Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

Venous thromboembolic disease in adults admitted to hospital in a setting with a high burden of HIV and TB

BACKGROUND

HIV and tuberculosis (TB) independently cause an increased risk for venous thromboembolic disease (VTE): deep vein thrombosis (DVT) and/or pulmonary embolism (PE). Data from high HIV and TB burden settings describing VTE are scarce. The Wells' DVT and PE scores are widely used but their utility in these settings has not been reported on extensively.

OBJECTIVES

To evaluate new onset VTE, compare clinical characteristics by HIV status, and the presence or absence of TB disease in our setting. We also calculate the Wells' score for all patients.

METHODS

A prospective cohort of adult in-patients with radiologically confirmed VTE were recruited into the study between September 2015 and May 2016. Demographics, presence of TB, HIV status, duration of treatment, CD4 count, viral load, VTE risk factors, and parameters to calculate the Wells' score were collected.

RESULTS

We recruited 100 patients. Most of the patients were HIV-infected (n=59), 39 had TB disease and 32 were HIV/TB co-infected. Most of the patients had DVT only (n=83); 11 had PE, and 6 had both DVT and PE. More than a third of patients on antiretroviral treatment (ART) (43%; n=18/42) were on treatment for <6 months. Half of the patients (51%; n=20/39) were on TB treatment for <1 month. The median (interquartile range (IQR)) DVT and PE Wells' score in all sub-groups was 3.0 (1.0 - 4.0) and 3.0 (2.5 - 4.5), respectively.

CONCLUSION

HIV/TB co-infection appears to confer a risk for VTE, especially early after initiation of ART and/or TB treatment, and therefore requires careful monitoring for VTE and early initiation of thrombo-prophylaxis.

Protocol for a randomised feasibility study of Point-Of-care HIV viral load testing to Enhance Re-suppression in South Africa: the POwER study

INTRODUCTION

Access to HIV viral load testing remains difficult for many people on antiretroviral therapy (ART) in low-income and middle-income countries. Weak laboratory and clinic systems often delay the detection and management of viraemia, which can lead to morbidity, drug resistance and HIV transmission. Point-of-care testing could overcome these challenges. We aim to assess whether it is feasible to conduct a randomised trial of point-of-care viral load testing to manage viraemia.

METHODS AND ANALYSIS

We will conduct an open-label, single-site, individually randomised, feasibility study of Point-Of-care HIV viral load testing to Enhance Re-suppression, in Durban, South Africa. We will enrol approximately 100 people living with HIV who are aged ≥18 years, receiving first-line ART but with recent viraemia ≥1000 copies/mL, and randomise them 1:1 to receive point-of-care viral load or standard laboratory viral load monitoring, after 12 weeks. All participants will continue to receive care from public sector healthcare workers following South African HIV management guidelines. Participants with persistent viraemia ≥1000 copies/mL will be considered for switching to second-line ART. We will compare the proportion in each study arm who achieve the primary outcome of viral suppression <50 copies/mL at 24 weeks after enrolment. Additional outcomes include proportions retained in the study, proportions with HIV drug resistance, time to viral load results and time to switching to second-line ART. We will assess implementation of point-of-care viral load testing using process evaluation data, and through interviews and focus groups with healthcare workers.

ETHICS AND DISSEMINATION

University of Oxford Tropical Research Ethics Committee and the Biomedical Research Ethics Committee of the University of KwaZulu-Natal have approved the study. We will present results to stakeholders, and through conferences and open-access, peer-reviewed journals.

TRIAL REGISTRATION NUMBER

PACTR202001785886049.

A packaged intervention to improve viral load monitoring within a deeply rural health district of South Africa

BACKGROUND

The KwaZulu-Natal (KZN) province of South Africa has the highest prevalence of HIV infection in the world. Viral load (VL) testing is a crucial tool for clinical and programmatic monitoring. Within uMkhanyakude district, VL suppression rates were 91% among patients with VL data; however, VL performance rates averaged only 38·7%. The objective of this study was to determine if enhanced clinic processes and community outreach could improve VL monitoring within this district.

METHODS

A packaged intervention was implemented at three rural clinics in the setting of the KZN HIV AIDS Drug Resistance Surveillance Study. This included file hygiene, outreach, a VL register and documentation revisions. Chart audits were used to assess fidelity. Outcome measures included percentage VL performed and suppressed. Each rural clinic was matched with a peri-urban clinic for comparison before and after the start of each phase of the intervention. Monthly sample proportions were modelled using quasi-likelihood regression methods for over-dispersed binomial data.

