Predictors of Impaired Glucose Regulation in Patients with Non-Alcoholic Fatty Liver Disease

Introduction. Many patients with non-alcoholic fatty liver disease (NAFLD) have impaired glucose regulation or type 2 diabetes mellitus (DM). We investigated characteristics of NAFLD patients associated with hyperglycemia. Methods. During a 2-hour oral glucose tolerance test (OGTT), serum glucose and insulin were measured in 152 NAFLD patients. Results. 48.7% of NAFLD patients had hyperglycemia. Age (odds ratio (OR) = 1.08, 95% confidence interval (CI): 1.03–1.13), body mass index (BMI) (OR = 1.12, 95% CI: 1.01–1.25), and lower high-density lipoprotein cholesterol (HDL-C) (OR = 0.95, 95% CI: 0.92–0.98) proved to be independent predictors of hyperglycemia. After OGTT, 30 min insulin was lower in hyperglycemic patients (74.2 ± 49.7 versus 94.5 ± 53.9 μIU/mL, P = 0.02), while 90 min insulin (170.1 ± 84.6 versus 122.9 ± 97.7 μU/mL, P = 0.01) and 120 min insulin (164.0 ± 101.2 versus 85.3 ± 61.9 μIU/mL, P < 0.01) were higher. Conclusions. NAFLD patients with higher BMI, lower HDL-C, or older age were more likely to have impaired glucose metabolism. An OGTT could be of value for early diagnosis of DM among this population

Etiology of Anemia in Patients With Advanced Heart Failure

ObjectivesWe prospectively investigated the causes of anemia in patients with advanced congestive heart failure (CHF).BackgroundAnemia is common in patients with advanced CHF, and its etiology is generally considered to be multifactorial. However, despite its importance, precise information is lacking regarding the prevalence of putative etiologic factors.MethodsPatients who were hospitalized for decompensated advanced CHF and who were stabilized after their initial treatment underwent evaluation of “clinically significant” anemia, defined as a hemoglobin content <12 g/dl for men and <11.5 g/dl for women. Patients with a serum creatinine concentration >3 mg/dl or patients with concurrent diseases that are known to cause anemia were not included. The initial evaluation included measurements of vitamin B12, folic acid, thyroid-stimulating hormone, erythropoietin, lactate dehydrogenase, Coombs test, multiple fecal occult tests, and bone marrow aspiration. Patients without diagnosis by these methods underwent red cell mass measurement with 51Cr assay.ResultsThe mean age of the 37 patients was 57.9 ± 10.9 years and mean left ventricular ejection fraction 22.5 ± 5.9%. Iron deficiency anemia was confirmed by bone marrow aspiration in 27 patients (73%), 2 patients (5.4%) had dilutional anemia, and 1 patient (2.7%) had drug-induced anemia. No specific cause was identified in 7 patients (18.9%) who were considered to have “anemia of chronic disease.” Serum ferritin for the iron-deficient patients was not a reliable marker of iron deficiency in this population.ConclusionsIn this group of patients, iron deficiency was the most common cause of anemia. The iron status of patients with end-stage chronic CHF should be thoroughly evaluated and corrected before considering other therapeutic interventions

Short epidemiological overview of the current situation on COVID-19 pandemic in Southeast European (SEE) countries

We are living in times where a viral disease has brought normal life in much of the world to a halt. The novel coronavirus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing coronavirus disease 2019 (COVID-19) started in December 2019 in Wuhan, China initially and in a short time crossed the European borders. After mitigating the epidemic in China, Italy became one of the most COVID-19 affected countries worldwide. International travelers are important sources of infectious diseases and a possible source of epidemic. Due to its political, geographic, and cultural similarities, Italy is one of the main economic partners of Southeast European (SEE) countries. Our data show that infection in index cases in all 11 SEE countries was travel-related with Italy being a source country for 8/11 countries. After the first case identifications on February 25, the number of cases in SEE countries is continually rising reaching the total number of 15,612 with 565 fatal cases and overall case fatality ratio (CFR) of 3.6 (median 3.8, range 0.8–5.5) by April 10, 2020. At a time when the COVID-19 pandemic is approaching its peak, apart from the problems with treatment of the disease and care for critically ill patients, there are other equally important problems, such as organization of outbreak response, provision of health care, lack of hospital personnel, disruption of personal protective equipment supply chains and health care workers (HCWs) protection. But what is more important is the heroic behavior of the HCWs who are showing their humanity by disregarding their lives

