Age in antiretroviral therapy programmes in South Africa: a retrospective, multicentre, observational cohort study.

BACKGROUND As access to antiretroviral therapy (ART) expands, increasing numbers of older patients will start treatment and need specialised long-term care. However, the effect of age in ART programmes in resource-constrained settings is poorly understood. The HIV epidemic is ageing rapidly and South Africa has one of the highest HIV population prevalences worldwide. We explored the effect of age on mortality of patients on ART in South Africa and whether this effect is mediated by baseline immunological status. METHODS In this retrospective cohort analysis, we studied HIV-positive patients aged 16-80 years who started ART for the first time in six large South African cohorts of the International Epidemiologic Databases to Evaluate AIDS-Southern Africa collaboration, in KwaZulu-Natal, Gauteng, and Western Cape (two primary care clinics, three hospitals, and a large rural cohort). The primary outcome was mortality. We ascertained patients' vital status through linkage to the National Population Register. We used inverse probability weighting to correct mortality for loss to follow-up. We estimated mortality using Cox's proportional hazards and competing risks regression. We tested the interaction between baseline CD4 cell count and age. FINDINGS Between Jan 1, 2004, and Dec 31, 2013, 84,078 eligible adults started ART. Of these, we followed up 83,566 patients for 174,640 patient-years. 8% (1817 of 23,258) of patients aged 16-29 years died compared with 19% (93 of 492) of patients aged 65 years or older. The age adjusted mortality hazard ratio was 2·52 (95% CI 2·01-3·17) for people aged 65 years or older compared with those 16-29 years of age. In patients starting ART with a CD4 count of less than 50 cells per μL, the adjusted mortality hazard ratio was 2·52 (2·04-3·11) for people aged 50 years or older compared with those 16-39 years old. Mortality was highest in patients with CD4 counts of less than 50 cells per μL, and 15% (1103 of 7295) of all patients aged 50 years or older starting ART were in this group. The proportion of patients aged 50 years or older enrolling in ART increased with successive years, from 6% (290 of 4999) in 2004 to 10% (961 of 9657) in 2012-13, comprising 9% of total enrolment (7295 of 83 566). At the end of the study, 6304 (14%) of 44,909 patients still alive and in care were aged 50 years or older. INTERPRETATION Health services need reorientation towards HIV diagnosis and starting of ART in older individuals. Policies are needed for long-term care of older people with HIV. FUNDING National Institutes of Health (National Institute of Allergy and Infectious Diseases), US Agency for International Development, and South African Centre for Epidemiological Modelling and Analysis.

From Truth to Justice: How Does Amnesty Factor In? A Comparative Analysis of South Africa and Sierra Leone's Truth and Reconciliation Commissions

Truth and Reconciliation Commissions (TRC) have emerged in the last few decades as a mechanism for a state to overcome widespread, grave, human rights violations. There are numerous approaches to a TRC all with an ultimate goal: that formerly warring factions, perpetrators, witnesses, and victims can move forward as a united people. I propose that the provision of amnesty is critical to the success of a TRC. I hypothesize that the form of amnesty chosen (i.e. blanket v. conditional amnesty) determines the revelation of truth and realization of justice, which in turn dictates whether a TRC can achieve reconciliation. To test this hypothesis, I use two case studies: South Africa, which has utilized conditional amnesty, and Sierra Leone which has employed blanket amnesty. I create a model for measuring reconciliation. I can then look at the implications of both types of amnesty and assess which, in the end, is more effective. My overarching conclusion is that the provision of conditional amnesty is more effective than blanket amnesty in achieving reconciliation. Ultimately, I hope that this conclusion can be generalized to other TRCs.

Comparison of clinical and economic outcomes between high-intensity care and hospice care for the end-of-life melanoma patients