RESULTS

Mkuze and Jozini clinics increased VL performance overall from 33·9% and 35·3% to 75·8% and 72·4%, respectively which was significantly greater than the increases in the comparison clinics (RR 1·86 and 1·68, p < 0·01). VL suppression rates similarly increased overall by 39·3% and 36·2% (RR 1·84 and 1·70, p < 0·01). The Chart Intervention phase showed significant increases in fidelity 16 months after implementation.

CONCLUSIONS

The packaged intervention improved VL performance and suppression rates overall but was significant in Mkuze and Jozini. Larger sustained efforts will be needed to have a similar impact throughout the province.

Extensively drug-resistant tuberculosis 'hotspots' and sociodemographic associations in Durban, South Africa

<sec> <title>BACKGROUND</title> In KwaZulu-Natal, South Africa, the incidence of extensively drug-resistant tuberculosis (XDR-TB) is driven by the transmission of resistant strains. As data suggest that cases may be spatially clustered, we sought to identify 'hotspots' and describe these communities. </sec> <sec> <title>METHODS</title> We enrolled XDR-TB patients diagnosed from 2011 to 2014 in eThekwini. Global positioning system (GPS) coordinates for participant homes were collected and hotspots were identified based on population-adjusted XDR-TB incidence. The sociodemographic features of hotspots were characterised using census data. For a subset of participants, we mapped non-home XDR-TB congregate locations and compared these with results including only homes. </sec> <sec> <title>RESULTS</title> Among 132 participants, 75 (57%) were female and 87 (66%) lived in urban or suburban locations. Fifteen of 197 census tracts were identified as XDR-TB hotspots with ≥95% confidence. Four spatial mapping methods identified one large hotspot in northeastern eThekwini. Hotspot communities had higher proportions of low educational attainment (12% vs. 9%) and unemployment (29.3% vs. 20.4%), and lower proportion of homes with flush toilets (36.4% vs. 68.9%). The case density shifted towards downtown Durban when congregate locations (e.g., workplaces) for 43 (33%) participants were mapped. </sec> <sec> <title>CONCLUSIONS</title> In eThekwini, XDR-TB case homes were clustered into hotspots with more poverty indicators than non-hotspots. Prevention efforts targeting hotspot communities and congregate settings may be effective in reducing community transmission. </sec>.

Comparative analyses of published cost effectiveness models highlight critical considerations which are useful to inform development of new models

Background: Comparative analyses of published cost effectiveness models provide useful insights into critical issues to inform the development of new cost effectiveness models in the same disease area.Objective: The purpose of this study was to describe a comparative analysis of cost-effectiveness models and highlight the importance of such work in informing development of new models. This research uses genotypic antiretroviral resistance testing after first line treatment failure for Human Immunodeficiency Virus (HIV) as an example.Method: A literature search was performed, and published cost effectiveness models were selected according to predetermined eligibility criteria. A comprehensive comparative analysis was undertaken for all aspects of the models.Results: Five published models were compared, and several critical issues were identified for consideration when developing a new model. These include the comparator, time horizon and scope of the model. In addition, the composite effect of drug resistance prevalence, antiretroviral therapy efficacy, test performance and the proportion of patients switching to second-line ART potentially have a measurable effect on model results. When considering CD4 count and viral load, dichotomizing patients according to higher cost and lower quality of life (AIDS) versus lower cost and higher quality of life (non-AIDS) status will potentially capture differences between resistance testing and other strategies, which could be confirmed by cross-validation/convergent validation. A quality adjusted life year is an essential outcome which should be explicitly explored in probabilistic sensitivity analysis, where possible.Conclusions: Using an example of GART for HIV, this study demonstrates comparative analysis of previously published cost effectiveness models yields critical information which can be used to inform the structure and specifications of new models.

Diagnostic accuracy and clinical role of rapid C-reactive protein testing in HIV-infected individuals with presumed tuberculosis in South Africa

OBJECTIVE

To determine the accuracy and role of rapid C-reactive protein (CRP) testing in human immunodeficiency virus (HIV) infected individuals with presumed tuberculosis (TB).

DESIGN

We enrolled HIV-infected adults (≥18 years)with a cough of ≥2 weeks and negative sputum smears for acid-fast bacilli in KwaZulu-Natal, South Africa. Participants were evaluated for pulmonary TB (PTB) by a nurse with rapid CRP, and independently by a physician by chest radiograph. Rapid CRP test results were compared with laboratory CRP and sputum sent for confirmation of TB.

RESULTS

Among 93 participants, 55 (59%) were female, the mean age was 35 years, and the median CD4 count was 177/mm3. Forty-five (54%) participants were diagnosed with PTB. Diagnostic sensitivity and specificity were respectively 95% (95%CI 74–99) and 51%(95%CI 35–66) for rapid CRP >8 mg/l, 87% (95%CI 73–96) and 53% (95%CI 38–68) for nurse assessment, and 69% (95%CI 52–83) and 76% (95%CI 61–87) for physician examination. Combining a negative rapid CRP(≤8 mg/l) with nurse and physician assessments reduced the post-test probability of PTB from 22% to 6% and from 32% to 6%, respectively.