Temporal Trends in the Impact Factor of European versus USA Biomedical Journals

BACKGROUND: The impact factors of biomedical journals tend to rise over time. We sought to assess the trend in the impact factor, during the past decade, of journals published on behalf of United States (US) and European scientific societies, in four select biomedical subject categories (Biology, Cell Biology, Critical Care Medicine, and Infectious Diseases). METHODS: We identified all journals included in the above-mentioned subject categories of Thomson Reuters Journal Citation Reports® for the years 1999, 2002, 2005, and 2008. We selected those that were published on behalf of US or European scientific societies, as documented in journal websites. RESULTS: We included 167 journals (35 in the subject category of Biology, 79 in Cell Biology, 27 in Critical Care Medicine, and 26 in Infectious Diseases). Between 1999 and 2008, the percentage increase in the impact factor of the European journals was higher than for the US journals (73.7±110.0% compared with 39.7±70.0%, p = 0.049). Regarding specific subject categories, the percentage change in the factor of the European journals tended to be higher than the respective US journals for Cell Biology (61.7% versus 16.3%), Critical Care Medicine (212.4% versus 65.4%), Infectious Diseases (88.3% versus 48.7%), whereas the opposite was observed for journals in Biology (41.0% versus 62.5%). CONCLUSION: Journals published on behalf of European scientific societies, in select biomedical fields, may tend to close the "gap" in impact factor compared with those of US societies. WHAT'S ALREADY KNOWN ABOUT THIS TOPIC?: The impact factors of biomedical journals tend to rise through years. The leading positions in productivity in biomedical research are held by developed countries, including those from North America and Western Europe. WHAT DOES THIS ARTICLE ADD?: The journals from European biomedical scientific societies tended, over the past decade, to increase their impact factor more than the respective US journals

Age Distribution of Cases of 2009 (H1N1) Pandemic Influenza in Comparison with Seasonal Influenza

INTRODUCTION: Several aspects of the epidemiology of 2009 (H1N1) pandemic influenza have not been accurately determined. We sought to study whether the age distribution of cases differs in comparison with seasonal influenza. METHODS: We searched for official, publicly available data through the internet from different countries worldwide on the age distribution of cases of influenza during the 2009 (H1N1) pandemic influenza period and most recent seasonal influenza periods. Data had to be recorded through the same surveillance system for both compared periods. RESULTS: For 2009 pandemic influenza versus recent influenza seasons, in USA, visits for influenza-like illness to sentinel providers were more likely to involve the age groups of 5-24, 25-64 and 0-4 years compared with the reference group of >64 years [odds ratio (OR) (95% confidence interval (CI)): 2.43 (2.39-2.47), 1.66 (1.64-1.69), and 1.51 (1.48-1.54), respectively]. Pediatric deaths were less likely in the age groups of 2-4 and <2 years than the reference group of 5-17 years [OR (95% CI): 0.46 (0.25-0.85) and 0.49 (0.30-0.81), respectively]. In Australia, notifications for laboratory-confirmed influenza were more likely in the age groups of 10-19, 5-9, 20-44, 45-64 and 0-4 years than the reference group of >65 years [OR (95% CI): 7.19 (6.67-7.75), 5.33 (4.90-5.79), 5.04 (4.70-5.41), 3.12 (2.89-3.36) and 1.89 (1.75-2.05), respectively]. In New Zealand, consultations for influenza-like illness by sentinel providers were more likely in the age groups of <1, 1-4, 35-49, 5-19, 20-34 and 50-64 years than the reference group of >65 years [OR (95% CI): 2.38 (1.74-3.26), 1.99 (1.62-2.45), 1.57 (1.30-1.89), 1.57 (1.30-1.88), 1.40 (1.17-1.69) and 1.39 (1.14-1.70), respectively]. CONCLUSIONS: The greatest increase in influenza cases during 2009 (H1N1) pandemic influenza period, in comparison with most recent seasonal influenza periods, was seen for school-aged children, adolescents, and younger adults

