Race as a variable in research ethics is investigated: to what extent is it morally appropriate to regard the race of research subjects as pivotal for research outcomes? The challenges it poses to deliberation in research ethics committees are considered, and it is concluded that race sometimes must be considered, subject to clearly stated qualifications.
Objectives. To explore linkage to and retention in HIV care after an episode of cryptococcal meningitis (CM) in rural South Africa.
Design. A retrospective case series of adult individuals (≥16 years old) with laboratory-confirmed CM from January - December 2007 at Hlabisa Hospital - a district hospital in northern KwaZulu-Natal.
Outcome measures. Inpatient mortality and associated risk factors were analysed. The proportion alive and on antiretroviral therapy (ART) at 2 years was determined by linkage to the HIV treatment programme.
Results. One hundred and four individuals were identified with laboratory diagnosis of CM; 74/104 (71.2%) with complete records were included in the analysis. Inpatient mortality was high (40.5%) and was significantly associated with reduced conscious level (aHR 3.09, 95% CI 1.30 - 7.33) and absence of headache (aHR 0.33 for headache, 95% CI 0.13 - 0.87). Only 8 individuals (10.8% of all study subjects) were alive and receiving ART 2 years after the CM episode.
Conclusions. Long-term outcomes of CM are poor in routine practice. Interventions to strengthen linkage to HIV treatment and care and continuation of secondary fluconazole prophylaxis are critical.
Background. Faith-based organisations have expanded antiretroviral therapy (ART) in community clinics across South Africa. Loss to follow-up (LTFU), however, limits the potential individual and population treatment benefits and optimal care.
Objective. To identify patient characteristics associated with LTFU 6 months after starting ART in a large community clinic.
Methods. Patients initiating ART between April 2004 and October 2006 in one South African Catholic Bishops' Conference HIV treatment clinic who had at least one follow-up visit were included and routinely monitored every 6 months after ART initiation. Standardised instruments were used to collect data. Rates of LTFU over time were estimated by the Kaplan-Meier method. The Cox proportional hazard regression examined the impact of age, baseline CD4 count, baseline HIV RNA, gender and pregnancy status on LTFU.
Results. Data from 925 patients (age >14 years, median age 36 years, 70% female, of whom 16% were pregnant) were included: 51 (6%) were lost to follow-up 6 months after ART initiation. Younger age (≤30 years) (hazard ratio (HR) 2.14, 95% confidence interval (CI) 1.05 - 4.38) and pregnancy for women (HR 3.75, 95% CI 1.53 - 9.16) were significantly associated with higher LTFU rates. When stratified by baseline CD4 count, gender and pregnancy status, pregnant women with lower baseline CD4 counts (≤200 cells/ μl) had 6.06 times the hazard (95% CI 2.20 - 16.71) of LTFU at 6 months compared with men.
Conclusions. HIV-infected pregnant women initiating ART were significantly more likely to be lost to follow-up in a community clinic in South Africa. Urgent interventions to successfully retain pregnant women in care are needed.
Background. Timely initiation of antiretroviral treatment (ART) is a critical component of the case management of patients with HIV-associated tuberculosis (TB) and advanced immunodeficiency. We sought to determine the impact of the introduction of provider-initiated HIV-testing in TB clinics in 2005 on subsequent referrals of patients with HIV-associated TB at a community-based ART service in Cape Town.
Methods. Retrospective analysis of an ART cohort database (2002 - 2008) stratified by calendar periods.
Results. Between 2002 and 2008, 3 770 ART-naive adults enrolled in the ART service. Overall, 27.4% of these patients had been referred from TB clinics with a diagnosis of HIV-associated TB. This proportion increased from 16.0% of referrals in the period 2002 - 2005 prior to the introduction of provider-initiated HIV testing, to 34.7% in 2007 - 2008 (p<0.001). The median duration of TB treatment completed prior to referral decreased from 3 months to 1 month (p<0.001) and patients enrolled with higher median CD4 cell counts (71 cells/μ l v. 95 cells/μ l; p<0.001). Moreover, the proportion with recurrent TB episodes decreased from 8.6% to 3.2% (p<0.001).
