Evaluation of the impact of PEPFAR transition on retention in care in South Africa's Western Cape Province.

BACKGROUND: Research on the impact of the US President's Emergency Plan for AIDS Relief (PEPFAR) transition in South Africa (SA) in 2012 found varying results in retention in care (RIC) of people living with HIV (PLWH). OBJECTIVES: To investigate the factors that impacted RIC during the PEPFAR transition in Western Cape Province, SA, in 2012. METHODS: We used aggregate data from 61 facilities supported by four non-governmental organisations from 2007 to 2015. The main outcome was RIC 12 months after antiretroviral therapy initiation for two periods - during PEPFAR and post PEPFAR. We used adjusted quantile regression to estimate the effect of the PEPFAR pull-out on RIC. RESULTS: Regression models (50th quantile) for 12-month RIC showed a 4.0% (95% CI -7.7 - -0.4%) decline in RIC post-direct service. Facilities supported by Anova/Kheth'impilo fared worst post PEFPAR, with a decline in RIC of -4.9% (95% CI -8.8 - -1.0%), while TB, HIV/AIDS, Treatment Support, and Integrated Therapy (that'sit) fared best (3.6% increase in RIC; 95% CI: -0.2 - 7.3%). There was a decrease in RIC when comparing urban with rural areas (-7.8%; 95% CI -12.8 - -2.9%). City of Cape Town combined with Western Cape Government health facilities showed a substantial decrease (-6.1%; 95% CI -10.6 - -1.7%), while community health clinic (v. central day clinics) declined (-6.4; 95% CI -10.6 - -2.1%) in RIC. We observed no RIC difference by facility size and a slight increase when two or more human resources transitioned from PEPFAR to the government. CONCLUSION: When PEPFAR funding decreased in 2012, there was a decrease in RIC. To ensure the continuity of HIV care when a major funder withdraws sufficient and stable transition resources, investment in organisations that understand the local context, joint planning and co-ordination are required.

A randomised comparative trial of infusional ECisF versus conventional FEC as adjuvant chemotherapy in early breast cancer: the TRAFIC trial.

BACKGROUND: The epirubicin with cisplatin and infusional 5-fluorouracil (5-FU) (ECisF) regimen was found to be highly active in the treatment of metastatic breast cancer and as neoadjuvant therapy. The UK TRAFIC (trial of adjuvant 5-FU infusional chemotherapy) trial (CRUK/95/007) compared this schedule with 5-FU, epirubicin and cyclophosphamide (FEC60) as adjuvant therapy in patients with early breast cancer. METHODS: In this multicentre, open-label, phase III randomised controlled trial, 349 women were randomly assigned to receive i.v. ECisF [epirubicin 60 mg/m(2), day 1, cisplatin 60 mg/m(2), day 1 and 5-FU 200 mg/m(2) by daily 24-h infusion (n = 172)] or FEC [5-FU 600 mg/m(2), day 1, epirubicin 60 mg/m(2), day 1 and cyclophosphamide 600 mg/m(2), day 1 (n = 177)]. Both treatments were delivered every 3 weeks for six cycles. The primary end point was relapse-free interval (RFI). TRAFIC is registered as an International Standard Randomised Controlled Trial (ISRCTN 83324925). RESULTS: All randomised patients were included in the intent-to-treat population. With a median follow-up of 112 months, there was no significant difference in RFI between the treatment groups [hazard ratio 0.84 (95% confidence interval 0.60-1.19); P = 0.33]. Toxic effects were more frequent in patients allocated to ECisF. CONCLUSIONS: While limited by size, TRAFIC has long follow-up. No evidence of a clinically worthwhile benefit for the infusional treatment compared with standard treatment was observed which would justify further investigation or widespread use.

Conformal rotation therapy with central axis beam block is a feasible alternative to intensity-modulated radiotherapy for chordomas of the cervical spine.

