South Africa's greatest health news story for the past decades has been the HIV / AIDS pandemic. The next great story, which will remain headline news as it unfolds, will be National Health Insurance (NHI). Changes envisaged for the USA and South Africa have similarities; both suffer from escalating health care costs, poor outcomes for expenditure on health care, and fragmentation of services.
A 14-year-old girl presented with a 4-year history of a clear, intermittent discharge oozing from the umbilicus (Fig. 1), which was confirmed to be urine on biochemical evaluation. A fistulogram demonstrated a tract communicating the umbilicus with the bladder (Fig. 2), consistent with a urachal fistula, which was successfully resected surgically.
A 14-year-old boy was referred to our division with a diagnosis of 'progressive myopathy with psoriasis' after a normal calf muscle biopsy excluded a previously suspected diagnosis of muscular dystrophy.
Julius Caesar was born on 13 July 100 BC, to patrician parents. He had two sisters, Julia major and Julia minor; the latter became the grandmother of Octavius (later named Augustus Caesar), Caesar's successor. He had an excellent education but very little is known of his childhood and upbringing.
The volume concludes with a section on future directions and recommendations. A lot of time is dedicated to evidence-based research outcomes, which the author skilfully summarises at the end of each subsection, adding at times, and aptly so, views on the clinical experience he has acquired with time.
In 2009 news media regularly reported examples of adverse events in a public health system that, many would argue, is in crisis, with widespread work stoppages by overworked doctors, shut-down of critical units in hospitals, shortages of vitally needed supplies and equipment - all of which result in denial of treatment to patients or, at best, inadequate treatment. Newly appointed health minister Dr Aaron Motsoaledi honestly conceded that the public health system faces 'very serious challenges'.
Objective. An audit of outcomes of cervical cancer screening and prevention services for HIV-positive women in Cape Town, South Africa.
Design. Retrospective review of clinic registers, patient records and pathology databases at three HIV primary health clinics and a tertiary colposcopy referral centre.
Subjects. Women recently diagnosed with HIV at three primary health clinics between 2006 and 2008 (N=2 240); new patients seen for colposcopy at a tertiary referral centre between 2006 and 2009 (N=2 031).
Outcome measures. The proportion of women undergoing cervical cancer screening after HIV diagnosis at primary health clinics, demographic characteristics of women referred for colposcopy at a tertiary centre, and outcomes of therapy for precancerous lesions of the cervix.
Results. The proportion of women undergoing at least one Pap smear at HIV primary health clinics after HIV diagnosis was low (13.1%). Women referred for colposcopy tended to be HIV-positive and over the age of 30 years, and in most (70.2%) cytological examination revealed high-grade cervical dysplasia. HIV-positive women treated with excision for precancerous lesions of the cervix were significantly more likely than their HIV-negative counterparts to undergo incomplete excision, experience persistent cervical disease after treatment, and be lost to follow-up.
Conclusion. Cervical cancer screening efforts must be scaled up for women with HIV. Treatment and surveillance guidelines for cervical intraepithelial neoplasia in HIV-positive women may need to be revised and new interventions developed to reduce incomplete treatment and patient default.
Objectives. Helicobacter pylori-associated infection is common in South Africa, as in other developing countries. Antibiotic resistance is recognised as a major cause of treatment failure. We studied the susceptibility and resistance patterns of H. pylori to guide empiric treatment and prevent the emergence of resistance.
Methods. Two hundred H. pylori strains obtained from gastric biopsies of patients presenting with gastric-related morbidities attending Livingstone Hospital, Port Elizabeth, were evaluated for their susceptibility to seven antibiotics - metronidazole, clarithromycin, tetracycline, amoxicillin, gentamicin, ciprofloxacin and erythromycin. H. pylori was isolated following standard microbiology procedures, and susceptibility determined using the Kirby-Bauer disc diffusion and agar dilution methods. Comparisons of antimicrobial resistance rates with sex of the patients were determined using the chi-square test; a p-value of π0.05 was considered significant.
