Best practice recommendations for bladder management in spinal cord-afflicted patients in South Africa.

Recent research on the standard of care and related quality of life of the spinal cord-afflicted community in South Africa (SA) has revealed significant gaps in practice, and challenges regarding levels of care and access to services and supplies specifically related to the neurogenic bladder.

The value of supplementary anatomy workshops for improving undergraduate performance.

BACKGROUND: With many anatomy courses within the medical curriculum suffering reductions in lecture and dissection time, supplementary programs in anatomy have shown to improve performance of medical students. This study was conducted to evaluate the efficacy of anatomy workshops on undergraduate anatomy grade performance. METHOD: From 2012 to 2014, mean anatomy and physiology scores of medical students who attended anatomy workshops were compared to those who did not attend. Furthermore, mean scores in anatomy were also compared between students who attended one workshop to those who attended multiple workshops. Data analyses included comparing mean test scores using Student's t-test for normally distributed data. RESULTS: A total of 55 medical students were included in this study. Significant differences in both anatomy (p < 0.0001) and physiology (p = 0.0113) scores were found between medical students who attended the anatomy workshops versus those who did not. Similarly, medical students who attended multiple workshops, compared to those that attended a single workshop, obtained significantly higher anatomy grade performance (p = 0.0043). CONCLUSION: The results of this study are supported by comparable studies that have shown similar improvements in grade performance. In a time where reduced undergraduate medical teaching time is prevalent, supplementary education in the basic sciences, with an emphasis on anatomy, may prove a successful adjunct to the medical curriculum.

Whole genome sequencing reveals genomic heterogeneity and antibiotic purification in Mycobacterium tuberculosis isolates.

BACKGROUND: Whole genome sequencing has revolutionised the interrogation of mycobacterial genomes. Recent studies have reported conflicting findings on the genomic stability of Mycobacterium tuberculosis during the evolution of drug resistance. In an age where whole genome sequencing is increasingly relied upon for defining the structure of bacterial genomes, it is important to investigate the reliability of next generation sequencing to identify clonal variants present in a minor percentage of the population. This study aimed to define a reliable cut-off for identification of low frequency sequence variants and to subsequently investigate genetic heterogeneity and the evolution of drug resistance in M. tuberculosis. METHODS: Genomic DNA was isolated from single colonies from 14 rifampicin mono-resistant M. tuberculosis isolates, as well as the primary cultures and follow up MDR cultures from two of these patients. The whole genomes of the M. tuberculosis isolates were sequenced using either the Illumina MiSeq or Illumina HiSeq platforms. Sequences were analysed with an in-house pipeline. RESULTS: Using next-generation sequencing in combination with Sanger sequencing and statistical analysis we defined a read frequency cut-off of 30% to identify low frequency M. tuberculosis variants with high confidence. Using this cut-off we demonstrated a high rate of genetic diversity between single colonies isolated from one population, showing that by using the current sequencing technology, single colonies are not a true reflection of the genetic diversity within a whole population and vice versa. We further showed that numerous heterogeneous variants emerge and then disappear during the evolution of isoniazid resistance within individual patients. Our findings allowed us to formulate a model for the selective bottleneck which occurs during the course of infection, acting as a genomic purification event. CONCLUSIONS: Our study demonstrated true levels of genetic diversity within an M. tuberculosis population and showed that genetic diversity may be re-defined when a selective pressure, such as drug exposure, is imposed on M. tuberculosis populations during the course of infection. This suggests that the genome of M. tuberculosis is more dynamic than previously thought, suggesting preparedness to respond to a changing environment.

Competence for internship: perceptions of final-year medical students.

CONTEXT: A 'new', problem-based medical curriculum was introduced at the University of Cape Town (UCT) in 2002. The objective of this study was to assess the perceptions of competence for internship and the factors influencing competence of final-year medical students. METHODS: Eighteen focus groups were conducted (six per year) with UCT final-year medical students in 2007 (n =27), 2008 (n =27), and 2009 (n =30). Guide questions covered student's expectations of internship, perceptions of competence, priorities regarding competence, and factors influencing competence. RESULTS: Participants felt generally positive about and competent to enter internship, and the transition into internship was characterized as having both personal and professional components. Participants identified interpersonal skills, theoretical grounding, and intellectual ability as strengths, and lack of basic science knowledge and certain procedural skills as weaknesses. Factors influencing competence included personal initiative, motivation, and clinical exposure. Curriculum strengths identified were teaching of interpersonal skills and development of students as lifelong learners. The main weaknesses identified were teaching and assessment of basic sciences, and problem-based learning (PBL). Overall, the participants felt generally positive about internship and the 'new' curriculum, and felt generally competent to enter internship. Their responses highlight the role of confidence in the development of competence. CONCLUSIONS: These findings highlight the complexities surrounding perceptions of students about competence and views about the content and methodology of the learning. Perceptions of students regarding competence are an important indicator of the attainment of intended curriculum outcomes, and provide valuable information for the improvement of curriculum.

