A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfillment for the degree Masters of Medicine in Paediatrics (MMed) Johannesburg 2012 / Introduction: Highly active antiretroviral treatment (HAART) programs in heavily HIV-TB burdened countries may reduce the risk of TB in children directly by improving the immune system of HIV-infected children; and indirectly by reducing the force of transmission from the adult population. The incidence of childhood TB is a sentinel measure of the control of infectious adult TB cases in the community. Objective: We evaluated the impact that scaling-up of the HAART program in Soweto had on the incidence of hospitalization for culture-confirmed TB in children. Methods: The study was undertaken in Soweto, where the prevalence of HIV was 4-5% in children between 2005 and 2009. The estimated HAART coverage increased from 43% in 2005 to 84% by 2009 in children with HIV/AIDS. Hospitalized cases of culture-confirmed TB in children 3 months to 14 years of age were identified through laboratory and clinical electronic databases. Results: Overall, the incidence (per 100 000) of hospitalization for culture-confirmed TB declined by 58% (95%CI 49.3-65.2) from 2005 (71.4) compared to 2008-9 (30.0); p<0.0001. This included a 67% (95%CI 58.5-74.8) reduction in incidence among HIV-infected children from 2005 (1 601) compared to 2008-9 (517; p<0.0001). v In addition, a 33% reduction was observed in HIV-uninfected children (incidence 19.3 vs 12.9; p=0.016). Fifty-six percent of TB episodes, across all study periods, occurred in HIV-infected children who were mainly (76%) severely immunocompromised. Conclusions: Up-scaling of the HAART program in South Africa has been associated with decline in the incidence of culture-confirmed TB, more so in HIV-infected than HIV-uninfected children. Severely immunocompromised HIV-infected children, however, need to be identified and targeted with HAART and other strategies to further reduce the burden of TB in this group.

Thesis (M.Sc. in Epidemiology)--University of the Witwatersrand, Faculty of Health Sciences, 2014. / Introduction: The prevalence of the Human Immunodeficiency Virus (HIV) in South Africa was 17.8% among 15 to 49 year olds in 2010. Antiretroviral therapy (ART) has thus played a crucial role in mitigating the impact of the HIV epidemic. Themba Lethu Clinic is one of the largest single clinics providing ART in South Africa. One of the challenges of ART provision is ensuring adherence to taking the medication. To date there has been no clear consensus on the ideal way to measure adherence in resource limited settings (RLS). Viral load is perhaps the best and most reliable indicator of poor adherence but is expensive and not easily accessible or available in many RLS. Surrogate markers such as mean cell volume (MCV), CD4 cell count, self-reported adherence and missed visits have been shown to be useful to measure adherence but their reliability remains unclear. The aim of the study was to identify other markers that can be used to measure adherence using viral load as the gold standard. Materials and methods: The study was a retrospective analysis of HIV-positive ART-naïve adults (≥ 18 years) initiating standard first-line ART at the Themba Lethu Clinic in Johannesburg, South Africa between April 2004 and January 2012. The association between the last self-reported adherence, change in MCV calculated from baseline to 6 months, change in CD4 count calculated from baseline to 6 months (≥ or < the expected increase of 50 cells/mm3 at 6 months) and missed visits (defined as a scheduled appointment that had been missed by ≥ 7 days but not by more than 3 months) and poor adherence (defined as a viral load ≥ 400copies/ml after 6 months on ART) was tested using Poisson regression models with robust error variance to estimate incidence rate ratio (IRR) and 95% confidence interval (CI). The IRR was used to approximate the relative risk (RR) of poor adherence. Interacting variables were stratified by each other, to create a new variable. The diagnostic accuracy of each identified marker of adherence was also tested using sensitivity, specificity, positive predictive values and negative predictive values. Results: 7160 patients were eligible for the study and of these 63.2% were female. The median age was 36.7 years. The median CD4 count was 101 cells/mm3 at baseline and 18.9% of the patients had poor adherence at 6 months. Variables associated with poor adherence at 6 months were change in CD4 count stratified by change in MCV at 6 months (change in CD4 count ≥ expected and change in MCV ≥ 14.5fL; adjusted relative risk (aRR) 1, change in CD4 count ≥ expected and change in MCV < 14.5fL; aRR 3.11 95% CI 2.41 – 4.02, change in CD4 < expected and change in MCV ≥ 14.5fL; aRR 1.23 95% CI 0.76 – 2.00 and change in CD4 count < expected and change in MCV < 14.5fL; aRR 6.98 95% CI 5.35 – 9.09), CD4 count at baseline (> 200 cells/mm3; aRR 1, 101 – 200 cells/mm3; aRR 1.05 95% CI 0.80 – 1.38, 51 – 100 cells/mm3; aRR 1.08 95% CI 0.80 – 1.47 and ≤ 50cells/mm3; aRR 1.34 95% CI 1.02 – 1.76) , WHO stage at baseline (stage I; aRR 1, stage II; aRR 1.16 95% CI 0.90 – 1.48, stage III; aRR 1.27 95% CI 1.04 – 1.55 and stage IV; aRR 1.44 95% CI 1.12 – 1.84) and MCV at baseline (< 80fL; aRR 1, 80 – 100fL; aRR 1.33 95% CI 1.01 – 1.75 and > 100fL aRR 0.98 95% CI 0.62 – 1.55). Sensitivity and specificity of the change in CD4 stratified by change in MCV at 6 months to predict poor adherence were 86.5% and 37.3% respectively for all eligible patients. For patients on AZT-based regimens the variables associated with poor adherence at 6 months were change in CD4 count at 6 months (≥ expected; aRR 1 and < expected; aRR 7.66 95% CI 0.98 – 59.91) and pregnancy during the first 6 months on ART (Never pregnant; aRR 1 and pregnant during follow up; aRR 9.11 95% CI 2.17 – 38.25). Sensitivity and specificity of the change in CD4 count at 6 months to predict poor adherence were 64.7% and 75.2% respectively for all eligible patients on AZT-based regimens. Sensitivity and specificity of pregnancy during the first 6 months on ART to predict poor adherence were 20% and 97.6% respectively for all eligible patients on AZT-based regimens. Discussion: Change in CD4 count stratified by change in MCV at 6 months was an expected marker of adherence as CD4 count is expected to rise in adherent patients on ART and since most patients (62.9%) were on d4T or AZT-based regimens. Pregnancy during the first 6 months on ART appeared as a marker of adherence for patients on AZT-based regimens before multiple imputation possibly due to missing data hence results for this variable should be interpreted with caution. Contrary to previous studies, self-reported adherence was not associated with poor adherence at 6 months before multiple imputation. This could have been due to the fact that that > 50% of patients had missing data for this variable. The variable is also vulnerable to recall and reporting bias so even after multiple imputation, the area under the receiver operating characteristic (ROC) curve remained < 0.55. The number of missed medical visits and regimen change were also markers of adherence in a few of the models after multiple imputation and require further investigation. In conclusion, the markers of adherence to ART are change in CD4 count stratified by change in MCV at 6 months and pregnancy during the first 6 months on ART for patients on AZT-based regimens. These could help health workers identify poor adherence in the absence of viral load testing and target patients for adherence interventions to prevent virological failure.

