Quality of care and cost of prescriptions for diabetes and hypertension at primary healthcare facilities in the Cape Town Metropole

Background: Quality of care for diabetes mellitus and hypertension has been found to be suboptimal at primary health care level. There is an expectation that improving quality will require the increased utilisation of resources. This research was intended to determine the quality of care and cost of prescriptions at 10 facilities in the Cape Town Metropole.Method: An analytical, cross-sectional study was conducted in order to relate the cost of medication to quality-of-care indicators for patients with diabetes mellitus and hypertension. Data were collected at the 10 facilities in the Cape Town Metropole over a three-month period.Results: Quality-of-care processes were performed more often in diabetic than in hypertensive patients, i.e. determination of body mass index (BMI) 52.4% vs. 46.4%, creatinine 45.2% vs. 35.7% and cholesterol 44.5% vs. 35.4%, respectively. Nevertheless, outcome measures were better in the hypertensive patients. Targets were achieved in hypertensive vs. diabetic patients, respectively, as follows: BMI (22.2% vs.18.1%), blood pressure (39.8% vs. 28.7%), creatinine (93.2% vs. 91.4%) and cholesterol (46.8% vs. 44%). The median cost per script was R44.66 and R30.06 for diabetic and hypertensive patients with good quality-of-care scores, respectively, and R51.18 and R31.00, for those with poor quality-of-care scores. Conclusion: The quality of care provided was poor when compared with the guideline recommendations, but was comparable to care provided in many other populations. There was no correlation between quality of care and the cost of the prescriptions.

An analysis of predictors of morbidity after stab wounds of the pancreas in 78 consecutive injuries

INTRODUCTION

Penetrating injuries of the pancreas may result in serious complications. This study assessed the factors influencing morbidity after stab wounds of the pancreas.

METHODS

A retrospective univariate cohort analysis was carried out of 78 patients (74 men) with a median age of 26 years (range: 16-62 years) with stab wounds of the pancreas between 1982 and 2011.

RESULTS

The median revised trauma score (RTS) was 7.8 (range: 2.0-7.8). Injuries involved the body (n=36), tail (n=24), head/uncinate process (n=16) and neck (n=2) of the pancreas. All 78 patients underwent a laparotomy. Sixty-five patients had AAST (American Association for the Surgery of Trauma) grade I or II pancreatic injuries and thirteen had grade III, IV or V injuries. Eight patients (10.3%) had an initial damage control operation. Sixty-nine patients (84.6%) had drainage of the pancreas only, six had a distal pancreatectomy and one had a pancreaticoduodenectomy. Most pancreas related complications occurred in patients with AAST grade III injuries; eight patients (10.2%) developed a pancreatic fistula. Four patients (5.1%) died. Grade of pancreatic injury (AAST grade I-II vs grade III-V injuries, p<0.001), RTS (odds ratio [OR]: 5.01, 95% confidence interval [CI]: 1.46-17.19, p<0.007), presence of shock on admission (OR: 3.31, 95% CI: 1.16-9.42, p=0.022), need for a blood transfusion (OR: 6.46, 95% CI: 2.40-17.40, p<0.001) and repeat laparotomy (p<0.001) had a significant influence on the development of general complications.

CONCLUSIONS

Although mortality was low after a pancreatic stab wound, morbidity was high. Increasing AAST grade of injury, high RTS, shock on admission to hospital, need for blood transfusion and repeat laparotomy were significant factors related to morbidity.

Optical trapping of nanotubes with cylindrical vector beams

We use laser beams with radial and azimuthal polarization to optically trap carbon nanotubes. We measure force constants and trap parameters as a function of power showing improved axial trapping efficiency with respect to linearly polarized beams. The analysis of the thermal fluctuations highlights a significant change in the optical trapping potential when using cylindrical vector beams. This enables the use of polarization states to shape optical traps according to the particle geometry, as well as paving the way to nanoprobe-based photonic force microscopy with increased performance compared to a standard linearly polarized configuration.

Provincial differences in infant deaths in South Africa – an effect of antiretroviral interventions?

Original article

Breast cancer incidence and determinants of cancer stage in the Western Cape

OBJECTIVE

To describe the overall and age-specific incidence rates for breast cancer and determinants of the stage of breast cancer at the time of diagnosis in the Western Cape, South Africa.

METHODS

Data were derived from a case-control study of the association between injectable progestagen contraceptives and breast cancer conducted over a 4-year period from January 1994 to December 1997. In all, 485 cases were drawn from a study population consisting of coloured and black women under the age of 55 years, who presented with a first occurrence of invasive breast cancer at two tertiary hospitals in Cape Town. A questionnaire was administered and information on a large number of variables was recorded.

