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A growing body of literature frames Last Chance Tourism as a key motivation for tourists visiting glaciers. Much of the discourse considers the contradiction of tourists contributing to the degradation of what they recognise to be a threatened attraction. Due to the significant acceleration of glacial retreat, glaciers and glacier tourism are a key focus. This paper explores the extent to which the "Last Chance" lexicon extends to the tourists' vocabulary when reflecting on their visits to Sólheimajökull Glacier and three glaciers distributed across the two hemispheres, through an analysis of 2004 TripAdvisor User Generated Content (UGC) reviews written between 2017 and 2019. The reviews reveal that a quarter of tourists are explicitly engaging in the "Last Chance" discourse. Topics of tourist satisfaction, access to the glacier, weather and guided tours are more common. For those who do mention the "Last Chance" aspect, commentary on the aesthetics of the glacier, a recognition of the impact of climate change, and warnings to future travelers are captured with no clear indication of experiences leading to an ambassadorship. The tourists engage in a vicious cycle enhancing the retreat of glaciers by viewing them. Understanding these perspectives is critical in managing these destinations sustainably. [ABSTRACT FROM AUTHOR]

Objective: Any needle biopsy procedure is associated with a false-negative rate; therefore, masses diagnosed as benign by needle biopsy should be followed to confirm their stability. This study determines patient compliance with recommended 6-month follow-up of breast masses that have had benign cytology.Materials and Methods: This study consists of a retrospective 5-year chart review from August 1994 to August 1999. The study includes patients who had an ultrasound-guided fine-needle aspiration biopsy of a solid breast mass diagnosed as benign and were told to return in 6 months for follow-up. Patients who had the masses surgically removed were excluded. Patients who did not follow-up within a 1-year period were sent a letter of reminder.Results: Over the 5-year period, a total of 462 patients had an ultrasound-guided fine-needle aspiration biopsy of a solid breast mass diagnosed as benign and were instructed to return at 6 months for follow-up. Two hundred ninety-six (64%) of these patients returned for follow-up within 1 year. The remaining 166 patients were sent a let-ter of reminder. Of these 166 patients, 71 (43%) responded to the letter; 5 patients were lost to follow-up because they had moved. Of all 462 patients, 367 (79%) eventually returned for follow-up, at an average of 9.2 months after biopsy.Conclusions: Over a 5-year period, 296 out of 462 (64%) patients were compliant with recommendations for follow-up, and an additional 71 patients responded to a letter of reminder. Noncompliance with recommended follow-up could lead to a delay in diagnosis of false-negative lesions. This study demonstrates the need for radiologists to have a system to track compliance. [ABSTRACT FROM AUTHOR]

In South Africa, symptoms of common mental disorders (CMDs) such as depression and anxiety are highly prevalent during the perinatal period and linked to experiences of domestic violence. However, limited routine detection and treatment is available to pregnant women with these problems, even though evidence suggests that screening and treating CMDs during pregnancy improves the health and economic outcomes of mothers and their children, and has been suggested as a key approach to improving the health of perinatal women and children. We investigated facilitators and barriers of service-providers and service-users in detecting and treating pregnant women with symptoms of CMDs and experiences of domestic violence. This study was conducted in four midwife obstetric units (MOUs) in Cape Town, South Africa, and in the non-profit organisations providing community-based support in the communities surrounding the MOUs. Service-provider perspectives were informed by qualitative interviews with 37 healthcare workers providing care to pregnant women. Qualitative interviews with 38 pregnant women attending the same MOUs for their first antenatal care visit provided service-user perspectives. Facilitators identified included the availability of a mental health screening questionnaire and the perceived importance of detection and treatment by both service-providers and -users. Barriers contributing to the low detection rates included service-users concerns about the lack of confidentiality and feelings of shame related to experiences of domestic violence as well as service providers discomfort in dealing with mental health issues, their limited time available and heavy patient load. In addition, service-providers highlighted the lack of standardised referral pathways and the poor uptake of referrals by women with symptoms of depression and anxiety, or experiences of domestic violence. While the system-level barriers need to be addressed at a policy level, the patient- and provider-level barriers identified indicate the need to strengthen health systems by training antenatal care nurses to detect symptoms of CMDs and experiences of domestic violence in pregnant women, developing standardised referral pathways and training lay healthcare workers to provide treatment for mild symptoms of depression and anxiety., (© 2023. The Author(s).)

To achieve universal health coverage, health system strengthening (HSS) is required to support the of delivery of high-quality care. The aim of the National Institute for Health Research Global Research Unit on HeAlth System StrEngThening in Sub-Saharan Africa (ASSET) is to address this need in a four-year programme, with three healthcare platforms involving eight work-packages. Key to effective health system strengthening (HSS) is the pre-implementation phase of research where efforts focus on applying participatory methods to embed the research programme within the existing health system. To conceptualise the approach, we provide an overview of the key methods applied across work-package to address this important phase of research conducted between 2017 and 2021.Work-packages are being undertaken in publicly funded health systems in rural and urban areas in Ethiopia, Sierra Leone, South Africa, and Zimbabwe. Stakeholders including patients and their caregivers, community representatives, clinicians, managers, administrators, and policymakers are the main research participants.In each work-package, initial activities engage stakeholders and build relationships to ensure co-production and ownership of HSSIs. A mixed-methods approach is then applied to understand and address determinants of high-quality care delivery. Methods such as situation analysis, cross-sectional surveys, interviews and focus group discussions are adopted to each work-package aim and context. At the end of the pre-implementation phase, findings are disseminated using focus group discussions and participatory Theory of Change workshops where stakeholders from each work package use findings to select HSSIs and develop a programme theory.ASSET places a strong emphasis of the pre-implementation phase in order to provide an in-depth and systematic diagnosis of the existing heath system functioning, needs for strengthening and stakeholder engagement. This common approach will inform the design and evaluation of the HSSIs to increase effectiveness across work packages and contexts, to better understand what works, for whom, and how.

