A comparison of physician emigration from Africa to the United States of America between 2005 and 2015

BACKGROUND

Migration of health professionals has been a cause for global concern, in particular migration from African countries with a high disease burden and already fragile health systems. An estimated one fifth of African-born physicians are working in high-income countries. Lack of good data makes it difficult to determine what constitutes "African" physicians, as most studies do not distinguish between their country of citizenship and country of training. Thus, the real extent of migration from African countries to the United States (US) remains unclear. This paper quantifies where African migrant physicians come from, where they were educated, and how these trends have changed over time.

METHODS

We combined data from the Educational Commission for Foreign Medical Graduates with the 2005 and 2015 American Medical Association Physician Masterfiles. Using a repeated cross-sectional study design, we reviewed the available data, including medical school attended, country of medical school, and citizenship when entering medical school.

RESULTS

The outflow of African-educated physicians to the US has increased over the past 10 years, from 10 684 in 2005 to 13 584 in 2015 (27.1% increase). This represents 5.9% of all international medical graduates in the US workforce in 2015. The number of African-educated physicians who graduated from medical schools in sub-Saharan countries was 2014 in 2005 and 8150 in 2015 (304.6% increase). We found four distinct categorizations of African-trained physicians migrating to the US: (1) citizens from an African country who attended medical school in their own country (86.2%, n = 11,697); (2) citizens from an African country who attended medical school in another African country (2.3%, n = 317); (3) US citizens who attended medical school in an African country (4.0%, n = 537); (4) citizens from a country outside Africa, and other than the United States, who attended medical school in an African country (7.5%, n = 1013). Overall, six schools in Africa provided half of all African-educated physicians.

CONCLUSIONS

The number of African-educated physicians in the US has increased over the past 10 years. We have distinguished four migration patterns, based on citizenship and country of medical school. The majority of African graduates come to the US from relatively few countries, and from a limited number of medical schools. A proportion are not citizens of the country where they attended medical school, highlighting the internationalization of medical education.

The impact of a faculty development programme for health professions educators in sub-Saharan Africa: an archival study

BACKGROUND

In 2008 the sub-Saharan FAIMER Regional Institute launched a faculty development programme aimed at enhancing the academic and research capacity of health professions educators working in sub-Saharan Africa. This two-year programme, a combination of residential and distance learning activities, focuses on developing the leadership, project management and programme evaluation skills of participants as well as teaching the key principles of health professions education-curriculum design, teaching and learning and assessment. Participants also gain first-hand research experience by designing and conducting an education innovation project in their home institutions. This study was conducted to determine the perceptions of participants regarding the personal and professional impact of the SAFRI programme.

METHODS

A retrospective document review, which included data about fellows who completed the programme between 2008 and 2011, was performed. Data included fellows' descriptions of their expectations, reflections on achievements and information shared on an online discussion forum. Data were analysed using Kirkpatrick's evaluation framework.

RESULTS

Participants (n=61) came from 10 African countries and included a wide range of health professions educators. Five key themes about the impact of the SAFRI programme were identified: (1) belonging to a community of practice, (2) personal development, (3) professional development, (4) capacity development, and (5) tools/strategies for project management and/or advancement.

CONCLUSION

The SAFRI programme has a positive developmental impact on both participants and their respective institutions.

Generic learning skills in academically-at-risk medical students: a development programme bridges the gap

BACKGROUND

Widening access to medical students from diverse educational backgrounds is a global educational mandate. The impact, on students' generic learning skills profiles, of development programmes designed for students at risk of attrition is unknown.

AIMS

This study investigated the impact of a 12-month Intervention Programme (IP) on the generic learning skills profile of academically-at-risk students who, after failing at the end of the first semester, completed the IP before entering the second semester of a conventional medical training programme.

METHODS

This prospective study surveyed medical students admitted in 2009 and 2010, on entry and on completion of first year, on their reported practice and confidence in information handling, managing own learning, technical and numeracy, computer, organisational and presentation skills.