Organic carbon and nitrogen content in low-strength wastewaters can be removed by conventional aerobic processes such as Modified Ludzak Ettinger (MLE), but these treatment methods are not appropriate for treating strong wastewaters. Treatment of highly polluted effluents from slaughterhouse, food processing, brewery, dairy, landfill leachates, etc., which are rich in organic matter and nutrients requires specific considerations. The main removal pathways in the aerobic processes are bacterial assimilation and complete nitrification-denitrification for nitrogen content removal which is accompanied by organic carbon removal during this process. Various biological aerobic treatment processes and operations have been tried in the past to effectively treat strong streams, but high energy requirement and sludge production are serious drawbacks. Anaerobic digestion (AD) is the best alternative to the aerobic processes for treatment of strong wastewaters but biological nutrient removal is not possible, and needs further treatment. In high-strength wastewater treatment, neither aerobic nor anaerobic treatment methods alone as a single-process can produce treated effluents complying with discharge standards. Therefore, existing conventional technologies for treatment of highly polluted streams are combined systems. These conventional combined systems are a pair of at least two separate processes in series. Most of the combined systems are applying the AD as a head system which is followed by a polishing aerobic process such as conventional activated sludge. Synchronizing two different processes in a series in combined systems is expensive and complicated with intensive operation and maintenance requirements. Hence, in order to prevail these difficulties, it is paramount to develop an efficient and less expensive single-process technology with simple operation and maintenance. In this thesis, a conventional MLE system as a single-process was modified for treating highly polluted wastewaters, with a performance similar to the combined systems. This modified system is referred to throughout the thesis as SAO/PND (Simultaneous Anaerobic Oxidation/Partial Nitrification–Denitrification). After several unsuccessful modifications were tried, the main successful modifications were increasing the hydraulic retention time (HRT) in the pre-anoxic reactor, and decreasing the solids retention time (SRT) to create favorable conditions for anaerobic oxidation and partial nitrification-denitrification. A laboratory-scale of SAO/PND was used to conduct the experiments in this research. SAO/PND looks like the MLE process regarding the reactor configurations and recycle and return lines. Ammonia concentrations above 150 mg/L can be toxic for the MLE system, but SAO/PND improves the situation so that ammonia concentration is not toxic until close to 290 mg/L. Another issue with MLE process is that it requires high amounts of oxygen and alkalinity which results in high amounts of sludge production. But, SAO/PND produces less sludge, and does not need high amounts of oxygen and alkalinity. The results showed more than 95% chemical oxygen demand (COD) and 90% total inorganic nitrogen (TIN) removal from synthetic wastewater, respectively, in our laboratory environment. In addition, volumetric design loading rates determined as 11.80 kg COD/(m3.d) and 0.63 kg TIN/(m3.d) with synthetic solution as a feed. Furthermore, the results showed high performance of the system in treating dairy and brewery industry effluents. In this modified single-process system, organic carbon was removed through anaerobic oxidation, assimilation, P–uptake by polyphosphate accumulating organisms (PAOs) and denitrifying PAOs (DPAOs), aerobic heterotrophs, and denitrification by DPAOs and denitrifying ordinary heterotrophic organisms (OHOs). Nitrogen content removal mechanisms were assimilation, partial nitrification–denitrification, anaerobic ammonium oxidation (anammox), and small portion uncharacterized processes. 95% and 90% less oxygen requirements along with 60% and 44% less sludge production compared to the conventional aerobic processes and conventional combined systems, respectively, resulted in significant potential cost savings by this modified system. Finally, the applied modified single-process system in this thesis is found as a sustainable, robust, cost-effective, and small footprint process with less intensive operation and maintenance requirements which will yield new insights into the design of treating highly polluted streams in the future.

