Perinatal Outcomes in Babies Born before Arrival at Prince Mshiyeni Memorial Hospital in Durban, South Africa.

OBJECTIVE: To evaluate the maternal demographics, incidence, perinatal outcomes, and characteristics of babies born before arrival (BBAs) to hospitals. METHODS: A prospective, observational study was conducted at a large maternity unit in Durban, KwaZulu-Natal. A total of 200 mothers who attended the hospital within 24 hours of an out-of-hospital birth were recruited and interviewed, and 142 participants were eligible. A total of 128 mothers who delivered their babies in hospital (inborns) were used as the control group. Specific maternal and neonatal characteristics were analysed. RESULTS: The incidence of BBAs was 2.2%. The percentage of premature neonates in the BBA group was 54% vs 17.9% for inborns (p ≤ 0.001). A total of 33.8% of BBA mothers were unbooked vs 2.4% of inborns (p ≤ 0.001). The majority (59%) of inborns were primigravidas whereas the majority (73.9%) in the BBA group were multigravidas (p ≤ 0.001). Women in the BBA group were more prone to genital tears (p ≤ 0.001). There were no significant differences in respect of NICU admission and all-cause mortality; however, an increased risk for hypothermia and hypoglycaemia was found. CONCLUSION: BBAs are at a significant risk of prematurity, low birth weight, hypothermia, and hypoglycaemia and are prone to longer hospital stays.

Training prostate cancer survivors and caregivers to be peer navigators: a blended online/in-person competency-based training program.

PURPOSE: Cancer navigation improves access to support and reduces barriers to care; however, appropriate training of navigators is essential. We developed the TrueNTH Peer Navigation Training Program (PNTP), a competency-based, blended online/in-person course. In this study, we evaluate the feasibility, acceptability, and effectiveness of the PNTP among prostate cancer (PC) survivors (patients, caregivers). METHODS: We employed an explanatory mixed method study design consisting of course usage data, pre-/post-questionnaires, and focus groups informed by the Kirkpatrick framework and self-efficacy theory. RESULTS: Three cohorts in two Canadian cities (n = 26) received the PNTP. Participants were motivated to support others like themselves (n = 20), fill a gap (n = 7), pay it forward (n = 6), and offer expertise (n = 4). Recruitment, retention, and questionnaire completion were 96.7%, 89.6%, and 92%. Participants contributed a total of 426 posts to the online forums (2 to 3 posts per participant/module). Satisfaction was 9.4/10 (SD = 0.7) and usability was 84.5/100 (SD = 10.1). All learning outcomes increased: understanding of learning objectives t(23) = - 6.12, p < 0.0001; self-efficacy to perform competencies t(23) = - 4.8, p < 0.0001; and eHealth literacy t(23) = - 4.4, p < 0.0001. Participants viewed the PTNP as intensive but manageable, improving knowledge and confidence and enhancing listening skills. Participants valued the flexibility of online learning, interactive online learning, in-person interactions for relationship building, and authentic role-playing for skill development. CONCLUSIONS: A facilitated online training program with in-person components is a highly acceptable and effective format to train PC survivors to become peer navigators. This competency-based peer navigator training program and delivery format may serve as a useful model for other cancer volunteer programs.

A core competency framework for prostate cancer peer navigation.

PURPOSE: Trained peer navigators can offer valuable peer support and mentorship to cancer patients and caregivers due to their highly relevant and unique perspective about the disease experience. In order to define the role of prostate cancer (PC) peer navigators within the cancer care system, it is important to establish the essential competencies of a PC peer navigator. We systematically identified and verified a set of core competencies for PC peer navigators and present a competency framework for PC peer navigators. METHODS: In phase 1, we conducted formative research consisting of a literature review and environmental scan as well as a secondary analysis of qualitative interviews. In phase 2, we drafted and mapped competencies. Finally in phase 3, expert stakeholders completed an anonymous survey to indicate whether they endorsed the competencies and to rank the importance of each competency to the peer navigator role. Open-ended feedback was also provided for each competency. RESULTS: Six core competency domains emerged: (1) self as navigator, (2) communication, (3) knowledge/information, (4) facilitate patient-centred care, (5) eHealth/technology, and (6) caregiver needs. Forty-seven core competency statements were mapped to these domains. Expert stakeholders (n = 27) included cancer survivors, caregivers, and healthcare providers. Most (89%) of core competency statements were endorsed by stakeholders and received high priority ratings, whereas only five of the competencies were less uniformly endorsed. CONCLUSIONS: This is the first attempt to list core competencies for PC peer navigators and may offer guidance for standardizing the PC peer navigator role and training.