RESULTS

Of 414 first year students, 80 (19%) entered the IP. Levels of practice and confidence for five of the six skills categories were significantly poorer at entry for IP students compared to conventional stream students. In four categories these differences were no longer statistically significant after students had completed the IP; 62 IP students (77.5%) progressed to second year.

CONCLUSIONS

A 12-month development programme, the IP, effectively addressed generic learning skills deficiencies present in academically-at-risk students entering medical school.

Developing an educational research framework for evaluating rural training of health professionals: a case for innovation

BACKGROUND

World-wide, rural clinical training of undergraduate medical students is looking to transform learning experiences, calling for the adoption of innovative approaches that create spaces for curriculum renewal and new ways of thinking. In order for these teaching models to gain acceptance and credibility among the relevant academic communities, it is critical that they be studied and evaluated.

AIM

This article describes an innovative rural education intervention and a concomitant, intentional process that was adopted to establish a research framework within which the intervention will be evaluated.

METHODS

Key role-players participated in a one-day workshop aimed at developing the framework. A collaborative, structured process that moved through three phases of deliberation and reflection was followed.

RESULTS

The documentation and raw data generated during the workshop was used to generate the framework that will serve as a blueprint for ensuring the study and evaluation of the educational innovation.

CONCLUSION

Establishing an educational research framework, by adopting a consultative and collaborative process, provides a vehicle for encouraging a culture of critical accountability that seeks to discern evidence of good practice in the training of health care workers in a rural context.

Career intentions of medical students trained in six sub-Saharan African countries

INTRODUCTION

Sub-Saharan Africa(SSA) is the world region worst affected by physician migration. Identifying reasons why medical students wish to stay or leave Africa could assist in developing strategies which favour retention of these graduates. This study investigated the career intentions of graduating students attending medical schools in SSA to identify interventions which may improve retention of African physicians in their country of training or origin.

METHODS

Final year medical students attending nine medical schools in SSA were surveyed--students from four schools in South Africa and one school each in the Democratic Republic of Congo, Kenya, Nigeria, Tanzania and Uganda. The response rate was 78.5% (990 of 1260 students); data from the 984 students who indicated they were remaining in medicine were entered into a database, and descriptive statistics were obtained.

RESULTS

Most (97.4%) of the 984 responding students were African by birth. The majority (91.2%) intended to undertake postgraduate training; the top three specialty choices were surgery (20%), internal medicine (16.7%), and paediatrics (9%). Few were interested in family medicine (4.5%) or public health (2.6%) or intended to practice in rural areas (4.8%). Many students (40%) planned to train abroad. About one fifth (21%) intended to relocate outside sub-Saharan Africa. These were about equally divided between South Africans (48%) and those from the other five countries (52%). The top perceived career-related factors favouring retention in Africa were career options and quality and availability of training opportunities. Several factors were reported significantly more by South African than the other students. The top personal factors for staying in Africa were a desire to improve medicine in Africa, personal safety, social conditions and family issues. The top career-related factors favouring relocation outside Africa were remuneration, access to equipment and advanced technology, career and training opportunities, regulated work environment and politics of health care in Africa. Several of these were reported significantly more by students from the other countries as compared with South Africans. The top personal factors favouring relocation outside Africa were personal safety, opportunity for experience in a different environment, social conditions and greater personal freedom.

DISCUSSION

The career intentions of African medical students are not aligned with the continent's health workforce needs. A number of interventions that warrant further attention were identified in this study.

Acute hospitalisation needs of adults admitted to public facilities in the Cape Town Metro district

INTRODUCTION

Public health care delivery in South Africa aims to provide equitable access at the most appropriate level of care. We studied to what extent the acute health care needs of adults admitted to public hospitals in the Cape Town Metropole were being appropriately met.