CONCLUSION

Rapid CRP testing helped exclude PTB,and may be a valuable test in assisting nurses and physicians in TB-endemic regions.

Factors Associated with Symptomatic Vulvovaginal Candidiasis: A Study among Women Attending a Primary Healthcare Clinic in Kwazulu-Natal, South Africa

Background:

Symptomatic vulvovaginal candidiasis (VVC) is one of the most common problems leading women to seek advice in primary healthcare facilities.

Aim:

The aim of this study is to describe the associations between some hypothesized factors and the presence of symptomatic VVC.

Subjects and Methods:

An analytical cross-sectional study was conducted. A total of 90 women diagnosed with symptomatic VVC and 108 women without symptomatic VVC were recruited when attending Umlazi D clinic, a primary health clinic in KwaZulu-Natal, South Africa between June 2011 and December 2011. Confirmed symptomatic VVC was determined by Gram stain and microbiological culture of vaginal swabs. For human immunodeficiency virus (HIV)-infected women, HIV ribonucleic acid load in plasma and genital fluid was determined by real-time-polymerase chain reaction (BioMerieux, Lyon, France). CD4 counts were obtained from patients’ medical records. Data were analyzed using the statistical package for the social sciences (SPSS) version 21.0 (SPSS Inc.; Chicago, IL, USA). Multiple logistic regression models were used to exclude univariate confounders. All tests were two-sided and a P < 0.05 was considered to be significant.

Results:

A total of 90% (81/90) of patients with symptomatic VVC complained of vulval itching, soreness and vaginal discharge when compared to 75.9% (82/108) of patients without symptomatic VVC (P < 0.01). Whilst pregnancy was independently associated with symptomatic VVC (P < 0.01), the latter was inversely related to Nugent's scores (P < 0.01). When compared with HIV negative women, the odds for symptomatic VVC increased among women with HIV-associated immunocompromise (CD4 counts < 200 cells/mm³, P < 0.001), significantly shedding HIV in their genital tracts (P = 0.04), with plasma HIV load > 1000 copies/mL (P < 0.001). There was a significant negative association between the use of highly active anti-retroviral therapy and the presence of symptomatic VVC in HIV-infected women (P < 0.01).

Conclusion:

Although symptomatic VVC is not classified as acquired immunodeficiency syndrome-related condition, HIV-related immune compromised women and particularly those who are anti-retroviral therapy-naïve are likely to develop symptomatic VVC.

International spread of MDR TB from Tugela Ferry, South Africa

We describe a death associated with multidrug-resistant tuberculosis and HIV infection outside Africa that can be linked to Tugela Ferry (KwaZulu-Natal, South Africa), the town most closely associated with the regional epidemic of drug-resistant tuberculosis. This case underscores the international relevance of this regional epidemic, particularly among health care workers.

Nutritional content and a phase-I safety clinical trial of a herbal-nutritional supplement (IMUNITI) with putative immune-modulating properties

The relationship between HIV and AIDS and poor nutrition has been well established. Poor nutrition hastens the progression of HIV infection to AIDS. The rising pandemic of HIV and AIDS and high toxicity associated with anti-retroviral use are major factors that have compelled research to explore traditional herbal medicines as potential alternatives or supplements to anti-retroviral agents. A Phase I clinical trial was conducted on IMUNITI Wellness Pack, a herbal product with putative immune-modulating properties. The product is a combination of 7 herbal preparations, minerals, vitamins, and a specially formulated soya-maize meal porridge and a bottle of water purifier. The aim was to evaluate the safety and tolerability of IMUNITI, with a purpose of developing it for use in HIV-infected patients. The phase I study was conducted at the MRC clinic in Botha's hill and the study lasted 5 weeks from date of participant dosing. The study was a randomised blinded placebo-controlled phase I clinical trial conducted on 48 healthy males. The participants were randomly divided into 4 groups of 12. The 3 groups received different escalating doses of IMUNITI while the forth group received placebo tablets. Participants consumed IMUNITI daily for a period of 5 weeks. Assessments were done at baseline, week 1 and week 5 to determine the safety parameters in all participants. In this study, IMUNITI did not show any safety concerns. In all study participants, there were no significant changes above the upper limit of the reference ranges of the laboratory tests for full blood count, INR, renal and biochemical safety parameters. IMUNITI was well tolerated. Furthermore, the nutritional content analysis of IMUNITI showed that it is a high kilojoule, high protein content product which contains a mixture of sugars, vitamins, traces of calcium, phosphorus and minerals.

A retrospective review of brachial artery injuries and repairs--is it still a "training artery"?

