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Background: Doxorubicin induces acute and chronic cardiotoxicity. This study is aimed to evaluate the efficacy and safety of vitamin E and levocarnitine (EL) as cardioprotective agents against acute doxorubicin cardiotoxicity in female adult breast cancer patients. Methods: A prospective, randomized controlled study was conducted in patients treated with doxorubicin and cyclophosphamide (AC). Patients were randomly assigned to EL plus AC or AC alone for the duration of 4 cycles. Cardiac enzymes (B-type natriuretic peptide, creatine kinase, troponin I (Trop)) and cardiac events were monitored during treatment to evaluate the cardioprotective efficacy of EL. Results: Seventy-four patients were recruited and received four cycles of chemotherapy. The intervention group (n = 35) showed a significant reduction in both the B-type natriuretic peptide and creatine kinase cardiac enzymes compared to the control group (n = 39). The median (IQR) change for BNP was 0.80 (0.00–4.00) for IG versus 1.80 (0.40–3.60) for CG groups (p < 0.001); creatine kinase was −0.08 (−0.25–0.05) for IG versus 0.20 (0.05–0.50) for CG (p < 0.001). The addition of EL decreased the cardiac events by 24.2% (p = 0.02). All adverse events were tolerable and manageable. Conclusion: This study supports the addition of EL as prophylaxis against acute doxorubicin cardiotoxicity and it was also very well tolerated by a majority of the patients. The co-administration of EL at higher doxorubicin (240 mg/m2) dose should be further investigated. [ABSTRACT FROM AUTHOR]

Rising ambient temperatures due to climate change will impact both indoor temperatures and heating and cooling utility costs. In traditionally colder climates, there are potential tradeoffs in how to meet the reduced heating and increased cooling demands, and issues related to lack of air conditioning (AC) access in older homes and among lower-income populations to prevent extreme heat exposure. We modeled a typical multi-family home in Boston (MA) in the building simulation program EnergyPlus to assess indoor temperature and energy consumption in current (2020) and projected future (2050) weather conditions. Selected households were those without AC (no AC), those who ran AC sometimes (some AC), and those with sufficient resources to run AC always (full AC). We considered stylized cooling subsidy policies that allowed households to move between groups, both independently and in conjunction with energy efficiency retrofits. Results showed that future weather conditions without policy changes yielded an increase in indoor summer temperatures of 2.1 °C (no AC), increased cooling demand (range: 34–50%), but led to a decrease in net yearly total utility costs per apartment (range: − $21 to − $38). Policies that allowed households to move to greater AC utilization yielded average indoor summer temperature decreases (− 3.5 °C to − 6.2 °C) and net yearly total utility increases (range: + $2 to + $94) per apartment unit, with greater savings for retrofitted homes primarily due to large decreases in heating use. Our model results reinforce the importance of coordinated public policies addressing climate change that have an equity lens for both health and climate goals. [ABSTRACT FROM AUTHOR]

Purpose: Children may be exposed to numerous in-home environmental exposures (IHEE) that trigger asthma exacerbations. Spatially linking social and environmental exposures to electronic health records (EHR) can aid exposure assessment, epidemiology, and clinical treatment, but EHR data on exposures are missing for many children with asthma. To address the issue, we predicted presence of indoor asthma trigger allergens, and estimated effects of their key geospatial predictors.Methods: Our study samples were comprised of children with asthma who provided self-reported IHEE data in EHR at a safety-net hospital in New England during 2004-2015. We used an ensemble machine learning algorithm and 86 multilevel features (e.g., individual, housing, neighborhood) to predict presence of cockroaches, rodents (mice or rats), mold, and bedroom carpeting/rugs in homes. We reduced dimensionality via elastic net regression and estimated effects by the G-computation causal inference method.Results: Our models reasonably predicted presence of cockroaches (area under receiver operating curves [AUC] = 0.65), rodents (AUC = 0.64), and bedroom carpeting/rugs (AUC = 0.64), but not mold (AUC = 0.54). In models adjusted for confounders, higher average household sizes in census tracts were associated with more reports of pests (cockroaches and rodents). Tax-exempt parcels were associated with more reports of cockroaches in homes. Living in a White-segregated neighborhood was linked with lower reported rodent presence, and mixed residential/commercial housing and newer buildings were associated with more reports of bedroom carpeting/rugs in bedrooms.Conclusions: We innovatively applied a machine learning and causal inference mixture methodology to detail IHEE among children with asthma using EHR and geospatial data, which could have wide applicability and utility. [ABSTRACT FROM AUTHOR]

Heating and cooling requirement differences across climates not only have carbon emissions and energy efficiency implications but also impact indoor air quality (IAQ) and health. Energy and IAQ building simulation models help understand tradeoffs or co‐benefits, but these have not been applied to evaluate climate zone or multi‐family home differences. We modeled a four‐story multi‐family home in six U.S. climate zones and quantified energy, IAQ, and health outcomes with EnergyPlus, CONTAM, and a pediatric asthma systems science model. Pollutant sources included cooking and ambient. Outputs were daily PM2.5 and NO2 indoor concentrations, infiltration, energy for heating and cooling, and asthma exacerbations, which were compared across climate zones, apartment units, and resident behaviors. Daily ambient‐sourced PM2.5 decreased and cooking‐sourced PM2.5 increased with higher ambient temperatures. Infiltration air changes per hour were higher on the first versus the fourth floor and in colder climates. Window opening during cooking led to decreases in total pollutant concentrations (11%–18% for PM2.5 and 9%–15% for NO2), 3%–4% decreases in asthma exacerbations within climate zones, and minimal impacts on cooling, but led to increased heating demand (4%–8%). Our results demonstrate the influence of meteorology, multi‐family building characteristics, and resident behavior on IAQ, energy, and health, focused on multi‐zone methodology. [ABSTRACT FROM AUTHOR]

Many workers are subjected to incidents of rudeness and ignorance at work. Emerging evidence suggests that exposure to such incivility has an immediate impact on people's well-being and commitment. In this article we contribute to this nascent area of enquiry by investigating the role of discrete emotions in explaining how exposure to incivility translates into detrimental daily consequences, and by examining whether the role of emotions varies depending on whether incivilities occur during face-to-face versus online interactions. In a diary study of 69 workers, we find that face-to-face incivility has a pronounced daily impact on workers' exhaustion and turnover intention, and that this impact is mediated by increased feelings of sadness and anger, but not fear. In contrast, cyber incivility only affects workers' emotional exhaustion as a result of increases in sadness. Our findings provide insight into the mechanisms of daily effects of workplace incivility and the divergent daily effects of face-to-face versus cyber incivility. [ABSTRACT FROM AUTHOR]

