Between the Clinic and the Community: Temporality and Patterns of ART Adherence in the Western Cape Province, South Africa

In an ethnographic study conducted over thirty months in South Africa’s Western Cape Province ending in 2012, we explored ART adherence amongst almost 200 patients attending three clinics. This setting contained significant political, structural, economic and socio cultural barriers to the uptake of, and adherence to, treatment. Such barriers certainly impacted patient drug use and the labelling of clients as ‘adherent’ or ‘non-adherent’. Yet, as our fieldwork developed, it became apparent that these labels also bore little relationship to the amount and regularity of drug consumption outside the clinic. Indeed, the people that we knew moved through these labels in ways that could not simply be explained by brute socio-economic circumstances, poor understanding of the functions of the drugs, or varying levels of family and community support, which themselves often changed over time. This paper presents four on-going ‘patterns of adherence’, which are clearly discernible in the communities in which we worked. Each pattern is demonstrated through the life of an ‘index patient’ whose case is seen to be representative of the range of experiences and practices observed under the terms ‘adherent’ and ‘non-adherent’. We argue that such terms are deeply contextual and, crucially, temporally situated. The complex intertwining of political, economic, socio cultural, gender, and biological factors that constitute the lives of participants exists in time and we call for a focus on evolving lives in relationship to changing health systems that can follow (and respond to) such developments to better deliver both information and services.Keywords: ART adherence, community, health systems, socio-cultural barriers drug consumptio

Barriers to Access and Adherence to ARVs

Poster Presentatio

Delay of natural bone loss by higher intakes of specific minerals and vitamins.

: Crit Rev Food Sci Nutr 2001 May;41(4):225-49 Related Articles, Books, LinkOut Delay of natural bone loss by higher intakes of specific minerals and vitamins. Schaafsma A, de Vries PJ, Saris WH. Friesland Coberco Dairy Foods, Dep. of Research & Development Leeuwarden, The Netherlands. [email protected] For early prevention or inhibition of postmenopausal and age-related bone loss, nutritional interventions might be a first choice. For some vitamins and minerals an important role in bone metabolism is known or suggested. Calcium and vitamin D support bone mineral density and are basic components in most preventive strategies. Magnesium is involved in a number of activities supporting bone strength, preservation, and remodeling. Fluorine and strontium have bone-forming effects. However, high amounts of both elements may reduce bone strength. Boron is especially effective in case of vitamin D, magnesium, and potassium deficiency. Vitamin K is essential for the activation of osteocalcin. Vitamin C is an important stimulus for osteoblast-derived proteins. Increasing the recommended amounts (US RDA 1989), adequate intakes (US DRI 1997), or assumed normal intakes of mentioned food components may lead to a considerable reduction or even prevention of bone loss, especially in late postmenopausal women and the elderly

Hypoxia induces no change in cutaneous thresholds for warmth and cold sensation

Hypoxia can affect perception of temperature stimuli by impeding thermoregulation at a neural level. Whether this impact on the thermoregulatory response is solely due to affected thermoregulation is not clear, since reaction time may also be affected by hypoxia. Therefore, we studied the effect of hypoxia on thermal perception thresholds for warmth and cold. Thermal perception thresholds were determined in 11 healthy overweight adult males using two methods for small nerve fibre functioning: a reaction-time inclusive method of limits (MLI) and a reaction time exclusive method of levels (MLE). The subjects were measured under normoxic and hypoxic conditions using a cross-over design. Before the thermal threshold tests under hypoxic conditions were conducted, the subjects were acclimatized by staying 14 days overnight (8 h) in a hypoxic tent system (Colorado Altitude Training: 4,000 m). For normoxic measurements the same subjects were not acclimatized, but were used to sleep in the same tent system. Measurements were performed in the early morning in the tent. Normoxic MLI cold sensation threshold decreased significantly from 30.3 ± 0.4 (mean ± SD) to 29.9 ± 0.7°C when exposed to hypoxia (P < 0.05). Similarly, mean normoxic MLI warm sensation threshold increased from 34.0 ± 0.9 to 34.5 ± 1.1°C (P < 0.05). MLE measured threshold for cutaneous cold sensation was 31.4 ± 0.4 and 31.2 ± 0.9°C under respectively normoxic and hypoxic conditions (P > 0.05). Neither was there a significant change in MLE warm threshold comparing normoxic (32.8 ± 0.9°C) with hypoxic condition (32.9 ± 1.0°C) (P > 0.05). Exposure to normobaric hypoxia induces slowing of neural activity in the sensor-to-effector pathway and does not affect cutaneous sensation threshold for either warmth or cold detection

