Assessing Adherence to Antihypertensive Therapy in Primary Health Care in Namibia: Findings and Implications

INTRODUCTION

Namibia has the highest burden and incidence of hypertension in sub-Sahara Africa. Though non-adherence to antihypertensive therapy is an important cardiovascular risk factor, little is known about potential ways to improve adherence in Namibia following universal access. The objective of this study is to validate the Hill-Bone compliance scale and determine the level and predictors of adherence to antihypertensive treatment in primary health care settings in sub-urban townships of Windhoek, Namibia.

METHODS

Reliability was determined by Cronbach's alpha. Principal component analysis (PCA) was used to assess construct validity.

RESULTS

The PCA was consistent with the three constructs for 12 items, explaining 24.1, 16.7 and 10.8% of the variance. Cronbach's alpha was 0.695. None of the 120 patients had perfect adherence to antihypertensive therapy, and less than half had acceptable levels of adherence (≥ 80%). The mean adherence level was 76.7 ± 8.1%. Three quarters of patients ever missed their scheduled clinic appointment. Having a family support system (OR = 5.4, 95% CI 1.687-27.6, p = 0.045) and attendance of follow-up visits (OR = 3.1, 95% CI 1.1-8.7, p = 0.03) were significant predictors of adherence. Having HIV/AIDs did not lower adherence.

CONCLUSIONS

The modified Namibian version of the Hill-Bone scale is reliable and valid for assessing adherence to antihypertensives in Namibia. There is sub-optimal adherence to antihypertensive therapy among primary health cares in Namibia. This needs standardized systems to strengthen adherence monitoring as well as investigation of other factors including transport to take full advantage of universal access.

Compliance to guidelines for the prescribing of antibiotics in acute infections at Namibia's national referral hospital: a pilot study and the implications

BACKGROUND

Sub-optimal antibiotic prescribing remains a public health concern in Namibia. The objective was to determine the level and predictors of compliance to guidelines in the prescribing of antibiotics in acute infections at a national referral hospital in Namibia to improve future prescribing.

METHODS

An analytical cross-sectional survey design. The clinical records of patients receiving care were reviewed. Prescribing practices were assessed using a self- administered questionnaire with reference to Namibia Standard Treatment Guidelines (NSTG).

RESULTS

The majority of prescriptions (62%) complied with the NSTGs; however, lower than national targets (95%). Most prescriptions were empiric and prescribers typically made reference to the NSTG (58%). Diagnosed infections were principally respiratory infections (58%) and penicillins were the most used antibiotics. Good concurrence between signs and symptoms with the diagnosis indicated on the prescription - OR=5.2 (95% CI: 1.4, 19.2), a diagnosis of upper respiratory tract (p=0.001), oral-dental OR=0.1(95% CI: 0.03,0.3) and urogenital infections OR=0.3(95% CI: 0.1,0.95) and the prescribing of penicillins (p=0.001) or combination antibiotics and amphenicols were independent predictors of compliance to the NSTGs. The main behaviours associated with antibiotic prescribing were patient influences, clinical state, and access to guidelines.

CONCLUSIONS

Compliance with NSTGs is suboptimal. Prescribing of combination antibiotics, penicillins and diagnosis of oral dental, genitourinary and ear, nose and throat infections were important predictors for NSTG compliance. There is a need to implement antibiotic indicators and stewardship programmes, and ensure access to NSTGs, to improve future antibiotic prescribing in Namibia.

Antarctic ice sheet discharge driven by atmosphere-ocean feedbacks at the Last Glacial Termination

Reconstructing the dynamic response of the Antarctic ice sheets to warming during the Last Glacial Termination (LGT; 18,000–11,650 yrs ago) allows us to disentangle ice-climate feedbacks that are key to improving future projections. Whilst the sequence of events during this period is reasonably well-known, relatively poor chronological control has precluded precise alignment of ice, atmospheric and marine records, making it difficult to assess relationships between Antarctic ice-sheet (AIS) dynamics, climate change and sea level. Here we present results from a highly-resolved ‘horizontal ice core’ from the Weddell Sea Embayment, which records millennial-scale AIS dynamics across this extensive region. Counterintuitively, we find AIS mass-loss across the full duration of the Antarctic Cold Reversal (ACR; 14,600–12,700 yrs ago), with stabilisation during the subsequent millennia of atmospheric warming. Earth-system and ice-sheet modelling suggests these contrasting trends were likely Antarctic-wide, sustained by feedbacks amplified by the delivery of Circumpolar Deep Water onto the continental shelf. Given the anti-phase relationship between inter-hemispheric climate trends across the LGT our findings demonstrate that Southern Ocean-AIS feedbacks were controlled by global atmospheric teleconnections. With increasing stratification of the Southern Ocean and intensification of mid-latitude westerly winds today, such teleconnections could amplify AIS mass loss and accelerate global sea-level rise.