Background: A quality improvement (QI) collaborative approach to enhancing integrated HIV-Tuberculosis (TB) services may be effective in scaling up and improving the quality of service delivery. Little is known of the role of organizational contextual factors (OCFs) in influencing the success of QI collaboratives. This study aims to determine which OCFs were associated with improvement in a QI collaborative intervention to enhance integrated HIV-TB services delivery.Methods: This is a nested sub-study embedded in a cluster-randomized controlled trial. Sixteen nurse supervisors (clusters) overseeing 40 clinics were randomized (1:1) to receive QI training and mentorship, or standard of care support (SOC). In the QI arm, eight nurse supervisors and 20 clinics formed a "collaborative" which aimed to improve HIV-TB process indicators, namely HIV testing, TB screening, isoniazid preventive therapy (IPT) initiations, viral load testing, and antiretroviral therapy for TB patients. OCFs measured at baseline were physical infrastructure, key staff, flexibility of clinic hours, monitoring data for improvement (MDI), and leadership support. Surveys were administered to clinic staff at baseline and month 12 to assess perceptions of supportiveness of contexts for change, and clinic organization for delivering integrated HIV-TB services. Linear mixed modelling was used to test for associations between OCFs and HIV-TB process indicators.Results: A total of 209 clinic staff participated in the study; 97 (46.4%) and 112 (53.6%) from QI and SOC arms, respectively. There were no differences between the QI and SOC arms scores achieved for physical infrastructure (78.9% vs 64.7%; p = 0.058), key staff (95.8 vs 92; p = 0.270), clinic hours (66.9 vs 65.5; p = 0.900), MDI (63.3 vs 65; p = 0.875, leadership support (46.0 vs 57.4; p = 0.265), and perceptions of supportiveness of contexts for change (76.2 vs 79.7; p = 0.128 and clinic organization for delivering integrated HIV-TB services (74.1 vs 80.1; p = 0.916). IPT initiation was the only indicator that was significantly improved in the parent study. MDI was a significantly associated with increasing IPT initiation rates [beta coefficient (β) = 0.004; p = 0.004].Discussion: MDI is a practice that should be fostered in public health facilities to increase the likelihood of success of future QI collaboratives to improve HIV-TB service delivery.Trial Registration: Clinicaltrials.gov , NCT02654613 . Registered 01 June 2015. [ABSTRACT FROM AUTHOR]

Background: Despite increased use of arterial grafts, the long saphenous vein (LSV) is often utilised as conduit for coronary artery bypass graft (CABG). Preoperative ultrasound (U/S) vein assessment is limited to patients with varicosities, clinical signs suggestive of poor vein conduits and a history of cardiac or vascular surgery. The aim of this study was to evaluate the usefulness and logistics of the surgeon incorporating intraoperative U/S assessment of the LSV into their regular practice.Methods: All patients undergoing coronary artery revascularisation and open vein harvest in our institution were recruited from July 2016 to February 2017. Demographics, including known risk factors for wound complications were documented, in addition to surgical details such as harvest time, vein length and surgical repairs of the conduit. Focussed U/S assessment was performed intraoperatively by the surgical registrar before beginning the procedure. The diameter of the leg pre and postoperatively, as well as the incidence, type and severity of wound complications were documented for further statistical analysis.Results: A total of 103 patients were included in this study. Two patients died perioperatively and were excluded from the study. The remaining 101 patients were separated in two cohorts-U/S group (n=32) and blind technique group (n=69). Demographics were similar between the groups, whilst other risk factors for harvest complications, such as presence of superficial varicosities on clinical examination and renal failure were significantly more frequent in the U/S group. The median harvest time was significantly lower within the U/S group (25 mins versus 40 mins; p=0.001), as was the rate of overall wound complications (6.2% vs 23.2%; p=0.04).Conclusions: Ultrasound assessment of the LSV by the surgical team intraoperatively is feasible, easy to learn and does not demand extra costs or delays. It significantly reduces surgical harvest time and it is associated with a reduced incidence of wound complications, swelling and postoperative mobility impairment. [ABSTRACT FROM AUTHOR]

Abstract: A bio‐inspired, pyrrolidine‐mediated, dimerization of para‐quinols has been developed. It represents one of the most complex, yet general, dimerization reactions ever disclosed, selectively forming four new bonds, four new rings, and eight new contiguous stereogenic centres. The para‐quinol starting materials are easily handled, bench‐stable compounds, accessed in just one step from aromatic feedstocks. The reaction can be scaled up to give grams of polycyclic material, primed for further elaboration. [ABSTRACT FROM AUTHOR]

Abstract: A bio‐inspired, pyrrolidine‐mediated, dimerization of para‐quinols has been developed. It represents one of the most complex, yet general, dimerization reactions ever disclosed, selectively forming four new bonds, four new rings, and eight new contiguous stereogenic centres. The para‐quinol starting materials are easily handled, bench‐stable compounds, accessed in just one step from aromatic feedstocks. The reaction can be scaled up to give grams of polycyclic material, primed for further elaboration. [ABSTRACT FROM AUTHOR]

Globally, the participation of women and girls in sport has increased tremendously. Much of this growth has been attributed to relatively recent changes in national and international law, yet few empirical studies exist that test this assertion. In this study, the role of law, specifically gender-based sports doctrine, is examined across four nations: the USA, Australia, Canada, and Iran. Results are mixed, suggesting women have increased their participation in elite sporting events despite national legal and bureaucratic variations regarding women in sport. On this basis, liberal feminist reliance on law as the primary determining factor for promotion of increased international opportunities for women is questioned. [ABSTRACT FROM AUTHOR]

Abstract: The contribution of the left inferior prefrontal cortex in semantic processing has been widely investigated in the last decade. Converging evidence from functional imaging studies shows that this region is involved in the “executive” or “controlled” aspects of semantic processing. In this study, we report a single case study of a patient, PW, with damage to the right prefrontal and temporal cortices following stroke. PW showed a problem in executive control of semantic processing, where he could not easily override automatic but irrelevant semantic processing. This case, thus, shows the necessary role of the right inferior prefrontal cortex in executive semantic processing. Compared to tasks previously used in the literature, our tasks placed higher demands on executive semantic processing. We suggest that the right inferior prefrontal cortex is recruited when the demands on executive semantic processing are particularly high. [Copyright &y& Elsevier]