Results. Marked susceptibility was observed for ciprofloxacin (100%) and amoxicillin (97.5%), and good activity for clarithromycin (80%) and gentamicin (72.5%). However, marked resistance (95.5%) was observed for metronidazole. The minimal inhibitory concentration (MIC) ranged from 0.0625 μg/ml to 8 μg/ml. The lowest MIC, with a range of 0.0625 - 1 μg/ml, was recorded for ciprofloxacin, while thehighest (5 - 8 μg/ml) was noted for gentamicin.
Conclusion. Multidrug resistance was commonly encountered - a finding of clinical significance that calls for continuous surveillance of antibiograms to guide empiric treatment. We advocate the inclusion of ciprofloxacin in the treatment regimen of H. pylori infection in our study environment.
Researchers should protect the welfare of research participants through providing methods to reduce their risk of acquiring HIV. This is especially important given that late-phase HIV vaccine trials enrol HIV-uninfected trial volunteers from high-risk populations.
Current ethical guidelines may be difficult for stakeholders to implement, and we know very little about what prevention services researchers are currently providing to participants or their successes, best practices and challenges. We recommend that current normative guidance be systematically reviewed and actual practice at vaccine sites be documented. Adding new tools to the current package of prevention services will involve complex decision making with few set standards, and regulatory and scientific challenges. We recommend that stakeholders (including regulators) convene to consider standards of evidence for new tools, and that decision-making processes be explicitly documented and researched. A further critical ethical task is exploring the threshold at which adding new tools will compromise the validity of trial results.
Background. Helicobacter pylori infection in Kenya is staggeringly high. Evidence links infection of the gastric mucosa by H. pylori with subsequent development of gastric pathologies.
Aim. We investigated the prevalence of H. pylori in dyspeptic patients, its relationship with gastric pathologies, and associated antibiotic susceptibility profiles, and compared two media to find the appropriate medium that enhances growth and expedites culture and isolation.
Methods. Rapid urease and histological tests were used to screen for H. pylori. Culture was performed to test sensitivity and evaluate media. Selective and nutritional supplements were added to culture media (Colombia blood agar and brain-heart infusion agar) for growth enhancement. E-test strips for metronidazole, amoxicillin and clarithromycin were used for susceptibility testing.
Results. The prevalence of H. pylori infection in children was 73.3%, and 54.8% in adults. All the H. pylori investigated in this study were largely sensitive to clarithromycin (100%, minimum inhibiting concentration (MIC) <2 μg/ml), amoxicillin (100%, MIC <2 μg/ml) and metronidazole (95.4%, MIC <8 μg/ml). There was, however, occasional resistance to metronidazole (4.6%, MIC >8 μg/ml). Both Colombia blood and brain-heart infusion agar, with the supplements, effectively supported H. pylori growth. Growth was achieved in an average of 36 hours for primary isolations and 24 hours for subcultures.
Conclusion. The media described here reduce the time required to culture and isolate bacteria and perform susceptibility testing. Despite the high prevalence of H. pylori infection, the associated pathology is low and does not parallel H. pylori prevalence in the population.
Objectives. To determine whether treatment of trichomoniasis increases the risk of prematurity.
Design. Sub-analysis of a randomised trial.
Setting. We analysed data from HPTN 024, a randomised trial of antenatal and intrapartum antibiotics to reduce chorioamnionitis-related perinatal HIV transmission.
Subjects. Pregnant women from four sites in Africa.
Outcome measures. Gestational age at the time of delivery or mean birth weight.
Results. Of 2 428 women-infant pairs included, 428 (18%) had trichomoniasis at enrolment. There were no differences in infant age or birth weight between women with or without trichomoniasis. By randomisation group, there were no differences in gestational age at birth or birth weight. Of the 428 women diagnosed with trichomoniasis, 365 (83%) received antibiotics and 63 (15%) did not. In analysis of actual use of antibiotics, women with trichomoniasis who received no treatment were more likely to deliver a preterm infant when the symphysis-fundal height was used to estimate gestational age (36% v. 23%; p=0.03), but not when the Ballard score was used (16% v. 21%; p=0.41). There were no differences in mean birth weight between groups.
Conclusions. In pregnant women in sub-Saharan Africa, most of whom were HIV-infected, neither trichomoniasis nor its treatment appears to influence the risk of preterm birth or a low-birth-weight infant.