AIMS: Paraspinal tumours, such as chordoma, represent a treatment challenge for oncologists, requiring high dose to the target volume without exceeding the tolerance dose of the spinal cord. Intensity-modulated radiotherapy (IMRT) is helpful in achieving sharp dose gradients and conformation of dose to the target volume. We present a simpler technique--conformal rotation therapy with a central axis beam block (CRT + BB), which can provide similar dose distributions. MATERIALS AND METHODS: A patient with a cervical chordoma developed postoperative recurrence and was treated with high-dose palliative radiotherapy. Treatment was delivered using CRT + BB, with three fixed beams and three coplanar arcs. A dose of 62 Gy in 31 fractions was delivered to the 100% isodose, giving a maximum spinal cord dose of 49.6 Gy. The patient relapsed 2 years later, and was re-treated using the same technique to a dose of 57 Gy in 30 fractions. Estimates of spinal cord repair rates in primates were used to determine the tolerance dose of the spinal cord for re-treatment. The patient remained well for a further 25 months before developing local recurrence, which was treated with palliative chemotherapy. RESULTS: Re-treatment plans using CRT + BB and IMRT were compared. Dose-volume histograms show equivalence of dose to the spinal cord, although the IMRT plan delivered a slightly higher dose to tumour and lower dose to surrounding soft tissues. CONCLUSION: Treatment using CRT + BB requires careful planning and discussion with neurosurgeons before surgery. The normal curvature of the cervical spine must be eliminated if possible, and the patient must be immobilised with the neck horizontal. If these geometric constraints can be satisfied, then CRT + BB can be used as a safe and effective alternative treatment to IMRT for tumours at this site.

The use of glyceryl trinitrate ointment with EMLA cream for i.v. cannulation in children undergoing routine surgery.

This prospective randomized controlled double-blind trial was performed to investigate whether glyceryl trinitrate (GTN) ointment, applied ten minutes after the removal of a eutectic mixture of local anaesthetic cream, lignocaine/ prilocaine (EMLA), influences site selection for intravenous cannulation in children. Eighty children aged between five and 15 years, having general surgery as day patients, received EMLA cream on both hands for 90 minutes prior to transfer to the theatre suite. Acting as their own controls, the children received GTN on one hand, and placebo on the other, after removal of the EMLA cream and ten minutes prior to the insertion of an intravenous cannula. The application of GTN or placebo to left or right hand was blinded and randomized. At induction, the hand with the visually best quality veins was selected and cannulated. The primary outcome was selection between the EMLA/GTN hand and EMLA/placebo hand. The selection having been made, the number of attempts at cannulation, ease of insertion and pain scores (VAS) for cannulation were also recorded. The choice of hand was positively influenced by the use of GTN, with the GTN hand chosen in 51 of 72 (70%) children who completed the protocol (P = 0.001). The findings of this study suggest that the application of GTN after EMLA removal may be clinically useful in aiding cannulation in children.

Impact of the oil industry on malaria diagnosis and management in north-east Scotland (1992-99).

In order to assess the current pattern of malaria presenting to the Aberdeen Infection Unit a retrospective casenote review was undertaken of 110 patients admitted with that diagnosis between 1st January 1992 and 31st August 1999. Oil-related work was the reason for travel in 48 (43.6%) of the UK residents, holiday in 35 (31.8%), backpacking in 8 (7.3%) and other work in 5 (4.5%). Sixty-five patients (59.1%) had PL falciparum malaria (pure or mixed), 25 (22.7%) had PL vivax, 6 (5.4%) PL ovale and 3 (2.7%) PL malariae infection. No prophylaxis had been taken by 66% of the 47 UK-based oil workers and by 36% of the other 48 UK residents who had returned from Africa. There is a need for better education of oil workers and holidaymakers travelling to areas endemic for malaria. We are now setting up a travel advisory service in our Unit to address the problem.

Tuberculosis drug issues: prices, fixed-dose combination products and second-line drugs.

Access to tuberculosis drugs depends on multiple factors. Selection of a standard list of TB drugs to procure is the first step. This paper reviews the advantages and disadvantages of procuring and using fixed-dose combination (FDC) products for both the intensive and continuation phases of treatment. The major advantages are to prevent the emergence of resistance, to simplify logistic management and to reduce costs. The major disadvantage is the need for the manufacturers to assure the quality of these FDCs by bioavailability testing. The paper reports on the inclusion of second-line TB drugs in the 1999 WHO Essential Drug List (EDL). The need to ensure that these drugs are used within established DOTS-Plus programs is stressed. The price of TB drugs is determined by many factors, including producer prices, local taxes and duties as well as mark-ups and fees. TB drug prices for both the public and private sectors from industrialized and developing countries are reported. Price trends over time are also reported. The key findings of this study are that TB drug prices have generally declined in developing countries while they have increased in developed countries, both for the public and private sectors. Prices vary between countries, with the US paying as much as 95 times the price paid in a specific developing country. The prices of public sector first-line TB drugs vary little between countries, although differences do exist due to the procurement methods used. The price of tuberculin, a diagnostic agent, has increased dramatically in the US, with substantial inter-country variations in price. The paper suggests that further research is necessary to identify the reasons for the price disparities and changes over time, and suggests methods which can be used by National Tuberculosis Programme managers to ensure availability of quality assured TB drugs at low prices.

