A practical guide to the supportive and palliative care of patients with chronic kidney disease

We are sure that all of us involved in the field of renal medicine in South Africa would agree that the guidelines, published on page 86 of this issue, around the supportive care of renal patients, especially those who cannot access renal replacement therapy – produced in collaboration between the South African Renal Society and the Association of Palliative Care Practitioners of South Africa – will prove valuable in assisting us in making difficult decisions and in providing constructive advice on the management of our patients with advanced chronic kidney disease (CKD).South Africa’s GDP per capita, of around US$3600, places it within the upper-middle-income economic group. Unfortunately, our economy must cope with limited resources with the burden of both non-communicable and communicable diseases. We have one of the highest prevalences of HIV infection in the world, with high frequencies for the APOL1 G1 and G2 risk alleles for HIV-associated (and other) nephropathies [1]. The World Health Organization’s Global Health Observatory (https://www.who.int/data/gho) reports the crude prevalence of hypertension in South Africa at 24%, diabetes at 9.8%, overweight at 51.9% and physical inactivity at 37.2%.The South African Renal Registry [2] reports that 84% of South Africans rely on state-funded medical facilities. A metaanalysis by Kaze et al. [3] quotes the prevalence of CKD stages 3 to 5 to be around 4.8% of the population in sub-Saharan African countries, and in South Africa this amounts to some 2.7 million people with significant kidney disease. Considering our risk profile for renal disease, this is unlikely to be an overestimate. According to the renal registry, only around 11 000 individuals in South Africa are on dialysis or have functioning kidney transplants, with 3100 served by the public sector. Unfortunately, our transplantation rate is low – 4.8 pmp in the public sector and 15.2 pmp in the private sector between 1991 and 2015 [4]. Transplant centres in the UK reported adult deceased donor renal transplant rates between 24 and 66 per million population in 2018/19 [5].We have large numbers of individuals with end-stage renal disease (ESRD), who are on a palliative care path, not by choice, and this is distressing. These guidelines should not be a substitute for ongoing efforts by our government to “move as expeditiously as possible towards the full realisation of the right to healthcare services”, as enshrined in Section 27 of our constitution.We congratulate our nephrology and palliative care community, and thank our visiting Australian colleagues, for well thought out and practical guidelines, which cover all aspects of supportive care for ESRD patients, including effective and caring communication, symptom management, preserving renal function, end-of-life care, care of paediatric patients, and models for setting up a renal palliative care service. The South African Essential Drugs List was used where possible to ensure that the medications are universally available in South Africa. Graham Paget and Vakhtang RekhviashvilliSouth African Renal Society [see PDF file for references

Cost effective diagnosis and monitoring of HIV-1 in a resource poor setting

The South African National Antiretroviral Treatment Guidelines recommend the use of HIV-1 viral load assays for routine monitoring of HIV-1 positive patients receiving highly active antiretroviral therapy (HAART). This thesis describes the innovative approaches to developing more affordable HIV-1 diagnostics and monitoring assays for South Africa, which take into account the tiered laboratory infrastructure of this country. An in-house HIV-1 viral load assay – the LUX assay, was developed and evaluated with a view of implementing this more affordable option in high tier laboratories. The LUX assay represents quantitative real-time RT-PCR that utilizes the LightCycler® technology (Roche) in a novel combination with a LUXÔ primer. The assay showed good analytical sensitivity, specificity and reproducibility of its linear dynamic range of 4x102 to 4x106 RNA copies/ml. Preliminary clinical evaluation (n = 458) of the LUX assay showed good agreement with the COBAS Amplicor assay, and demonstrated its usefulness for long term monitoring of HAART patients. ELISA based viral load testing approaches were investigated as low cost and less technically complex alternatives for medium tier laboratories. The HiSens HIV-1 p24 Ag Ultra (Perkin Elmer) and the ExaVir™ Load Quantitative HIV-RT kits (CAVIDI) were compared with the Roche Amplicor assay. Both assays showed strong association with the Roche Amplicor assay, with R2 = 0.686 and R2 = 0.810, respectively (n = 117). These alternative assays seemed most useful in the serial monitoring of patients on HAART. Major drawbacks included the wide variability of both assays, insufficient sensitivity of the p24 antigen assay and low throughput of the RT assay. Development of a point-of-care HIV-1 RNA assay could address issues related to early and cost effective diagnosis of acute HIV infection. A novel isothermal amplification technique termed the Reverse Transcription Loop Dependant Amplification (RT-LDA) was developed as one component for a potential point-of-care HIV-1 RNA assay. The RT-LDA converted RNA into partially looped ssDNA amplicons, over a wide RNA concentration range (4x103 to 4x108 copies/ml) using a 1 hour incubation at 53ºC. The RT-LDA technology is fully compatible with a lateral flow detection system using dipsticks and highly suitable for point-of-care testing. Overall, this study demonstrates the feasibility of developing novel, more affordable HIV-1 testing options that would be appropriate for the tiered laboratory infrastructure present in South Africa. Evaluation of commercially available, less expensive alternative HIV viral load assays in local settings facilitates their implementation