Background: Improved treatment of sexually transmitted infections (STIs) is associated with decreased HIV incidence. However, the success of such programs among HIV-positive sex workers has not been shown. GOAL The goal of the study was to determine the incidence of STIs ( and infections) among HIV-positive sex workers.Study Design: A cohort of HIV-positive sex workers was treated for all STIs at baseline and observed monthly to detect and treat new infections.Results: Seventy-seven HIV-positive sex workers were followed up for a total of 58.1 women-years. The incidence rate per 100 women-years was 150 (CI: 120-180) infections; 66 (CI: 45-87) infections; 30 (CI: 14-42) infections; and 244 (CI: 200-280) STIs of any type.Conclusion: In this cohort of HIV-positive sex workers the incidence of STIs was high, despite their participation in a prevention program comprising monthly STI treatment, counseling, and condom promotion. [ABSTRACT FROM AUTHOR]

Gays and lesbians have recently turned to the courts and the law for recognition of their families. Some of the most successful cases are those won by a gay or lesbian "second-parent" of a child whose biological or legally adoptive parent is his or her partner. The court opinions granting these second-parent adoptions have often portrayed these petitioners as similar to an idealized heterosexual family unit, albeit with two same-sex parents. In this study, 20 parents who successfully pursued a second-parent adoption were interviewed to examine their experiences with the legal system. Results indicate that these petitioners did not envision themselves as similar to heterosexual families and resisted attempts by state actors who tried to formulate them as such. The literature on legal consciousness and pragmatism is used to analyze the respondents' experiences. [ABSTRACT FROM AUTHOR]

Analyzes the difference between single perpetrator and multiple parties in domestic violence situations and arrest in the United States. Notion on arrest decisions of responding police officers; Comparison between men and women's use of violence; List of arrest factors; Significance of arrest factors in single perpetrator and multiple party incidents.

Infective endocarditis in pregnancy is associated with high maternal and fetal morbidity and mortality and is estimated to complicate approximately 1 in 100,000 pregnancies. We report the case of a 33-year-old patient who presented at 30 weeks and 3 days gestation in her third pregnancy. The patient described a 3 week history of feeling generally unwell, an episode of temporary speech disturbance, right shoulder tip pain, left subscapular pain on inspiration and chest discomfort. Investigations included an echocardiogram, which revealed a large mobile mass on the aortic coronary cusp and a small mass on the non-coronary cusp. There was significant aortic regurgitation. Blood cultures were positive for staphylococcus lugdunensis. A diagnosis of infective endocarditis was made. The patient deteriorated, with worsening cardiac function, and proceeded to have a caesarean section on day 7 of admission. Her baby had multiple limb abnormalities, subsequently diagnosed as arthrogryposis multiplex congenita. Aortic valve replacement with a mechanical valve was then performed on day 3 post partum. The patient recovered well post operatively and was discharged home with her baby on day 45 post partum. The commonest complications of IE are congestive cardiac failure, perivalvular extension and systemic embolization. The management of infective endocarditis in pregnancy is similar to that of the non-pregnant however there is high foetal mortality associated with cardiopulmonary by-pass for cardiac surgery. The patient described here developed staphylococcus lugdunensis infective endocarditis, which is a rare but aggressive causative organism in infective endocarditis. Infective endocarditis in pregnancy is a rare but serious condition with significant fetal and maternal morbidity and mortality. Early diagnosis with a multidisciplinary team approach is essential to improve outcomes. [ABSTRACT FROM AUTHOR]

Knowledge of scientific inquiry (SI) is considered essential to the development of an individual's Scientific Literacy (SL) and therefore, SI is included in many international science education reform documents. Two previous large scale international studies assessed the SI understandings of students entering middle school and secondary students at the end of their formal K-12 science education. The purpose of this international project was to use the VASI-E to collect data on what primary level students have learned about SI in their first few years of school. This study adds to previous research to bridge the landscape of SI understandings now with representation from primary, middle and high school samples. A total of 4,238 students from 35 countries/regions spanning six continents participated in the study. The results show that globally, primary students are not adequately informed about SI for their age group. However, when compared with the students in the previous international studies (grades seven and 12), the primary students' understandings were surprisingly closer to the levels of understanding of SI of the secondary school students than those in the seventh grade study. [ABSTRACT FROM AUTHOR]

This article examines the role of the United States Supreme Court in constraining federal intervention in response to white supremacist violence during the Reconstruction Period from 1866 to 1877. Contemporary research on the modern civil rights movement stresses the importance of a triad pattern of civil rights protest, white violence and federal intervention. Sociologists have devoted considerable efforts to analyze the modern civil rights movement. They have given little attention, however, to civil rights activity in the Reconstruction era 1865-1877. Social movement theorists contend that the political system's openness to change varies, thereby affecting the chances for successful collective protest. Research has shown that there is no consistent relationship between repression and social movement growth. Evidence indicates that repression can have both positive and negative effects on social movements. The Supreme Court's states' rights stance during Reconstruction had a major impact on the viability of a civil rights movement. Judicial decisions consigned almost all trials involving white violence and civil and voting rights violations to state courts.

ObjectivesThe University of Natal Medical School in South Africa provides training for a student body composed of two groups: one with English as a first language and the other with an African language as a first language and English as the second. A new methodology was developed to evaluate an innovative course using modified problem-based learning techniques in this heterogeneous environment. DesignThe learning model proposed required achieving a balance of three components: content, enquiry/learning process and social interaction/group process. A multidimensional system, felt to be consistent with this educational philosophy, was developed using seven different quantitative and qualitative techniques. SettingThe University of Natal Medical School. SubjectsFirst-year multilingual medical students. ResultsThe results revealed that social interaction was highly successful in reducing barriers between the student groups and between students and facilitators. However, the emphasis on group participation may have overshadowed the enquiry process, leading to superficial discussions of problems and feelings of repetitiveness. During the course students and facilitators expressed concern that the innovative assessments used did not assess the course content adequately. While the group presentations and projects were useful exercises for consolidation and group interaction, they did not enable facilitators to identify struggling students. ConclusionsThe outcome of the evaluation stressed the need of achieving an appropriate balance both in the curriculum and assessments of the three components of the learning model, particularly in a setting where student backgrounds and language ability differ. Multidimensional methodology is needed for effective evaluation that promotes critical reflection. [ABSTRACT FROM AUTHOR]

Focuses on the North American Free Trade Agreement (NAFTA), while presenting an indepth analysis of North American Free Trade Agreement of Labor Cooperation (NAALC) for the promotion of labor rights. Names of countries involved in NAFTA; What NAFTA provides; Objectives of the NAALC; What NAFTA has argued.