BACKGROUND

A retrospective analysis of operatively managed brachial artery injuries spanning a five-year period from January 2003 to December 2007.

METHODS

The medical records of all patients who had operative management of brachial artery injuries were reviewed. Demographic data, mechanism of injury, pathology of injury, associated injuries, duration of injury, operative management and outcomes were analysed.

RESULTS

A total of 115 patients were included in the review. Twelve patients (10.4%) were female and 103 (89.6%) were male. The mean age was 27.3 years with the oldest patient being 70 years and the youngest 13 years. Most of the injuries were caused by stabs to the brachial artery (53%). 33% were due to gunshot wounds, 11.3% were due to blunt trauma and 2.9% were due to other mechanisms of injury. The majority of injuries (58.3%) were repaired with a reverse saphenous vein graft. Most patients had a pulse restored on discharge with only 4.4% of repairs occluding and of the repairs that occluded only one patient needed an ablation. Four patients (3.5%) had an ablation due to a non-viable limb. 13.9% of patients had a fasciotomy, 54.8% had an associated peripheral nerve injury and 14.8% had an associated venous injury.

CONCLUSION

Brachial artery injuries are still common in our practice, with most being managed operatively. Due to the good collateral circulation in the arm, most brachial artery injuries do not result in limb loss even with a significant time delay and even when the repair occludes. Brachial artery injuries are thus a good vessel for surgical registrars to train on.

Low effectiveness of syndromic treatment services for curable sexually transmitted infections in rural South Africa

Objectives:

Syndromic sexually transmitted infection (STI) treatment remains a cost-saving HIV prevention intervention in many countries in Africa. We estimate the effectiveness of syndromic treatment for curable STIs in rural KwaZulu-Natal, South Africa, and the trend in STI prevalences before and after the introduction of syndromic treatment in 1995.

Methods:

Data were available from various clinical studies, surveys of public and private health providers, the general population and women attending antenatal, family planning and child immunisation clinics in rural northern KwaZulu-Natal between 1987 and 2004. Overall effectiveness was defined as the estimated proportion of the annual number of symptomatic curable STI episodes cured by syndromic treatment based on separate estimates for six curable STI aetiologies by gender.

Results:

Median overall effectiveness was 13.1% (95% CI 8.9 to 17.8%) of symptomatic curable STI episodes cured. Effectiveness increased to 25.0% (95% CI 17.3 to 33.8%), 47.6% (95% CI 44.5 to 50.8%) or 14.3% (95% CI 9.9 to 19.4%) if 100% treatment seeking, 100% correct treatment provision or 100% cure were assumed, respectively. Time-trends were difficult to assess formally but there was little evidence of decreasing STI prevalences. Including incurable but treatable herpes simplex virus (HSV)-2 ulcers in the effectiveness calculation would halve the proportion of ulcers cured or correctly treated, but this reduction could be entirely countered by including episodic antiviral treatment in the national guidelines.

Conclusion:

Overall effectiveness of syndromic treatment for curable STIs in rural KwaZulu-Natal remains low and there is little evidence of reduced curable STI prevalences. As syndromic treatment is likely to be a cost-saving HIV prevention intervention in South Africa, innovative strategies are urgently needed to increase rates of treatment seeking and correct treatment provision.

High-risk sexual behaviour in men attending a sexually transmitted infection clinic in Durban, South Africa

OBJECTIVES

A study of men with genital ulcer disease (GUD) in Durban, South Africa, at the start of the local HIV epidemic in 1988/1989 found that 36% of men with GUD continued with sexual intercourse despite symptoms. The aim of this study was to determine whether this high-risk behaviour was still prevalent and to enquire about similar risk behaviours with other sexually transmitted infection (STI)-related problems.

METHODS

650 Men attending the main Durban STI clinic with a new complaint were enrolled. A standard questionnaire was administered. Polymerase chain reaction (PCR) tests were performed to diagnose genital herpes from ulcer specimens and gonorrhoea and chlamydia from those with urethral discharge and/or dysuria. Serology tests were performed for HIV, herpes simplex virus type 2 (HSV-2) and syphilis.

RESULTS

Sex since the start of symptoms was reported by between 33.3% and 43.9% of men with GUD, herpetic ulcers, gonorrhoea and/or chlamydia or dysuria. The incidence of condom use was very low in all groups having sex despite symptoms. In 87 men with genital ulcers confirmed positive for genital herpes by PCR testing, 30 (34.4%) had had sex since the start of symptoms, 28 (93.3%) of whom had had unprotected sex.

