Mind the gap: Patterns of red blood cell product usage in South Africa, 2014 - 2019

Background. A key component of any successful healthcare system is the availability of sufficient, safe blood products delivered in an equitable manner. South Africa (SA) has a two-tiered healthcare system with public and privately funded sectors. Blood utilisation data for both sectors are lacking. Evaluation of blood utilisation patterns in each healthcare sector will enable implementation of systems to bring about more equality.Objectives. To conduct a critical evaluation of red blood cell (RBC) product utilisation patterns at the South African National Blood Service (SANBS).Methods. Operationally collected data from RBC requests submitted to SANBS blood banks for the period 1 January 2014 - 31 March 2019 were used to determine temporal RBC product utilisation patterns by healthcare sector. Demographic patterns were determined, and per capita RBC utilisation trends calculated.Results. Of the 2 356 441 transfusion events, 65.9% occurred in the public and 34.1% in the private sector. Public sector patients were younger (median (interquartile range (IQR)) 33 (22 - 49) years) than in the private sector (median (IQR) 54 (37 - 68) years), and mainly female in both sectors (66.2% in the public sector and 53.4% in the private sector). Between 2014 and 2018, per capita RBC utilisation decreased from 11.9 to 11.0/1 000 population in the public sector, but increased from 34.8 to 38.2/1 000 population in the private sector.Conclusions. We confirmed distinctly different RBC utilisation patterns between the healthcare sectors in SA. Possible drivers for these differences may be healthcare access, differing patient populations and prescriber habits. Better understanding of these drivers may help inform equitable public health policy

A multicentre cross-sectional descriptive study evaluating the cardiovascular risk profile of preoperatively identified patients with hypertension

Background. The prevalence of hypertension in adults in South Africa (SA) is 35%. Hypertension is the most important modifiable risk factor for cardiovascular (CV) and chronic kidney disease (CKD) in sub-Saharan Africa. However, 49% of people are unaware of their blood pressure status. Screening for hypertension prior to surgery provides a unique opportunity to diagnose and treat affected individuals. Furthermore, assessing overall CV risk identifies patients at highest risk for complications, and improves the utilisation of scarce resources. Objectives. To evaluate the CV risk profile of hypertensive patients in the adult population of the Western Cape Province presenting for elective non-cardiac, non-obstetric surgery. Methods. This report documents the CV risk profile of patients recruited to the HASS-2 study (Hypertension and Surgery Study 2), which was undertaken in seven Western Cape hospitals. Patients were screened for hypertension and pharmacological treatment was initiated or adjusted in patients with stages 1 and 2 disease. Stage 3 patients were referred to a physician. In the present substudy, patients with stages 1 and 2 hypertension were assessed for associated CV risk factors, the presence of target organ damage, and documented CV or kidney disease; they received an overall risk stratification according to the 2018 European Society of Cardiology and the European Society of Hypertension Guidelines. Results. Sixty-one patients with stage 1 and 12 with stage 2 hypertension were analysed. Established CV disease was present in 13.7% of the study population, and CKD (eGFR <60 mL/min) in 10.8%. Seventy-one percent of the study group had a raised body mass index, and 55.9% underlying metabolic syndrome. Prediabetes and diabetes were present in 16.1% and 14.5%, respectively. According to the 2018 European guidelines, 34.7% were at moderate, 33.3% at high and 16.7% at very high risk for a CV event in the following 10 years.Conclusions. The perioperative period is a critical time during which surgeons, nurses and anaesthetists can influence patients’ CV risk of adverse events. This involves appropriate screening, education and treatment. In this study population, nearly 9 out of 10 elective surgical patients with stage 1 or 2 hypertension had CV risk factors placing them at moderate to very high risk. The simultaneous assessment of these additional CV risk parameters, in addition to diagnosis and management of hypertension, may further decrease the health and financial burden in resource-limited facilities in SA, and improve CV outcomes.

A multicentre prospective observational study of the prevalence and glycaemic control of diabetes mellitus in adult non-cardiac elective surgical patients in hospitals in Western Cape Province, South Africa

Background. Diabetes mellitus (DM) is a common condition. The high burden of undiagnosed DM and a lack of large population studies make accurate prevalence estimations difficult, especially in the surgical environment. Furthermore, poorly controlled DM is associated with an increased risk of perioperative complications and mortality.Objectives. The primary objective was to establish the prevalence of DM in elective adult non-cardiac, non-obstetric surgical patients in hospitals in Western Cape Province, South Africa. The secondary objectives were to assess the glycaemic control and compliance with treatment of known diabetics.Methods. A 5-day multicentre, prospective observational study was performed at six government-funded hospitals in the Western Cape. Screening for DM was done using finger-prick capillary blood glucose (CBG) testing. Patients found to have a CBG ≥6.5 mmol/L had their glycated haemoglobin (HbA1c) level measured. DM was diagnosed based on the Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) diagnostic criteria. Patients known to have DM had their HbA1cmeasured and completed a Morisky Medication Adherence Scale (MMAS-4) questionnaire to assess glycaemic control and compliance with treatment.Results. Of the 379 participants, 61 were known diabetics (16.2%; 95% confidence interval (CI) 12.4 - 19.8). After exclusion of 8 patients with incomplete results, a new diagnosis of DM was made in 5/310 patients (1.6%; 95% CI 0.2 - 3.0). The overall prevalence of DM was 17.8% (66/371; 95% CI 13.9 - 21.7). HbA1c results were available for 57 (93.4%) of the 61 known diabetics. Of these, 27 (47.4%; 95% CI 34.4 - 60.3) had an HbA1c level ≥8.5% and 14 (24.6%; 95% CI 13.4 - 35.8) had a level ≤7%. Based on positive responses to two or more questions on the MMAS-4 questionnaire, 12/60 participants (20.0%) were deemed non-compliant.Conclusions. There is a low rate of undiagnosed DM in our elective surgical population, but in a high proportion of patients with DM the condition is poorly controlled. Poorly controlled DM is known to increase postoperative complications and is likely to increase the burden of perioperative care. Resources should be focused on improvement of long-term glycaemic control in patients presenting for elective surgery.