Etiology of anemia in end - stage chronic heart failure

Introduction: The prevalence of chronic heart failure in the general population is increasing. End-stage chronic heart failure portends a poor prognosis. Anemia is commonly encountered in patients with chronic heart failure, with increasing prevalence as the severity of heart failure increases. Anemia can have an adverse impact on the cardiovascular system, and has been found to be independently associated with poorer quality of life, and greater morbidity and mortality in chronic heart failure patients. The main pathophysiological mechanisms that are thought to contribute to the development of anemia in chronic heart failure include underlying chronic systemic inflammation, which is associated with inhibition of erythropoiesis, impaired absorption and utilization of iron, absolute iron deficiency, chronic renal dysfunction, blunted erythropoietin production and bone marrow response to erythropoietin, as well as drug-induced anemia due to inhibitors of the renin-angiotensin system. The role of iron deficiency has not been clarified given that the iron indices are influenced by co-existing inflammation.Objective: We hypothesized that iron deficiency is common in end-stage chronic heart failure patients. The aim of the study was to investigate all the main possible etiologic mechanisms of clinically-significant anemia in patients with end-stage heart failure.Methods: We performed a single-center, cross-sectional study to determine the prevalence of the different etiologies for clinically-significant anemia, in consecutive adult patients with chronic heart failure due to systolic dysfunction, who had not responded to optimized heart failure medical treatment and required intravenous infusion of inotropic drugs. We defined clinically-significant anemia as a hemoglobin concentration lower or equal to 11.5 and 12 g/dl, for females and males, respectively, after clinical stabilization. We excluded patients with anemia attributed to a concomitant disorder, those with serum creatinine higher than 3 mg/dl, and those who had recently received iron intravenously or epoetin. The medical history was taken from the included patients and physical examination was performed, as well as a standard cardiology work-up. Blood was drawn for a full laboratory panel with specific tests for anemia, including reticulocytes, ferritin, erythropoietin, vitamin B12, folic acid, thyroid stimulating hormone, and inflammatory markers. A fecal occult blood test was ordered. Bone marrow was aspirated for evaluation of the iron stores and the red cell volume was measured with 51Cr-labeled red cells. The patients were followed prospectively for major clinical events, for 3 months.Results: We included 37 patients (35 males), with mean age of 57.9±10.9 years and median heart failure duration of 60 months. Twenty-six (70.3%) patients were in NYHA functional class IV, and the remaining were in class III. The mean pulmonary capillary wedge pressure was 25.8±7.5 mmHg, the cardiac index was 1.9±0.5 L/m2/min, and the left ventricular ejection fraction was 22.5±5.9%. The patients had a mean hemoglobin concentration of 10.1±0.9 g/dl, ferritin of 113.2±94.4 ng/ml, erythropoietin of 68.6±54.7 mU/ml, C-reactive protein of 3.4±3.8 mg/dl, and serum creatinine of 1.7±0.6 mg/dl. Twenty-seven (73.0%, 95% confidence interval 57.1-85.4%) out of the 37 patients had iron deficiency (absence of bone marrow iron stores). According to the adjusted for body weight criteria for red cell volume, all 15 patients with iron deficiency had true anemia,while out of the remaining patients, 7 (18.9%) had anemia of chronic disease, 2 (5.4%) had hemodilution (normal red cell volume and increased plasma volume), and 