Lesbians and gay men are turning to the courts to recognize their family relationships. In this article every reported court decision where a lesbian or gay couple has successfully completed a second-parent adoption is reviewed to analyze the presentation and judicial analysis of the petitioning parties in conjunction with the current debates within family theory. Traditional family theorists argue that the contemporary family is in transition but will always be recognizable as the traditional family; postmodern theorists argue that the traditional "family" is a fiction. Results from this study indicate that judges in second-parent adoption cases rely on a traditional definition and vision of the family in evaluating the gay and lesbian petitioners before them. [ABSTRACT FROM AUTHOR]

There are two broad categories of family court decisions involving same-sex ‘second-parents"’ first, cases where a second-parent is seeking visitation with her former partner's children; and second, adoption cases where the couple is seeking legal recognition of the second-parent's role in raising the children. Several jurisdictions grant same-sex second-parent adoptions; however, lesbian or gay second-parents, without a formal legal relationship with the children have rarely been successful in their attempts for visitation. In this paper the courts' analyses of the legal arguments made by the parties is reviewed. The results indicate that similar arguments are used in each of the different types of cases, but that the courts rely more heavily on statutory interpretation in the adoption cases. [ABSTRACT FROM AUTHOR]

Background: Adipose-derived stem cells (ASC) and adipocytes are involved in numerous physiological and pathophysiological conditions, which have been extensively described in subcutaneous and visceral fat depots over the past two decades. However, much less is known about ASC and adipocytes outside classical fat tissue depots and their necessity in tissue remodeling after injury. Therefore, we investigated the etiology of adipocytes in human granulation tissue and define their possible role wound healing. Methods: Identification of human wound tissue adipocytes was determined by immunohistochemical staining of granulation tissue sections from patients undergoing surgical debridement. Stromal cell fractions from granulation tissue and subcutaneous fat tissue were generated by collagenase type II-based protocols. Pro- and anti-inflammatory wound bed conditions were mimicked by THP1- and CD14+ monocyte-derived macrophage models in vitro. Effects of macrophage secretome on ASC differentiation and metabolism were determined by immunoblotting, flow cytometry, and microscopy assessing early and late adipocyte differentiation states. Functional rescuing experiments were conducted by lentiviral transduction of wildtype PPARG, IL1RA, and N-chlorotaurine (NCT) treatment. Results: Single and clustered adipocyte populations were detected in 11 out of 13 granulation tissue specimens and single-cell suspensions from granulation tissue showed adipogenic differentiation potential. Pro-inflammatory signaling by IFNG/LPS-stimulated macrophages (M (IFNG/LPS)) inhibited the maturation of lipid droplets in differentiated ASC. In contrast, anti-inflammatory IL4/IL13-activated macrophages (M (IL4/IL13)) revealed minor effects on adipocyte development. The M (IFNG/LPS)-induced phenotype was associated with a switch from endogenous fatty acid synthesis to glycolysis-dominated cell metabolism and increased pro-inflammatory cytokine production. Impaired adipogenesis was associated with increased, but seemingly non-functional, CEBPB levels, which failed to induce downstream PPARG and CEBPA. Neither transgenic PPARG overexpression, nor inhibition of IL1B was sufficient to rescue the anti-adipogenic effects induced by IFNG/LPS-activated macrophages. Instead, macrophage co-treatment during stimulation with NCT, a mild oxidant produced by activated granulocytes present in human wounds in vivo, significantly attenuated the anti-adipogenic effects. Conclusions: In conclusion, the appearance of adipocytes in wound tissue indicates a prevailing anti-inflammatory environment that could be promoted by NCT treatment and may be associated with improved healing outcomes. [ABSTRACT FROM AUTHOR]

IgG4 related thoracic aortitis is a recent addition to the differential diagnosis for inflammatory aortic disease - a condition which is often underappreciated until complications arise such as aneurysmal formation or aortic dissection. Currently, IgG4 aortitis remains a post-surgical diagnosis reliant on positive immunohistochemistry findings. Management is guided by the extent of disease involvement, which can be gauged by serum IgG4 levels and radiological findings. Options include surgical resection, corticosteroid therapy and steroid-sparing agents to prevent relapses. [ABSTRACT FROM AUTHOR]

Background: Mercury is a toxic metal however its use in traditional healthcare systems remains widespread. The aim of this study was to determine the prevalence of mercury use by South African Traditional Health Practitioners (THP) and to document reasons for use and administration methods. Methods: A cross-sectional study design was employed. A total of 201 THPs were enrolled from two main metropolitan areas of KwaZulu-Natal (South Africa), and 198 were included in the final analysis. Information on demographic characteristics, reasons for using or not using mercury as well as mercury administration methods were collected. Results: Of the 198 THPs, 78 (39 %) used mercury for healing purposes and 74 (95 %) of the mercury users stated that they were taught to use it by another THP. The two main routes of administration were oral and sub-cutaneous implantations (ukugcaba) at 85 % (n =66) and 59%(n = 46), respectively. The most common responses for mercury administration were for child birth (n = 70; 90 %) and protection against guns (n = 39; 50 %). Conclusion: This is the first study to describe the prevalence and practice of mercury use in South African traditional medicine. Socio-cultural mercury use is a potential source of exposure to both THPs and their patients. In light of such findings, public education messages and regulatory measures need to be effected. [ABSTRACT FROM AUTHOR]

Background: Mercury is a toxic metal however its use in traditional healthcare systems remains widespread. The aim of this study was to determine the prevalence of mercury use by South African Traditional Health Practitioners (THP) and to document reasons for use and administration methods. Methods: A cross-sectional study design was employed. A total of 201 THPs were enrolled from two main metropolitan areas of KwaZulu-Natal (South Africa), and 198 were included in the final analysis. Information on demographic characteristics, reasons for using or not using mercury as well as mercury administration methods were collected. Results: Of the 198 THPs, 78 (39 %) used mercury for healing purposes and 74 (95 %) of the mercury users stated that they were taught to use it by another THP. The two main routes of administration were oral and sub-cutaneous implantations (ukugcaba) at 85 % (n = 66) and 59 % (n = 46), respectively. The most common responses for mercury administration were for child birth (n = 70; 90 %) and protection against guns (n = 39; 50 %). Conclusion: This is the first study to describe the prevalence and practice of mercury use in South African traditional medicine. Socio-cultural mercury use is a potential source of exposure to both THPs and their patients. In light of such findings, public education messages and regulatory measures need to be effected. [ABSTRACT FROM AUTHOR]