The intensity of care for patients at the end-of-life is increasing in recent years. Publications have focused on intensity of care for many cancers, but none on melanoma patients. Substantial gaps exist in knowledge about intensive care and its alternative, hospice care, among the advanced melanoma patients at the end of life. End-of-life care may be used in quite different patterns and induce both intended and unintended clinical and economic consequences. We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked databases to identify patients aged 65 years or older with metastatic melanoma who died between 2000 and 2007. We evaluated trends and associations between sociodemographic and health services characteristics and the use of hospice care, chemotherapy, surgery, and radiation therapy and costs. Survival, end-of-life costs, and incremental cost-effectiveness ratio were evaluated using propensity score methods. Costs were analyzed from the perspective of Medicare in 2009 dollars. In the first journal Article we found increasing use of surgery for patients with metastatic melanoma from 13% in 2000 to 30% in 2007 (P=0.03 for trend), no significant fluctuation in use of chemotherapy (P=0.43) or radiation therapy (P=0.46). Older patients were less likely to receive radiation therapy or chemotherapy. The use of hospice care increased from 61% in 2000 to 79% in 2007 (P =0.07 for trend). Enrollment in short-term (1-3 days) hospice care use increased, while long-term hospice care (≥ 4 days) remained stable. Patients living in the SEER Northeast and South regions were less likely to undergo surgery. Patients enrolled in long-term hospice care used significantly less chemotherapy, surgery and radiation therapy. In the second journal article, of 611 patients identified for this study, 358 (59%) received no hospice care after their diagnosis, 168 (27%) received 1 to 3 days of hospice care, and 85 (14%) received 4 or more days of hospice care. The median survival time was 181 days for patients with no hospice care, 196 days for patients enrolled in hospice for 1 to 3 days, and 300 days for patients enrolled for 4 or more days (log-rank test, P < 0.001). The estimated hazard ratios (HR) between 4 or more days hospice use and survival were similar within the original cohort Cox proportional hazard model (HR, 0.62; 95% CI, 0.49-0.78, P < 0.0001) and the propensity score-matched model (HR, 0.61; 95% CI, 0.47-0.78, P = 0.0001). Patients with ≥ 4 days of hospice care incurred lower end-of-life costs than the other two groups ($14,298 versus $19,380 for the 1- to 3-days hospice care, and $24,351 for patients with no hospice care; p < 0.0001). In conclusion, Surgery and hospice care use increased over the years of this study while the use of chemotherapy and radiation therapy remained consistent for patients diagnosed with metastatic melanoma. Patients diagnosed with advanced melanoma who enrolled in ≥ 4 days of hospice care experienced longer survival than those who had 1-3 days of hospice or no hospice care, and this longer overall survival was accompanied by lower end-of-life costs.^

Foraminifera and microfossil occurence in Late Jurassic sediments of the North and South Atlantic

Biostratigraphical, taxonomical, and palaeocological results were obtained from Oxfordian to Tithonian foraminifers of the Northern and Southern Atlantic Ocean boreholes of the DSDP Legs 1, 11, 36, 41, 44, 50, and 79. An oversight on the cored Jurassic sections of the DSDP Legs 79 and the corresponding foraminiferal descriptions are given. The reddish brown, clayey and carbonaceous Cat Gap Formation (Oxfordian to Tithonian) of the Northern Atlantic Ocean, rich in radiolarians, yields less or more uniform, in most cases allochthonous foraminiferal faunas of Central European shelf character. No Callovian and Upper Tithonian foraminiferaI zones can be established. The zone of Pseudomarssonella durnortieri covers the Oxfordian/Kimmeridgian, the zone of Neobulimina atlantica the Kimmeridgian/Lower Tithonian interval. Characteristic foraminiferal faunas are missing since the Upper Tithonian to Valanginian for reason of a widely distributed regression which caused hiatuses observed all over the Northern Atlantic Ocean and in parts of Europe. The Upper Jurassic cannot be subdivided into single stages by foraminiferal biostratigraphy alone. The fovaminiferal zones established by Moullad (1984) covering a Callovian-Tithonian interval may be of some local importance in the Tethyan realm: It has too long-ranging foraminiferal species to be used as index marker in the word-wide DSDP boreholes. Some taxonomical confusion is caused because in former publications some foraminiferal species have got different names both in the Jurassic and Cretaceous. The foraminiferal biostratigraphy of drilled sections from DSDP boreholes is restricted by the drilling technique and for palaeo-oceanographical, biological, and geological reasons. Foraminiferal faunas from the DSDP originally described as ,,bathyal, or ,,abyssal,, have to be derived from shallower water. This contrasts the palaeo-water depths of 3000-4000 m which result from sedimentological and palaeo-geographical investigations.

Planktonic foraminifera in the latest Maastrichtian of Walvis Ridge, South Atlantic

An abrupt global warming of 3-4°C occurred near the end of the Maastrichtian at 65.45-65.10 Ma. The environmental effects of this warm event are here documented based on stable isotopes and quantitative analysis of planktonic foraminifera at the South Atlantic DSDP Site 525A. Stable isotopes of individual species mark a rapid increase in temperature and a reduction in the vertical water mass stratification that is accompanied by a decrease in niche habitats, reduced species diversity and/or abundance, smaller species morphologies or dwarfing, and reduced photosymbiotic activity. During the warm event, the relative abundance of a large number of species decreased, including tropical-subtropical affiliated species, whereas typical mid-latitude species retained high abundances. This indicates that climate warming did not create favorable conditions for all tropical-subtropical species at mid-latitudes and did not cause a massive retreat in the local mid-latitude population. A noticeable exception is the ecological generalist Heterohelix dentata Stenestad that dominated during the cool intervals, but significantly decreased during the warm event. However, dwarfing is the most striking response to the abrupt warming and occurred in various species of different morphologies and lineages (e.g. biserial, trochospiral, keeled globotruncanids). Dwarfing is a typical reaction to environmental stress conditions and was likely the result of increased reproduction rates. Similarly, photosymbiotic activity appears to have been reduced significantly during the maximum warming, as indicated by decreased delta13C values. The foraminiferal response to climate change is thus multifaceted resulting in decreased species diversity, decreased species populations, increased competition due to reduced niche habitats, dwarfing and reduced photosymbiotic activity.