A numerical case study of a multistage compressor with relative supersonic rotors is presented. The purpose of the investigation was to determine the flow instability mechanism of the UEET compressor and its relation to the rotor shock structure in the relative velocity reference frame. The computational study was conducted with the NASA code ADPAC , utilizing the mixing-plane assumption for the boundary condition between adjacent, relatively-rotating blade rows. A steady, five-blade-row, numerical simulation using the Baldwin-Lomax turbulence model was performed, creating several constant speed lines. The results are presented, highlighting the role shock structure plays in the stability of the compressor. The shock structure in the downstream rotor isolates the upstream rotor from the exit conditions until the shock detaches from the leading edge. At this point the shock structure in the upstream rotor moves, changing the conditions for the downstream rotor. This continues with increasing pressure at the exit until the shock in the upstream rotor detaches from the leading edge. This event causes an instantaneous drop in the mass flow rate, initiating positive incident separation on the suction side of stator-two. / Master of Science

>Magister Scientiae - MSc / Adverse effects are a significant factor that determine how long patients will tolerate a given antiretroviral drug regimen. They also influence treatment options, and play an important role in the much needed adherence to treatment by patients on Highly Active Antiretroviral Therapy (HAART). This study is aimed at understanding adverse effects experienced by patients on the first line antiretroviral therapy at Keetmanshoop Hospital in Namibia. Methods : A retrospective quantitative method was used to review records of patients on first line antiretroviral treatment who started treatment between November 1st 2007 and December 1st, 2008 and followed up until they reached 36 – 48 months on treatment. Records of 94 patients were found eligible to be included in the study. Data was analysed using Stata 12 data analysis software. Results : The most reported adverse effect was musculoskeletal disorders (25%) whereas headache (16%) was the least reported. Low haemoglobin (78%) was the most common recorded hematologic adverse effect whereas low red cell distribution width and low mean platelet volume were the least recorded adverse effects (0%). A Male patient was more likely to experience a low haemoglobin levels compared to a female patient (adjusted OR: 3.29, 95% CI: 1.3 – 8.3). A male patient was found to be 64% times less likely to experience a higher mean cell haemoglobin compared to a female patient (adjusted OR. 0.31, 95% CI: 0.11 – 0.87). A patient on nevirapine was more likely to experience an elevated creatinine level compared to a patient on efavirenz (adjusted OR; 36.0, 95%CI: 2.02 – 62.5). At baseline, a patient who had prior exposure to ART had an 81 times (adjusted OR: 81.4, 95%CI: 5.3 – 119, p-value=0.00) increased odds of experiencing a high mean cell volume (MCV) compared to a patient with no ART exposure. A patient with a higher CD4 count was also less likely to experience a low hemoglobin compared to a patient with low CD4 count (adjusted OR; 0.31, 95% CI: 0.12 – 0.77). The author recommends further studies with higher sample size to confirm whether higher creatinine levels are more prevalent in patients on nevirapine compared to patients on efavirenz; this will have clinical implications especially in patients with impaired renal system. Antiretroviral treatment increases chances of developing macrocytosis anaemia; clinical implication of this condition may need to be investigated.