Background: Nosocomial transmission has been implicated as a key factor in the outbreak of extensively drug resistant (XDR) and multidrug-resistant (MDR-TB) tuberculosis at Church of Scotland Hospital (CoSH), in KwaZulu-Natal (KZN), South Africa. The aim of this study was to quantify the burden of potentially infectious tuberculosis and the proportion of drug resistance among hospital inpatients throughout the province of KZN. Methods: Inpatients with current cough, capable of producing sputum were selected from 19 public hospitals in KZN. After informed consent, demographic and clinical data, and sputum samples were collected. Samples were processed for fluorescent microscopy, liquid culture and first and second-line anti-tuberculosis drug susceptibility testing. Results: There were a total of 2,964 inpatients where sampling was done. About 1,585 inpatients (53%) had a current cough and sufficient microbiological and clinical data for inclusion. Mycobacterium tuberculosis was isolated from 543 inpatients (34% of those tested and 18% of all inpatients). Eighty-four (15%) inpatients with TB were found to be MDR-TB infected and 16 (3%) had XDR-TB. There was no association between the prevalence of MDR-TB and proximity to CoSH. Among patients with microbiologically confirmed TB, MDR/XDR-TB was associated with male sex, a longer length of stay between hospital admission and date of sample collection, and current or previous TB treatment. Conclusions: One in five inpatients had potentially infectious TB. This is an underestimate since patients without current cough were not tested. MDR-TB was frequently observed and was found in nearly one in six active TB inpatients. While present at lower levels than the original outbreak report at CoSH, XDR-TB was detected in hospitals throughout KZN. The high burden of potentially infectious TB and confirmed MDR-TB, much of it undiagnosed, indicates a serious risk for nosocomial transmission and the need for intensified infection control within the inpatient setting. [ABSTRACT FROM AUTHOR]

Background: Post-hepatectomy liver failure (PHLF) represents the major determinant for death after liver resection. Early recognition is essential. Perioperative lactate dynamics for risk assessment of PHLF and associated morbidity were evaluated. Methods: This was a multicentre observational study of patients undergoing hepatectomy with validation in international highvolume units. Receiver operating characteristics analysis and cut-off calculation for the predictive value of lactate for clinically relevant International Study Group of Liver Surgery grade B/C PHLF (clinically relevant PHLF (CR-PHLF)) were performed. Lactate and other perioperative factors were assessed in a multivariable CR-PHLF regression model. Results: The exploratory cohort comprised 509 patients. CR-PHLF, death, overall morbidity and severe morbidity occurred in 7.7, 3.3, 40.9 and 29.3 per cent of patients respectively. The areas under the curve (AUCs) regarding CR-PHLF were 0.829 (95 per cent c.i. 0.770 to 0.888) for maximum lactate within 24 h (Lactate_Max) and 0.870 (95 per cent c.i. 0.818 to 0.922) for postoperative day 1 levels (Lactate_POD1). The respective AUCs in the validation cohort (482 patients) were 0.812 and 0.751 and optimal Lactate_Max cut-offs were identical in both cohorts. Exploration cohort patients with Lactate_Max 50 mg/dl or greater more often developed CR-PHLF (50.0 per cent) than those with Lactate_Max between 20 and 49.9 mg/dl (7.4 per cent) or less than 20 mg/dl (0.5 per cent; P<0.001). This also applied to death (18.4, 2.7 and 1.4 per cent), severe morbidity (71.1, 35.7 and 14.1 per cent) and associated complications such as acute kidney injury (26.3, 3.1 and 2.3 per cent) and haemorrhage (15.8, 3.1 and 1.4 per cent). These results were confirmed in the validation group. Combining Lactate_Max with Lactate_POD1 further increased AUC (DAUC=0.053) utilizing lactate dynamics for risk assessment. Lactate_Max, major resections, age, cirrhosis and chronic kidney disease were independent risk factors for CR-PHLF. A freely available calculator facilitates clinical risk stratification (www.liver-calculator.com). Conclusion: Early postoperative lactate values are powerful, readily available markers for CR-PHLF and associated complications after hepatectomy with potential for guiding postoperative care. [ABSTRACT FROM AUTHOR]

Aim: To compare the efficacy of furosemide infusion with that of low-dose dopamine infusion in improving urine output and subsequent renal function in preeclamptic/eclamptic patients with oliguria in the immediate postpartum period. Design: Prospective randomised single blind clinical trial. Setting: Obstetric High Care Unit of King Edward VIII Hospital, a large referral tertiary hospital. Method: Eighty postpartum patients with severe preeclampsia/eclampsia with oliguria were enrolled. Hypovolaemia was corrected under central venous pressure (CVP) monitoring and urine output monitored for 4 hr. Patients who remained oliguric were randomly assigned to a continuous infusion of low-dose dopamine (3 µg/kg/min), or furosemide 5 mg/hr infusion, for 12 hr. In patients with no response after 12 hr, the drugs were switched and continued for a further 12 hr. A subgroup of patients who responded 4 hr after correction of hypovolaemia was observed for 12 hr. The primary outcome measured involved the comparison in urine output between the different drug regimes and the number of patients requiring haemodialysis. Secondary outcome measures involved assessment of serum urea and creatinine values in the two treatment groups. Results: Of the 80 patients enrolled, 20 improved their urine outputs within the 4-hr observation period. Sixty patients were randomised to furosemide or low-dose dopamine infusion. There was no statistical significant difference in the mean hourly urine output, rate of change in urine output over time and the mean urea or creatinine levels between the treatment groups. Ten percent of patients that failed on furosemide primarily, and 8.5% of patients that failed on initial low-dose dopamine, received haemodialysis. The difference in demographic and clinic data between these groups was not statistically significant. Conclusion: Administration of continuous infusion of furosemide showed comparable efficacy to low-dose dopamine infusion in ameliorating... [ABSTRACT FROM AUTHOR]