Background: South Africa has a high burden of perinatal common mental disorders (CMD), such as depression and anxiety, as well as high levels of poverty, food insecurity and domestic violence, which increases the risk of CMD. Yet public healthcare does not include routine detection and treatment for these disorders. This pilot study aims to evaluate the implementation outcomes of a health systems strengthening (HSS) intervention for improving the quality of care of perinatal women with CMD and experiences of domestic violence, attending public healthcare facilities in Cape Town., Methods: Three antenatal care facilities were purposively selected for delivery of a HSS programme consisting of four components: (1) health promotion and awareness raising talks delivered by lay healthcare workers; (2) detection of CMD and domestic violence by nurses as part of routine care; (3) referral of women with CMD and domestic violence; and (4) delivery of structured counselling by lay healthcare workers in patients' homes. Participants included healthcare workers tasked with delivery of the HSS components, and perinatal women attending the healthcare facilities for routine antenatal care. This mixed methods study used qualitative interviews with healthcare workers and pregnant women, a patient survey, observation of health promotion and awareness raising talks, and a review of several documents, to evaluate the acceptability, appropriateness, feasibility, adoption, fidelity of delivery, and fidelity of receipt of the HSS components. Thematic analysis was used to analyse the qualitative interviews, while the quantitative findings for adoption and fidelity of receipt were reported using numbers and proportions., Results: Healthcare workers found the delivery and content of the HSS components to be both acceptable and appropriate, while the feasibility, adoption and fidelity of delivery was poor. We demonstrated that the health promotion and awareness raising component improved women's attitudes towards seeking help for mental health conditions. The detection, referral and treatment components were found to improve fidelity of receipt, evidenced by an increase in the proportion of women undergoing routine detection and referral, and decreased feelings of distress in women who received counselling. However, using a task-sharing approach did not prove to be feasible, as adding additional responsibilities to already overburdened healthcare workers roles resulted in poor fidelity of delivery and adoption of all the HSS components., Conclusions: The acceptability, appropriateness and fidelity of receipt of the HSS programme components, and poor feasibility, fidelity of delivery and adoption suggest the need to appoint dedicated, lay healthcare workers to deliver key programme components, at healthcare facilities, on the same day., (© 2022. The Author(s).)

Background: During the perinatal period, common mental disorders (CMDs) such as depression and anxiety are highly prevalent, especially in low-resource settings, and are associated with domestic violence, poverty, and food insecurity. Perinatal CMDs have been associated with several adverse maternal and child outcomes. While the Department of Health in South Africa provides healthcare workers with the tools to detect psychological distress and experiences of domestic violence, few healthcare workers routinely screen pregnant women at clinic visits, citing discomfort with mental health issues and the lack of standardised referral pathways as the key barriers. The aim of this study is to select and evaluate a set of health systems strengthening (HSS) interventions aimed at improving the care and outcomes for perinatal women with CMDs and experiences of domestic violence, attending public healthcare facilities in Cape Town., Methods: This study consists of a pre-implementation, development, and implementation phase. Contextual barriers identified during the pre-implementation phase included poor patient knowledge and health-seeking behaviour, high levels of stigma, and poor detection, referral, and treatment rates. Implementation science determinant frameworks were applied to findings from the pre-implementation phase to identify determinants and gaps in delivering high-quality evidence-informed care. A participatory Theory of Change workshop was used to design a HSS programme, consisting of awareness raising, detection, referral, and treatment. HSS interventions selected to support the delivery of the HSS programme includes training, health promotion, change to the healthcare environment, task-sharing, audit and feedback, and performance monitoring. The implementation phase will be used to assess several implementation and clinical outcomes associated with the delivery of the HSS programme, which will be piloted at three healthcare facilities. Qualitative and quantitative methods will be used to evaluate the implementation and clinical outcomes., Discussion: This pilot implementation study will inform us about a range of implementation and clinical outcome measures that are relevant for assessing HSS interventions for perinatal women with depression, anxiety, or experiences of domestic violence in low-resource settings. Lessons learnt from the pilot study will be incorporated into the design of a cluster randomised control trial for which further funding will be sought., (© 2022. The Author(s).)

Background: Common mental disorders (CMDs), i.e. depression and anxiety, are highly prevalent during the perinatal period, and is associated with poverty, food insecurity and domestic violence. We collected data from perinatal women at two time-points during the COVID-19 pandemic to test the hypotheses that (1) socio-economic adversities at baseline would be associated with CMD prevalence at follow-up and (2) worse mental health at baseline would be associated with higher food insecurity prevalence at follow-up., Methods: Telephonic interviews with perinatal women attending healthcare facilities in Cape Town, South Africa. Multivariable (multilevel) regression analysis was used to model the associations of baseline risk factors with the prevalence of household food insecurity and probable CMD at 3 months follow-up., Results: At baseline 859 women were recruited, of whom 217 (25%) were pregnant, 631 (73%) had given birth in the previous 6 months, 106 (12%) had probable CMD, and 375 (44%) were severely food insecure. At follow-up ( n = 634), 22 (4%) were still pregnant, 603 (95%) had given birth, 44 (7%) had probable CMD, and 207 (33%) were severely food insecure. In the multivariable regression model, after controlling for confounders, unemployment [incidence rate ratio (IRR) 1.19 (1.12-2.27); p < 0.001] and had higher scores on the Edinburgh Postnatal Depression Scale [IRR 1.05 (1.03-1.09); p < 0.001] at baseline predicted food insecurity at follow-up; and experiencing domestic violence [OR 2.79 (1.41-5.50); p = 0.003] at baseline predicted CMD at follow-up., Conclusions: This study highlights the complex bidirectional relationship between mental health and socio-economic adversity among perinatal women during the COVID-19 pandemic., (© The Author(s) 2022.)