In the next five-to-ten years, Generation Y (born between 1979 and 1994) will be the largestgroup in Chinese firms. This generation is better educated and has unique characteristics.However, most of Chinese firms still employ a classic control system in management process.We argue that unless companies take MCSs as a package and consider HRM in the wholemanagement process, they cannot reduce the agency conflict with highly-educated Generation Yemployees. In order to reduce the agency conflict, the key thing is to identify the motivationsamong highly-educated Generation Y. This research firstly reviews the extrinsic and intrinsicmotivations based on the relevant studies. Then through the in-depth interviews with HR andmiddle managers, we find the special opinions of HR and middle managers in Chinese firms.After that, we design a questionnaire and conduct a survey. Our study identifies that themotivation scales among the Chinese highly educated Generation Y are different from those inthe theoretical studies, and the most important scale for Generation Y is Reward, Personal fit andSelf-fulfillment. Besides, the 1980s and 1990s groups have significantly different requirementsfrom the work environment. Our research indicates that companies should take the ten scales ofmotivations into consideration in the whole process of management control, and supervisorsshould know the motivations of their employees, thereby avoiding misunderstanding.

Migracijos reiškinys yra analizuojamas jau seniai. Iki Lietuvos narystės ES (ir po Lietuvos įstojimo į ES) paskelbta daug darbų migracijos tema. Ypač skaudi valstybei bei aktuali yra aukštąjį išsilavinimą turinčių žmonių emigracija, nes tokiu būdu yra ne tik prarandamos lėšos įdėtos į kvalifikuotos darbo jėgos paruošimą, bet ir prastėja valstybės teikiamų paslaugų kokybė, smunka vidutinis šalies kvalifikacijos lygis, o kartu ir šalies konkurencingumas tarptautinėje rinkoje. Darbo objektas – darbo rinkos politikos įtaka aukštos kvalifikacijos specialistų emigracijai. Pagrindiniai uždaviniai - išryškinti emigracijos esmę bei pasekmes; išskirti teorinius aukštos kvalifikacijos specialistams pritaikytus bei su darbo rinka susijusius emigracijos veiksnius; atskleisti Lietuvoje taikomą migracijos politiką; įvertinti aukštos kvalifikacijos specialistų emigracijos veiksnius Lietuvoje, didelį dėmesį skiriant darbo rinkos politikai; atlikti ketinimų emigruoti dėl darbo rinkos situacijos kiekybinį tyrimą bei sukurti jo rezultatus apibendrinantį modelį. Darbas susideda iš trijų pagrindinių dalių. Pirmojoje darbo dalyje išryškinama teoriniai aukštos kvalifikacijos specialistų migracijos aspektai, antrojoje darbo dalyje nagrinėjama statistiniai su emigracija susiję Lietuvos ir emigracijos tikslo šalių duomenys, trečiojoje darbo dalyje atliekamas empirinis tyrimas, siekiant įvertinti ketinimų emigruoti sąryšį su darbo rinkos situaciją. Pagal tyrimų rezultatus, pateikiamos išvados bei... [toliau žr. visą tekstą] / The subject of the Master work is emigration of highly qualified specialists. Emigration of highly qualified specialists is known for a long period of time, just now the scales of emigration is higher than ever. Economic recession is playing a big part in this, as all the countries are affected by recession at the different level. Due to migration of highly qualified specialists government looses money, which was spend in gaining the qualification, as well country looses tax payers and overall country looses competitiveness in international arena. The object of the study is the influence of labor market policy to the emigration of highly qualified specialists. The main tasks are to highlight the nature and consequences of emigration; to reveal theoretical immigration–related factors; to evaluate Lithuania’s migration policy; focusing on labor market policy to distinguish to high–qualified specialists orientated emigration factors; to perform a quantitative survey and create a model summarizing the results. Work structure: work consists of three main parts: in the first part is made an analysis of theoretical high qualified specialists emigration aspects, in the second part is made a statistical analysis of Lithuania’s and other countries migration related data and in third – an empirical research made to evaluate the influence of labor market factors to the emigration decision. Working volume: 73 pages, 23 tables, 26 figures and 83 references used: 55 Lithuanian and 28... [to full text]