To create a prognostic model for complications of blood culture-proven typhoid fever in adults (≥15 y old), a retrospective cohort was assembled though review of the medical records of the hospitalized patients treated for typhoid fever over a 3-y period ending January 1995. Of the 59 patients included, 21 (35.6%) developed various complications of typhoid fever. No patient included died. Four baseline variables (abdominal pain, systolic blood pressure <100 mmHg, hypoalbuminaemia <32 g/l and laboratory evidence of disseminated intravascular coagulation) were independently associated with complications and were used to create a prognostic model. The prediction accuracy of the model was determined using the concordance index (c-index). The results (c-index, 0.915 [95% CI, 89.0-93.0]) showed that the model predicted complications significantly better than chance. The model stratified patients into 3 prognostic stages: low risk for complications (0%; stage I), intermediate risk (42.9%; stage II) and high risk (92.3%; stage III) (p=0.001). If validated in other settings, it will help clinicians in predicting complications in patients with blood culture-proven typhoid fever on admission. [ABSTRACT FROM AUTHOR]

Background: There is a high burden of depression globally, including in South Africa. Maternal depression is associated with poverty, unstable income, food insecurity, and lack of partner support, and may lead to poor outcomes for mothers and children. In South Africa one-third of working women are in informal work, which is associated with socioeconomic vulnerability. Methods: A cross sectional survey explored work setting and conditions, food security and risk of depression among informal working women with young children (0–3 years). Depression risk was assessed using the Edinburgh Postnatal Depression Score (EPDS) and Whooley score. Food insecurity was evaluated using Household Food Insecurity Access Scale. Data was analysed using SPSS and Stata. Results: Interviews were conducted with 265 informal women workers. Types of work included domestic work, home-based work, informal employees and own account workers, most of whom were informal traders. Most participants (149/265; 56.2%) earned between US$70–200 per month, but some participants (79/265; 29.8%) earned < US$70 per month, and few earned > US$200 per month (37/265; 14.0%). Many participants experienced mild (38/267; 14.3%), moderate (72/265; 27.2%) or severe (43/265; 16%) food insecurity. Severe food insecurity was significantly higher among participants with the lowest income compared to those with the highest income (p = 0.027). Women who received financial support from the baby's father were less likely to be food insecure (p = 0.03). Using EPDS scores, 22/265 (8.3%) women were designated as being at risk of depression. This was similar among postnatal women and women with older children. Household food insecurity was significantly associated with depression risk (p < 0.001). Conclusions: Informal women workers were shown to be vulnerable with low incomes and high rates of food insecurity, thus increasing the risk for poor maternal health. However, levels of depression risk were low compared to previous estimates in South Africa, suggesting that informal workers may have high levels of resilience. Interventions to improve social protection, access to health services, and support for safe childcare in the workplace could improve the health and wellbeing of these mothers and support them to care for their children. [ABSTRACT FROM AUTHOR]

Background: There is a high burden of depression globally, including in South Africa. Maternal depression is associated with poverty, unstable income, food insecurity, and lack of partner support, and may lead to poor outcomes for mothers and children. In South Africa one-third of working women are in informal work, which is associated with socioeconomic vulnerability. Methods: A cross sectional survey explored work setting and conditions, food security and risk of depression among informal working women with young children (0–3 years). Depression risk was assessed using the Edinburgh Postnatal Depression Score (EPDS) and Whooley score. Food insecurity was evaluated using Household Food Insecurity Access Scale. Data was analysed using SPSS and Stata. Results: Interviews were conducted with 265 informal women workers. Types of work included domestic work, home-based work, informal employees and own account workers, most of whom were informal traders. Most participants (149/265; 56.2%) earned between US$70–200 per month, but some participants (79/265; 29.8%) earned < US$70 per month, and few earned > US$200 per month (37/265; 14.0%). Many participants experienced mild (38/267; 14.3%), moderate (72/265; 27.2%) or severe (43/265; 16%) food insecurity. Severe food insecurity was significantly higher among participants with the lowest income compared to those with the highest income (p = 0.027). Women who received financial support from the baby's father were less likely to be food insecure (p = 0.03). Using EPDS scores, 22/265 (8.3%) women were designated as being at risk of depression. This was similar among postnatal women and women with older children. Household food insecurity was significantly associated with depression risk (p < 0.001). Conclusions: Informal women workers were shown to be vulnerable with low incomes and high rates of food insecurity, thus increasing the risk for poor maternal health. However, levels of depression risk were low compared to previous estimates in South Africa, suggesting that informal workers may have high levels of resilience. Interventions to improve social protection, access to health services, and support for safe childcare in the workplace could improve the health and wellbeing of these mothers and support them to care for their children. [ABSTRACT FROM AUTHOR]

Objectives. This paper describes an audit of a community-based tuberculosis treatment program involving directly observed therapy in South Africa. Methods. A program audit of 2473 consecutive tuberculosis patients in Hlabisa Health District, KwaZulu/Natal, South Africa, was conducted between 1991 and 1994. Results. Monthly admissions increased from 34 per month in 1991 to 66 in 1994. Of 2186 patients managed in Hlabisa, 1903 (87%) received directly observed therapy. Of those receiving directly observed therapy, 1034 (55%) were supervised by volunteers; 743 (72%) of these were supervised by storekeepers. Among those patients managed locally, 1679 (85%) of 1967 surviving patients completed treatment. Completion rates for patients supervised by health workers and non-health workers were the same. Completion fell from a high of 90% in 1992 to 78% in 1994. Mortality increased from 5% in 1991 to 10% in 1994. Conclusion. Community-based directly observed therapy that uses an intermittent drug regime and volunteers as supervisors can achieve high treatment completion rates for tuberculosis, even in resource-poor settings. [ABSTRACT FROM AUTHOR]