Purpose: We aimed to explore the relationship between common mental disorders (CMDs), food insecurity and experiences of domestic violence among pregnant women attending public sector midwife obstetric units and basic antenatal care clinics in Cape Town during the COVID-19 lockdown., Methods: Perinatal women, attending 14 healthcare facilities in Cape Town, were enrolled in the study during baseline data collection before the COVID-19 lockdown. During the lockdown period, fieldworkers telephonically contacted the perinatal women who were enrolled in the study and had provided contact details. The following data were collected from those who consented to the study: socio-demographic information, mental health assessment, food insecurity status and experiences of domestic violence. Poisson regression was used to model the associations of a number of risk factors with the occurrence of CMDs., Results: Of the 2149 women enrolled in the ASSET study, 885 consented to telephonic interviews. We found that 12.5% of women had probable CMDs and 43% were severely food insecure. Psychological distress increased significantly during the lockdown period, compared to before the COVID-19 outbreak. Using multivariate Poisson regression modelling, we showed that the risk of CMDs was increased in women who were severely food insecure or who experienced psychological or sexual abuse., Conclusions: This study provides evidence of the effect of the COVID-19 lockdown on the mental health status of perinatal women living in low-resource settings in Cape Town and highlights how a crisis such as the COVID-19 lockdown amplifies the psycho-social risk factors associated with CMDs in perinatal women., (© 2021. The Author(s).)

Background: Symptoms of depression and anxiety are highly prevalent amongst perinatal women in low-resource settings of South Africa, but there is no access to standardised counselling support for these conditions in public health facilities. The aim of this study is to develop a task-sharing psychological counselling intervention for routine treatment of mild to moderate symptoms of perinatal depression and anxiety in South Africa, as part of the Health Systems Strengthening in sub-Saharan Africa (ASSET) study., Methods: We conducted a review of manuals from seven counselling interventions for depression and anxiety in low- and middle-income countries and two local health system training programmes to gather information on delivery format and common counselling components used across task-sharing interventions. Semi-structured interviews were conducted with 20 health workers and 37 pregnant women from four Midwife Obstetric Units in Cape Town to explore perceptions and needs relating to mental health. Stakeholder engagements further informed the intervention design and appropriate service provider. A four-day pilot training with community-based health workers refined the counselling content and training material., Results: The manual review identified problem-solving, psychoeducation, basic counselling skills and behavioural activation as common counselling components across interventions using a variety of delivery formats. The interviews found that participants mostly identified symptoms of depression and anxiety in behavioural terms, and lay health workers and pregnant women demonstrated their understanding through a range of local idioms. Perceived causes of symptoms related to interpersonal conflict and challenging social circumstances. Stakeholder engagements identified a three-session counselling model as most feasible for delivery as part of existing health care practices and community health workers in ward-based outreach teams as the best placed delivery agents. Pilot training of a three-session intervention with community-based health workers resulted in minor adaptations of the counselling assessment method., Conclusion: Input from health workers and pregnant women is a critical component of adapting existing maternal mental health protocols to the context of routine care in South Africa, providing valuable data to align therapeutic content with contextual needs. Multisector stakeholder engagements is vital to align the intervention design to health system requirements and guidelines.

Background: Pregnant and postnatal adolescent women are a high-risk group for common mental disorders (CMDs); however, they have low levels of engagement and retention with mental health services. Negative consequences of CMDs have been documented for both mother and child., Aim: The study aimed to explore the barriers and facilitators to service access for adolescents in low-resource settings., Setting: We interviewed 12 adolescents, aged 15-19 years, from low-resource settings in Cape Town, South Africa. Participants had previously engaged with a mental health service, integrated into maternity care., Methods: Twelve semi-structured, individual interviews were used for this qualitative study. Interviews were recorded, transcribed and coded. A framework analysis was employed for data analysis., Results: Adolescents perceived considerable stigma around both teenage pregnancy and mental illness, which inhibited use of mental health services. Other barriers included fearing a lack of confidentiality as well as logistical and environmental obstacles. Service uptake was facilitated by support from other adults and flexible appointment times. Face-to-face individual counselling was their preferred format for a mental health intervention., Conclusion: Several key components for adolescent-friendly mental health services emerged from our findings: integrate routine mental health screening into existing obstetric services to de-stigmatise mental health problems and optimise screening coverage; coordinate obstetric and counselling appointment times to rationalise the use of limited resources; and sensitise care providers to the needs of adolescents to reduce stigma around adolescent sexual activity and mental illness. A non-judgemental, caring and confidential relationship between counsellors and clients is crucial for successful interactions.

Background: In South Africa, the prevalence of symptoms of common mental disorders (CMD), i.e. depression, anxiety and suicidal thoughts are high. This study aimed to use a cognitive interviewing technique to validate the content and structure of a 4-item screening tool, to adapt the tool accordingly, and to use receiver operating curve (ROC) analysis to determine the optimum cut-point for identifying pregnant women with symptoms of CMD., Methods: We conducted a mixed method study at a Midwife Obstetric Unit in Cape Town. Women attending the clinic for their first antenatal visit during the recruitment period, whose first language was English, Afrikaans or isiXhosa, were invited to participate. A 4-item screening tool was administered in the first language of the interviewee, after which a cognitive interviewing technique was used to examine the question-response processes and considerations used by respondents as they formed answers to the screening tool questions. The Edinburgh Postnatal Depression Scale (EPDS) was used to identify women with symptoms of CMD., Results: A 2-week recall period performed well. Questions about (1) being unable to stop worrying, or thinking too much, (2) feeling down, depressed or hopeless, and (3) having thoughts and plans to harm yourself, were well understood. The question that referred to feeling little interest or pleasure in doing things, was poorly understood across all languages. Using ROC analysis with the EPDS as the reference standard, and a cut-point of ≥13, we showed that a 3-item version of the screening tool was able to correctly classify 91% of the women screened., Conclusions: Cognitive interviewing enabled testing and refining of the language and constructs of an ultra-brief screening tool. The shortened, 3-item tool is well understood and effective at identifying pregnant women with symptoms of CMD, across the three most commonly spoken languages and cultures in Cape Town.