Medical Students' Attitudes Towards the Primary Health Care Approach : What are they; how do they Change and where are they from?

Background: The context of the research presented in this article is the new MBChB curriculum at the University of Cape Town (UCT) that has been running since 2002. This new curriculum is PHC-driven and has an emphasis on the integration of the biological and psychosocial. This context of curriculum reform at UCT can be placed within the wider South African context in which the South African Department of Health has committed to the primary health care (PHC) approach. The aim of this research was to provide an understanding of medical students' attitudes towards the (PHC) approach. The findings presented in this article form part of a broader set of findings for a PhD research study that aimed to qualitatively explore medical students' attitudes towards and perceptions of the PHC.Methods: A qualitative approach was taken and focus groups and interviews were conducted with second; third and fourth-year medical students from UCT. A total of eighty-two students were purposively selected to participate in this research. A content analytic approach was used to analyse the focus group and interview data.Results: Students have a generally positive attitude towards the PHC approach and were positive about UCT's choice to promote this approach. Some however were concerned about the international relevance and status of their degree; and concerns were also raised about the contrast between the theory and reality of the approach; many labelling PHC as idealistic. Students' responses indicate that attitudes towards the PHC approach are open to change through the course of their academic career and are influenced by a range of factors. Some of these factors were related to the medical school environment; such as the PHC approach itself; how PHC was taught; and the views of other students and staff at UCT. Other factors that were not related to the university included personality; students' background and exposure to health facilities; and clinical exposure outside UCT.Conclusion: These findings raise the question of whether students are able to think and feel positively about the PHC approach but not actually internalise the philosophy of the PHC approach. Students' struggle with the incongruence between what is perceived as the idealistic theory of PHC and the reality of health care in South Africa is also an issue that needs to be acknowledged. These issues are particularly significant in South Africa where a commitment has been made by the South African Department of Health to the PHC approach; and where doctors are set to play a vital role in the implementation and success of this approach

Frequency and implications of pyrazinamide resistance in managing previously treated tuberculosis patients.

OBJECTIVE: To determine the extent of pyrazinamide (PZA) resistance in isolates from previously treated patients from the Western Cape, South Africa. DESIGN: Drug-resistant isolates, isolates resistant to one or more drugs other than PZA (PZA resistance is not routinely determined) (n = 127), and drug-susceptible (n = 47) clinical isolates of Mycobacterium tuberculosis from previously treated patients from the Western Cape were phenotypically (BACTEC MGIT 960) and genotypically (pncA gene sequencing) analysed for PZA resistance. RESULTS: MGIT analysis found that 68 of the 127 drug-resistant isolates were PZA-resistant. Nearly all (63/68) PZA-resistant isolates had diverse nucleotide changes scattered throughout the pncA gene, and five PZA-resistant isolates had no pncA mutations. Of the 47 phenotypically susceptible isolates, 46 were susceptible to PZA, while one isolate was PZA-monoresistant (OR = 53.0, 95% CI = 7.1-396.5). A pncA polymorphism (Thr114Met) that did not confer PZA resistance was also identified. PZA resistance was strongly associated with multidrug-resistant tuberculosis (MDR-TB). CONCLUSION: An alarmingly high proportion of South African drug-resistant M. tuberculosis isolates are PZA-resistant, indicating that PZA should not be relied upon in managing patients with MDR-TB in the Western Cape. A method for the rapid detection of PZA resistance would be beneficial in managing patients with suspected drug resistance.

Interventions for early stage Hodgkin's disease in children.

BACKGROUND: Hodgkin's disease is one of the most curable cancers in children, particularly at the early stages. However it is not clear which combinations of treatment strategies are most effective at maintaining high cure rates and minimising long term harmful effects or sequelae of treatment. OBJECTIVES: To assess the effects of radiotherapy, chemotherapy or combined radiotherapy and chemotherapy on relapse free survival and overall survival rates in children with early (stage I to IIA) Hodgkin's disease. SEARCH STRATEGY: We searched the Cochrane Library (issue 4, 2001), MEDLINE (1966 to July 2001), EMBASE, Cinahl, Cancer-CD and reference lists of relevant articles. We also handsearched six journals. SELECTION CRITERIA: Randomised controlled trials of involved field radiotherapy, extended field radiotherapy, anthracycline based chemotherapy regimens, or alkylating chemotherapy agents in children to 19 years of age with Hodgkin's disease. DATA COLLECTION AND ANALYSIS: Trial eligibility and quality were assessed and study authors were contacted for additional information. MAIN RESULTS: Four trials involving 334 children were included. It was not possible to combine the outcomes as they covered different treatment regimens. The trials were of variable quality. One trial comparing radiotherapy alone showed no discernible difference in relapse free survival (relative risk 0.73, 95% confidence interval 0.49 to 1.09) or overall survival (relative risk 0.92, 95% confidence interval 0.79 to 1.07) between involved field and extended field radiotherapy. No discernible difference was found between involved field radiotherapy plus chemotherapy and extended field radiotherapy and chemotherapy (based on one small trial). In another trial, involved field radiotherapy plus chemotherapy appeared to increase relapse free survival compared to either involved field or extended field radiotherapy alone, although a discernible difference was found for overall survival. Extended field radiotherapy alone appeared to increase relapse free survival compared to extended radiotherapy plus chemotherapy (relative risk 0.34, 95% confidence interval 0.14 to 0.83) but no discernible difference was apparent for overall survival (based on one trial). REVIEWER'S CONCLUSIONS: There is little evidence from randomised controlled trials to evaluate the consensus approach of short course chemotherapy and local radiotherapy, although no discernible difference in survival was detected between involved field and extended field radiotherapy in one randomised trial.