METHODS

A retrospective study was conducted of the hospital records of adults admitted to medical beds in public hospitals in Cape Town between August and November 2008. Intensive care unit patients were not included.

RESULTS

Of 802 beds in use, the estimated occupancy was at least 95%. The average time elapsed since admission was 7.9 days; 94.3% of medical admissions were acute; 45% were severely to critically ill on admission; and co-morbid disease was present in 78.1%. Of all admissions, 31.9% were HIV-positive, and 17% had active tuberculosis. At least 396 (51.6%) patients were deemed to have required specialist or subspecialist consultation to expedite appropriate care; 386 (50.3%) accessed the appropriate level of medical care required; 339 (44.2%) accessed a more sophisticated level of care than required; and 42 (5.5%) did not access an adequate level of care. CT scan and ultrasound accounted for 59% of all restricted tests done.

CONCLUSIONS

Our findings support the plan to provide more primary care hospital facilities in the metropolitan area. Most patients needing specialised care are accessing such care, and most patients accessing a higher level of care than needed can be addressed by ensuring that they first access primary care and are referred according to protocols.

Patient perception of cervical screening among women living with human immuno-deficiency virus infection attending an antiretroviral therapy clinic in urban South Africa

This study aims to ascertain the perception of cervical screening practices among HIV-positive women attending an ART clinic in urban South Africa. It is a prospective cross-sectional study of 100 randomly selected patients using semi-structured interviews. Answers to fixed-response questions were recorded for statistical analysis and themes were identified from responses to open-ended questions. The study found that 59% of women surveyed reported ever having had a Papanicolau (Pap) smear and that 41% of these women had never been notified of the result. Many women surveyed lacked understanding of cervical screening; 78% had never heard of cervical cancer and around 40% had no correct knowledge about Pap smears. The findings suggest that cervical screening practices among HIV-positive women living in urban South Africa do not comply with the recommendations that are based on evidence of increased risk for this population. Systematic cervical screening programmes should be offered to HIV-positive women attending ART clinics in South Africa.

Turning words into numbers: establishing an empirical cut score for a letter graded examination

BACKGROUND

High stakes postgraduate specialist certification examinations have considerable implications for candidates' future careers. The cut score i.e. pass/fail mark of such examinations needs to be determined in a defensible and credible manner. A number of methods, suitable for use with numeric scoring methods, have been described. Determining the cut score of letter-graded examinations is, however, not described in the literature.

AIM

The aim of this study was to determine a defensible and credible method for deriving the cut score of a letter-graded examination.

METHOD

The cut score of the Fellowship examination of the College of Physicians of South Africa was estimated using a novel method. This method was validated by comparing the results obtained to those obtained using the contrasting groups method.

RESULTS

By using the examiners' decision as the 'gold standard' we found that a cut score of 50% best approximated the cutpoint of this letter-graded examination, achieving a sensitivity and specificity of 83.7% and 82.8% respectively.

CONCLUSION

This paper describes a useful strategy for estimating the cut score of letter-graded examinations.

Modified early warning score predicts the need for hospital admission and inhospital mortality

BACKGROUND

The modified early warning score (MEWS) is a useful tool for identifying hospitalised patients in need of a higher level of care and those at risk of inhospital death. Use of the MEWS as a triage tool to identify patients needing hospital admission and those at increased risk of inhospital death has been evaluated only to a limited extent.

AIM

To evaluate the use of the MEWS as a triage tool to identify medical patients presenting to the emergency department who require admission to hospital and are at increased risk of inhospital death.

METHODS

Physiological parameters were collected from 790 medical patients presenting to the emergency department of a public hospital in Cape Town, South Africa. MEW scores were calculated from the data and multivariate regression analysis was performed to identify independent predictors of hospital admission and inhospital mortality.