Background:  Changing global health and development trends have resulted in a need for continued professional development (CPD) within the health and development sectors. In low-resource settings, where the need for training and CPD may be highest, there are significant challenges for disseminating information and skills. There is a need to improve mental health literacy and reduce levels of stigma about maternal mental illness. The Bettercare series of distance learning books provides a peer-based format for CPD. We aimed to evaluate the Bettercare Maternal Mental Health book as a format for CPD., Aim:  The aim of this study was to determine whether the Bettercare Maternal Mental Health book significantly improves knowledge and decreases stigma around mental health for care providers from the health and social development sectors., Setting:  One hundred and forty-one participants (social workers, nursing students and health professionals) were provided with the Bettercare Maternal Mental Health book to study., Methods:  Before and after studying the book, the same multiple-choice knowledge test and the Mental Illness Clinicians' Attitude Scale were used to assess cognitive knowledge and mental health stigma, respectively., Results:  Participants' knowledge showed a statistically significant (p < 0.001) improvement between the pre- and post-test results, for all six chapters of the book. However, participants' attitudes towards mental illness did not show a statistically significant change between the pre- and post-test results., Conclusion:  We found that this method of learning elicited significant improvement in mental health knowledge for care providers. Continued professional development policy planners and curriculum developers may be interested in these findings.

The development of lipodystrophy is associated with the long-term use of antiretroviral therapy (ART). We assessed agreement between patient-reported lipodystrophy and body composition measures using dual-energy X-ray absorptiometry (DXA) and developed objective measures to define lipoatrophy and lipohypertrophy in black South Africans. One hundred and eighty-seven ART-naïve HIV-infected adults were enrolled in a 24-month longitudinal study. Self-reported information on regional fat loss and fat gain, anthropometry, and DXA measures were collected at baseline, three, six, 12, 18, and 24 months after starting ART. Receiver operating characteristic curves were used to describe the performance of anthropometric variables using change in limb and trunk fat measured by DXA, as the reference standard. The proportion of men and women who developed lipoatrophy and lipohypertrophy increased over the 24-month period, with lipoatrophy occurring more frequently in men (21% versus 10%). In women, lipoatrophy was best determined by thigh skinfold thickness (80.3% correctly classified) and mid-arm circumference (77.6% correctly classified). None of the anthropometric measures performed well for defining lipoatrophy in men. Anthropometric measures performed well for defining lipoatrophy in women, but not lipohypertrophy.

Purpose: Food insecurity has been linked with maternal depression in low-income settings. Few studies have looked at factors associated with both food insecurity and maternal depression as outcomes. This study aimed to assess factors associated with food insecurity and depression in a sample of pregnant South African women., Methods: We conducted a cross-sectional study at a Midwife Obstetric Unit in a low-income suburb in Cape Town. Pregnant women attending the clinic for their first antenatal visit were invited to participate. The shortened form of the US Household Food Security Survey Module was used to measure food insecurity. The Expanded Mini-International Neuropsychiatric Interview was used to diagnose depression, anxiety, alcohol and drug dependence, and assess for suicidal ideation and behaviour. Logistic regression modelling was conducted to explore factors associated with food insecurity and depression in separate models., Results: We found that 42% of households were food insecure and that 21% of participants were depressed (N = 376). The odds of being food insecure were increased in women with suicidal behaviour (OR = 5.34; 95% CI 1.26-22.57), with depression (4.27; 1.43-12.70) and in those with three or more children (3.79; 1.25-11.55). The odds of depression was greater in women who were food insecure (5.30; 1.63-17.30), substance dependent (15.83; 1.31-191.48) or diagnosed with an anxiety disorder (5.04; 1.71-14.82)., Conclusions: Food insecurity and depression are strongly associated in pregnant women. The relationship between food insecurity and depression is complex and requires further investigation. Interventions that improve both food security and mental health during the perinatal period are likely to benefit the physical and mental well-being of mothers and children.

Long-term use of antiretroviral therapy (ART) increases the risk of developing lipodystrophy. Few studies from Africa have used longitudinal data to assess the development of lipoatrophy and lipohypertrophy. We use clinical anthropometry and dual-energy X-ray absorptiometry (DEXA) to describe changes in body fat distribution over a 24-month period in individuals initiated on ART. A convenience sample of black South Africans (55 men and 132 women) were recruited and followed for 24 months after commencing ART. Body fat distribution was assessed using anthropometric measurements and DEXA scans at baseline and then at 3, 6, 12, 18, and 24 months after commencing ART. DEXA was also used to estimate abdominal visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT). Women gained more overall weight and more regional fat in all areas analyzed on DEXA scans. Women, not men, experienced a significant increasing trend in trunk fat and a significant decreasing trend in limb fat, when expressed as a percentage of total body fat. In men, the risk of developing lipoatrophy was more than two times greater than that of women, after adjusting for age, baseline body mass index, and ART regimen. Lipohypertrophy occurred similarly in men and women. VAT and SAT increased significantly in men and women, with women gaining considerably more than men. These findings are of great concern as an increased waist circumference is associated with increased mortality in HIV-infected populations. Further investigation is required to understand the mechanisms underlying the sex differences in changes in body fat distribution and its effects on cardiovascular risk.

Background: Numerous studies in schools in the Western Cape Province, South Africa have shown that children have an unhealthy diet with poor diversity and which is high in sugar and fat. HealthKick (HK) was a three-year randomised controlled trial aimed at promoting healthy eating habits., Methods: Sixteen schools were selected from two low-income school districts and randomly allocated to intervention (n = 8) or control school (n = 8) status. The HK intervention comprised numerous activities to improve the school nutrition environment such as making healthier food choices available and providing nutrition education support. Dietary intake was measured by using a 24-h recall in 2009 in 500 grade 4 learners at intervention schools and 498 at control schools, and repeated in 2010 and 2011. A dietary diversity score (DDS) was calculated from nine food groups and frequency of snack food consumption was determined. A school level analysis was performed., Results: The mean baseline (2009) DDS was low in both arms 4.55 (SD = 1.29) and 4.54 (1.22) in the intervention and control arms respectively, and 49 % of learners in HK intervention schools had a DDS ≤4 (=low diversity). A small increase in DDS was observed in both arms by 2011: mean score 4.91 (1.17) and 4.83 (1.29) in the intervention and control arms respectively. The estimated DSS intervention effect over the two years was not significant [0 .04 (95 % CI: -0.37 to 0.46)]. Food groups least consumed were eggs, fruit and vegetables. The most commonly eaten snacking items in 2009 were table sugar in beverages and/or cereals (80.5 %); followed by potato crisps (53.1 %); non-carbonated beverages (42.9 %); sweets (26.7 %) and sugar-sweetened carbonated beverages (16 %). Unhealthy snack consumption in terms of frequency of snack items consumed did not improve significantly in intervention or control schools., Discussion: The results of the HK intervention were disappointing in terms of improvement in DDS and a decrease in unhealthy snacking. We attribute this to the finding that the intervention model used by the researchers may not have been the ideal one to use in a setting where many children came from low-income homes and educators have to deal with daily problems associated with poverty., Conclusions: The HK intervention did not significantly improve quality of diet of children.