1 (2.7%) had drug-induced anemia due to angiotensin converting enzyme inhibitors. Serum ferritin had a good diagnostic value for iron-deficiency versus non-iron deficiency (75.3±59.1 versus 211.9±99.9 ng/ml, p=0.002; area under curve 0.890, 95% confidence interval: 0.783-0.997). According to the international criteria for prediction of the normal red cell and plasma volumes by the body surface area, 8 (33.3%) out of the 24 specifically-examined patients had true anemia, 7 (29.2%) had pseudoanemia with normal plasma volumes and 9 (37.5%) had hemodilution, with no relevant differences between iron-deficient and non-iron-deficient patients. Regarding all 37 patients, 2 additionally had hypothyroidism, 6 had estimated glomerular filtration rate below 30 ml/min/1.73m2, while 3 had a low ratio of log observed to predicted erythropoietin. Within 3 months, 20 (54.1%) of the patients survived without need for urgent cardiac surgery. There was no association between iron deficiency and hemodilution with survival. Conclusion: Iron deficiency is very common in end-stage chronic heart failure patients with anemia. Serum ferritin could serve as a non-invasive diagnostic marker of iron deficiency in chronic heart failure, but the degree of underlying inflammation should be taken into consideration. Irrespectively of the iron status of patients, there is considerable variation in the red cell and plasma volumes. The comprehensive diagnostic algorithm of anemia followed in our study, allows for the individualization of treatment in patients with end-stage chronic heart failure, whose prognosis is dismal.Εισαγωγή: Η συχνότητα της καρδιακής ανεπάρκειας στον γενικό πληθυσμό βαίνει αυξανόμενη. Η χρόνια καρδιακή ανεπάρκεια τελικού σταδίου χαρακτηρίζεται από ιδιαιτέρως πτωχή πρόγνωση. Η αναιμία συνυπάρχει συχνά σε ασθενείς με χρόνια καρδιακή ανεπάρκεια και η συχνότητα της αυξάνεται σημαντικά με τη βαρύτητα της καρδιακής ανεπάρκειας. Η αναιμία έχει ποικίλες αρνητικές παθοφυσιολογικές επιπτώσεις στο καρδιαγγειακό σύστημα και έχει τεκμηριωθεί ως ανεξάρτητος προγνωστικός παράγοντας μειωμένης ποιότητας ζωής, αυξημένης νοσηρότητας και θνητότητας των ασθενών με χρόνια καρδιακή ανεπάρκεια. Οι κύριοι αιτιοπαθογενετικοί μηχανισμοί που θεωρείται ότι σχετίζονται με την εμφάνιση της αναιμίας στην χρόνια καρδιακή ανεπάρκεια είναι η υποκείμενη χρόνια συστηματική φλεγμονή, που προκαλεί καταστολή του μυελού καθώς και διαταραχή στην απορρόφηση και τη χρησιμοποίηση του σιδήρου, η αληθής σιδηροπενία, η χρόνια νεφρική δυσλειτουργία, η αναλογικά μειωμένη παραγωγή και η αντίσταση στη δράση της ερυθροποιητίνης, η αιμοαραίωση, καθώς και η φαρμακευτική αναιμία από αναστολείς του συστήματος ρενίνης-αγγειοτασίνης. Ο ρόλος της σιδηροπενίας δεν έχει επαρκώς διερευνηθεί, δεδομένου ότι οι σχετικοί διαγνωστικοί δείκτες επηρεάζονται από την υποκείμενη φλεγμονή.Σκοπός: Υποθέσαμε ότι η σιδηροπενία απαντάται συχνά σε ασθενείς με χρόνια καρδιακή ανεπάρκεια τελικού σταδίου. Ο σκοπός της μελέτης είναι η σε βάθος διερεύνηση των πιθανών αιτιολογικών μηχανισμών της κλινικά σημαντικής αναιμίας που εμφανίζουν οι ασθενείς με χρόνια καρδιακή ανεπάρκεια τελικού σταδίου.Μέθοδοι: Πραγματοποιήσαμε μια μελέτη επιπολασμού των αιτιών της κλινικά σημαντικής αναιμίας σε συνεχόμενους ενήλικες ασθενείς με χρόνια καρδιακή ανεπάρκεια λόγω συστολικής δυσλειτουργίας της αριστερής κοιλίας που δεν ανταποκρίνονταν σε βέλτιστη από του στόματος φαρμακευτική αγωγή και χρειάστηκαν ενδοφλέβια χορήγηση φαρμάκων με θετική ινότροπη δράση. Η αναιμία θεωρήθηκε κλινικά σημαντική όταν η συγκέντρωση αιμοσφαιρίνης ήταν μικρότερη ή ίση των 11,5 και 12 g/dl, για γυναίκες και άνδρες, αντίστοιχα, μετά την κλινική σταθεροποίηση. Αποκλείστηκαν οι ασθενείς με αναιμία που αποδιδόταν σε συνυπάρχον