RESULTS

The proportion of patients admitted and those who died in hospital increased significantly as the MEW score increased (p<0.001). Multivariate regression analysis identified five independent predictors of hospital admission: systolic blood pressure < or =100 mm Hg, pulse rate > or =130 beats per minute, respiratory rate > or =30 breaths per minute, temperature > or =38.5 degrees C and an impaired level of consciousness. Independent predictors of inhospital death were: abnormal systolic blood pressure (< or =100 or > or =200 mm Hg), respiratory rate > or =30 breaths per minute and an impaired level of consciousness.

CONCLUSION

The MEWS, specifically five selected parameters, may be used as a rapid, simple triage method to identify medical patients in need of hospital admission and those at increased risk of inhospital death.

Effect of introduction of nurse triage on waiting times in a South African emergency department

BACKGROUND

In a resource poor setting with poverty, a high burden of disease and critically low medical staff numbers, triage could potentially improve the long waiting times experienced at South African public hospital emergency departments (ED) and render timely emergency care to those in most need.

AIM

To evaluate the impact of introducing nurse triage (using the Cape Triage Score (CTS)) on waiting times for patients presenting to a South African public hospital ED.

METHODS

Pre-triage waiting times were collected retrospectively through accessing hospital records of four randomly chosen months of the preceding year. This was compared with data collected prospectively over a 3 month period using nurse triage and the CTS triage tool. Captured data included CTS priority category, time of nurse triage and time of attendance by ED doctor.

RESULTS

Waiting times were significantly reduced in all but the lowest priority category. The introduction of nurse triage, using the CTS, resulted in an overall reduction in waiting time from 237 min to 146 min (p<0.001). Patients triaged "red" (highest priority) demonstrated a mean reduction in waiting time from 216 min to 38 min (p<0.001).

CONCLUSIONS

The results demonstrate that use of the CTS, as implemented by trained nurses, dramatically reduced the waiting time of patients attending a busy public hospital ED in South Africa.

A prospective evaluation of the Cape triage score in the emergency department of an urban public hospital in South Africa

BACKGROUND

Until recently South Africa had no triage system for emergency department (ED) use. The Cape triage group developed a triage scale called the Cape triage score (CTS). This system consists of a basic physiology score, mobility score and a short list of important discriminators that cannot be accurately triaged on a physiological score alone. Highest priority is given to a red colour code, followed by orange, yellow and green.

AIM

The purpose was to evaluate the components of the CTS and identify amendments that would improve the quality of the scale in terms of its accuracy to identify patients more likely to require admission or at high risk of death in the ED.

METHODS

Data were prospectively collected over a 4-month period. Data captured included the parameters of a basic physiological score (respiratory rate, pulse rate, systolic blood pressure, temperature and a simplified score measuring level of consciousness), mobility, a list of selected clinical conditions (discriminator list), final clinical diagnosis and final outcome in the ED (admission to hospital or death).

RESULTS

798 patients were triaged and analyzed. The CTS undertriaged 24% (overtriage 25%) of cases who required admission. By altering the colour code parameters, amending the discriminator list as well as the addition of a trauma factor, undertriage was reduced to 12% (with an overtriage of 45%).

CONCLUSIONS

The amended CTS has an acceptably low undertriage rate and is capable of predicting patient disposal over a wide spectrum of ED presentations.

Are specialist certification examinations a reliable measure of physician competence?

High stakes postgraduate specialist certification examinations have considerable implications for the future careers of examinees. Medical colleges and professional boards have a social and professional responsibility to ensure their fitness for purpose. To date there is a paucity of published data about the reliability of specialist certification examinations and objective methods for improvement. Such data are needed to improve current assessment practices and sustain the international credibility of specialist certification processes. To determine the component and composite reliability of the Fellowship examination of the College of Physicians of South Africa, and identify strategies for further improvement, generalizability and multivariate generalizability theory were used to estimate the reliability of examination subcomponents and the overall reliability of the composite examination. Decision studies were used to identify strategies for improving the composition of the examination. Reliability coefficients of the component subtests ranged from 0.58 to 0.64. The composite reliability of the examination was 0.72. This could be increased to 0.8 by weighting all test components equally or increasing the number of patient encounters in the clinical component of the examination. Correlations between examination components were high, suggesting that similar parameters of competence were being assessed. This composite certification examination, if equally weighted, achieved an overall reliability sufficient for high stakes examination purposes. Increasing the weighting of the clinical component decreased the reliability. This could be rectified by increasing the number of patient encounters in the examination. Practical ways of achieving this are suggested.