RESULTS

The 249 cases who were interviewed during the first 2 years of the study constituted the numerator for estimates of incidence rates. The overall incidence rate was 23.1 per 100,000 women per year. The incidence rate for coloured women was 25.6 per 100,000, almost twice that for black women (14.7 per 100,000). The incidence rate in urban areas was 26.6 per 100,000, almost twice that in the rural areas (16.3 per 100,000). Stages 1 and 2 accounted for 57.8% of the cases. Early stage at diagnosis was significantly associated with a higher educational level, membership of a medical aid, residence in an urban area and a positive family history.

CONCLUSION

The data suggest that there is scope for improvement in the detection of the disease through education and access to diagnostic measures, particularly in rural and disadvantaged populations.

The spatial relationship between the perineuronal proteoglycan network and the synaptic boutons as visualized by double staining with cationic colloidal iron method and anti-calbindin-D-28K immunohistochemistry in rat cerebellar nuclei

The present study demonstrated the precise spatial relationship between meshes in the perineuronal proteoglycan network and the terminal boutons of synaptically associated axons. Sections from the rat cerebellum were stained with cationic colloidal iron (pH 1.0-1.5), and successively immunostained with anti-calbindin-D-28K monoclonal antibody. Cationic iron stained sulfated proteoglycans around the nerve cell of the medial cerebellar nucleus, whereas the anti-calbindin antibody labeled the Purkinje cells including their axons terminating on large neurons in the cerebellar nucleus. It was found that each synaptic bouton fits into a mesh of the perineuronal network. The individual meshes appeared to be divided by partitions faintly stained with the colloidal iron. Electron microscopy of cationic colloidal iron-stained ultrathin sections revealed that the synaptic boutons were separated from each other by the proteoglycan matrix and that each of them was further divided into two or more contact areas of presynaptic membrane by the same matrix. This suggests that individual synapses are protected against the effects of adjacent synaptic transmission, and that each of them may be subdivided by this manner of partitioning, like pads of a cat's paw.

Histological evaluation of poly(L-lactide/epsilon-caprolactone) membrane implanted subcutaneously in rats

BACKGROUND

Poly(L-lactide/epsilon-caprolactone) [P(L-LA/epsilon-CL)] 50/50 membranes is an absorbable membrane which has been developed recently for possible use in tissue engineering.

AIMS

To look at histological tissue reactions to the membrane and its behaviour upon its in vivo implantation in rats.

MATERIAL AND METHODS

P(L-LA/e-CL) 50/50 membranes, 0.4 mm thick, were implanted subcutaneously in the dorsal neck of 20 Wistar rats. The rats were followed-up for 1, 3, 6, 12 and 28 months. After sacrifice, subcutaneous tissues with implants were taken as specimens, inspected for any gross abnormality and histological examination was carried out.

RESULTS

No significant macroscopic changes were noticed except for two implants that were grossly rounded. Histologically, the membranes had undergone cracking, fragmentation and progressive degradation. Cracks appeared initially at the periphery of the implant. Large cracks progressed mainly in longitudinal planes. Cracks occurred in the middle of implants and led to membrane bending in some cases. "Neomembrane" formation, comprised of fibrous tissue and the implant, was seen. The foreign-body reaction to the membrane involved macrophages and foreign-body giant cells. In one case an acute type of polymorphonuclear cell reaction was observed and in a second case a predominantly lymphocytic reaction was seen at three months. They were thought to be the results of infection. No other adverse effects were seen.

CONCLUSIONS

P(L-LA/e-CL) 50/50 membrane was found to be biocompatible when implanted subcutaneously in rats. It was degraded to a great extent but not completely in 28 months.

Ultrastructure of the thyroid gland of the one-humped camel (Camelus dromedarius)

Follicular epithelium of the thyroid gland of the one-humped camel was examined by light and electron microscopy. It consisted of a single type of epithelial cell which varied from flattened to columnar in shape. Follicular epithelial cells were characterized by the presence of markedly dilated cisternae of rough-surfaced endoplasmic reticulum, well developed Golgi apparatus, abundant small vesicles (150 nm to 200 nm in diameter) in the apical cytoplasm, and electron-dense colloid droplets measuring from 250 nm to 1600 nm. Follicular epithelial cells frequently showed apocrine secretion into colloidal lumens. Apocrine protrusions with smooth surface were dome-like or balloon-like structures and contained a fine granular matrix. These findings indicate that the morphological features of the follicular epithelial cells of the thyroid gland of the camel are essentially similar to those of mammals except for the presence of apocrine secretion, which is unique to the camel.

