Predictive value of retinal function by the Purkinje test in patients scheduled for cataract surgery in Kinshasa, DR Congo

AIM: To assess the retinal function in patients with dense cataracts in resource poor settings in Kinshasa, DR Congo. METHODS: In a tertiary eye care center, the Purkinje entoptic test was performed as part of the ophthalmological examination in 98 eyes in patients with cataract, using a penlight. Totally 92 cataract patients including 86 patients suffered from unilateral and 6 from bilateral cataracts were included in the study. The investigator asked the patients about their perception of the vascular pattern most commonly described as a leafless or dead tree. Visual acuity≥6/60 was considered an indication of good visual function and visual acuity<6/60 of poor function. Following small incision cataract surgery, best corrected visual acuity (BCVA) was determined and compared with the preoperative findings. RESULTS: Out of 98 eyes, there were 80 (81.6%) where the Purkinje entoptic phenomenon was reported by the patients. After cataract surgery, out of the 80 eyes, there were 75 (93.8%) with a BCVA of better than 6/60, whereas in 5 eyes (6.2%), BCVA was 6/60 or less. Out of the 18 eyes (18.4%) where no Purkinje tree was recognized, there were 14 (77.8%) with BCVA of better than 6/60, whereas in 4 (22.2%) BCVA was 6/60 or less. CONCLUSION: The Purkinje entoptic test is successfully used for preoperative assessment of retinal function in patients with dense cataract. However, further investigation and refinement of the test is necessary to validate the method for use in sub-Saharan conditions.     

National response to orphans and other vulnerable children in sub-Saharan Africa: The OVC Policy and Planning Effort Index, 2004

Abstract

The orphaned and vulnerable children (OVC) Policy and Planning Effort Index measures the amount of effort put into place by governments, non-governmental organizations (NGOs) and other stakeholders in countries in response to the needs of the increasing numbers of orphans and children made vulnerable by HIV/AIDS. The OVC Index was applied to 36 countries in sub-Saharan Africa in 2004. All countries have some organized effort to respond to the needs of OVC. Most countries have established a coordination mechanism and organized a national consultation to discuss the situation of these children. However, the average score for sub-Saharan Africa was just 48% of the maximum effort and only five countries scored 70 or above. There is considerable room for improvement in all sub-regions and countries. The best efforts are in the areas of coordination and consultation of stakeholders, action planning and government commitment. Legislative review and monitoring and evaluation are the weakest areas. The development of a widely adopted policy specific for orphans and other vulnerable children is another challenge for most countries. The challenge is to build and expand on current efforts and the commitment expressed by governments to assure that the needs of the growing number of children orphaned and made vulnerable by the AIDS epidemic are addressed.     

The introduction of umbilical cord lactate measurement and associated neonatal outcomes in a South African tertiary hospital labor ward

Purpose: To investigate the utility of umbilical artery (UA) lactate measurements in a South African hospital for assessing intrapartum care and predicting neonatal outcomes.

Materials and methods: From 3 March–12 November 2014, we conducted a prospective cohort study of UA lactate levels at Kalafong Hospital, Pretoria, South Africa. Following birth, a UA blood sample (<0.5uL) was taken from a double-clamped segment of cord and the lactate measured. Maternal and neonatal characteristics and outcomes were recorded.

Results: During the study, there were 4668 deliveries; including 1091 emergency cesarean and 154 instrumental deliveries. A lactate was recorded for 946 deliveries (20.3%). 190 babies required neonatal resuscitation, with an optimal cutoff for lactate of 5.45?mmol/L (sensitivity 68%, specificity 72%). 124 babies required nursery admission with the optimal cutoff for lactate 4.95?mmol/L (sensitivity 61%, specificity 59%). 55 babies had an Apgar score <7 at 5?min and the optimal lactate for this outcome was 5.65?mmol/L (sensitivity 64%, specificity of 69%).

Conclusions: Umbilical lactate can be used in a middle-low resource setting as a measurement of intrapartum hypoxia, with reasonable sensitivity and specificity for the prediction of, or need for, resuscitation, admission to the nursery, and low Apgar scores.     

