Improving health outcomes and quality at the subdistrict level: Evaluation of the '3 feet model' in Waterberg District, Limpopo Province, South Africa

BACKGROUND

There is a gap in understanding of potential roles and actions at the subdistrict level to improve quality of care and health outcomes in South Africa (SA).

OBJECTIVES

To report on the evaluation of a subdistrict health system-strengthening initiative that aimed to reduce maternal, newborn and child mortality, referred to as the '3 feet model' in Waterberg District, Limpopo Province, SA. The model is centred on systems of real-time morbidity/mortality surveillance and co-ordinated responses. It was implemented in three of five Waterberg subdistricts over an 18-month period in 2021 and 2022.

METHODS

A prospective, process-tracing evaluation was conducted jointly between researchers, intervention partners and subdistrict decision-makers. Data sources combined ~100 hours of researcher participant observation, interviews with 14 health system actors, structured reflections by three subdistrict managers and information from the routine District Health Information System. Sources were triangulated and analysed based on a priori hypotheses on mechanisms of action.

RESULTS

Following uptake of the model, the perinatal mortality rate (PMR) improved by 28.8%, 11.5% and 28% in the three subdistricts, respectively, while the PMR worsened in two of four neighbouring subdistricts. Plausible factors in implementation successes were the presence of stable and committed hybrid (clinical-managerial) subdistrict leaders and their ability to overcome entrenched silos between a variety of system actors; new collaborative relationships between primary healthcare facilities, hospitals and emergency medical services; the generation and packaging of information in ways that directed responses ('actionable intelligence'); and support from senior district managers.

CONCLUSION

While not advocating for a cut-and-paste approach to improving quality and outcomes, positive experiences in Waterberg District suggest that the principles and mechanisms of action of the 3 feet model have wider relevance for policy and practice, especially as emphasis shifts towards the subdistrict as a core unit of population health and wellbeing in SA.

[Surgical voice rehabilitation in unilateral vocal fold paralysis]

Unilateral recurrent nerve paralysis leads to glottic insufficiency, significantly reducing vocal ability. Due to its unusually long course, the recurrent laryngeal nerve is prone to iatrogenic lesions involves many medical fields generally with little expertise in voice disorders. Whenever the etiology is uncertain, a complete diagnostic work-up is mandatory. Indirect laryngoscopy confirms the diagnosis. Laryngeal electromyography is of great value because it differentiates between paralysis and ankylosis of the cricoarytenoid joint. Moreover in many cases laryngeal electromyography yields a reliable prognosis of clinical outcome. While unfavorable results can be predicted with high accuracy, correct prognosis of complete recovery is more difficult. Speech therapy is the treatment of choice in cases of unilateral recurrent nerve palsy. Patients with persistent glottal gap may express the wish for surgical voice rehabilitation. Nowadays a broad spectrum of endoscopic and open approaches are available for this purpose. This review describes advanced techniques of voice-improving surgery available in specialized centers today.

Relationship of thrombopoietin and interleukin-11 levels to thrombocytopenia associated with dengue disease

Thrombocytopenia is one of the main clinical findings of dengue. In this work we examined the levels of thrombopoietin (TPO) and interleukin-11 (IL-11), two of the most potent regulators of platelet production, in serum from 28 patients with dengue fever (DF). Patients with DF had increased levels of TPO, compared with healthy individuals (p<0.005). Patients with dengue hemorrhagic fever (DHF, n=7), the more severe form of dengue, had higher TPO levels than patients with DF (p<0.001). Serum TPO levels and platelet counts were inversely correlated in both DF and DHF patients. IL-11 was detectable in neither DF nor DHF patients. Our results demonstrate that thrombocytopenia in dengue disease is associated with changes in the serum levels of TPO, but not IL-11, suggesting that this cytokine could be a potential early clinical marker of the severity of dengue disease.

Platelet dysfunction-eosinophilia syndrome in parasitized Venezuelan children

Platelet dysfunction was detected in six children with purpura and eosinophilia. We conducted clinical evaluations, hematologic and platelet function tests, clotting studies (bleeding time, prothrombin time, partial thromboplastin time, thrombin time, factor XIII, factor VIII, and von Willebrand factor), assays for IgG and IgM antibodies to platelets, and a search for stool parasites. Mild bleeding phenomena (ecchymoses, petechiae, epistaxis, and gingival) were transient. All children showed intestinal parasites and marked eosinophilia (mean count = 2,615.2 cells/muL, 95% confidence interval = 1,259.6-5,429.8). Main abnormalities included prolonged bleeding times (50%) and defective aggregation with collagen (100%) adrenaline (66%), or ADP (66%). Antibodies to platelets were not detected. Anti-parasite therapy reversed the hemorrhagic manifestations and normalized eosinophil counts and platelet alterations. No relationship could be established between excess eosinophils, intensity of bleeding, or type and degree of platelet abnormalities. Thrombocytopathic features mimicked the intrinsic defect of storage pool disease. The possible pathogenic roles of eosinophilia and parasitism are reviewed. This is the first report of this pathologic combination in Latin American children.

Proinflammatory factors present in sera from patients with acute dengue infection induce activation and apoptosis of human microvascular endothelial cells: possible role of TNF-alpha in endothelial cell damage in dengue

There is evidence that severe dengue disease is associated with alterations of the microvascular endothelium. We examined the hypothesis that activation and damage of microvascular endothelial cells (EC) could be induced by inflammatory mediators present in dengue patient's sera. We cultured human microvascular EC (HMEC-1) in vitro with sera from patients with acute dengue infection. Sera from patients with acute dengue induced an increase in ICAM-1 expression on HMEC-1. This effect was greater with samples from the acute febrile phase than with samples from the convalescent phase of the disease. Acute dengue sera had elevated levels of TNF-alpha and the endothelial activating effect of acute dengue sera was inhibited up to 80% by pre-treatment with monoclonal antibodies against TNF-alpha. Furthermore, acute dengue sera induced apoptosis in HMEC-1. These findings support the pathophysiologic significance of microvascular EC and serum inflammatory mediators in dengue.