Background: A number of metabolic abnormalities, such as dysglycaemia, insulin resistance, lipodystrophy and dyslipidaemia, are associated with the use of antiretroviral drugs. We aimed to assess the effects of long-term antiretroviral exposure on blood pressure, glycaemia, insulin secretion and anthropometric measures in black South African women., Methods: A convenience sample of HIV-infected women on first-line ART for a median of 16 months at baseline, had the following evaluations twice, at baseline and after approximately 5 years: anthropometry, including skin fold thicknesses, blood pressure, oral glucose test, and insulin. Insulin sensitivity and secretion (HOMA-IR, IGI and DIo) were estimated., Results: At baseline more than half the 103 women were using stavudine and efavirenz. The median interval between baseline and follow-up evaluation was 66 months. Weight, waist circumference, and waist-hip ratio increased over time, while limb skinfold thickness decreased over time. Systolic and diastolic blood pressure increased significantly and the proportion of participants with hypertension increased from 3.9 to 15.5% (p < 0.001). There were increases from baseline in plasma glucose concentrations at 30 and 120 min; insulin concentrations at 0 and 30 min; and IGI and DIo. The proportion of participants with diabetes increased from 1 to 7.5% (p = 0.070)., Conclusion: In black South African women with long-term exposure to ART, increases in hypertension and possibly diabetes were observed. Participants experienced an increase in central fat and a decrease in peripheral fat distribution. Early identification and management of these metabolic changes are important, especially in a region with the highest HIV-infected population in the world.

Background: Lipohypertrophy does not appear to be an adverse ART reaction while lipoatrophy is clearly associated with the use of stavudine (d4T) and zidovudine (AZT). In low and middle income countries d4T has only recently been phased out and AZT is still widely being used. Several case definitions have been developed to diagnose lipodystrophy, but none of them are generalizable to sub-Saharan Africa where black women have less visceral adipose tissue and more subcutaneous adipose tissue than white women. We aimed to develop a simple, objective measure to define lipoatrophy and lipohypertrophy by comparing patient report to anthropometric and dual-energy X-ray absorptiometry (DXA) -derived variables., Methods: DXA and anthropometric measures were obtained in a cross sectional sample of black HIV-infected South African men (n = 116) and women (n = 434) on ART. Self-reported information on fat gain or fat loss was collected using a standard questionnaire. Receiver operating characteristic (ROC) curves were used to describe the performance of anthropometric and DXA-derived variables using patient reported lipoatrophy and lipohypertrophy as the reference standard., Results: Lipoatrophy and lipohypertrophy were more common in women (25% and 33% respectively) than in men (10% and 13% respectively). There were insufficient numbers of men with DXA scans for meaningful analysis. The best predictors of lipoatrophy in women were the anthropometric variables tricep (AUC = 0.725) and thigh skinfold (AUC =0.720) thicknesses; and the DXA-derived variables percentage lower limb fat (AUC = 0.705) and percentage lower limb fat/height (AUC = 0.713). The best predictors of lipohypertrophy in women were the anthropometric variable waist/hip ratio (AUC = 0.645) and the DXA-derived variable percentage trunk fat/percentage limb fat (AUC = 0.647)., Conclusions: We were able to develop simple, anthropometric measures for defining lipoatrophy and lipohypertrophy, using a sample of black HIV-infected South African women with DXA scans. This is of particular relevance in resource limited settings, where health professionals need simple and inexpensive methods of diagnosing patients with lipoatrophy and lipohypertrophy.

Inflammatory pseudotumor (IPT) of the liver is a rare, benign lesion that may be mistaken for malignancy. IPTs are difficult to diagnose due to non-specific clinical, laboratory and imaging features. We report the case of a 38-year old Asian male who presented with fatigue, weight loss and hepatomegaly. He was found to have a large hepatic IPT and underwent surgical resection; approximately two and a half years later, he developed acute cholangitis secondary to IPT recurrence. We present the imaging features of hepatic IPT using ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI). We also review the literature on the diagnosis and management of this disease. The unique features of this case include the IPT's recurrence following surgical resection, large size and multiple modalities presented.

Objective: To determine the frequency and content of food-related television (TV) advertisements shown on South African TV., Design: Four national TV channels were recorded between 15.00 and 21.00 hours (6 h each day, for seven consecutive days, over a 4-week period) to: (i) determine the number of food-related TV advertisements; and (ii) evaluate the content and approach used by advertisers to market their products. The data were viewed by two of the researchers and coded according to time slots, food categories, food products, health claims and presentation., Results: Of the 1512 recorded TV advertisements, 665 (44 %) were related to food. Of these, 63 % were for food products, 21 % for alcohol, 2 % for multivitamins, 1 % for slimming products and 13 % for supermarket and pharmacy promotions. Nearly 50 % of food advertisements appeared during family viewing time. During this time the most frequent advertisements were for desserts and sweets, fast foods, hot beverages, starchy foods and sweetened drinks. The majority of the alcohol advertisements (ninety-three advertisements, 67 %) fell within the children and family viewing periods and were endorsed by celebrities. Health claims were made in 11 % of the advertisements. The most frequently used benefits claimed were ‘enhances well-being’, ‘improves performance’, ‘boosts energy’, ‘strengthens the immune system’ and ‘is nutritionally balanced’., Conclusions: The majority of food advertisements shown to both children and adults do not foster good health despite the health claims made. The fact that alcohol advertisements are shown during times when children watch TV needs to be addressed.