Quality of patient- and proxy-reported outcomes for children with impairment of the lower extremity:A systematic review using the COnsensus-based Standards for selection of health Measurement INstruments methodology

Background: Patient-reported outcome measures have become crucial in the clinical evaluation of patients. Appropriate selection, in a young population, of the instrument is vital to providing evidence-based patient-centered healthcare. This systematic review applies the COnsensus-based Standards for selection of health Measurement INstruments methodology to provide a critically appraised overview of patient-reported outcome measures targeted at pediatric orthopedic patients with lower limb impairment.Method: A systematic search of electronic databases was performed to identify original studies reporting the development and/or validation of patient-reported outcome measures evaluating children with impairment of the lower extremity. Data extraction, quality assessment, and risk of bias evaluation were performed following the COnsensus-based Standards for selection of health Measurement INstruments guidelines and Preferred Reporting Items for Systematic reviews and Meta-Analyses statement.Results: A total of 6919 articles were screened. Thirty-three studies were included, reporting evidence on the measurement properties of 13 different patient-reported outcome measures and 20 translations. Four studies reported on content validity and patient-reported outcome measure development. The methodological quality of studies on structural validity, content validity, or patient-reported outcome measure development was mostly rated as "doubtful" or "very good." The quality of evidence on measurement properties varied noticeably, with most studies needing to perform improve their methodological quality to justify their results.Conclusion: This review provides an extensive overview of all available patient-reported outcome measures for patients with lower extremity impairment within pediatric orthopedics. We cautiously advise the use of four patient-reported outcome measures. However, the scarce availability of research on content validity and patient-reported outcome measure development highlights an area for future research endeavors to improve our knowledge on the currently available patient-reported outcome measures.Level of evidence: Diagnostic level

Between the Clinic and the Community: Temporality and Patterns of ART Adherence in the Western Cape Province, South Africa

In an ethnographic study conducted over thirty months in South Africa’s Western Cape Province ending in 2012, we explored ART adherence amongst almost 200 patients attending three clinics. This setting contained significant political, structural, economic and socio-cultural barriers to the uptake of, and adherence to, treatment. Such barriers certainly impacted patient drug use and the labelling of clients as ‘adherent’ or ‘non-adherent’. Yet, as our fieldwork developed, it became apparent that these labels also bore little relationship to the amount and regularity of drug consumption outside the clinic. Indeed, the people that we knew moved through these labels in ways that could not simply be explained by brute socio-economic circumstances, poor understanding of the functions of the drugs, or varying levels of family and community support, which themselves often changed over time. This paper presents four on-going ‘patterns of adherence’, which are clearly discernible in the communities in which we worked. Each pattern is demonstrated through the life of an ‘index patient’ whose case is seen to be representative of the range of experiences and practices observed under the terms ‘adherent’ and ‘non-adherent’. We argue that such terms are deeply contextual and, crucially, temporally situated. The complex intertwining of political, economic, socio-cultural, gender, and biological factors that constitute the lives of participants exists in time and we call for a focus on evolving lives in relationship to changing health systems that can follow (and respond to) such developments to better deliver both information and services

An attenuated, adult case of AADC deficiency demonstrated by protein characterization