Feminist Responses to Right-Wing Governance in Hungary: The Emergence of Anti-Gender Feminism

This dissertation employs ethnographic data about Hungary’s feminist activist and academic circles to explore the impacts of right-wing anti-gender politics on feminist activists and scholars in Hungary. The right-wing anti-gender context presented multiple challenges to the feminist actors, such as increased visibility of their work in a hostile climate and decreased political and financial support. Feminist actors coped with the restrictive political context by either openly opposing the right-wing politics, self-censoring, deploying strategic language and activities, or leaving the country. The right-wing Anti-gender climate also contributed to the intensification of the debates among various feminist groups. The debates focused on finding feminist strategies for surviving within the hostile, right-wing anti-gender context. I argue that the tensions brought to the Hungarian feminist movement by the right-wing, anti-gender climate contributed to the emergence and discursive dominance of what I call anti-gender feminism. Anti-gender feminist discourse is articulated as a “new” and “progressive” feminist strategy for overcoming the critiques of gender-related work by right-wing anti-gender actors. Anti-gender feminism is grounded in a particular articulation of leftist perspectives and claims that the feminist movement must center on the needs of the majority of women and appeal to the sensibilities of “everyday people”. According to this discourse, a leftist perspective allows for overcoming the failings of liberal feminist approaches, for example, West-imposed identitarian struggles. According to anti-gender feminist arguments, such approaches dismiss the structural reasons for inequalities affecting the wider public and result in hostility towards feminist initiatives. In its desire to appeal to the wider masses, and operate without interference from the right-wing government, anti-gender feminist discourse distances itself from other marginalized struggles such as trans and sex-workers’ rights and racial justice. It also brings feminist arguments dangerously close to the white-supremacist, nationalist-populist rhetoric of the Hungarian state

Gyrokinetic simulations of neoclassical electron transport and bootstrap current generation in tokamak plasmas in the TRIMEG code

For magnetic confinement fusion in tokamak plasmas, some of the limitations to the particle and energy confinement times are caused by turbulence and collisions between particles in toroidal geometry, which determine the "anomalous" and the neoclassical transport, respectively. In this work, we focus on the implementation of neoclassical physics in the gyrokinetic code TRIMEG, which is a TRIangular MEsh-based Gyrokinetic code that can handle both the closed and open field line geometries of a divertor tokamak. We report on the implementation of a simplified Lorentz collision operator in TRIMEG. Since the code uses an unstructured mesh, a procedure for calculating the flux surface averages of particle and energy fluxes and the bootstrap current is derived without relying on the poloidal coordinate, which is useful also for other simulations in unstructured meshes. With the newly implemented collision operator, we study electron transport and bootstrap current generation for various simplified and realistic geometries. In comparison to neoclassical theory, good agreement is obtained for the large aspect ratio case regarding the particle and energy fluxes as well as the bootstrap current. However, some discrepancies are observed at moderate aspect ratio and for a case with the realistic geometry of the ASDEX Upgrade tokamak. These deviations can be explained by different treatments and approximations in theory and simulation. In this paper, we demonstrate the capability to calculate the electron transport and bootstrap current generation in TRIMEG, which will allow for the self-consistent inclusion of neoclassical effects in gyrokinetic simulations in the future

The circumstances of migrant families raising children with disabilities in five European countries: Updating knowledge and pursuing new research

In 2017, specialists in several fields (health, education, and social work) from five European countries (France, Georgia, Italy, Norway, and Switzerland) established a network to jointly pursue studies on migration and disability. An initial workshop provided an opportunity to discuss their previous individual work and to develop a comparative research project. This article presents the key aspects of the discussion and the resulting plans for collaborative study. First, migrant children with disabilities remain statistically invisible in some countries. Separate policies and systems address their needs as migrants and their needs as persons with disabilities. Second, in all countries covered by the research network, there is an important gap between legal norms and the circumstances of migrant families raising children with disabilities. The same holds true for collaboration between public agencies, or between those agencies and NGOs (serving persons with disabilities, migrants, and/or national minorities). Further comparative and cross-disciplinary study must focus on increasing the social participation of children with disabilities and their families through social, educational, and health interventions within an intercultural context