νόσημα, όσοι είχαν κρεατινίνη ορού μεγαλύτερη των 3 mg/dl, και όσοι είχαν λάβει προσφάτως σίδηρο ενδοφλεβίως ή ερυθροποιητίνη. Από τους ασθενείς που συμμετείχαν στη μελέτη λαμβανόταν ιστορικό και γινόταν κλινική εξέταση, πλήρης τακτικός καρδιολογικός έλεγχος, καθώς και αιμοληψία για γενικό και ειδικό για την αναιμία εργαστηριακό έλεγχο. Ο τελευταίος περιελάμβανε μέτρηση δικτυοερυθροκυττάρων, φερριτίνης, ερυθροποιητίνης, βιταμίνης B12, φυλλικού οξέος, θυρεοειδοτρόπου ορμόνης και δεικτών φλεγμονής. Επίσης πραγματοποιούνταν εξέταση αιμοσφαιρίνης κοπράνων και εξέταση του επιχρίσματος του μυελού των οστών για τις αποθήκες σιδήρου, καθώς και μέτρηση του όγκου των ερυθρών αιμοσφαιρίων με ραδιοσημασμένα με 51Cr ερυθρά. Οι ασθενείς παρακολουθούνταν προοπτικά επί τρίμηνο για μείζονα κλινικά συμβάματα. Αποτελέσματα: Στη μελέτη συμπεριλήφθηκαν 37 ασθενείς (35 άνδρες) με μέση ηλικία 57,9±10,9 έτη και διάμεση διάρκεια καρδιακής ανεπάρκειας 60 μήνες. Είκοσι έξι (70,3%) ασθενείς ευρίσκονταν σε λειτουργική κλάση IV κατά NYHA και οι υπόλοιποι σε κλάση ΙΙΙ. Η μέση πίεση ενσφήνωσης πνευμονικών τριχοειδών των ασθενών ήταν 25,8±7,5 mmHg, ο καρδιακός δείκτης 1,9±0,5 L/m2/min, και το κλάσμα εξωθήσεως της αριστερής κοιλίας 22,5±5,9%. Η μέση συγκέντρωση αιμοσφαιρίνης των ασθενών ήταν 10,1±0,9 g/dl, της φερριτίνης 113,2±94,4 ng/ml, της ερυθροποιητίνης 68,6±54,7 mU/ml, της C-αντιδρώσας πρωτεΐνης 3,4±3,8 mg/dl, και της κρεατινίνης ορού 1,7±0,6 mg/dl. Είκοσι επτά (73,0%, 95% διάστημα εμπιστοσύνης 57,1-85,4%) εκ των 37 ασθενών είχαν σιδηροπενία (εξάλειψη των αποθηκών σιδήρου του μυελού των οστών). Λαμβάνοντας υπόψη τα προσαρμοσμένα προς το σωματικό βάρος κριτήρια για τον όγκο των ερυθρών αιμοσφαιρίων, όλοι οι 15 ασθενείς με σιδηροπενία που ελέγχθηκαν σχετικά είχαν αληθή αναιμία, ενώ, αναφορικά με τους υπόλοιπους ασθενείς, 7 (18,9%) είχαν αναιμία χρονίας νόσου, 2 (5,4%) είχαν αιμοαραίωση (φυσιολογικό όγκο ερυθρών αιμοσφαιρίων και αυξημένο όγκο πλάσματος), και 1 (2,7%) ασθενής είχε αναιμία φαρμακευτικής αιτιολογίας από λήψη αναστολέων του μετατρεπτικού ενζύμου της αγγειοτασίνης. Η φερριτίνη ορού είχε καλή διαγνωστική αξία για τη σιδηροπενία έναντι της μη σιδηροπενίας (75,3±59,1 έναντι 211,9±99,9 ng/ml, p=0,002, περιοχή κάτω από την καμπύλη 0,890, 95% διάστημα εμπιστοσύνης: 0,783-0,997). Λαμβάνοντας υπόψη τα διεθνή κριτήρια υπολογισμού των φυσιολογικών τιμών του όγκου ερυθρών αιμοσφαιρίων και πλάσματος με βάση την επιφάνεια σώματος, 8 (33,3%) εκ των 24 ασθενών που ελέγχθηκαν είχαν αληθή αναιμία, 7 (29,2%) είχαν ψευδοαναιμία με φυσιολογικό όγκο πλάσματος και 9 (37,5%) είχαν αιμοαραίωση, χωρίς διαφορά μεταξύ των σιδηροπενικών και μη ασθενών. Εκ των 37 ασθενών, σε 2 συνυπήρχε υποθυρεοειδισμός, 6 είχαν εκτιμώμενο ρυθμό σπειραματικής διήθησης μικρότερο των 30 ml/min/1,73m2 και 3 είχαν χαμηλό λόγο λογαρίθμων παρατηρούμενης προς αναμενόμενη τιμή ερυθροποιητίνης. Εντός τριμήνου, 20 (54,1%) των ασθενών επιβίωσαν χωρίς να χρειαστούν επείγουσα καρδιολογική χειρουργική επέμβαση. Η σιδηροπενία και η αιμοαραίωση δεν συσχετίζονταν με την πιθανότητα επιβίωσης.Συμπέρασμα: Η σιδηροπενία είναι λίαν συχνή στην αναιμία των ασθενών με χρόνια καρδιακή ανεπάρκεια τελικού σταδίου. Η φερριτίνη ορού θα μπορούσε να χρησιμεύσει ως αδρός μη επεμβατικός διαγνωστικός δείκτης της σιδηροπενίας σε ασθενείς με χρόνια καρδιακή ανεπάρκεια, αλλά με προσαρμοσμένα όρια στο βαθμό της φλεγμονής. Ανεξάρτητα από την ύπαρξη ή μη σιδηροπενίας, οι ασθενείς παρουσιάζουν μεγάλη διακύμανση όσον αφορά τον όγκο των ερυθρών αιμοσφαιρίων και του πλάσματος. Ο πλήρης διαγνωστικός έλεγχος της αναιμίας με βάση τον αλγόριθμο της μελέτης μας επιτρέπει την εξατομίκευση της θεραπείας στους ασθενείς με χρόνια καρδιακή ανεπάρκεια τελικού σταδίου, μιας ομάδας ασθενών με χαμηλό προσδόκιμο επιβίωσης