In my paintings and mixed media works, I incorporate rough textures and vibrant, high contrast colors. I find beauty and intrigue in the gnarled roots of a tree; the crumbling plaster on a wall; and the wrinkled, roughened hands of my grandmother. To explore these types of surfaces, the materials are distorted by twisting, ripping, and pulling the pieces apart. For instance, canvas is layered and stitched together in an uneven manner with knots and lumps added to the distressed surface. I view these distorted, strained surfaces as different forces in my life that push or pull me in varied directions. This metaphor helps me to express myself through formal elements. I approach my compositions gesturally and intuitively by letting them evolve during my process. As a compositional device, I sometimes use a gridded infrastructure or multi-piece presentation. This underlying framework allows me to organize my presentation as I apply marks and manipulate surfaces. I use complementary color palettes that are bright and vibrant. These palettes have a virile quality that emanates a strong sense of purpose and commands attention from the viewer.

MSc, Paediatrics and Child Health, Faculty of Health Sciences,University of the Witwatersrand / Background To investigate whether in-utero exposure to highly active antiretroviral treatment (HAART) is associated with low birth weight and/or preterm birth in a population of South African women with advanced HIV infection. Methods A retrospective observational study was performed on women with CD4 cell counts ≤250 cells/mm3 attending antenatal antiretroviral clinics at two clinics in Johannesburg between October 2004 and March 2007. Low birth weight (<2.5kg) and preterm birth rates (<37 weeks) were compared in those exposed versus unexposed to HAART during pregnancy. Effects of different HAART regimen and duration (<28 weeks or ≥ 28 weeks) were assessed. Results Among HAART-unexposed infants 27% (60/224) were low birth weight (LBW) compared to 23% (90/388) of early HAART-exposed and 19% (76/407) of late HAART-exposed infants (P=0.05). In the early HAART group, older maternal age was associated with LBW and higher CD4 cell count protective against LBW (AOR 1.06, 95% CI 1.00- 1.12 and AOR 0.58, 95% CI 0.46-0.73, P<0.001, respectively). HAART-exposed infants had an increased risk of preterm birth vii (<37 weeks) (15% [138/946] versus 5% [7/147], p=0.001), with early (<28 weeks) nevirapine and efavirenz having the strongest associations with preterm birth (AOR 5.4, 95%CI 2.1-13.7, P<0.001 and AOR 5.6, 95%CI 2.1-15.2, P=0.001, respectively). Conclusion Among infants born to women with CD4 cell counts <250 cells/mm3, HAART exposure was associated with preterm birth, but not with low birth weight. More advanced immunosuppression was a significant risk factor for both LBW and preterm birth, highlighting the importance of earlier HAART initiation in pregnant women, both to optimize maternal health and to improve infant outcomes

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfilment of the requirements for the degree of Master of Medicine in Family Medicine. / Introduction South Africa has more people living with HIV than any other country in the world.1 Women infected with HIV have a high risk in the development of cervical dysplasia and cancer of the cervix more so than women who are not infected.2,3 Methods A cross-sectional descriptive study was carried out by reviewing cervical smears of HIV positive women in a district hospital. Three hundred and ninety cervical Pap smears were classified according to the Bethesda system. Adherence was measured by the patient’s report and viral load. Data was collected through the use of self administered questionaire and data capture sheet. Results The prevalence of abnormal Pap smears was 57 per cent and LSIL was the commonest abnormality seen (142/390, 36%). Eighty-four per cent (328/390) had stage 1 WHO-HIV classification. WHO stage 3 participants seemed to be three times more likely to have abnormal Pap smears than those with WHO stage 1 (OD 3.3, STD. error 1.70, p=0.018, 95% CI 1.23-9.04). Abnormal pap smears were seen more in participants with CD4 cell count ≤ 350 cells/μL as compared to participants with CD4 cell count ≥ 500 cells/μL { 122/172, (71.00 %) vs 48/117, (41.03%), p-0.000, 95% CI : 0.09-0.37}. Similarly, participants who did not use HAART had more abnormal results as compared to those who used HAART {42/60(70.00%) vs 180/330 (55.00%), p-0.028, 95% CI 0.28-0.93}.Adherence to HAART did not show any link with abnormal smears. Conclusion The more immune-suppressed a woman is, the higher the risk of developing cervical cancer precursors. The high risk group in this study was found to be the participants with the CD4 cell count of ≤ 350 cells/μL and the viral load ≥1000 copies/mm3. The self-reported adherence level did not show any impact.