Basic and comprehensive emergency obstetric and neonatal care in 12 South African health districts

Aim. To assess the functionality of healthcare facilities with respect to providing the signal functions of basic and comprehensive emergency obstetric care in 12 districts.Setting. Twelve districts were selected from the 52 districts in South Africa, based on the number of maternal deaths, the institutional maternal mortality ratio and the stillbirth rate for the district.Methods. All community health centres (CHCs) and district, regional and tertiary hospitals were visited and detailed information was obtained on the ability of the facility to perform the basic (BEmONC) and comprehensive (CEmONC) emergency obstetric and neonatal care signal functions.Results. Fifty-three CHCs, 63 district hospitals (DHs), 13 regional hospitals and 4 tertiary hospitals were assessed. None of the CHCs could perform all seven BEmONC signal functions; the majority could not give parenteral antibiotics (68%), perform manual removal of the placenta (58%), do an assisted delivery (98%) or perform manual vacuum aspiration of the uterus in a woman with an uncomplicated incomplete miscarriage (96%). Seventeen per cent of CHCs could not bag-and-mask ventilate a neonate. Less than half (48%) of the DHs could perform all nine CEmONC signal functions (81% could perform eight of the nine functions), 24% could not perform caesarean sections, and 30% could not perform assisted deliveries.Conclusions. The ability of the CHCs and district hospitals to perform the signal functions (lifesaving services) of basic and comprehensive emergency obstetric care was poor in many of the districts studied. This implies that safe maternity care was not consistently available at many facilities conducting births

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose: Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods: Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results: The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion: We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes

Barriers to Male-Partner Participation in Programs to Prevent Mother-to-Child HIV Transmission in South Africa

Efforts to prevent mother-to-child HIV transmission (PMTCT) in sub- Saharan Africa have focused overwhelmingly on women, to the unintended exclusion of their male partners. A cross-sectional study was conducted in Tshwane, South Africa, to determine barriers to male-partner participation during PMTCT. In-depth interviews were conducted with 124 men whose partners had recently been pregnant, and five focus group discussions were held with physicians, nurses, HIV counselors, and community representatives. Qualitative analysis revealed that while most fathers believed that HIV testing is an important part of preparing for fatherhood, there are formidable structural and psychosocial barriers: the perception of clinics as not “male-friendly,” a narrow focus on HIV testing instead of general wellness, and a lack of expectations and opportunities for fathers to participate in health care. Coupled with more family-oriented approaches to PMTCT, measurable improvements in the way that male partners are invited to and engaged in HIV prevention during pregnancy can help PMTCT programs to achieve their full potential.http://www.guilford.comhb201

Barriers to early prenatal care in South Africa

OBJECTIVE : To understand the barriers delaying early prenatal care for women in South Africa. METHODS : Amixedmethods study was conducted at a center in Pretoria. RESULTS : Following interviews with 21women at a prenatal clinic in Pretoria, a quantitative survey was completed by 204 postpartum women. During interviews, women described presenting late owing to contemplating induced abortion, fear of HIV testing, and fear of jealousy and bewitching. The survey results demonstrated that a majority of women (133 [65.2%]) reported knowledge of recommendations to present before 12 weeks; however, the average gestational age at initial presentation was 19.1 ± 7.7 weeks. Women were more likely to present earlier if the pregnancy was planned (P = 0.013) and were less likely to if they had at any point contemplated induced abortion (P=0.021). Fears of bewitching and harmful psychological stress owing to a positive HIV test result prevailed in both the interviews and the surveys. CONCLUSION : Significant efforts should be devoted to improving access to contraception and prepregnancy counseling in order to improve early prenatal care attendance. Similarly, addressing cultural concerns and fears regarding pregnancy is imperative in promoting early attendance.In part by the Doris Duke Charitable Foundation through a grant supporting the Doris Duke International Clinical Research Fellows Program at Yale University.http://www.elsevier.com/locate/ijgo2017-01-30hb201