Hypertensive disorders in primigravid black South African women: A one-year descriptive analysis.

OBJECTIVE: To describe the incidence and obstetric and perinatal outcomes in primigravid Black South Africans with hypertensive disorders of pregnancy (HDP). METHOD: All primigravidae who booked for antenatal care were followed up until hospital discharge. Relevant clinical and demographic data were collected in structured data forms. RESULTS: A total of 5860 primigravidae delivered during the study period. Of these, 731 had an HDP, giving an incidence of 12.5%. The diagnosis of gestational hypertension was made in 6.7% of all primigravidae but was the commonest HDP subcategory (n = 394/731; 53.9%). On the other hand, mild to moderate preeclampsia or non-severe preeclampsia, severe preeclampsia, and eclampsia occurred in 222, 84, and 31 of the 5860 primigravidae, respectively. Therefore, preeclampsia-eclampsia syndrome occurred in 337/5860 or 5.75% of the study population. Severe preeclampsia occurred in 1.43% (84/5860) of the primigravidae. The rates of caesarean deliveries in women with preeclampsia were approximately 50%. There were no perinatal deaths in the gestational hypertension group, but the overall perinatal mortality rate in all preeclamptics was 5.9%, in comparison to 2.2% in all primigravidae. CONCLUSION: Hypertensive disorders of pregnancy developed in 12.5% (n = 731/5860) of primigravidae seen over a one-year period. Gestational hypertension comprised the commonest subcategory of the HDP and there were no perinatal deaths in this group.

Cardiovascular disease (CVD) risk factors: a patient’s perspective

OBJECTIVES: To identify CVD risk factors present in patients presenting with stroke; to assess knowledge of patients on risk factors for CVD; and to identify management methods employed (prior to admission) by patients to deal with these risk factors. DESIGN AND METHODS: This study used a cross-sectional, incident case design. All patients admitted to the hospital, within a 6 week period, given an initial diagnosis of stroke by the attending physician, were eligible for the study. Patients were recruited using consecutive sampling. Data on patient risk awareness and management methods were gathered using a survey. Data on risk factors present in patients were collected using patient records. RESULTS: A total of 102 patients were interviewed. The two major risk factors present in patients were hypertension (80.2%) and diabetes (57.8%). 83.3% of patients identified hypertension as a risk factor and 78.8% identified diabetes. However, 32.2% of hypertensive patients and 40.5% of diabetics reported not taking medication despite being awareness of their risk. Similarly 81.3% of patients knew lack of exercise was a risk factor, but only half were exercising frequently in the past 2 years. CONCLUSION: In this study, hypertension and diabetes were found to be the two major risk factors present in stroke patients. While patient knowledge about risk factors was high, their management of their risk factors as well as general knowledge about stroke prevention were lacking. This could be helpful in formulating public health strategy, if supported by larger population based studies.

Leprosy - knowledge, attitudes and practices among clinic attenders

OBJECTIVE: To investigate the knowledge, attitudes and practices among leprosy clinic attendees and to review the epidemiology of leprosy in Trinidad. DESIGN AND METHODS: A cross-sectional study was undertaken utilizing an interviewer administered structured questionnaire. All leprosy clinic attendees over the age of 18 years who attend 3 of the 5 leprosy clinics in Trinidad were included. Data were collected from April to July 2014. RESULTS: All 21 responders who were invited to participate agreed, giving a response rate of 100%. Fifty-two percent (52%) were unaware of how the disease is contracted. Most patients (81%) believed that educating the public would help eradicate leprosy-related stigma. Ninety percent (90%) reported that they were compliant with taking their medication and 86% reported that they attended all clinic appointments. The majority (76%) felt self-conscious about their disease and 50% have experienced negative feelings after diagnosis. CONCLUSION: Patients appear to be aware of signs and symptoms of leprosy but less so about transmission. There appears to be a need for educating patients about their illness as well as the public to reduce stigma associated with the illness. There was also a need for counselling of patients to minimize the reported distress, sadness and worry they experience after being diagnosed.

Comparative genomics of bacteria from the genus Collimonas: linking (dis)similarities in gene content to phenotypic variation and conservation.