New treatments of multidrug-resistant Gram-negative ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) remains an important clinical problem globally, being associated with significant morbidity and mortality. As management of VAP requires adequate and timely antibiotic administration, global emergence of antimicrobial resistance poses serious challenges over our ability to maintain this axiom. Development of antimicrobials against MDR Gram-negative pathogens has therefore emerged as a priority and some new antibiotics have been marketed or approach late stage of development. The aim of this review is to analyse new therapeutic options from the point view of potential treatment of VAP. Among recently developed antimicrobials presented herein, it is obvious that we will have promising therapeutic options against VAP caused by Enterobacteriaceae excluding those producing metallo-beta-lactamases, against which only cefiderocol and aztreonam/avibactam are expected to be active. Against infections caused by carbapenem non-susceptible Pseudomonas aeruginosa, ceftolozane/tazobactam and to a lesser extend ceftazidime/avibactam may cover a proportion of current medical needs, but there still remain a considerable proportion of strains which harbor other resistance mechanisms. Murepavadin and cefiderocol hold promise against this particularly notorious pathogen. Finally, Acinetobacter baummannii remains a treatment-challenge. Eravacycline, cefiderocol and probably plazomicin seem to be the most promising agents against this difficult-to treat pathogen, but we have still a long road ahead, to see their position in clinical practice and particularly in VAP. In summary, despite persisting and increasing unmet medical needs, several newly approved and forthcoming agents hold promise for the treatment of VAP and hopefully will enrich our antimicrobial arsenal in the next few years. Targeted pharmacokinetic and clinical studies in real-life scenario of VAP are important to position these new agents in clinical practice, whereas vigilant use will ensure their longevity in our armamentarium

MRSA in Africa: filling the global map of antimicrobial resistance.

We sought to assess the prevalence of methicillin-resistance among Staphylococcus aureus isolates in Africa. We included articles published in 2005 or later reporting for the prevalence of MRSA among S. aureus clinical isolates. Thirty-two studies were included. In Tunisia, the prevalence of MRSA increased from 16% to 41% between 2002-2007, while in Libya it was 31% in 2007. In South Africa, the prevalence decreased from 36% in 2006 to 24% during 2007-2011. In Botswana, the prevalence varied from 23-44% between 2000-2007. In Algeria and Egypt, the prevalence was 45% and 52% between 2003-2005, respectively. In Nigeria, the prevalence was greater in the northern than the southern part. In Ethiopia and the Ivory Coast, the prevalence was 55% and 39%, respectively. The prevalence of MRSA was lower than 50% in most of the African countries, although it appears to have risen since 2000 in many African countries, except for South Africa