CONCLUSIONS

There is a high level of risk behaviour in this group of men in whom genital herpes is the most common cause of GUD. This risky sexual behaviour could reflect disinhibition, possibly because so many have already been infected with HSV-2, lack of education or other unknown factors. Syndromic STI management should be strengthened with intensive health education to promote community awareness of both genital ulceration and genital herpes and their role in facilitating HIV transmission. The low level of condom use indicates that condom promotion programmes still have much to achieve.

CTX-M-37 in Salmonella enterica serotype Isangi from Durban, South Africa

Beta-lactamase-mediated resistance was investigated in 59 putative extended-spectrum beta-lactamase (ESBL)-positive Salmonella spp. from the paediatric ward of a tertiary hospital in Durban, South Africa. Three Salmonella enterica serotype Isangi cultured from stool samples were multidrug resistant, with susceptibility only to meropenem, piperacillin/tazobactam and cefoxitin. Isoelectric focusing revealed beta-lactamases with isoelectric points of pI 5.8, 6.8 and 7.2. Sequencing identified beta-lactamases CTX-M-37 and TEM-1. To our knowledge, this is the first report of CTX-M-37 from S. enterica serotype Isangi in South Africa.

Aetiology of male urethritis in patients recruited from a population with a high HIV prevalence

The aetiology of urethritis, the significance of potential pathogens and the relation of urethritis to HIV infection were determined in 335 men (cases) with and 100 men (controls) without urethral symptoms. Urethral swab specimens were tested for different organisms by PCR or by culture for Neisseria gonorrhoeae. The prevalence of N. gonorrhoeae and Chlamydia trachomatis was 52 and 16%, respectively. The potential pathogens: Mycoplasma genitalium, Ureaplasma urealyticum, Trichomonas vaginalis and herpes simplex virus (HSV), were present in 5, 36, 6 and 6% of the cases respectively. M. genitalium was the only potential pathogen associated with microscopic urethritis. After excluding gonococcal infections, U. urealyticum was more frequent in symptomatic patients, while the prevalence of T. vaginalis was similar among cases and controls. These results strongly suggest an a etiological role for M. genitalium in male urethritis, a possible role for U. urealyticum, but not for T. vaginalis. The control group, with 97% genital ulcer disease patients, was not suitable for the investigation of the role of HSV. The sero-prevalence of HIV was 45%. Current infections were not associated with HIV. However, a history of previous urethral discharge was associated with HIV in a multivariate analysis and supported the hypothesis that non-ulcerative sexually transmitted diseases facilitate HIV transmission.

Quality of Life in Patients Treated with First-Line Antiretroviral Therapy Containing Nevirapine And/Or Efavirenz

Objective

To assess whether differences in safety profiles between nevirapine (NVP) and efavirenz (EFV), as observed in the 2NN study, translated into differences in ‘health related quality of life’ (HRQoL).

Design

A sub-study of the 2NN study, with antiretro-viral-naive patients randomly allocated to NVP (once or twice daily), EFV or NVP+EFV, in addition to stavudine and lamivudine.

Methods

Comparing differences in changes of HRQoL over 48 weeks as measured with the Medical Outcomes Study HIV Health Survey (MOS-HIV) questionnaire, using analysis of variance.

Results

The 2NN study enrolled 1216 patients. No validated questionnaires were available for 244 patients, and 55 patients had no HRQoL data at all, leaving 917 patients eligible for this sub-study. A total of 471 (51%) had HRQoL measurements both at baseline and week 48. The majority (69%) of patients without HRQoL measurements did, however, complete the study. The change in the physical health score (PHS) was 3.9 for NVP, 3.4 for EFV and 2.4 for NVP+EFV ( P=0.712). For the mental health score (MHS) these values were 6.1, 7.0 and 3.9, respectively ( P=0.098). A baseline plasma HIV-1 RNA concentration (pVL) ≥100 000 copies/ml and a decline in pVL (per log10) were independently associated with an increase of PHS. An increase of MHS was only associated with pVL decline. Patients experiencing an adverse event during follow-up had a comparable change in PHS but a significantly smaller change in MHS, compared with those without an adverse event.

Conclusions

First-line ART containing NVP and/or EFV leads to an improvement in HRQoL. The gain in HRQoL was similar for NVP and EFV, but slightly lower for the combination of these drugs.

Identification of women at high STD risk among STD clinic attendees: implications for STD programmes

We showed an association between current infection with a recognized sexually transmitted infection (STI) pathogen and HIV infection in women but not in men with non-ulcerative genital disease. While the accuracy of recognition of male urethritis and genital ulcer syndromes is high, this is significantly less for non-ulcerative STIs in women. The symptoms associated with the latter have a broad differential diagnosis including conditions of a non-STI nature. Local sexually transmitted disease (STD) clinic attendees often comprise patients with and without STIs. We hypothesized that this may be responsible for the association of current STI pathogens and HIV in women. To identify a group of women that would be representative of a true STD clinic population we looked at those with a past history of treated genital ulcers. When we analysed in this subset the association of current STI pathogen and HIV infection, a pattern emerged that was comparable with that in men.