Conclusions. Introduction of provider-initiated HIV testing by the TB control programme was temporally associated with a major increase in referrals of patients with HIV-associated TB to this ART service, a progressive decline in referral delay, improvements in baseline CD4 cell counts, and fewer recurrent TB episodes. Such trends are likely to be associated with improved survival, and these data strongly support this HIV-testing strategy.
Background. During 2008, Rift Valley fever (RVF) virus re-emerged in South Africa as focal outbreaks in several provinces.
Aims. To investigate an outbreak affecting cattle farmers and farm workers, and the staff and students of a veterinary school, assess the prevalence of infection during the outbreak, document the clinical presentation of cases, and identify potential risk factors.
Methods. We conducted a cross-sectional serological survey of exposed veterinarians and farmers, who were examined to determine the presence of current or recent illness. Blood specimens were collected for virus isolation, nucleic acid detection and serology. A subset was interviewed using a standardised questionnaire to obtain data on recent exposures and risk factors for infection.
Results. Of 53 participants potentially exposed to infected domestic ruminants, 15% had evidence of recent infection and 4% evidence of past exposure to the RVF virus. The prevalence of acute infection was 21% in veterinarians compared with 9% in farmers and farm workers. After a mean incubation period of 4.3 days, the most frequent symptoms experienced included myalgia (100%), headache (88%) and malaise (75%). No asymptomatic cases were identified. Transmission by direct contact with infected animals was the major risk factor in these professional groups. Performing animal autopsies was significantly associated with acute infection (risk ratio 16.3, 95% confidence interval 2.3 - 114.2).
Conclusions. Increased risks associated with veterinary practices highlight a need for the use of personal protective equipment, and identify veterinarians as a primary target group for future vaccination.
Self-expanding metal stents for palliation of oesophageal cancer - a 4-year review
Outcome of endotherapy in bleeding peptic ulcer patients at Groote Schuur Hospital
Amylase and alanine transaminase levels as discriminators of aetiology in an urban South African population with acute pancreatitis
Cox-2 and pparg expression in colorectal cancer: a role for inflammation?
Identifying families with lynch syndrome in South Africa
Case report: upper gastro-intestinal Kaposi's sarcoma in an HIV-positive patient without cutaneous disease as a cause for anaemia and abdominal pain
Over-the-counter sale of non-steroidal anti-inflammatory drugs should be banned!
Questran colonic crystal: bystander or offender?
Jaundice as an unusual presentation of Hodgkin's lymphoma in a patient with tuberculosis
Massive and multi-organ intra-abdominal hydatid disease: case report
The spectrum of the operative management of acute appendicitis at a district hospital
Case report: the cystic spleen - a diagnostic dilemma
Objectives. We aimed to compare the presenting features and management of prostate cancer among different racial groups.
Patients and methods. We studied all patients diagnosed with prostate cancer at the Urological Oncology Clinic, Tygerberg Hospital, from January 1995 to December 2005. Most presented symptomatically as PSA screening is not readily available in the referral area of the hospital. Race was self-defined as white, coloured or black. Statistical analysis was performed using Student's t-test or Fisher's exact test, where appropriate. A two-tailed p-value <0.05 was accepted as statistically significant.
Results. There were 901 patients: 291 (32.3%) white, 539 (59.8% coloured and 71 (7.9%) black. Mean age at presentation was significantly higher in the white than the coloured and black groups (69.7, 67.9 and 68.9 years, respectively). Grade 1 adenocarcinoma was most common in the white (37%) and coloured groups (38%), and grade 2 was most common in the black group (39%). There was a significantly lower percentage of patients with T3-4 disease at diagnosis in the white group (47%) than the coloured (61%) and black (62%) groups. Mean serum PSA at diagnosis was significantly higher in the black than the coloured and white groups (766.1, 673.3 and 196.1 ng/ml, respectively). Potentially curative therapy (radical prostatectomy or radiotherapy) was chosen by 31% of white, 23% of coloured and only 12% of black patients. The mean duration of follow-up was significantly shorter in the black than in the white or coloured groups (24.0, 31.5 and 35.0 months, respectively).
Conclusions. Black men presented with higher grade and stage disease and higher serum PSA, received potentially curative treatment less often, and had a shorter follow-up (probably owing to shorter survival) than the white and coloured groups. Greater prostate cancer awareness and education among patients and physicians and more widespread use of PSA screening of presymptomatic men at risk of prostate cancer is needed.