Pulmonary development in the fetal one-humped camel: morphometry

The structural development of the fetal camel lung is described and quantified morphometrically in this report. During fetal development the lung weight and volume increased polynomially with body length. The correlation coefficient between lung weight and body length is +0.991, and between lung volume and body length is +0.995. Volume density of the future bronchial tree showed a progressive increment with gestational age and is relatively higher in male than female fetuses, and the differences are statistically significant at 340-420 mm CRL. The proportion of lung tissue occupied by saccular airspaces increased enormously during the canalicular and alveolar stage, and the differences between both sexes are statistically significant at the former stage. The number of alveoli per unit area correlates closely with body length (r = +0.928) and the correlation coefficient between alveolar diameter and body length is +0.991. On the other hand, the correlation coefficient between the number of alveolar ducts per unit area and body length is -0.993, and is about +0.977 between the diameter of alveolar ducts and body length.

Surface ultrastructure of fetal bronchial epithelium in camel

The surface ultrastructural features of fetal camel bronchial epithelium were studied at various stages of development. The bronchial epithelium in fetuses of 90-280 mm crown-to-rump length (CRL) presented a large number of disintegrating sloughed epithelial cells and a few ciliogenic cells at different stages of ciliary differentiation. The disintegrating cells had vacuolated electron lucent cytoplasm, which contained variable amounts of glycogen, swollen mitochondria, strands of dilated rough endoplasmic reticulum and irregular pyknotic nuclei. They were joined by a distorted junctional complex at their luminal ends. From 330-480 mm CR length fetuses, the disintegrating sloughed cells of the bronchial epithelium of camel lung were relatively fewer than those observed at the previous fetal stage. On the other hand, the non-ciliated microvilli-covered cells and the ciliogenic cells were increased in number. On reaching 500-560 mm CR length, the disintegrating sloughed cells had completely disappeared from the bronchial surface, and the lining epithelium was characterized by the presence of abundant ciliogenic cells at various stages of differentiation. Towards 570-700 mm CR length, most of the bronchial surface cells underwent ciliogenesis. From 830 mm CRL up to term, the bronchial epithelium demonstrated ciliated and non-ciliated microvilli-covered cells, together with some cells possessing microplicae at their apical surface.

Malignant melanoma in Cape Town, South Africa

There is a world-wide increase in the incidence of cutaneous malignant melanoma among white people. Absence of accurate population-based data on the incidence of melanoma in South Africa prompted a study to determine the incidence, anatomical sites and pathological details of melanoma in Cape Town. In a prospective study from 1 January 1990 to 31 December 1995, all the histopathology reports of melanoma presenting in a geographically defined area of Cape Town, were actively retrieved from every pathologist practising in this area. The data evaluated included information on age, sex, ethnic group and location of residence. Details of melanoma comprised body site, Clark level of invasion, Breslow thickness in millimetres and histogenetic type. The histology slides were reviewed by a panel in those cases where the recorded information was ambiguous or incomplete. A final number of 595 reports of primary invasive cutaneous melanomas in white people was analysed. Of these 50.3% were men and 49.7% women. The overall age-standardized incidence rate was 24.4 per 100,000 per annum (27.5 for men and 22.2 for women). There was no change in the incidence rate over the study period. Most melanomas in both sexes (74% of women and 71% of men) were < 1.5 mm Breslow thickness. Results of this study indicate a high incidence rate of melanoma in white South Africans, comparable with that in Australia, which demands urgent preventive health measures.

Poll glands of the one-humped camel (Camelus dromedarius): a histochemical and scanning electron microscopic study

Poll glands of the one-humped camel were obtained to examine their secretory mechanism by lectin histochemistry, immunohistochemistry and scanning electron microscopy. The glands were composed of numerous conical lobules which consisted of apocrine tubules. Lectins of peanut agglutinin (PNA), Dolicos biflorus agglutinin (DBA) and wheat germ agglutinin (WGA) showed a variety of staining in the Golgi areas and secretory granules in secretory cells of the apocrine tubules. Most myoepithelial cells stained intensely with a-smooth muscle actin. Varicose nerve fibers immunostained with protein gene product 9.5 were scattered among apocrine tubules. Scanning electron microscopy revealed that the luminal surface of secretory cells was covered with microvilli and that secretory cells pinched off smooth-surfaced apocrine blebs. After pinching off, crater-like pits remained on the luminal surface of secretory cells. These findings are similar to those obtained from the infraorbital glands of the serows.