Educating leaders in hospital management: A pre-post study in Ethiopian hospitals

Abstract

Despite recent focus on health systems strengthening, few studies report large-scale efforts to improve hospital management capacity in low-income countries, a central component of improving health care delivery. We sought to assess the contributions of a systems-based approach, the Ethiopian Hospital Management Initiative (EHMI), which established hospital chief executive officers (CEOs) trained through a Masters of Healthcare and Hospital Administration (MHA) degree programme in Ethiopia. We conducted a pre-post study of 24 hospitals that are managed by CEOs in the MHA programme. We measured changes in hospital functioning based on adherence to a set of 86 hospital performance standards across 12 management domains published in the Standards for Hospital Management in Ethiopia. We found that adherence to hospital performance standards increased significantly during the one-year follow-up (27% compared with 51% of standards met at baseline and follow-up, respectively; P-value < 0.001); overall improvement was driven by improvement in seven of the 12 management domains. The EHMI is an example of health systems strengthening with focus on building hospital management capacity. Early evidence suggests that the establishment of hospital CEOs and MHA training to equip them with management skills may promote scalable improvements in health facility functioning.     

Strategies to destigmatize mental illness in South Africa: Social work perspective

Stigma is a contributing factor to non-help-seeking behavior and social isolation of mental health-care users. The study examined social workers’ perspective regarding strategies that can be implemented to destigmatize mental illness in South Africa. A qualitative study method was adopted. Data were sourced through focus group discussions with social work students and telephone interviews with social workers working in hospitals. Data were analyzed using a thematic approach. Active involvement, education, and awareness campaigns, creating opportunities for improved well-being and constant support, were identified as relevant strategies. Given that stigma is multidimensional, various strategies are important if mental illness is to be destigmatized.     

Which dietary diversity indicator is best to assess micronutrient adequacy in children 1 to 9 y?

ObjectivesThe aim of this study was to determine the best dietary diversity indicator to measure dietary diversity and micronutrient adequacy in children.MethodsA national representative cross-sectional survey of children ages 1 to 9 y (N = 2,200) was undertaken in all ethnic groups in South Africa. A 24-h recall was done with the mother or caregiver of each child. A dietary diversity score (DDS), the number of food groups consumed at least once in a period of 24 h, was calculated for each child in accordance with 6-, 9-, 13-, and 21-food group (G) indicators and compared with a mean adequacy ratio (MAR). The nutrient adequacy ratio (NAR) was calculated for 11 micronutrients by comparing the distributions of estimated intakes with the Estimated Average Requirements for that micronutrient. The MAR was the average of all NARs. Correlations were done between MAR and DDS and sensitivity and specificity calculated for each group indicator.ResultsPearson’s correlations between food group indicators and MAR indicate that r values were all highly significant (P < 0.0001). There were no consistent or large differences found between the different group indicators although G13 and G21 appeared to be marginally better. Sensitivity and specificity values in the current study lay between DDS of 3 and 5, suggesting one of these as the best indication of (low) micronutrient adequacy.ConclusionsOverall results seem to indicate that any of the four G indicators can be used in dietary assessment studies on children, with G13 and G21 being marginally better. A cut-off DDS of 4 and 5, respectively, appear best.     