Muscle cramping during exercise : causes, solutions and questions remaining

Muscle cramp is a temporary but intense and painful involuntary contraction of skeletal muscle that can occur in many different situations. The causes of, and cures for, the cramps that occur during or soon after exercise remain uncertain, although there is evidence that some cases may be associated with disturbances of water and salt balance, while others appear to involve sustained abnormal spinal reflex activity secondary to fatigue of the affected muscles. Evidence in favour of a role for dyshydration comes largely from medical records obtained in large industrial settings, although it is supported by one large-scale intervention trial and by field trials involving small numbers of athletes. Cramp is notoriously unpredictable, making laboratory studies difficult, but experimental models involving electrical stimulation or intense voluntary contractions of small muscles held in a shortened position can induce cramp in many, although not all, individuals. These studies show that dehydration has no effect on the stimulation frequency required to initiate cramping and confirm a role for spinal pathways, but their relevance to the spontaneous cramps that occur during exercise is questionable. There is a long history of folk remedies for treatment or prevention of cramps; some may reduce the likelihood of some forms of cramping and reduce its intensity and duration, but none are consistently effective. It seems likely that there are different types of cramp that are initiated by different mechanisms; if this is the case, the search for a single strategy for prevention or treatment is unlikely to succeed.Publisher PDFPeer reviewe

Genome of Diuraphis noxia, a global aphid pest of small grains

Background: The Russian wheat aphid, Diuraphis noxia Kurdjumov, is one of the most important pests of small grains throughout the temperate regions of the world. This phytotoxic aphid causes severe systemic damage symptoms in wheat, barley, and other small grains as a direct result of the salivary proteins it injects into the plant while feeding.Results: We sequenced and de novo assembled the genome of D. noxia Biotype 2, the strain most virulent to resistance genes in wheat. The assembled genomic scaffolds span 393 MB, equivalent to 93% of its 421 MB genome, and contains 19,097 genes. D. noxia has the most AT-rich insect genome sequenced to date (70.9%), with a bimodal CpG(O/E) distribution and a complete set of methylation related genes. The D. noxia genome displays a widespread, extensive reduction in the number of genes per ortholog group, including defensive, detoxification, chemosensory, and sugar transporter groups in comparison to the Acyrthosiphon pisum genome, including a 65% reduction in chemoreceptor genes. Thirty of 34 known D. noxia salivary genes were found in this assembly. These genes exhibited less homology with those salivary genes commonly expressed in insect saliva, such as glucose dehydrogenase and trehalase, yet greater conservation among genes that are expressed in D. noxia saliva but not detected in the saliva of other insects. Genes involved in insecticide activity and endosymbiont-derived genes were also found, as well as genes involved in virus transmission, although D. noxia is not a viral vector.Conclusions: This genome is the second sequenced aphid genome, and the first of a phytotoxic insect. D. noxia's reduced gene content of may reflect the influence of phytotoxic feeding in shaping the D. noxia genome, and in turn in broadening its host range. The presence of methylation-related genes, including cytosine methylation, is consistent with other parthenogenetic and polyphenic insects. The D. noxia genome will provide an important contrast to the A. pisum genome and advance functional and comparative genomics of insects and other organisms.Peer reviewedBiochemistry and Molecular Biolog

Attention deficit hyperactivity and oppositional defiance disorder in HIV-infected South African children

Objective: To determine the prevalence of attention deficit-hyperactivity disorder (ADHD) and oppositional defiance disorder (ODD) in HIV-infected South African children. Methods: Swanson, Nolan and Pelham (SNAP-IV) questionnaires were used to determine ADHD and ODD severity and a draw-a-person (DAP) test was used to screen for developmental disorders. Associations between behavioural subtypes, psychological functioning, demographic and health variables were investigated. Results: The SNAP-IV caregiver questionnaires showed a 26% prevalence of ADHD inattentive type; 38% hyperactive type and 24% combined type. The prevalence of ODD was 12% on parent questionnaires and 9.5% on teacher's questionnaires. Conclusions: Parents/caregiver-only SNAP-IV questionnaires indicate a high prevalence of significant ADHD (all subtypes) and ODD in HIV-infected children. No significant differences were found between the severity of HIV disease and the presence of a behavioural disorder. The SNAP IV questionnaires and DAP test may prove valuable screening tools in HIV children with behavioural problems. © The Author [2009]. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]