Background: Right ventricular (RV) dysfunction frequently occurs and independently prognosticates in left-sided heart failure. It is not clear which RV afterload measure has the greatest impact on RV function and prognosis. We examined the determinants, prognostic role, and response to treatment of pulmonary arterial capacitance (PAC, ratio of stroke volume over pulmonary pulse pressure), in relation to pulmonary vascular resistance (PVR) in heart failure., Methods and Results: We reviewed 724 consecutive patients with heart failure who underwent right heart catheterization between 2000 and 2005. Changes in PAC were explored in an independent cohort of 75 subjects treated for acute decompensated heart failure. PAC showed a strong inverse relation with PVR (r=-0.64) and wedge pressure (r=-0.73), and provides stronger prediction of significant RV failure than PVR (area under the curve ROC 0.74 versus 0.67, respectively, P=0.003). During a mean follow-up of 3.2±2.2 years, both lower PAC (P<0.0001) and higher PVR (P<0.0001) portend more adverse clinical events (all-cause mortality and cardiac transplantation). In multivariate analysis, PAC (but not PVR) remains an independent predictor (Hazard ratio=0.92 [95% CI: 0.84-1.0, P=0.037]). Treatment of heart failure resulted in a decrease in PVR (270±165 to 211±88 dynes·s(-1)·cm(-5), P=0.002), a larger increase in PAC (1.65±0.64 to 2.61±1.42 mL/mm Hg, P<0.0001), leading to an increase in pulmonary arterial time constant (PVR×PAC) (0.29±0.12 to 0.37±0.15 second, P<0.0001)., Conclusions: PAC bundles the effects of PVR and left-sided filling pressures on RV afterload, explaining its strong relation with RV dysfunction, poor long-term prognosis, and response to therapy.

Background: This study evaluated the primary school environment in terms of being conducive to good nutrition practices, sufficient physical activity and prevention of nicotine use, with the view of planning a school-based health intervention., Methods: A sample of 100 urban and rural disadvantaged schools was randomly selected from two education districts of the Western Cape Education Department, South Africa. A situation analysis, which comprised an interview with the school principal and completion of an observation schedule of the school environment, was done at all schools., Results: Schools, on average, had 560 learners and 16 educators. Principals perceived the top health priorities for learners to be an unhealthy diet (50%) and to far lesser degree, lack of physical activity (24%) and underweight (16%). They cited lack of physical activity (33%) and non-communicable diseases (NCDs; 24%) as the main health priorities for educators, while substance abuse (66%) and tobacco use (31%) were prioritised for parents. Main barriers to health promotion programmes included lack of financial resources and too little time in the time table. The most common items sold at the school tuck shops were crisps (100%), and then sweets (96%), while vendors mainly sold sweets (92%), crisps (89%), and ice lollies (38%). Very few schools (8%) had policies governing the type of food items sold at school. Twenty-six of the 100 schools that were visited had vegetable gardens. All schools reported having physical activity and physical education in their time tables, however, not all of them offered this activity outside the class room. Extramural sport offered at schools mainly included athletics, netball, and rugby, with cricket and soccer being offered less frequently., Conclusion: The formative findings of this study contribute to the knowledge of key environmental and policy determinants that may play a role in the health behaviour of learners, their parents and their educators. Evidently, these show that school environments are not always conducive to healthy lifestyles. To address the identified determinants relating to learners it is necessary to intervene on the various levels of influence, i.e. parents, educators, and the support systems for the school environment including the curriculum, food available at school, resources for physical activity as well as appropriate policies in this regard.

Background: During the last century we have seen wide-reaching changes in diet, nutritional status and life expectancy. The change in diet and physical activity patterns has become known as the nutrition transition. At any given time, a country or region within a country may be at different stages within this transition. This paper examines a range of nutrition-related indicators for countries in Sub-Saharan Africa (SSA) and attempts to develop a typical model of a country in transition., Methods: Based on the availability of data, 40 countries in SSA were selected for analysis. Data were obtained from the World Health Organisation, Demographic and Health Surveys and the Food and Agriculture Organisation of the United Nations. Multiple linear regression analysis (MLRA) was used to explore the determinants of infant mortality. A six point score was developed to identify each country's stage in the nutrition transition., Results: MLRA showed that underweight-for-age, protein and the percentage of exclusively breastfed infants were associated with the infant mortality rate (IMR). The majority of countries (n = 26) used in the analysis had nutrition transition scores of zero and one. Most of them had a high prevalence of infant mortality, children that were stunted or underweight-for-age, small percentages of women that were overweight and obese, and low intakes of energy, protein, and fat. Countries with the highest scores include South Africa, Ghana, Gabon, Cape Verde and Senegal which had relatively low IMRs, high levels of obesity/overweight, and low levels of underweight in women, as well as high intakes of energy and fat. These countries display classic signs of a population well established in the nutrition-related non-communicable disease phase of the nutrition transition., Conclusions: Countries in SSA are clearly undergoing a nutrition transition. More than half of them are still in the early stage, while a few have reached a point where changes in dietary patterns are affecting health outcomes in a large portion of the population. Those in the early stage of the transition are especially important, since primordial prevention can still be introduced.