Molecular genetic analysis of severe protein C deficiency

Severe protein C deficiency is a rare, early onset, venous thrombotic condition that is inherited as an autosomal recessive trait. The protein C (PROC) genes of nine unrelated individuals with severe protein C deficiency were sequenced yielding a total of 13 different lesions. Eight of these were novel, including a gross gene deletion, three missense mutations, two micro-deletions, a splicing mutation and a single base-pair substitution in the HNF-3 binding site in the PROC gene promoter. Evidence for the pathogenicity of the mutations detected was obtained by molecular modelling, in vitro splicing assay and reporter gene assay. Neither the plasma protein C activity level nor the nature of the PROC gene lesions detected were found to be a good prognostic indicator of the age of onset or clinical severity of thrombotic symptoms. Other factors may thus complicate the relationship between genotype and clinical phenotype. Indeed, in two patients, the inheritance of either one or two Factor V Leiden alleles in addition to two PROC gene lesions could have served to precipitate the thrombotic events. No association was however apparent between clinical severity and the possession of a particular promoter polymorphism genotype. Despite the absence of a clear genotype-phenotype relationship, the molecular genetic analysis of the severe recessive form of protein C deficiency potentiates both the counselling of affected families and the provision of antenatal exclusion diagnosis.

[The knowledge and application of regulations on smoking in secondary teaching centers]

OBJECTIVES

Despite the growing body of legal and normative regulations regarding promotion, sales and consumption of cigarettes, a few studies have already pointed to a low enforcement and commitment of these restrictions. This study explores the degree of awareness and compliance of these norms in the secondary school.

DESIGN

Cross-sectional, observational study. A telephone survey was carried out.

PARTICIPANTS

A simple of school principals or deputy principal was surveyed.

MEASUREMENTS

A questionnaire was designed to obtain respondents knowledge of the current policies regarding smoking, as well as on the existence of visible signals in the school wards. Besides, opinion on tolerance towards smoking behavior among the school teachers was ascertained.

RESULTS

Virtually at the respondents (98.8%) declared to know the existence of the regulations, although only 74.4% declared to have specific regulations at the school level. Smoking by teachers was allowed in their own offices in 61.6% of the centers. In open grounds, only 4.7% of the centers authorized adults to smoke while 18.6% permitted to smoke to the students. Public centers were less restrictive than private centers.

DISCUSSION

Principals of secondary schools are aware of the existing, policy, and in most cases largely restrict public consumption. However, there are still some important gaps regarding signals, consumption in outdoor public spaces and teachers consumption in their own offices. Specific interventions seem to be necessary to overcome this situation.

Prothrombin carora: hypoprothrombinaemia caused by substitution of Tyr-44 by Cys

Two members of a family from Carora, Venezuela, were found to have prothrombin activity levels at 4% of normal and undetectable antigen levels. All exons of the prothrombin gene from the proband were sequenced and a mutation at nucleotide 1305 was identified that would result in the substitution of Cys for Tyr at residue 44. Residue 44 is present in the aromatic stack region of the protein. Substitution of a Cys in this region would result in an abnormal folding of the protein which could be the cause for the observed lack of secretion of the abnormal prothrombin.

Further specificity characterization of von Willebrand factor inhibitors developed in two patients with severe von Willebrand disease

Circulating inhibitors against von Willebrand factor (vWF) that show the properties of heterologous IgG antibodies have been described in a few patients with severe von Willebrand disease (vWD). The present study provides further characterization of inhibitors from two patients with severe vWD. Inhibitors in both, like polyclonal rabbit antibody, detected all sizes of multimers and the complex structure of each multimer from platelets and plasma of normal individuals as well as from plasma of patients with IIA, IIB, and IIC vWD. Both inhibitors and the rabbit antibody reacted mainly with the intact 225-Kd vWF subunit and the 189-H and 140-Kd fragments in contrast to monoclonal antibodies specific for vWF fragments that detected a higher relative proportion of 176-Kd fragment. Furthermore, all these antibodies recognized fragment III, although one inhibitor and rabbit polyclonal antibody reacted poorly and the other inhibitor did not react at all with reduced fragment II of vWF digested with Staphylococcus aureus V-8 protease. These data suggest that although human inhibitors from severe vWD patients may behave, to some extent, as polyclonal heterologous antibodies against native vWF, the former show striking differences in their target specificity as well as a much broader specificity than that described for human factor VIII inhibitors.

An unusual case of hyper-production of IgE, treated by plasmapheresis

A 15-year-old boy with severe inflammatory skin lesions from an early age was found to have extremely elevated serum IgE levels (up to 376.000 IU/ml). His skin showed positive direct immunofluorescence for IgE and he had peripheral and bone marrow eosinophilia. No evidence for atopic disease was found, but he suffered intestinal helminthic infection of moderate intensity. He showed a somewhat depressed cell mediated immune response but a normal polymorphonuclear function. Various treatments that included anti-inflammatory, anti-allergic, anti-parasitic, anti-mycotic and PUVA therapy did not significantly improve his condition A therapeutic test using plasmapheresis produced marked, though short-lived clinical improvement. We believe that this case might result from the superimposition of the stimulatory effects of intestinal helminthiasis on a background of intrinsic hyper-production of IgE.