Collimonas is a genus of soil bacteria comprising three recognized species: C. fungivorans, C. pratensis and C. arenae. Collimonads share the ability to degrade chitin (chitinolysis), feed on living fungal hyphae (mycophagy), and dissolve minerals (weathering), but vary in their inhibition of fungi (fungistasis). To better understand this phenotypic variability, we analysed the genomic content of four strains representing three Collimonas species (Ter14, Ter6, Ter91 and Ter10) by hybridization to a microarray based on reference strain C. fungivorans Ter331. The analysis revealed genes unique to strain Ter331 (e.g. those on the extrachromosomal element pTer331) and genes present in some but not all of the tested strains. Among the latter were several candidates that may contribute to fungistasis, including genes for the production and secretion of antifungals. We hypothesize that differential possession of these genes underlies the specialization of Collimonas strains towards different fungal hosts. We identified a set of 136 genes that were common in all tested Collimonas strains, but absent from the genomes of three other members of the family Oxalobacteraceae. Predicted products of these 'Collimonas core' genes include lytic, secreted enzymes such as chitinases, peptidases, nucleases and phosphatases with a putative role in mycophagy and weathering.

Relationship of biochemical parameters, BMI and blood pressure with age, gender and ethnicity of Trinidadian type 2-diabetic subjects.

OBJECTIVE: To determine the relationship of biochemical parameters, BMI and blood pressure with age, gender and ethnicity of Trinidadian type 2-diabetic subjects. METHODS: A retrospective case control study comprised of 1794 patient (740 males and 1054 females). RESULTS: The correlation was found for lipid profile with age and gender in diabetic subjects. There was a positive significant correlation in LDL-C values for all age groups. Serum creatinine concentrations significantly varied amongst ethnicity (p = 0.02). Of the known ethnicities, East Indians had the highest mean creatinine value (1.00 ± 0.47 mg/dl). The univariate general linear model showed that lipid profile had many associations with gender and ethnicity in type 2 diabetic subjects. LDL-C had significant differences between gender (p = 0.04) and diabetes (p = 0.01). CONCLUSIONS: Varied lipid profile with elevated systolic blood pressure and BMI are associated in type 2 diabetic patients with respect to age, gender and ethnicity.

The detection of mupirocin resistance and the distribution of methicillin-resistant Staphylococcus aureus at the University Hospital of the West Indies, Jamaica / Detección de la resistencia a la mupirocina y distribución de Staphylococcus aureus resistente a la meticilina en el Hospital Universitario de West Indies, Jamaica

OBJECTIVES: The objectives of this study were to determine the susceptibility of Methicillin Resistant Staphylococcus aureus (MRSA) isolates to Mupirocin and other antimicrobial agents and to record the prevalence and distribution of this organism at the University Hospital of the West Indies (UHWI). METHODS: MRSA isolates collected between January 1, 2008 and December 31, 2008, were tested for low and high level resistance to Mupirocin. Susceptibility testing to other antibiotics including cotrimoxazole, minocycline, tetracycline, clindamycin, erythromycin, gentamicin and vancomycin was also done. Laboratory records for all patients from whom MRSA was recovered were reviewed and data on type and source of isolates, clinical diagnosis, history of previous hospitalization and use of mupirocin were extracted. In addition, the laboratory records for 2004 and 2005 were also reviewed to determine prevalence during these periods. RESULTS: Seven per cent of Staphylococcus aureus isolates were resistant to methicillin (MRSA) and of these, 30% and 24% showed low level and high level resistance to mupirocin, respectively. Ninety-four per cent of MRSA strains were resistant to erythromycin while 52% showed resistance to clindamycin. Resistance to tetracycline, co-trimoxazole and minocycline was 27%, 12% and 6%, respectively, while about one-third ofthe isolates were resistant to gentamicin. There was no resistance to vancomycin. More than half (58%) of the isolates were from skin and soft tissue specimens while isolates from respiratory and urinary tracts and the bloodstream accounted for 19%, 13% and 4%, respectively. There has been a steady increase in prevalence from 4% in 2004 to 5% in 2007 and 7% in 2008. CONCLUSION: Resistance of MRSA to mupirocin appears to be an emerging problem at the UHWI and must be monitored carefully. There is also significant resistance to commonly used antimicrobial agents and strict adherence to antibiotic policy is required to preserve the usefulness of these agents.