Interventions for early stage Hodgkin's disease in children.

BACKGROUND: Hodgkin's Disease is one of the most curable cancers in children, particularly at the early stages. The debate rests now more with retention of high cures and eliminating treatment sequelae. OBJECTIVES: To assess relapse free survival and overall survival rates in children with Stage l-llA Hodgkin's Disease treated with radiotherapy, chemotherapy or a combination of the two treatments. SEARCH STRATEGY: MEDLINE, EMBASE, CINAHL, Cancer-CD and the Cochrane Library were searched for randomised controlled trials. Key words included 'Hodgkin's Disease', 'Reed-Sternberg cells' and variations of 'child'. SELECTION CRITERIA: Treatments with a combination of the following therapies; involved field radiotherapy, extended field radiotherapy, anthracycline based chemotherapy regimens, or alkylating chemotherapy agents. Patients included children to 19 years of age. DATA COLLECTION AND ANALYSIS: Seven papers were identified as meeting the selection criteria. Of these four were usable, though one only covered a small section of the paper. It was not possible to combine the outcomes as they covered different treatment regimens and the numbers in one study were inaccurate. MAIN RESULTS: The results comparing IF with EF radiotherapy for children are based on one large multi-centred trial. Although the study is substantial and methodologically rigorous, the evidence for efficacy rests simply on this one trial. The results from the other three studies are not generalizable. The outcomes could not be combined as the studies assessed different treatment regimens. In addition there is little evidence to suggest that the methodological quality, particularly in terms of randomisation and simple arithmetic, is of a sufficiently robust nature in two of the studies. REVIEWER'S CONCLUSIONS: The treatment of Hodgkin's Disease Stage l -llA for children has undergone considerable evolution and development in the previous three decades with the introduction and refinement of combined modality treatments. There is now overall consensus that the prognosis for these patients following a short course of chemotherapy and low dose local radiotherapy is very good with a large percentage achieving long-term survival or relapse free survival. The main issues and problems facing practitioners in the field is the reduction and management of late effects and sequelae of treatment. The evidence for this overall agreement is based on a mass of cohort studies that have influenced changes in practice and significantly improved outcomes. However, apart from the collaborative study looking at radiotherapy alone, there is little evidence from randomised controlled trials to support this consensus.

Pitfalls of bungee jumping. Case report and review of the literature.

A case of cervical spine injury related to bungee jumping is presented. Surgical intervention resulted in resolution of the patient's quadriparesis. The incidence of serious injury connected with this pastime is not inconsiderable, and it is recommended that safer jumping practices be followed. Inspection of bungee equipment and certification of instructors is now voluntary but should be mandated. Jumping heights should be limited and the use of air cushions encouraged.

Cross-sectional survey of growth of urban and rural "cape coloured" schoolchildren: anthropometry and functional tests.

The patterns of physical growth (height, weight, length of body segments, circumferences, and widths) and function (grip strength, reflexes, and pulse rates) of "Cape Coloured" schoolchildren were studied. Urban and rural groups were selected with maximum contrasting socioeconomic status (SES). Data were collected between 1986 and 1988 and included 906 males and 1,068 females of high SES between 5 and 20 years in the Cape Town urban area and 834 males and 940 females of low SES between 5 and 19 years in the Little Karoo region. Means and standard deviations of 20 characteristics by age are presented separately for males and females and urban and rural groups. The heights and weights of prepubertal urban children match American reference data, but postpubertally they decline somewhat, whereas these measurements of the rural children consistently lie ∼1 standard deviation below the urban group. Skinfold thicknesses of urban children match or exceed the American reference, implying that their nutritional needs are being met well. Functional indicators of rural children are much poorer than those of urban children. The results of the urban children may provide a target for the improvement in growth status of rural children. Am. J. Hum. Biol. 10:73-85, 1998. © 1998 Wiley-Liss, Inc.