Objective: To identify and describe factors associated with food shop (known as tuck shop in South Africa) and lunchbox behaviours of primary-school learners in South Africa., Design: Analysis of data collected in 2008 from a cross-sectional survey., Setting: Sixteen primary schools in the Western Cape, South Africa., Subjects: A total of 717 grade 4 learners aged 10-12 years., Results: A 24 h recall established that 69 % of learners carried a lunchbox to school and 49 % had consumed at least one item purchased from the school food shop/vendor. Most lunchboxes contained white bread with processed meat, whereas the most frequent food shop/vendor purchase comprised chips/crisps. Learners who carried a lunchbox to school had significantly lower BMI percentiles (P = 0·002) and BMI-for-age (P = 0·034), compared with their counterparts. Moreover, they were younger, had higher standard-of-living and dietary diversity scores, consumed more meals per day, had greater self-efficacy and came from predominantly urban schools, compared with those who did not carry a lunchbox to school. Learners who ate food shop/vendor purchases had a lower standard-of-living score and higher dietary diversity and meal scores. Only 2 % of learners were underweight, whereas 19 % were stunted and 21 % were overweight/obese (BMI ≥ 25 kg/m2)., Conclusions: Children who carried a lunchbox to school appeared to have greater dietary diversity, consumed more regular meals, had a higher standard of living and greater nutritional self-efficacy compared with those who did not carry a lunchbox to school.

Background: The burden of non-communicable diseases, including type 2 diabetes, is growing in South Africa. This country has a complex mix of over- and under-nutrition, especially in low-income communities, and concerning levels of physical inactivity in children and youth. This paper describes HealthKick, a school-based nutrition and physical activity intervention in primary schools in these settings aimed at reducing diabetes risk factors., Methods/design: This study includes schools within historically disadvantaged, low-income communities from an urban area close to the city of Cape Town and from two rural areas outside of Cape Town, South Africa. The three Educational Districts involved are Metropole North, Cape Winelands and the Overberg. The study has three phases: intervention mapping and formative assessment, intervention development, and outcome and process evaluation. Sixteen schools were purposively selected to participate in the study and randomly allocated as intervention (eight schools) and control (eight schools).The primary aims of HealthKick are to promote healthful eating habits and increase regular participation in health-enhancing physical activity in children, parents and teachers, to prevent overweight, and reduce risk of chronic diseases (particularly type 2 diabetes); as well as to promote the development of an environment within the school and community that facilitates the adoption of healthy lifestyles.The components of HealthKick are: action planning, toolkit (resource guide, a resource box and physical activity resource bin), and an Educators' Manual, which includes a curriculum component., Discussion: This study continues to highlight the key role that educators play in implementing a school-based intervention, but that developing capacity within school staff and stakeholders is not a simple or easy task. In spite of the challenges experienced thus far, valuable findings are being produced from this study, especially from Phase 1. Materials developed could be disseminated to other schools in low-income settings both within and outside of South Africa. Owing to the novelty of the HealthKick intervention in low-income South African primary schools, the findings of the evaluation phase have the potential to impact on policy and practice within these settings.

Data supporting the use of oral isosorbide dinitrate and/or hydralazine (I/H) as add-on therapy to standard neurohormonal antagonists in advanced decompensated heart failure (ADHF) are limited, especially in the non-African-American population. Our objective was to determine if addition of I/H to standard neurohormonal blockade in patients discharged from the hospital with ADHF is associated with improved hemodynamic profiles and improved clinical outcomes. We reviewed consecutive patients with ADHF admitted from 2003 to 2006 with a cardiac index < or =2.2 L/min/m(2) admitted for intensive medical therapy. Patients discharged with angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers (control group) were compared with those receiving angiotensin-converting enzyme inhibitors/angiotensin receptor blockers plus I/H (I/H group). The control (n = 97) and I/H (n = 142) groups had similar demographic characteristics, baseline blood pressure, and renal function. Patients in the I/H group had a significantly higher estimated systemic vascular resistance (1,660 vs 1,452 dynes/cm(5), p <0.001) and a lower cardiac index (1.7 vs 1.9 L/min/m(2), p <0.001) on admission. The I/H group achieved a similar decrease in intracardiac filling pressures and discharge blood pressures as controls, but had greater improvement in cardiac index and systemic vascular resistance. Use of I/H was associated with a lower rate of all-cause mortality (34% vs 41%, odds ratio 0.65, 95% confidence interval 0.43 to 0.99, p = 0.04) and all-cause mortality/heart failure rehospitalization (70% vs 85%, odds ratio 0.72, 95% confidence interval 0.54 to 0.97, p = 0.03), irrespective of race. In conclusion, the addition of I/H to neurohormonal blockade is associated with a more favorable hemodynamic profile and long-term clinical outcomes in patients discharged with low-output ADHF regardless of race.

Objectives: To determine whether venous congestion, rather than impairment of cardiac output, is primarily associated with the development of worsening renal function (WRF) in patients with advanced decompensated heart failure (ADHF)., Background: Reduced cardiac output is traditionally believed to be the main determinant of WRF in patients with ADHF., Methods: A total of 145 consecutive patients admitted with ADHF treated with intensive medical therapy guided by pulmonary artery catheter were studied. We defined WRF as an increase of serum creatinine >/=0.3 mg/dl during hospitalization., Results: In the study cohort (age 57 +/- 14 years, cardiac index 1.9 +/- 0.6 l/min/m(2), left ventricular ejection fraction 20 +/- 8%, serum creatinine 1.7 +/- 0.9 mg/dl), 58 patients (40%) developed WRF. Patients who developed WRF had a greater central venous pressure (CVP) on admission (18 +/- 7 mm Hg vs. 12 +/- 6 mm Hg, p < 0.001) and after intensive medical therapy (11 +/- 8 mm Hg vs. 8 +/- 5 mm Hg, p = 0.04). The development of WRF occurred less frequently in patients who achieved a CVP <8 mm Hg (p = 0.01). Furthermore, the ability of CVP to stratify risk for development of WRF was apparent across the spectrum of systemic blood pressure, pulmonary capillary wedge pressure, cardiac index, and estimated glomerular filtration rates., Conclusions: Venous congestion is the most important hemodynamic factor driving WRF in decompensated patients with advanced heart failure.