OBJETIVOS: Los objetivos de este estudio fueron determinar la susceptibilidad de aislados de Staphylococcus aureus resistentes (MRSA) frente a la mupirocina y otros agentes antimicrobianos, y grabar la prevalencia y distribución de este organismo en el Hospital Universitario de West Indies (UHWI). MÉTODOS: Aislados de MRSA recogidos entre el 1ero. de enero de 2008 y el 31 de diciembre de 2008, fueron sometidos a prueba a fin de determinar sus niveles bajo y alto de resistencia a la mupirocina. También se investigó la susceptibilidad frente a otros antibióticos tales como co-trimoxazol, minociclina, tetraciclina, clindamicina, eritromicina, gentamicina y vancomicina. Se revisaron las historias de laboratorio de todos los pacientes de quienes de recobró MRSA, y se extrajeron datos sobre el tipo y fuente de los aislados, el diagnóstico clínico, la historia de hospitalización previa, y el uso de mupirocina. Además, se revisaron las historias clínicas de laboratorio de 2004 y 2005 a fin de determinar la prevalencia durante estos periodos. RESULTADOS: Setenta por ciento de los ailados de estafilococo dorado era resistente a la meticilina (MRSA) y de éstos, 30% y 24% mostraron un bajo nivel y un alto nivel de resistencia a la mupirocina, respectivamente. Noventa y cuatro por ciento de las cepas de MRSA eran resistentes a la eritromicina, mientras que el 52% mostró resistencia a la clindamicina. La resistencia a la tetraciclina, el cotrimoxazol, y la minociclina fue de 27%, 12% y 6%, respectivamente, mientras que aproximadamente un tercio de los aislados eran resistentes a la gentamicina. No hubo resistencia a la vancomicina. Más de la mitad (58%) de los aislados procedían de especimenes de tejido blando y de la piel, mientras que los aislados de las vías respiratorias y urinarias así como del torrente sanguíneo constituyeron el 19%, 13% y 4%, respectivamente. Ha habido un aumento constante de la prevalencia de 4% en 2004 a 5% en 2007 y 7% en 2008. CONCLUSIÓN: La resistencia de MRSA a la mupirocina parece ser un problema emergente en el HUWI y debe monitorearse cuidadosamente. Hay también una resistencia significativa a los agentes antimicrobianos normalmente usados y se requiere una adhesión estricta a la política antibiótica a fin de preservar la utilidad de estos agentes.

The detection of mupirocin resistance and the distribution of methicillin-resistant Staphylococcus aureus at the University Hospital of the West Indies, Jamaica.

OBJECTIVES: The objectives of this study were to determine the susceptibility of Methicillin Resistant Staphylococcus aureus (MRSA) isolates to Mupirocin and other antimicrobial agents and to record the prevalence and distribution of this organism at the University Hospital of the West Indies (UHWI). METHODS: MRSA isolates collected between January 1, 2008 and December 31, 2008, were tested for low and high level resistance to Mupirocin. Susceptibility testing to other antibiotics including cotrimoxazole, minocycline, tetracycline, clindamycin, erythromycin, gentamicin and vancomycin was also done. Laboratory records for all patients from whom MRSA was recovered were reviewed and data on type and source of isolates, clinical diagnosis, history of previous hospitalization and use of mupirocin were extracted. In addition, the laboratory records for 2004 and 2005 were also reviewed to determine prevalence during these periods. RESULTS: Seven per cent of Staphylococcus aureus isolates were resistant to methicillin (MRSA) and of these, 30% and 24% showed low level and high level resistance to mupirocin, respectively. Ninety-four per cent of MRSA strains were resistant to erythromycin while 52% showed resistance to clindamycin. Resistance to tetracycline, co-trimoxazole and minocycline was 27%, 12% and 6%, respectively, while about one-third of the isolates were resistant to gentamicin. There was no resistance to vancomycin. More than half (58%) of the isolates were from skin and soft tissue specimens while isolates from respiratory and urinary tracts and the bloodstream accounted for 19%, 13% and 4%, respectively. There has been a steady increase in prevalence from 4% in 2004 to 5% in 2007 and 7% in 2008. CONCLUSION: Resistance of MRSA to mupirocin appears to be an emerging problem at the UHWI and must be monitored carefully. There is also significant resistance to commonly used antimicrobial agents and strict adherence to antibiotic policy is required to preserve the usefulness of these agents.

Multimodal therapy for the initial management of genital embryonal rhabdomyosarcoma in childhood.

Rhabdomyosarcoma is the most common soft tissue sarcoma found in children. A polypoid form of the embryonal type of rhabdomyosarcoma, namely, sarcoma botryoides, is often found in girls younger than 5 years, and typically presents as a polypoid mass protruding from the vagina. Over the years, there has been a shift in the treatment of this condition from radical surgery to a multimodal approach involving conservative surgery with chemotherapy and radiotherapy. This approach has been associated with improved survival and preservation of normal anatomy and function. We discuss the initial management of a 4-year-old girl with pelvic embryonal rhabdomyosarcoma using a multimodal approach.