A case of an adult with borderline AADC deficiency symptoms is presented here. Genetic analysis revealed that the patient carries two AADC variants (NM_000790.3: c.1040G &gt; A and c.679G &gt; C) in compound heterozygosis, resulting in p.Arg347Gln and p.Glu227Gln amino acid alterations. While p.Arg347Gln is a known pathogenic variant, p.Glu227Gln is unknown. Combining clinical features to bioinformatic and molecular characterization of the AADC protein population of the patient (p.Arg347Gln/p.Arg347Gln homodimer, p.Glu227Gln/p.Glu227Gln homodimer, and p.Glu227Gln/p.Arg347Gln heterodimer), we determined that: i) the p.Arg347Gln/p.Arg347Gln homodimer is inactive since the alteration affects a catalytically essential structural element at the active site, ii) the p.Glu227Gln/p.Glu227Gln homodimer is as active as the wild-type AADC since the alteration occurs at the surface and does not change the chemical nature of the amino acid, and iii) the p.Glu227Gln/p.Arg347Gln heterodimer has a catalytic efficiency 75% that of the wild-type since only one of the two active sites is compromised, thus demonstrating a positive complementation. By this approach, the molecular basis for the mild presentation of the disease is provided, and the experience made can also be useful for personalized therapeutic decisions in other mild AADC deficiency patients. Interestingly, in the last few years, many previously undiag- nosed or misdiagnosed patients have been identified as mild cases of AADC deficiency, expanding the phenotype of this neurotransmitter disease

Energy compensation in the real world. Good compensation for small portions of chocolate and biscuits over short time periods in complicit consumers using commercially available foods.

While investigations using covert food manipulations tend to suggest that individuals are poor at adjusting for previous energy intake, in the real world adults rarely consume foods with which they are ill-informed. This study investigated the impact in fully complicit consumers of consuming commercially available dark chocolate, milk chocolate, sweet biscuits and fruit bars on subsequent appetite. Using a repeated measures design, participants received four small portions (4 × 10-11 g) of either dark chocolate, milk chocolate, sweet biscuits, fruit bars or no food throughout five separate study days (counterbalanced in order), and test meal intake, hunger, liking and acceptability were measured. Participants consumed significantly less at lunch following dark chocolate, milk chocolate and sweet biscuits compared to no food (smallest t(19) = 2.47, p = 0.02), demonstrating very good energy compensation (269-334%). No effects were found for fruit bars (t(19) = 1.76, p = 0.09), in evening meal intakes (F(4,72) = 0.62, p = 0.65) or in total intake (lunch + evening meal + food portions) (F(4,72) = 0.40, p = 0.69). No differences between conditions were found in measures of hunger (largest F(4,76) = 1.26, p = 0.29), but fruit bars were significantly less familiar than all other foods (smallest t(19) = 3.14, p = 0.01). These findings demonstrate good compensation over the short term for small portions of familiar foods in complicit consumers. Findings are most plausibly explained as a result of participant awareness and cognitions, although the nature of these cognitions cannot be discerned from this study. These findings however, also suggest that covert manipulations may have limited transfer to real world scenarios

The adaptation of nutrient oxidation to nutrient intake on a high-fat diet.

Department of Human Biology, Maastricht University, The Netherlands. Intervention studies have shown that the adaptation of fat oxidation to fat intake, when changing the dietary fat content, is not abrupt. This study was conducted to measure the time course of adaptation of oxidation rates to increases in the fat content of the diet, when feeding subjects at energy balance. Twelve healthy, non-obese males and females (age: 26 +/- 2, BMI: 21.4 +/- 0.5, habitual fat intake: 29 +/- 1% energy) consumed a low-fat diet for 6 days (days 1-6) followed by a high-fat diet for 7 days (day 7-13). Days 5-9 and day 13 were spent in a respiration chamber. After adjusting energy intake to 24h energy expenditure on day 5, subjects were in energy balance (range -0.15 to +0.23 kJ/day) on days 6-9 and day 13. Fat balance was zero on day 6 but became positive after changing to the high-fat diet (1.06 +/- 0.15, 0.75 +/- 0.15, and 0.55 +/- 0.14 MJ/day for days 7, 8, and 9 respectively, p. < 0.05), reaching a new balance on day 13, 7 days afterwards. Thus, in case of energy balance, lean subjects are capable of adjusting fat oxidation to fat intake within 7 days, when dietary fat content is increased