Background: There is a high burden of depression globally, including in South Africa. Maternal depression is associated with poverty, unstable income, food insecurity, and lack of partner support, and may lead to poor outcomes for mothers and children. In South Africa one-third of working women are in informal work, which is associated with socioeconomic vulnerability.Methods: A cross sectional survey explored work setting and conditions, food security and risk of depression among informal working women with young children (0-3 years). Depression risk was assessed using the Edinburgh Postnatal Depression Score (EPDS) and Whooley score. Food insecurity was evaluated using Household Food Insecurity Access Scale. Data was analysed using SPSS and Stata.Results: Interviews were conducted with 265 informal women workers. Types of work included domestic work, home-based work, informal employees and own account workers, most of whom were informal traders. Most participants (149/265; 56.2%) earned between US$70-200 per month, but some participants (79/265; 29.8%) earned < US$70 per month, and few earned > US$200 per month (37/265; 14.0%). Many participants experienced mild (38/267; 14.3%), moderate (72/265; 27.2%) or severe (43/265; 16%) food insecurity. Severe food insecurity was significantly higher among participants with the lowest income compared to those with the highest income (p = 0.027). Women who received financial support from the baby's father were less likely to be food insecure (p = 0.03). Using EPDS scores, 22/265 (8.3%) women were designated as being at risk of depression. This was similar among postnatal women and women with older children. Household food insecurity was significantly associated with depression risk (p < 0.001).Conclusions: Informal women workers were shown to be vulnerable with low incomes and high rates of food insecurity, thus increasing the risk for poor maternal health. However, levels of depression risk were low compared to previous estimates in South Africa, suggesting that informal workers may have high levels of resilience. Interventions to improve social protection, access to health services, and support for safe childcare in the workplace could improve the health and wellbeing of these mothers and support them to care for their children. [ABSTRACT FROM AUTHOR]

Heat poses an urgent threat to public health in cities, as the urban heat island (UHI) effect can amplify exposures, contributing to high heat-related mortality and morbidity. Urban trees have the potential to mitigate heat by providing substantial cooling, as well as co-benefits such as reductions in energy consumption. The City of Boston has attempted to expand its urban canopy, yet maintenance costs and high tree mortality have hindered successful canopy expansion. Here, we present an interactive web application called Right Place, Right Tree—Boston that aims to support informed decision-making for planting new trees. To highlight priority regions for canopy expansion, we developed a Boston-specific Heat Vulnerability Index (HVI) and present this alongside maps of summer daytime land surface temperatures. We also provide information about tree pests and diseases, suitability of species for various conditions, land ownership, maintenance tips, and alternatives to tree planting. This web application is designed to support decision-making at multiple spatial scales, to assist city officials as well as residents who are interested in expanding or maintaining Boston's urban forest. [ABSTRACT FROM AUTHOR]

Background: Despite policies and guidelines recommending integration of health services in South Africa, provision of maternal and child health services remains fragmented. This study evaluated a rapid, scaleable, quality improvement (QI) intervention to improve integration of maternal and child health and HIV services at a primary health level, in KwaZulu-Natal, South Africa.Methods: A three-month intervention comprised of six QI mentoring visits, learning sessions with clinic staff to share learnings, and a self-administered checklist aimed to assist health workers monitor and implement an integrated package of health services for mothers and children. The study evaluated 27 clinics in four sub-districts using a stepped-wedge design. Each sub-district received the intervention sequentially in a randomly selected order. Five waves of data collection were conducted in all participating clinics between December 2016-February 2017. A multi-level, mixed effects logistic regression was used to account for random cluster fixed time and group effects using Stata V13.1.Results: Improvements in some growth monitoring indicators were achieved in intervention clinics compared to control clinics, including measuring the length of the baby (77% vs 63%; p = 0.001) and health workers asking mothers about the child's feeding (74% vs 67%; p = 0.003), but the proportion of mothers who received feeding advice remained unchanged (38% vs 35%; p = 0.48). Significantly more mothers in the intervention group were asked about their baby's health (44% vs 36%; p = 0.001), and completeness of record keeping improved (40% vs 26%; I = < 0.0001). Discussions with the mother about some maternal health services improved: significantly more mothers in the intervention group were asked about HIV (26.5% vs 19.5%; p = 0.009) and family planning (33.5% vs 19.5%; p <  0.001), but this did not result in additional services being provided to mothers at the clinic visit.Conclusion: This robust evaluation shows significant improvements in coverage of some services, but the QI intervention was unable to achieve the substantial changes required to provide a comprehensive package of services to all mothers and children. We suggest the QI process be adapted to complex under-resourced health systems, building on the strengths of this approach, to provide workable health systems strengthening solutions for scalable implementation.Trial Registration: ClinicalTrials.gov NCT04278612. Date of Registration: February 19, 2020. Retrospectively registered. [ABSTRACT FROM AUTHOR]

Uniting the perspective of narrative psychology with feminist and narrative criminology, we analyzed interviews with 58 formerly incarcerated women. We identified four distinct ontologies of blame that the women used to characterize the events, actors, and circumstances that resulted in their incarceration. We argue that these four ontologies of blame—personal responsibility, socioeconomic exclusion, relational caregiving associations, and compromised decision-making—each derive from the dominant U.S. cultural value of accountability that accords great social, moral, and personal weight to accepting responsibility for, and expressing willingness to endure the consequences of, wrongdoing. Our findings suggest that academics and therapeutic practitioners could assist the formerly incarcerated women with whom they work by encouraging a critique of dominant cultural values; by expanding accountability from the individual to the community; by situating accountability in past, present, and future contexts; and by facilitating ontologies of security. Online slides for instructors who want to use this article for teaching are available on PWQ’s website athttp://journals.sagepub.com/page/pwq/suppl/index [ABSTRACT FROM AUTHOR]

Background: Rifampicin and protease inhibitors are difficult to use concomitantly in patients with HIV-associated tuberculosis because of drug-drug interactions. Rifabutin has been proposed as an alternative rifamycin, but there is concern that the current recommended dose is suboptimal. The principal aim of this study was to compare bioavailability of two doses of rifabutin (150 mg three times per week and 150 mg daily) in patients with HIV-associated tuberculosis who initiated lopinavir/ritonavir-based antiretroviral therapy in Vietnam. Concentrations of lopinavir/ritonavir were also measured. Methods: This was a randomized, open-label, multi-dose, two-arm, cross-over trial, conducted in Vietnamese adults with HIV-associated tuberculosis in Ho Chi Minh City (Clinical trial registry number NCT00651066). Rifabutin pharmacokinetics were evaluated before and after the introduction of lopinavir/ritonavir -based antiretroviral therapy using patient randomization lists. Serial rifabutin and 25-O-desacetyl rifabutin concentrations were measured during a dose interval after 2 weeks of rifabutin 300 mg daily, after 3 weeks of rifabutin 150 mg daily with lopinavir/ritonavir and after 3 weeks of rifabutin 150 mg three times per week with lopinavir/ritonavir. Results: Sixteen and seventeen patients were respectively randomized to the two arms, and pharmacokinetic analysis carried out in 12 and 13 respectively. Rifabutin 150 mg daily with lopinavir/ritonavir was associated with a 32% mean increase in rifabutin average steady state concentration compared with rifabutin 300 mg alone. In contrast, the rifabutin average steady state concentration decreased by 44% when rifabutin was given at 150 mg three times per week with lopinavir/ritonavir. With both dosing regimens, 2 – 5 fold increases of the 25-O-desacetyl- rifabutin metabolite were observed when rifabutin was given with lopinavir/ritonavir compared with rifabutin alone. The different doses of rifabutin had no significant effect on lopinavir/ritonavir plasma concentrations. Conclusions: Based on these findings, rifabutin 150 mg daily may be preferred when co-administered with lopinavir/ritonavir in patients with HIV-associated tuberculosis. Trial Registration: ClinicalTrials.gov NCT00651066 [ABSTRACT FROM AUTHOR]