The menopause, hormone replacement therapy and informed consent: are women in an underresourced country adequately aware?

Recent evidence on the long-term effects of HRT have resulted in increased emphasis being placed on individualised counselling, patient choice and informed consent when managing the menopause. We assessed whether women in an underresourced country have adequate knowledge of the menopause/HRT to engage in patient - provider discussions and provide full informed consent for HRT. Specific 'knowledge scores' for the menopause and HRT were developed and utilised in structured questionnaires to determine the existing levels of knowledge in 150 women from different racial, educational and occupational backgrounds. Some 92% were aware of the menopause and 54% were aware of HRT. Specific knowledge about the menopause and HRT overall was low (39% and 38%, respectively). There was a significant association between higher education levels, race and occupational status on the knowledge of the menopause but not of HRT. Television, radio and pamphlets were the preferred sources to gain further information. There is a need to create awareness and provide further education to women in underresourced countries about the menopause and HRT to empower them to make informed choices about their health during this period.

Intersex conditions in children and adolescents: surgical, ethical, and legal considerations.

INTRODUCTION: Approximately one in 2000 children globally is born with an intersex condition. There is unfortunately a relative paucity of data on the choices and the surgical and psychosocial outcomes in patients who undergo genital surgery for intersex conditions and ambiguous genitalia, especially in developing countries. Specialists in these and other countries, where patient follow-up is generally poor, are faced with the daunting task of offering the appropriate medical and surgical management, in the absence of guidelines or recommendations. SURGICAL CONSIDERATIONS: A surgical procedure in these patients sometimes involves clitoral recession, reduction, vaginoplasty, and gonadectomy. The best surgical outcome is likely to be achieved with a multidisciplinary surgical team; however, the choice of surgery and appropriate timing remains controversial. Some authors have suggested delaying surgery until the child becomes competent to make his/her own decisions. LEGAL/ETHICAL CONSIDERATIONS: All procedures should conform to an ethical code of practice and be in the interest of the child. Exhaustive counseling of all parties and informed consent is of paramount importance, as is adherence to laws that protect the rights of the child as outlined in respective constitutions. RECOMMENDATIONS: Recommendations in this article, which have been put together from the combined input of three departments, are broad-based. They emphasize the need for extensive counseling, informed consent, adherence to ethical and legal norms, a multidisciplinary input and a shift away from a paternalistic approach.

Behavioural assessment of disturbed, institutionalized retardates.

While behavioural assessment has had wide application in a number of educational and treatment settings, relatively little has been done to develop programmes specifically for use with retardates who have been institutionalized for the treatment of disturbed behaviour. As a result, the development of appropriate procedures for the latter group requires extrapolation from the use of behavioural techniques in other settings. The current literature on behavioural assessment stresses the importance of identifying meaningful response units and their controlling variables, if efficacious treatment programmes are to be mounted. To be maximally useful, assessment must provide a relatively simple description in objective, non-inferential terms of how a patient responds to the demands of daily living. While many reports of treatment programmes focus on the assessment of a single, narrowly defined variable, the occurrence of which can be readily counted, this is not appropriate for the initial assessment procedures of a residential treatment centre. What is required is an omnibus approach which samples the patient's responses to a broad array of environmental situations which are relevant to the centre and its population. A review of available behavioural scales reveals that there are very few reliable omnibus scales available for use with retardates and none which adequately assesses the behavioural concommitants of disturbed retardates. To deal with this group of patients, it is proposed that, initially, two scales be used to sample both normal and maladaptive behaviour. A number of suggestions have been made for implementing behavioural assessment procedures in residential treatment centres, especially for disturbed retardates.

Dynamic changes of serum gamma-glutamyl transferase in chronic alcoholism.

Elevated serum gamma-glutamyl transferase (GGT) levels were found in 29% of 155 chronic alcoholics undergoing detoxification treatment. Alkaline phosphatase (AP) was increased in 16%, alanine aminotransferase--SGPT (ALT) in 12% of the patients, while 23% had elevations of either AP or ALT or both. Of the foregoing parameters, GGT was the best single indicator of liver involvement. In course of the follow-ups GGT/ALT correlation improved, but GGT/AP correlation deteriorated. In 9 patients, abstinence during follow-up was associated with progressive decrease in previously elevated serum GGT. Because of its unique sensitivity, GGT may be useful as a screening and/or monitoring aid in alcoholism.