Diagnosis of bacterial vaginosis on self-collected vaginal tampon specimens

A vaginal tampon specimen was previously shown to be suitable for the molecular diagnosis of non-ulcerative sexually transmitted infections (STIs). Different tampon fluid preparations were evaluated for the diagnosis of bacterial vaginosis (BV). Women with pregnancy related problems were enrolled. Two observers evaluated the different tampon fluid preparations and vaginal smears collected during speculum examination using the Nugent score. Using the Amsel criteria, 21% of the 84 women enrolled were diagnosed with BV. Results of the tampon fluid preparations and vaginal smears showed excellent agreement for both observers (Spearman >0.80). The overall sensitivity and specificity was 91.7% (95% CI: 81.6-96.5) and 79.3% (95% CI: 67.2-87.8), respectively, using the Amsel criteria as reference standard. The tampon provides a specimen for the combined diagnosis of non-ulcerative STIs and BV. This non-invasively collected specimen may facilitate self-initiated testing and population-based studies as well as longitudinal studies that are necessary to gain insight in the epidemiology of BV related to STIs and HIV.

Evolution in the trends of antimicrobial resistance in Neisseria gonorrhoeae isolated in Durban over a 5 year period: impact of the introduction of syndromic management

Antimicrobial susceptibility testing was performed on isolates of Neisseria gonorrhoeae obtained from patients attending the City Health STD clinic in Durban, KwaZuluNatal, using the following drugs: penicillin, tetracycline, ciprofloxacin, ofloxacin, ceftriaxone, spectinomycin, erythromycin and azithromycin. These isolates were collected over a 6 year period from 1995 to 2000. Four hundred and fifteen strains were tested: 61 in 1995, 198 in 1997, 98 in 1998/99 and 58 in 1999/2000. A shift to the right is observed in the susceptibilities of N. gonorrhoeae to the currently recommended drugs in the syndromic management guidelines viz. penicillin, tetracycline, ceftriaxone, ciprofloxacin, spectinomycin and erythromycin. The prevalence of penicillinase-producing N. gonorrhoeae is currently c. 30%, whereas that of plasmid-mediated tetracycline-resistant N. gonorrhoeae is c. 50%. There is a definite association between the MICs of strains falling within the penicillin and tetracycline chromosomally resistant group, and strains exhibiting a decreased susceptibility to ciprofloxacin and ceftriaxone. The MICs of azithromycin showed a similar distribution when compared with erythromycin for 1999/2000 isolates. We postulate that the presence of efflux pumps might play a role in the increasing MICs that we observe among structurally unrelated groups of drugs. Furthermore, widespread use of these antimicrobials in the community may offer a selective advantage to the development of resistance. The implications of this are far reaching and the local susceptibility trends of N. gonorrhoeae need to be monitored constantly to direct therapy.

Sexually transmitted infections, adverse pregnancy outcome and neonatal infection

Prevention and treatment of sexually transmitted infections (STIs) in the sexually active population are the main steps to prevent perinatal infection. However, the spread of STIs continues at an astronomical pace despite various attempts at controlling the epidemic. An important reason for this lack of STI control is that a large percentage of infected people go untreated because they have asymptomatic or unrecognized infections. The microbial differential diagnosis of STIs implicated in adverse pregnancy outcome is broad and includes viral, bacterial and protozoal infections. Infertility, ectopic pregnancy, pelvic inflammatory disease, chorioamnionitis, premature rupture of membranes, preterm birth and puerperal sepsis are some of complications seen in women as a result of infection with sexually transmitted pathogens. In addition, STIs may facilitate the acquisition and transmission of HIV. In the fetus or neonate, complications include abnormalities of the major organ systems. Infections in the form of pneumonia or conjunctivitis may also occur. Due to the lack of simple, inexpensive and sensitive point-of-care tests, screening for STIs in pregnancy is not performed routinely.

Does HIV status influence the outcome of patients admitted to a surgical intensive care unit? A prospective double blind study

OBJECTIVES

(a) To assess the impact of HIV status (HIV negative, HIV positive, AIDS) on the outcome of patients admitted to intensive care units for diseases unrelated to HIV; (b) to decide whether a positive test result for HIV should be a criterion for excluding patients from intensive care for diseases unrelated to HIV.

DESIGN

A prospective double blind study of all admissions over six months. HIV status was determined in all patients by enzyme linked immunosorbent assay (ELISA), immunofluorescence assay, western blotting, and flow cytometry. The ethics committee considered the clinical implications of the study important enough to waive patients' right to informed consent. Staff and patients were blinded to HIV results. On discharge patients could be advised of their HIV status if they wished.