Antimicrobial treatment of fish tank granuloma.

Three patients with fish tank granuloma of the hand and forearm are reported. Each patient was treated with antimicrobial regimes which have rarely or never been previously used in this condition. Two patients responded well to treatment, one who received ciprofloxacin plus clarithromycin and another who was given clarithromycin plus ethambutol. The third patient received six different antimicrobial regimes before responding to a combination of rifabutin and ciprofloxacin. Our experience suggests that there now exist a number of effective alternatives to antimicrobials which have been traditionally used in the treatment of cutaneous Mycobacterium marinum infection.

An audit of the clinical features and use of antimicrobials in adult diarrhoea.

We reviewed the case records of 128 adult patients hospitalized with diarrhoea. A relevant stool pathogen was isolated from 45, a diagnosis of culture-negative or non-specific gastroenteritis (NSGE) was made in 40 and the remaining 43 patients had no enteric infection. A history of fever or bloody stools was more common in those with culture-positive gastroenteritis than it was in those with NSGE or other diarrhoeal illness. The mean duration of diarrhoea prior to admission was significantly shorter in those with all forms of gastroenteritis than it was in the remainder. Epirical treatment with ciprofloxacin was commenced in 46% of all cases of gastroenteritis, of which 51% were found to have a relevant pathogen on stool culture. Patients with NSGE were just as likely to be treated with ciprofloxacin as those who were subsequently found to have culture-positive gastroenteritis. A history of abdominal tenderness or bloody stools did not discriminate for treatment with empirical ciprofloxacin in any patient group. Patients with positive stool cultures were more likely to be given ciprofloxacin if they were febrile but the same was not true for the other patients. In the patients reviewed, a significantly higher proportion of those with culture-positive diarrhoea presented with a history of fever or bloody stools. Despite this, the empirical use of ciprofloxacin in suspected infective gastroenteritis appeared to be only partially guided by the clinical features.

Epidermal growth factor and insulin use in corneal preservation. Results of a multi-center trial. The Corneal Preservation Study Group.

PURPOSE: The ability of DexSol medium, supplemented with two growth factors, human epidermal growth factor (hEGF) and human insulin, to improve long-term endothelial survival after penetrating keratoplasty was evaluated in a multi-center, randomized, prospective, double-masked clinical trial. METHODS: Donor cornea pairs, one stored in DexSol and the other in DexSol with hEGF (10 ng/ml) and human insulin (10 micrograms/ml) (ProCell), were transplanted into 105 pairs of recipients matched by diagnosis and procedure and followed postoperatively for graft and endothelial survival. RESULTS: No primary donor failures occurred in either group. Graft clarity did not differ between the ProCell and DexSol groups at all postoperative periods: 3 months (98% versus 99%), 6 months (94% versus 98%), and 1 year (95% versus 97%), respectively. Postoperative complications (e.g., glaucoma, rejection) occurred with comparable frequencies in both groups. Mean endothelial cell loss did not significantly differ between the ProCell and DexSol groups at 3 months (5.7% versus 5.1%), 6 months (8.1% versus 10.1%), and 1 year (12.3% versus 15.6%), respectively. Similarly, there were no clinically and statistically significant differences in other endothelial morphometric parameters. CONCLUSIONS: The use of corneas stored in DexSol medium with added hEGF and insulin in corneal transplantation resulted in a safety and efficacy profile comparable with that observed in patients receiving DexSol-stored corneas; however, there were no clinically and statistically significant differences in postoperative endothelial morphometric parameters.

Treatment of symptomatic enteric aeromonas hydrophila infection with ciprofloxacin.

As a part of local sporadic outbreak of Aeromonas hydrophila gastroenteritis, 3 symptomatic patients required hospitalisation. Treatment with ciprofloxacin appeared to accelerate recovery from severe or persistent diarrhoea due to this organism. All the isolates from the outbreak were sensitive to this drug.

In vivo photomicrography of the corneal endothelium.

A technique and apparatus for observing and photographing the corneal endothelium in vivo at a magnification of approximately times 200 is described. The method is suitable for animal experimentation and for diagnostic observation and clinical research in humans.