(Table 1) Activity of strontium-90 in waters of the Northeast Atlantic at the end of 1965 and the beginning of 1966

In 1965-1966 R/V Mikhail Lomonosov conducted studies on concentrations of artificial radioactive products in the Northeast Atlantic. Concentration of strontium-90 at the end of 1965 and the beginning of 1966 was higher than the average level for the ocean and reached about 53 dpm/100 l in the surface layer. The most intense transport of artificial radioactive products out of the Irish Sea was detected in the northern and northeastern directions along the Hebrides and the Orkneys. In addition to radioactive fission products from nuclear weapons tests, radioactive wastes of atomic industrial facilities discharged into the ocean are an important source of radioactive contamination of some regions of the world ocean.

Granulometry of two sediment cores from Maxwell Bay, South Shetland Islands, West Antarctica

The climate evolution of the South Shetland Islands during the last c. 2000 years is inferred from the multiproxy analyses of a long (928 cm) sediment core retrieved from Maxwell Bay off King George Island. The vertical sediment flux at the core location is controlled by summer melting processes that cause sediment-laden meltwater plumes to form. These leave a characteristic signature in the sediments of NE Maxwell Bay. We use this signature to distinguish summer and winter-dominated periods. During the Medieval Warm Period, sediments are generally finer which indicates summer-type conditions. In contrast, during the Little Ice Age (LIA) sediments are generally coarser and are indicative of winter-dominated conditions. Comparison with Northern and Southern Hemisphere, Antarctic, and global temperature reconstructions reveals that the mean grain-size curve from Maxwell Bay closely resembles the curve of the global temperature reconstruction. We show that the medieval warming occurred earlier in the Southern than in the Northern Hemisphere, which might indicate that the warming was driven by processes occurring in the south. The beginning of the LIA appears to be almost synchronous in both hemispheres. The warming after the LIA closely resembles the Northern Hemisphere record which might indicate this phase of cooling was driven by processes occurring in the north. Although the recent rapid regional warming is clearly visible, the Maxwell Bay record does not show the dominance of summer-type sediments until the 1970s. Continued warming in this area will likely affect the marine ecosystem through meltwater induced turbidity of the surface waters as well as an extension of the vegetation period due to the predicted decrease of sea ice in this area.

(Table 1) Iceberg characteristics and start and end date and location of iceberg buoys in the Weddell Sea

The drift of 52 icebergs tagged with GPS buoys in the Weddell Sea since 1999 has been investigated with respect to prevalent drift tracks, sea ice/iceberg interaction, and freshwater fluxes. Buoys were deployed on small- to medium-sized icebergs (edge lengths ? 5 km) in the southwestern and eastern Weddell Sea. The basin-scale iceberg drift of this size class was established. In the western Weddell Sea, icebergs followed a northward course with little deviation and mean daily drift rates up to 9.5 ± 7.3 km/d. To the west of 40°W the drift of iceberg and sea ice was coherent. In the highly consolidated perennial sea ice cover of 95% the sea ice exerted a steering influence on the icebergs and was thus responsible for the coherence of the drift tracks. The northward drift of buoys to the east of 40°W was interrupted by large deviations due to the passage of low-pressure systems. Mean daily drift rates in this area were 11.5 ± 7.2 km/d. A lower threshold of 86% sea ice concentration for coherent sea ice/iceberg movement was determined by examining the sea ice concentration derived from Special Sensor Microwave Imager (SSM/I) and Advanced Microwave Scanning Radiometer for EOS (AMSR-E) satellite data. The length scale of coherent movement was estimated to be at least 200 km, about half the value found for the Arctic Ocean but twice as large as previously suggested. The freshwater fluxes estimated from three iceberg export scenarios deduced from the iceberg drift pattern were highly variable. Assuming a transit time in the Weddell Sea of 1 year, the iceberg meltwater input of 31 Gt which is about a third of the basal meltwater input from the Filchner Ronne Ice Shelf but spreads across the entire Weddell Sea. Iceberg meltwater export of 14.2 × 103 m3 s?1, if all icebergs are exported, is in the lower range of freshwater export by sea ice.