Twenty-year birth prevalence of Down syndrome in Cape Town, South Africa

The 20-year birth prevalence of Down syndrome in Cape Town, South Africa, was determined. All cases delivered to mothers in Cape Town, plus terminations following prenatal diagnosis, between 1 January 1974 and 31 December 1993 were ascertained. There were 784 Down syndrome pregnancies, of which 95% were trisomies. The 32 terminations comprised 18.3% of the white, 5.8% of the coloured (mixed race) and 1.4% of the black cases. The overall prevalence rate was 1.49 per 1000 (white 1.88, coloured 1.54 and black 1.29 per 1000). Analysis for linear trends showed a significant decline in rates for the total population and for whites, a downward trend for coloureds, but no decline for blacks. Over the last 5-year period the prevalence rates in all three population groups were 1.3 per 1000. An increasing risk with advancing maternal age was confirmed, but no maternal age-specific differences in rates by race were demonstrated.

The effect of Edmonston-Zagreb and Schwarz measles vaccines on immune response in infants

The effects of measles immunization on immune responses in infants and the roles of vaccine strain and age of immunization are not known. Eighty-eight children were immunized at 6 or 9 months of age with the Edmonston-Zagreb (EZ) or Schwarz (SW6, SW9) strain of measles vaccine. Children were studied before and 2 weeks and 3 months after immunization. Seroconversion was similar, but geometric mean neutralizing titers at 3 months differed by vaccine group: SW9, 1367 mIU/mL; SW6, 982; and EZ, 303 (P = .003). Mitogen-induced lymphoproliferation was decreased at 2 weeks in the SW9 group and at 3 months in all groups and was negatively correlated with measles antibody level at 3 months (r = -.387, P = .003). CD8 T cells, soluble CD8, neopterin, and beta2-microglobulin were increased at 2 weeks in the SW9 group, and soluble CD8 and beta2-microglobulin remained elevated at 3 months. Therefore, measles immunization resulted in suppression of lymphoproliferation, which was most evident in infants with the highest antibody responses and most immune activation.

Epidemiology of acute leukaemia in the Cape Province of South Africa

Of 535 consecutive cases of acute leukaemia diagnosed in the Cape Province between 1978 and 1985, demographic data are incomplete in 75 black patients and they have had to be excluded from the spatial analysis. Of the remaining 460 cases, 223 (48.5%) occurred in white patients and 237 (51.5%) in those of mixed ancestry, classified as coloureds according to the Population Registration Act No. 30 of 1950. The average incidence was 2.12, 1.37 and 0.58/100,000 for whites, coloureds and blacks respectively. There was no temporal trend in the incidence of acute leukaemia between the three race groups. The median age for whites was 30 years and for the coloureds was 15 years, which is comparable to the 16 years for the black patients. The two-peak age distribution for leukaemia was seen in the white group, but was absent in the other two groups. This is accounted for by a different distribution in non-lymphoblastic as opposed to lymphoblastic subtypes. Furthermore, there was a disproportionately high frequency of acute progranulocytic leukaemia in the black patients, whereas the white and coloured groups were similar. There was a single, clearly defined macro-scale cluster restricted to white patients in Statistical Region 17 (SR-17). This exploratory study provides the first epidemiologic data for acute leukaemia in the Cape Province. It needs to be extended in order to verify these observations under more controlled circumstances and to seek evidence for some environmental factors that may account for the geographical cluster.

Postural development in very low birth weight and normal birth weight infants

In this study the seven postural responses selected by Vojta to evaluate neuromotor development were applied to 68 very low birth weight (VLBW) (greater than 1500 g) infants and to 28 healthy infants of normal birth weight (less than 2500 g). Of the 68 VLBW infants, 41 were small for gestational age and 27 appropriate for gestational age. All infants were examined between 37 and 40 weeks postmenstrual age. They were all later assessed on the Griffiths Mental Developmental Scale at 12 and 18 months. There were significant differences in postural reactions between the two groups which confirmed the lower tone and greater extension previously described in very low birth weight infants. An important finding in the study was that poor head and trunk righting noted at four months corrected age in very low birth weight infants, was associated with less developed locomotion at 12 and 18 months as assessed by the Griffiths Mental Developmental Scale. Thus, a delay in maturation in very low birth weight infants which was apparent from the assessment of postural responses in early infancy was still identifiable on the locomotor subscales at 12 and 18 months. Five of Vojta's responses were shown to be useful as part of the neurological assessment of high risk infants.