External Beam Radiotherapy in Western Africa: 1969–2019

AimsWe describe the absolute and per capita numbers of megavoltage radiotherapy machines (MVMs) in Western Africa from 1969 to 2019.Materials and methodsWestern Africa was defined in accordance with the United Nations' delineation and inclusive of 16 countries. A literature search for publications detailing the number of cobalt-60 machines (COs) and linear accelerators (LINACs) in radiotherapy centres was carried out. Population data from the World Bank Group and crude cancer rates from the International Agency for Research on Cancer were used to calculate ratios of million persons per MVM and MVMs per 1000 cancer cases.ResultsThe numbers of MVMs in Western Africa in 1969, 1979, 1989, 1999 and 2009 were zero, two, three, six and nine, respectively. In 2019 there were 22 MVMs distributed across Ghana (five), Côte d’Ivoire (two), Mali (one), Mauritania (two), Nigeria (nine) and Senegal (three). Nine countries (56.3%) had no history of external beam radiotherapy (EBRT). The largest increase in absolute EBRT capacity occurred from 2017 to 2019, during which 13 MVMs were commissioned. The largest decrease in EBRT capacity occurred from 2015 to 2017, during which four LINACs and three COs were rendered non-operational. The ratio of million persons per MVM improved from 67.0 in 1979 to 17.8 in 2019. As of 2019, there was 0.09 MVM per 1000 cancer cases.ConclusionsWestern African nations have experienced an increase in the absolute number of MVMs and per capita radiotherapy capacity during the last 50 years, especially in the last decade. As non-functional LINACs contributed to a temporary decline in the EBRT infrastructure, dual use of CO/LINAC technologies may act to promote the availability of EBRT treatment in centres with capacity for multiple MVMs.     

Regional prevalence of health worker absenteeism in Tanzania

Absenteeism of health workers in developing countries is common and can severely undermine the reliability of the health system. Therefore, it is important to understand where the prevalence of absenteeism is high. We develop a simple imputation method that combines a Service Delivery Indicators survey and a Service Provision Assessment survey to estimate the prevalence of absenteeism of health workers at the level of regions in Tanzania. The resulting estimates allow one to identify the regions in which the prevalence of absenteeism is significantly higher or lower than the national average and help policymakers determine priority areas for intervention.     

Enhanced Heterosexual Transmission Hypothesis for the Origin of Pandemic HIV-1

HIV-1 M originated from SIVcpz endemic in chimpanzees from southeast Cameroon or neighboring areas, and it started to spread in the early 20th century. Here we examine the factors that may have contributed to simian-to-human transmission, local transmission between humans, and export to a city. The region had intense ape hunting, social disruption, commercial sex work, STDs, and traffic to/from Kinshasa in the period 1899–1923. Injection treatments increased sharply around 1930; however, their frequency among local patients was far lower than among modern groups experiencing parenteral HIV-1 outbreaks. Recent molecular datings of HIV-1 M fit better the period of maximal resource exploitation and trade links than the period of high injection intensity. We conclude that although local parenteral outbreaks might have occurred, these are unlikely to have caused massive transmission. World War I led to additional, and hitherto unrecognized, risks of HIV-1 emergence. We propose an Enhanced Heterosexual Transmission Hypothesis for the origin of HIV-1 M, featuring at the time and place of its origin a coincidence of favorable co-factors (ape hunting, social disruption, STDs, and mobility) for both cross-species transmission and heterosexual spread. Our hypothesis does not exclude a role for parenteral transmission in the initial viral adaptation.     

Diversity of patient preparation activities before initiation of antiretroviral therapy in Cape Town,South Africa

Objective  To investigate patient education and counseling activities prior to the initiation of antiretroviral therapy (ART) at public sector services across Cape Town, South Africa. Methods  Key informant interviews and programme reviews were conducted with government bodies and non‐governmental organisations involved in patient preparation activities. Results  All 11 organisations in Cape Town involved in training and managing personnel to prepare patients for ART during 2010 participated. Each organisation reported a different approach to patient preparation within public sector clinics and in each aspect of patient preparation activities. The number of patient education sessions ranged from 3 to 7, and the delays to ART initiation introduced by patient preparation ranged from 3 to 6 weeks. Different patient education materials (pamphlets, posters and flipcharts) were used by various programmes, and all programmes reported that shortages in materials meant that patient preparation often took place without any educational materials. Each programme also reported attention to mental illness and alcohol/substance use disorders, but none employed formal screening tools consistently, and the handling of patients with potential mental health‐ or substance‐related problems varied. Conclusion  Approaches to prepare patients before ART initiation are wide ranging in one part of South Africa. Their relative value requires investigation, as there is little evidence for the impact of varying approaches. Moreover, the risks associated with delayed ART initiation may outweigh any benefits of patient education before the start of treatment.