The burden of chronic kidney disease (CKD) in children in developing countries remains unknown, due to the lack of a national data-reporting system. We undertook a retrospective study of all children < 16 years old in our hospital, which is the tertiary referral centre for children with complex kidney disorders, to analyse the spectrum of CKD (stages 2–5) from 1994–2006. Six hundred and fifty-three children with kidney disorders were screened for CKD; 286 (44.0%) were < 5 years old. Of these, 177 (62%) were male, 202 (70.6%) were black, 77 (26.9%) were Indian, five (1.8%) were mixed race and two (0.7%) were white. One hundred and twenty-six children had CKD (stages 2–5); 55 (43.7%) were < 5 years olds; 41 (74.5%) were male. There were 71 (56.3%) that were > 5 years old, 42 (59.2%) were male. The commonest cause of CKD (stages 2–5) in all children was nephrotic syndrome, comprising 30.9% in children < 5 years old and 40.8% in children > 5 years old. Within the observation period of 11 years, end-stage kidney disease was diagnosed in 20 children; only nine had been on long-term dialysis, and seven qualified for transplantation. Five (25%) children had died, four from sepsis during dialysis and one from tuberculosis after receiving a transplant. We concluded that lack of resources, late referrals, and high cost of renal replacement therapy in developing countries leads to poor outcome in CKD. [ABSTRACT FROM AUTHOR]

Background. The pathogenetic mechanisms by which individuals with chronic hepatitis B virus (HBV) infection develop membranous nephropathy (MN) are probably dependent on interactions between viral, host and environmental factors; some evidence suggests a genetic predisposition. HBVMN constitutes a major etiological group in black children with nephrotic syndrome. We therefore explored the HLA associations in black children with HBVMN. Method. Thirty black children, age range 2 to 16 years, with biopsy-proven HBVMN, were the subjects of the study. HBV status was determined using third generation ELISA. HLA A, B and C antigens were determined using a two-stage lymphocytotoxic test. HLA DRB1* and DQB1* typing was done using sequence-specific primers. HLA class 1 and II antigen frequencies of the study subjects were compared to controls that were randomly chosen healthy blood donors from the same population. Results. HLA DQB1*0603 was increased in patients with HBVMN compared to controls (χ² = 13.65, RR = 4.3). DRB1*07 and DQB1*02 were increased in frequency in the study subjects but failed to reach statistical significance. There was no significant difference in the frequencies of class 1 antigens in the study group compared to controls. Conclusion. To our knowledge, this is the first report of HLA associations in black patients with HBVMN in whom Class 1 and 11 antigens were determined using molecular methodology. There was a high frequency of DQB1*0603 in subjects compared to controls, suggesting a possible genetic predisposition to the development of HBVMN. [ABSTRACT FROM AUTHOR]

HBV and proteinuria in relatives and contacts of children with hepatitis B virus-associated membranous nephropathy. Background. Hepatitis B virus (HBV)-associated membranous nephropathy (HBVMN) is an important cause of childhood nephrotic syndrome in regions endemic for the virus, but little is understood of the biosocial context in which the disease develops. We evaluated HBV status and proteinuria in family members and household contacts of index children with HBVMN to test the hypothesis that HBV carriage and asymptomatic proteinuria are closely linked and may be causally associated. Methods. Thirty-one black children with biopsy-proven HBVMN were the index cases. One hundred and fifty-two family members and 43 black household contacts were the subjects of the study. We assessed HBV carrier status by testing for HBV antigens and antibodies using enzyme-linked immunosorbent assays (ELISA) and for HBV DNA by using slot-blot hybridization and the polymerase chain reaction. Sequencing of the precore region of HBV was done in a subset of both index cases and subjects. Proteinuria was assessed by measuring the urinary protein/creatinine ratio. Results. Seventy-two (37%) of the 195 family members and household contacts were HBV carriers, and 53 (27%) had a protein/creatinine ratio greater than the physiological limit. The frequency of abnormal proteinuria was not significantly different in those with [22 out of 72 (30.5%)] or without [33 out of 104 (32%)] HBV carriage. This lack of association remained when carriers were classified into those who were HBsAg positive only and those with active viral replication (HBsAg and/or HBeAg and/or HBV DNA; P = 0.01). Family members were more predisposed to HBV carriage than household contacts, but abnormal proteinuria was present with equal frequency (P = 0.48). Age had a significant impact on proteinuria, with children less than five years being more likely to have abnormal proteinuria (P = 0.008). The prevalence of abnormal... [ABSTRACT FROM AUTHOR]

An amendment to this paper has been published and can be accessed via the original article. [ABSTRACT FROM AUTHOR]

Objectives. This study was undertaken to determine the prevalence of sexually transmitted diseases (STDs) in pregnant women in rural South Africa and to determine the value of using abnormal urogenital symptoms to identify infected women. Methods. This was a cross-sectional study of 327 patients attending prenatal clinics. Results. Of the 271 women with complete data, 141 (52%) had at least 1 STD and 49 (18%) had more than 1. Abnormal symptoms were common (n = 225; 83%), but associations were weak, and the positive predictive value of different symptoms for infection ranged from 2% to 54%. Conclusions. Most STDs in rural South African women remain undetected and untreated. As the scope for laboratory diagnosis in resource-poor settings is limited, presumptive treatment of pregnant women and their partners may be a cost-effective option to reduce transmission of STDs and HIV infection. [ABSTRACT FROM AUTHOR]