SETTING

A 16 bed surgical intensive care unit.

SUBJECTS

All 267 men and 135 women admitted to the unit during the study period.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

APACHE II score (acute physiological, age, and chronic health evaluation), organ failure, septic shock, durations of intensive care unit and hospital stay, and intensive care unit and hospital mortality.

RESULTS

No patient had AIDS. 52 patients were tested positive for HIV and 350 patients were tested negative. The two groups were similar in sex distribution but differed significantly in age, incidence of organ failure (37 (71%) v 171 (49%) patients), and incidence of septic shock (20 (38%) v 54 (15%)). After adjustment for age there were no differences in intensive care unit or hospital mortality or in the durations of stay in the intensive care unit or hospital.

CONCLUSIONS

Morbidity was higher in HIV positive patients but there was no difference in mortality. In this patient population a positive HIV test result should not be a criterion for excluding a patient from intensive care.

Bacterial vaginosis and associated infections in pregnancy

OBJECTIVE

To assess the role of bacterial vaginosis (BV) on pregnancy complications in a developing community where mixed cervico-vaginal infections are common.

SETTING

The antenatal clinic at King Edward VIII Hospital (KEH), Durban, South Africa, which is a large urban tertiary hospital serving mainly a Black underprivileged population of KwaZulu/Natal.

METHODS

Asymptomatic pregnant women < or = 30 weeks gestation were recruited at their first antenatal visit. Clinical data including the sexual history were recorded. Swab specimens were collected from the vagina and endocervix for diagnosing BV, trichomoniasis, candidiasis, gonorrhea and chlamydial infection. Venous blood specimens were tested for antibody to syphilis and human immunodeficiency virus (HIV). All women continued standard antenatal care and hospital records were reviewed following delivery to evaluate pregnancy outcome.

RESULTS

BV was found in 52% of the women studied and was the commonest infection diagnosed. Mixed vaginal infections of BV and trichomoniasis were diagnosed in 14%. Only 29% of asymptomatic women did not have any microbiological evidence of a lower genital tract infection. A total of 46% of women studied had poor pregnancy outcome as measured by obstetrical complications, pregnancy loss and/or neonatal morbidity. There was a significant difference in outcome in women with BV (55 of 88) compared to those having infections other than BV (13 of 31), or no infection (5 of 9)-P = 0.005. This difference was for obstetrical complications of preterm delivery, premature rupture of membranes and intrauterine infection, but not for pregnancy losses and neonatal morbidity.

CONCLUSIONS

The high prevalence of BV and concomitant lower genital tract infections among asymptomatic pregnant women and the resultant adverse pregnancy outcome associated with BV, confirms reports from developed countries of the need for screening for BV at the initial antenatal clinic visit. Whether pregnancy outcome was worse in the presence of BV and other infections than BV alone could not be determined. Future studies with appropriate interventions are needed to evaluate the unique problems of developing countries.

Perception of problems in psychiatric inpatients: denial, race and service usage

The importance of the ways in which people with psychiatric problems construe their difficulties is considered in this study. A study of 60 consecutive acute admissions to wards serving an inner city area in London (UK) is reported. The results indicated that 55.8% of the sample did not consider themselves to have psychiatric problems: 15.4% said that they had no problems at all and 40.4% thought they had physical or social problems rather than psychiatric ones. Although more younger people denied that they had problems and none of those who denied having problems sought the help of a general practitioner, there was a significant association between diagnosis and perception of problems, and when this was taken into account these associations disappeared. Of those who denied having any problems, only one person had no police involvement on admission. Significantly more of those who denied problems were compulsorily admitted and there were significant differences in the proportions of whites and African-Caribbeans reporting different types of problems. African-Caribbeans were both more likely to consider that they had no problems at all and to be compulsorily admitted. Although African-Caribbeans were also more likely to be diagnosed as experiencing psychotic disorders, it was their ethnic status rather than their diagnostic category that determined both their status on admission and the way in which they construed their problems. Denial among whites tended to take the form of somatisation or construction of problems in terms of social difficulties.

Computed axial brain tomograms in long-term benzodiazepine users

Computed axial brain tomograms were recorded in four groups of subjects: (a) subjects who had never taken benzodiazepines (n = 25); (b) subjects who had taken them in the past for less than a year (n = 9); (c) patients currently taking benzodiazepines (n = 30); and (d) patients who had taken benzodiazepines in the past for at least a year and who had been withdrawn from medication for at least 6 months (n = 17). Ventricle-to-brain ratios and tissue absorption to X-rays were computed. No overall differences were found between the main groups. However, a few brain regions differed in density between nonusers and heavy users, particularly those taking lorazepam.

