based care for tuberculosis in Cape Town, South Africa.

SETTING: Guguletu and Nyanga areas of Cape Town, South Africa. OBJECTIVE: To evaluate the affordability and cost-effectiveness of community involvement in tuberculosis (TB) care. DESIGN: A cost-effectiveness analysis comparing treatment for new smear-positive pulmonary and retreatment TB patients in two similar townships, one providing clinic-based-care with community-based observation options available for its TB patients (Guguletu) and one providing clinic-based care only, with no community-based observation of treatment (Nyanga). Costs were assessed from a societal perspective in 1997 US dollars, and cost-effectiveness was calculated as the cost per patient successfully treated. RESULTS: TB treatment in Guguletu was more cost-effective than TB treatment in Nyanga for both new and retreatment patients (dollars 726 vs. dollars 1201 and dollars 1419 vs. dollars 2058, respectively). This reflected both lower costs (dollars 495 vs. dollars 769 per patient treated for new cases; dollars 823 vs. dollars 1070 per patient treated for retreatment cases) and better treatment outcomes (successful treatment rate 68% vs. 64% and 58% vs. 52% for new and retreatment patients, respectively). Within Guguletu, community-based care was more than twice as cost-effective as clinic-based care (dollars 392 vs. dollars 1302 per patient successfully treated for new patients, and dollars 766 vs. dollars 2008 for retreatment patients), for similar reasons (e.g., for new cases, dollars 314 vs. dollars 703 per patient treated, successful treatment rate 80% vs. 54%). CONCLUSION: Community involvement in TB care can improve the affordability and cost-effectiveness of TB treatment in urban South Africa. Expansion in the Western Cape and in similar areas of the country is worthy of serious consideration by planners and policy-makers.

Evaluation of a bladder tumor antigen test as a screening test for transitional cell carcinoma of the lower urinary tract in dogs.

OBJECTIVE: To evaluate the veterinary version of the bladder tumor antigen (V-BTA) test as a screening test for transitional cell carcinoma (TCC) of the lower urinary tract of dogs. ANIMALS: 229 client-owned dogs. PROCEDURE: Urine samples from dogs were shipped overnight to a single laboratory to facilitate testing within 48 hours of collection by use of the V-BTA rapid latex agglutination urine dipstick test. Groups of dogs included the following: 1) dogs with TCC of the lower urinary tract, 2) healthy control dogs, 3) unhealthy control dogs with non-TCC urinary tract disease, and 4) unhealthy control dogs without urinary tract disease. Test sensitivity and specificity were calculated by use of standard methods. Logistic models were developed to assess the effect of disease status, test conditions, urine composition, and signalment on the performance of the V-BTA test. RESULTS: A total of 229 urine samples were analyzed, including 48 from dogs with suspected (n = 3) or confirmed (45) TCC. Test sensitivities were 88, 87, and 85% for all dogs with (suspected and confirmed) TCC, dogs with confirmed TCC at any site, and dogs with confirmed TCC of the urinary bladder, respectively. Test specificities were 84, 41, and 86% for healthy control dogs, unhealthy control dogs with non-TCC urinary tract disease, and unhealthy control dogs without urinary tract disease, respectively. The test performed slightly better on centrifuged urine samples than on uncentrifuged urine samples. CONCLUSIONS AND CLINICAL RELEVANCE: Our results indicate that the V-BTA test is useful in screening for urinary tract TCC in dogs.