Broad population studies of patients with stable ambulatory heart failure have associated female gender with better age-adjusted survival. This study investigated whether there are gender-specific differences in clinical presentation, response to intensive medical therapy, and outcomes in patients admitted with advanced (cardiac index <2.4 L/min/m(2)) decompensated heart failure (ADHF). We reviewed 278 consecutive patients (age 54 +/- 12 years, cardiac index 1.7 +/- 0.4 L/kg/m(2), pulmonary capillary wedge pressure 26 +/- 9 mm Hg, serum creatinine 1.4 +/- 0.8 mg/dl) with ADHF treated with intensive medical therapy guided by pulmonary artery catheter in a dedicated heart failure intensive care unit from 2000 to 2006. Compared with men (n = 226), women (n = 52) had similar baseline characteristics with the exception of a higher prevalence of nonischemic cause. No differences in medical therapy on admission, during intensive medical therapy, or at discharge were observed. Intensive medical therapy was associated with significant hemodynamic improvement independent of gender. All-cause mortality and heart failure rehospitalization rates were similar between genders. However, adjusted for cause, women with ischemic cardiomyopathy had higher all-cause mortality rates (50% vs 37%, hazard ratio 1.95, 95% confidence interval 0.98 to 3.90, p = 0.05) and those with nonischemic cardiomyopathy had lower all-cause mortality rates (19% vs 40%, hazard ratio 0.40, 95% confidence interval 0.17 to 0.96, p = 0.01) than men. In conclusion, women presenting with ADHF had baseline characteristics and response to therapy similar to men. Overall outcomes were similar between men and women, although subgroup analysis suggested better survival for women with a nonischemic cause.

Background: Our group recently reported that elevated intra-abdominal pressure (IAP, defined as > or = 8 mm Hg) can be associated with renal dysfunction in patients with advanced decompensated heart failure (ADHF). We hypothesize that in the setting of persistently elevated IAP and progressive renal insufficiency refractory to intensive medical therapy, mechanical fluid removal can be associated with improvements in IAP and renal function., Methods and Results: The renal and hemodynamic profiles of 9 consecutive, volume-overloaded subjects with ADHF and elevated IAP, refractory to intensive medical therapy, were prospectively collected. All subjects experienced progressive elevation of serum creatinine and IAP in response to intravenous loop diuretics. Within 12 hours after mechanical fluid removal via paracentesis (n = 5, mean volume removed 3187 +/- 1772 mL) or ultrafiltration (n = 4, mean volume removed 1800 +/- 690 mL), there was a significant reduction in IAP (from 13 +/- 4 mm Hg to 7 +/- 2 mm Hg, P = .001), with corresponding improvement in renal function (serum creatinine from 3.4 +/- 1.4 mg/dL to 2.4 +/- 1.1 mg/dL, P = .01) without significantly altering any hemodynamic measurement., Conclusion: In volume-overloaded patients admitted with ADHF refractory to intensive medical therapy, we observed a reduction of otherwise persistently elevated IAP with corresponding improvement in renal function after mechanical fluid removal.

Objectives: This study was designed to examine the safety and efficacy of sodium nitroprusside (SNP) for patients with acute decompensated heart failure (ADHF) and low-output states., Background: Inotropic therapy has been predominantly used in the management of patients with ADHF presenting with low cardiac output., Methods: We reviewed all consecutive patients with ADHF admitted between 2000 and 2005 with a cardiac index < or =2 l/min/m(2) for intensive medical therapy including vasoactive drugs. Administration of SNP was chosen by the attending clinician, nonrandomized, and titrated to a target mean arterial pressure of 65 to 70 mm Hg., Results: Compared with control patients (n = 97), cases treated with SNP (n = 78) had significantly higher mean central venous pressure (15 vs. 13 mm Hg; p = 0.001), pulmonary capillary wedge pressure (29 vs. 24 mm Hg; p = 0.001), but similar demographics, medications, and renal function at baseline. Use of SNP was not associated with higher rates of inotropic support or worsening renal function during hospitalization. Patients treated with SNP achieved greater improvement in hemodynamic measurements during hospitalization, had higher rates of oral vasodilator prescription at discharge, and had lower rates of all-cause mortality (29% vs. 44%; odds ratio: 0.48; p = 0.005; 95% confidence interval: 0.29 to 0.80) without increase in rehospitalization rates (58% vs. 56%; p = NS)., Conclusions: In patients with advanced, low-output heart failure, vasodilator therapy used in conjunction with optimal current medical therapy during hospitalization might be associated with favorable long-term clinical outcomes irrespective of inotropic support or renal dysfunction and remains an excellent therapeutic choice in hospitalized ADHF patients.

Conivaptan, a dual vasopressin receptor antagonist, is a member of an emerging class of medications for the treatment of euvolemic hyponatremia. These agents induce a free-water diuresis as compared to the natriuretic effect of loop diuretics and make them an intriguing prospect for the treatment of congestive heart failure. Article also includes recent patents on this topic.

Previous heart failure (HF) risk models have included clinical and noninvasive variables and have been derived largely from clinical trial databases or decompensated HF registries. The importance of hemodynamic assessment is less established, particularly in ambulatory patients with advanced HF. In this study, 513 consecutive ambulatory patients (mean age 54+/-11 years, mean left ventricular ejection fraction 20+/-9%) with symptomatic HF who underwent diagnostic right-sided cardiac catheterization as part of outpatient assessment from 2000 to 2005 were reviewed. After a total of 1,696 patient-years of follow-up, 139 (27%) patients had died and 116 (23%) had undergone cardiac transplantation. The 1- and 2-year overall survival rates (defined as freedom from death or cardiac transplantation) were 77% and 67%, respectively. Overall, 65% of patients had elevated intracardiac filling pressures, and 40% had cardiac indexes<2.2 L/min/m2. In multivariate analysis, mean pulmonary arterial pressure, cardiac index, and the severity of mitral regurgitation were the 3 strongest predictors of all-cause mortality and cardiac transplantation. Renal dysfunction was also an independent predictor of all-cause mortality. When a clinical model for Cox multivariate analysis of all-cause mortality was compared with a model that also included cardiac index and mean pulmonary arterial pressure, the chi-square score increased from 45 to 69 (p<0.0001). In conclusion, in ambulatory patients with advanced HF, hemodynamic and renal function assessments remain strong independent predictors of all-cause mortality.