Factors Affecting Disclosure in South African HIV-Positive Pregnant Women

To provide understanding of social and psychological factors that affect disclosure of HIV status among women diagnosed HIV-positive in pregnancy, 438 HIV positive women attending antenatal clinics in Pretoria, South Africa were invited to participate in a longitudinal study. A total of 293 (62%) women were enrolled from June 2003 to December 2004. Questionnaires assessing sociodemographics and psychological measures were administered during pregnancy and at 3 months postdelivery. At enrollment, 59% had disclosed to their partners and 42% to others. This rose to 67% and 59%, respectively, by follow-up. Logistic regression analysis identified being married (adjusted odds Ratio [AOR] 2.32; 95% confidence interval [CI] 1.20–4.47), prior discussion about testing (AOR 4.19; CI 2.34–7.49), having a partner with tertiary education (AOR 2.76; CI 1.29–5.88) and less experience of violence (AOR 0.48; CI 0.24–0.97) as factors associated with having disclosed to partners prior to enrollment. Better housing (AOR 1.26; CI 1.06–1.49), less financial dependence on partners (AOR 0.46; CI 0.25–0.85), and knowing someone with HIV (AOR 2.13; CI 1.20–3.76) were associated with prior disclosure to others. Increased levels of stigma at baseline decreased the likelihood of disclosure to partners postenrollment (AOR 0.91; CI 0.84–0.98) and increased levels of avoidant coping decreased subsequent disclosure to others (AOR 0.84; CI 0.72–0.97). These results provide understanding of disclosure for women diagnosed as HIV positive in pregnancy, and identify variables that could be used to screen for women who require help

Bevacizumab, Irinotecan, or Topotecan Added to Temozolomide for Children With Relapsed and Refractory Neuroblastoma: Results of the ITCC-SIOPEN BEACON-Neuroblastoma Trial.

PURPOSE Outcomes for children with relapsed and refractory high-risk neuroblastoma (RR-HRNB) remain dismal. The BEACON Neuroblastoma trial (EudraCT 2012-000072-42) evaluated three backbone chemotherapy regimens and the addition of the antiangiogenic agent bevacizumab (B). MATERIALS AND METHODS Patients age 1-21 years with RR-HRNB with adequate organ function and performance status were randomly assigned in a 3 × 2 factorial design to temozolomide (T), irinotecan-temozolomide (IT), or topotecan-temozolomide (TTo) with or without B. The primary end point was best overall response (complete or partial) rate (ORR) during the first six courses, by RECIST or International Neuroblastoma Response Criteria for patients with measurable or evaluable disease, respectively. Safety, progression-free survival (PFS), and overall survival (OS) time were secondary end points. RESULTS One hundred sixty patients with RR-HRNB were included. For B random assignment (n = 160), the ORR was 26% (95% CI, 17 to 37) with B and 18% (95% CI, 10 to 28) without B (risk ratio [RR], 1.52 [95% CI, 0.83 to 2.77]; P = .17). Adjusted hazard ratio for PFS and OS were 0.89 (95% CI, 0.63 to 1.27) and 1.01 (95% CI, 0.70 to 1.45), respectively. For irinotecan ([I]; n = 121) and topotecan (n = 60) random assignments, RRs for ORR were 0.94 and 1.22, respectively. A potential interaction between I and B was identified. For patients in the bevacizumab-irinotecan-temozolomide (BIT) arm, the ORR was 23% (95% CI, 10 to 42), and the 1-year PFS estimate was 0.67 (95% CI, 0.47 to 0.80). CONCLUSION The addition of B met protocol-defined success criteria for ORR and appeared to improve PFS. Within this phase II trial, BIT showed signals of antitumor activity with acceptable tolerability. Future trials will confirm these results in the chemoimmunotherapy era

Growing research in geriatric medicine

Academic geriatric medicine activity lags behind the scale of clinical activity in the specialty. A meeting of UK academic geriatricians was convened in March 2018 to consider causes and solutions to this problem. The meeting highlighted a lack of research-active clinicians, a perception that research is not central to the practice of geriatric medicine and a failure to translate discovery science to clinical studies. Solutions proposed included better support for early-career clinical researchers, schemes to encourage non-University clinicians to be research-active, wider collaboration with organ specialists to broaden the funding envelope, and the need to co-produce research programmes with end-users. Solutions to grow academic geriatric medicine are essential if we are to provide the best care for the growing older population