High throughput non-invasive determination of foetal Rhesus D status using automated extraction of cell-free foetal DNA in maternal plasma and mass spectrometry

Purpose: To examine the potential high throughput capability and efficiency of an automated DNA extraction system in combination with mass spectrometry for the non-invasive determination of the foetal Rhesus D status. Methods: A total of 178 maternal plasma samples from RHD-negative pregnant women were examined, from which DNA was extracted using the automated Roche MagNA Pure™ system. Presence of the foetal RHD gene was detected by PCR for RHD exon 7 and subsequent analysis using the Sequenom MassArray™ mass spectrometric system. Results: We determined that as little as 15pg of RHD-positive genomic DNA could be detected in a background of 585pg of RHD-negative genomic DNA. The analysis of the clinical samples yielded a sensitivity and specificity of 96.1 and 96.1%, respectively. Conclusion: Our study indicated that automated DNA extraction in combination with mass spectrometry permits the determination of foetal Rhesus D genotype with an accuracy comparable to the current approaches using real-time PC

КЛИНИЧЕСКИЙ СЛУЧАЙ ЛЕЧЕНИЯ ПРОПРАНОЛОЛОМ ГЕМАНГИОМЫ ПЕЧЕНИ У НОВОРОЖДЕННОГО

Clinical observation of conservative treatment of the left hemi-liver haemangioma by propranolol in the full-term newborn with initial symptoms of cardiac failure is presented. Extensive hepatic haemangioma was diagnosed prenatally on the 23–24th week of a gestation. After the birth the clinical diagnosis was confirmed by means of ultrasound investigation (the size — 50×30 mm) and by the data of computer tomography. The starter dose of propranolol made 0.5 mg/kg per day with further increase to 1,5 mg/kg per day; the preparation was prescripted at the age of 2 days of life. Episodes of decrease in cardiac rate to 95 b/min are noted among side effects. The child was dismissed for out-patient observation at the age of 12 days of life in a stable state. The positive dynamics is registered during ultrasound investigation in 6 months after initiation of treatment: lesion was significantly decreased in the size, and there was a considerable decrease in a blood flow. Treatment by propranolol in a dose of 1,5 mg/kg per day was continued. Modern data on possible mechanisms of propranolol effect at haemangiomas in children, regimen, side effects and complications are provided in discussion. It is noted that this drug can be considered as the agent of choice in the treatment of infantile haemangiomas in children of difficult localization since the neonatality period.Представлено клиническое наблюдение консервативного лечения пропранололом гемангиомы левой доли печени у доношенного новорожденного с начальными признаками сердечной недостаточности. Обширная гемангиома печени диагностирована внутриутробно на 23–24-й нед гестации. После рождения клинический диагноз был подтвержден при помощи ультразвукового исследования (размеры 50×30 мм) и данными компьютерной томографии. Стартовая доза пропранолола составила 0,5 мг/кг в сут с дальнейшим увеличением до 1,5 мг/кг в сут; препарат был назначен в возрасте 2 сут жизни. Из побочных эффектов отмечены эпизоды снижения частоты сердечных сокращений до 95 уд./мин. В возрасте 12 сут жизни в стабильном состоянии ребенок был выписан на амбулаторное наблюдение. Через 6 мес от начала лечения при ультразвуковом исследовании зарегистрирована положительная динамика: образование существенно уменьшилось в размерах, и произошло значительное снижение кровотока. Лечение пропранололом в дозе 1,5 мг/кг в сут было продолжено. В обсуждении приведены современные данные о возможных механизмах действия пропранолола при гемангиомах у детей, схемы его назначения, побочные эффекты и осложнения. Отмечено, что данное средство может рассматриваться как препарат выбора при лечении инфантильных гемангиом у детей сложной локализации, начиная с периода новорожденности

'Supra is not for women' : hospitality practices as a lens on gender and social change in Georgia

Peer reviewe

Generalized Hamilton's Principle with Fractional Derivatives

We generalize Hamilton's principle with fractional derivatives in Lagrangian L(t,y(t),{}_0D_t^\al y(t),\alpha) so that the function $y$ and the order of fractional derivative $\alpha$ are varied in the minimization procedure. We derive stationarity conditions and discuss them through several examples