Non-Saccharomyces yeasts protect against epithelial cell barrier disruption induced by Salmonella enterica subsp. enterica serovar Typhimurium

The human gastrointestinal epithelium makes up the largest barrier separating the body from the external environment. Whereas invasive pathogens cause epithelial barrier disruption, probiotic micro-organisms modulate tight junction regulation and improve epithelial barrier function. In addition, probiotic strains may be able to reduce epithelial barrier disruption caused by pathogenic species. The aim of this study was to explore non-Saccharomyces yeast modulation of epithelial cell barrier function in vitro. Benchmarking against established probiotic strains, we evaluated the ability of four nonpathogenic yeast species to modulate transepithelial electrical resistance (TER) across a monolayer of differentiated human colonocytes (Caco-2 cells). Further, we assessed yeast modulation of a Salmonella Typhimurium-induced epithelial cell barrier function insult. Our findings demonstrate distinct patterns of non-Saccharomyces yeast modulation of epithelial cell barrier function. While the established probiotic yeast Saccharomyces boulardii increased TER across a Caco-2 monolayer by 30%, Kluyveromyces marxianus exhibited significantly stronger properties of TER enhancement (50% TER increase). In addition, our data demonstrate significant yeast-mediated modulation of Salmonella-induced epithelial cell barrier disruption and identify K. marxianus and Metschnikowia gruessii as two non-Saccharomyces yeasts capable of protecting human epithelial cells from pathogen invasion.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study demonstrates distinct patterns of non-Saccharomyces yeast modulation of epithelial cell barrier function in vitro. Further, our data demonstrate significant yeast-mediated modulation of Salmonella Typhimurium-induced epithelial cell barrier disruption and identify Kluyveromyces marxianus and Metschnikowia gruessii as two non-Saccharomyces yeasts capable of protecting human epithelial cells from pathogen invasion. This study is the first to demonstrate significant non-Saccharomyces yeast-mediated epithelial cell barrier protection from Salmonella invasion, thus encouraging future efforts aimed at confirming the observed effects in vivo and driving further strain development towards novel yeast probiotics.

Portable LED fluorescence instrumentation for the rapid assessment of potable water quality

Characterising the organic and microbial matrix of water are key issues in ensuring a safe potable water supply. Current techniques only confirm water quality retrospectively via laboratory analysis of discrete samples. Whilst such analysis is required for regulatory purposes, it would be highly beneficial to monitor water quality in-situ in real time, enabling rapid water quality assessment and facilitating proactive management of water supply systems. A novel LED-based instrument, detecting fluorescence peaks C and T (surrogates for organic and microbial matter, respectively), was constructed and performance assessed. Results from over 200 samples taken from source waters through to customer tap from three UK water companies are presented. Excellent correlation was observed between the new device and a research grade spectrophotometer (r(2)=0.98 and 0.77 for peak C and peak T respectively), demonstrating the potential of providing a low cost, portable alternative fluorimeter. The peak C/TOC correlation was very good (r(2)=0.75) at low TOC levels found in drinking water. However, correlations between peak T and regulatory measures of microbial matter (2 day/3 day heterotrophic plate counts (HPC), E. coli, and total coliforms) were poor, due to the specific nature of these regulatory measures and the general measure of peak T. A more promising correlation was obtained between peak T and total bacteria using flow cytometry. Assessment of the fluorescence of four individual bacteria isolated from drinking water was also considered and excellent correlations found with peak T (Sphingobium sp. (r(2)=0.83); Methylobacterium sp. (r(2)=1.0); Rhodococcus sp. (r(2)=0.86); Xenophilus sp. (r(2)=0.96)). It is notable that each of the bacteria studied exhibited different levels of fluorescence as a function of their number. The scope for LED based instrumentation for in-situ, real time assessment of the organic and microbial matrix of potable water is clearly demonstrated.

Acute paraspinal compartment syndrome as a rare cause of loin pain

A significant proportion of emergency urological admissions are comprised of ureteric colic presenting as loin pain. A variety of alternative pathologies present in this manner and should be considered during systematic assessment. We report the case of a patient admitted with severe unilateral back and flank pain after strenuous deadlift exercise. Clinical examination and subsequent investigation following a significant delay demonstrated acute paraspinal compartment syndrome (PCS) after an initial misdiagnosis of ureteric colic. The patient was managed conservatively. We review the current literature surrounding the rare diagnosis of PCS and discuss the management options.