Psychotropic medication and ethnicity: an inpatient survey

A survey of the catchment area psychiatric inpatient population of the Bethlem and Maudsley Hospitals showed that more black (Afro Caribbean) than non-black (white British) patients received anti-psychotic medication. This finding ceased to be significant after adjustment for diagnosis because a larger proportion of black than non black patients received a diagnosis of schizophrenia. However, after adjustment for diagnosis, black patients were significantly more likely to be receiving depot anti-psychotic medication, to be detained under a section and to have been involved in a violent incident during the present admission. There were no significant ethnic differences in total dose equivalents of anti-psychotic medication but doses of the depot form were significantly higher for black patients.

Routes to psychiatric inpatient care in an Inner London Borough

A study is reported in which pathways to psychiatric inpatient care were investigated in an Inner London Borough. Data were collected on a series of 52 consecutive admissions of adults to the psychiatric wards serving the area. The most striking feature of the results was the variety of routes taken to inpatient care, combined with a high level of police involvement (23.1% of admissions) and low level of referral from General Practitioners (15.4% of admissions). Significant age differences in routes to care were found: those under 30 years were usually brought to hospital by the police or presented directly to psychiatric emergency services; those over 30 typically came via medical/surgical hospital services, domiciliary psychiatric services or psychiatric outpatients. There were no differences in the routes taken by Afro-Caribbean and white people or by men and women. Higher proportions of Afro-Caribbeans received a diagnosis of schizophrenia, considered themselves to have nothing wrong with them and were compulsorily detained. Higher proportions of whites were diagnosed as depressed and considered themselves to have physical problems rather than psychiatric ones. However, results clearly indicated that it was ethnic status rather than diagnostic category that accounted for the higher rates of compulsory detention of Afro-Caribbean people. The implications of the findings for service development and delivery are considered.

Failure of clonidine treatment in benzodiazepine withdrawal

Six subjects, dependent on benzodiazepines for at least 2 years, were gradually withdrawn, using placebo substitution, while taking clonidine. After withdrawal was complete, subjects were switched to clonidine-placebo. Despite administration of clonidine at doses sufficient to produce a fall in blood pressure, an abstinence syndrome was seen in five of the subjects. In none of these cases was the withdrawal syndrome exacerbated by changing from clonidine to clonidine-placebo. Scores of depression, subjective anxiety, observed anxiety and somatic symptoms did not change throughout the study.

Mesenchymal hamartoma of the liver. A report of 5 cases

Mesenchymal hamartoma of the liver is a rare benign tumour of childhood, characterised by an admixture of ductal structures within a copious loose connective tissue stroma. Less consistent features include hepatocytes and haemopoietic elements. The stroma has a propensity to accumulate fluid and to create macroscopic cystic spaces. Five cases are reported.

Delusional depression following benzodiazepine withdrawal

Withdrawal from long-term treatment with benzodiazepines was followed in three patients by a severe delusional depression. The delusional depression may be related to the neurotransmitter changes accompanying benzodiazepine withdrawal. Caution should be exercised in long-term use of benzodiazepines in susceptible individuals.

Cognitive impairment in long-term benzodiazepine users

In view of the very extensive and often prolonged use of benzodiazepines in therapeutic practice, this study was designed to investigate whether or not cognitive ability is impaired in long-term benzodiazepine users, and to determine the nature and extent of any deficit. Fifty patients currently taking benzodiazepines for at least one year, thirty-four who had stopped taking benzodiazepines, and a matched control group of subjects who had never taken benzodiazepines or who had taken benzodiazepines in the past for less than one year were administered a battery of neuropsychological tests designed to measure a wide range of cognitive functions. It was found that patients taking high doses of benzodiazepines for long periods of time perform poorly on tasks involving visual-spatial ability and sustained attention. This is consistent with deficits in posterior cortical cognitive function.

Management of benzodiazepine dependence

Dependence is a recognized problem in a significant number of patients taking therapeutic doses of benzodiazepines. A characteristic withdrawal syndrome has been described. These patients are best managed as outpatients with gradual dosage reduction over 4-12 weeks. Pharmacological adjuncts such as propranolol and non-benzodiazepine hypnotics are useful for certain specific symptoms, but so far no single substance has proved useful in attenuating the majority of symptoms. Psychological and social support should be maximized, but here again no single technique has been shown to be more than moderately successful. The best treatment is thoughtful prescribing ab initio.

Effects of clorazepate dipotassium and placebo on psychomotor skills

24 normal, healthy subjects were assigned randomly to 15 mg clorazepate dipotassium or placebo groups in a double-blind study. Their performance on a psychological test battery was assessed 45 min. later. Clorazepate dipotassium produced statistically significant impairment in attention and simple reaction time compared with placebo. Performance on more complex tests of cognitive functioning showed no drug effects.