Use of a structured interview to assess portfolio-based learning

CONTEXT

Portfolio-based learning is a popular educational tool usually examined by document review which is sometimes accompanied by an oral examination. This labour-intensive assessment method prohibits its use in the resource-constrained settings typical of developing countries.

OBJECTIVES

We aimed to determine the feasibility and internal consistency of a portfolio-based structured interview and its impact on student learning behaviour.

METHODS

Year 4 medical students (n = 181) recorded 25 patient encounters during a 14-week medical clerkship. Portfolios were examined in a 30-minute, single-examiner interview in which four randomly selected cases were discussed. Six standard questions were used to guide examiners in determining the ability of candidates to interpret and synthesise clinical data gathered during patient encounters. Examiners were trained to score responses using a global rating scale. Pearson's correlation co-efficient, Cronbach's alpha coefficient and the standard error of measurement (SEM) of the assessment tool were determined. The number of students completing more than the required number of portfolio entries was also recorded.

RESULTS

The mean (+/- standard deviation [SD], 95% confidence interval [CI]) interview score was 67.5% (SD +/- 10.5, 95% CI 66.0-69.1). The correlation coefficients for the interview compared with other component examinations of the assessment process were: multiple-choice question (MCQ) examination 0.42; clinical case-based examination 0.37; in-course global rating 0.08, and overall final score 0.54. Cronbach's alpha coefficient was 0.88 and the SEM was 3.6. Of 181 students, 45.3% completed more than 25 portfolio entries.

CONCLUSIONS

Portfolio assessment using a 30-minute structured interview is a feasible, internally consistent assessment method that requires less examination time per candidate relative to methods described in published work and which may encourage desirable student learning behaviour.

Mortality in patients treated for tuberculous pericarditis in sub-Saharan Africa

OBJECTIVE

To determine the mortality rate and its predictors in patients with a presumptive diagnosis of tuberculous pericarditis in sub-Saharan Africa.

DESIGN

Between 1 March 2004 and 31 October 2004, we enrolled 185 consecutive patients with presumed tuberculous pericarditis from 15 referral hospitals in Cameroon, Nigeria and South Africa, and observed them during the 6-month course of antituberculosis treatment for the major outcome of mortality. This was an observational study, with the diagnosis and management of each patient left at the discretion of the attending physician. Using Cox regression, we have assessed the effect of clinical and therapeutic characteristics (recorded at baseline) on mortality during follow-up.

RESULTS

We obtained the vital status of 174 (94%) patients (median age 33; range 14 - 87 years). The overall mortality rate was 26%. Mortality was higher in patients who had clinical features of HIV infection than in those who did not (40% v. 17%, p=0.001). Independent predictors of death during followup were: (i) a proven non-tuberculosis final diagnosis (hazard ratio (HR) 5.35, 95% confidence interval (CI) 1.76 - 16.25), (ii) the presence of clinical signs of HIV infection (HR 2.28, CI 1.14 - 4.56), (iii) coexistent pulmonary tuberculosis (HR 2.33, CI 1.20 - 4.54), and (iv) older age (HR 1.02, CI 1.01 - 1.05). There was also a trend towards an increase in death rate in patients with haemodynamic instability (HR 1.80, CI 0.90 - 3.58) and a decrease in those who underwent pericardiocentesis (HR 0.34, CI 0.10 - 1.19).

CONCLUSION

A presumptive diagnosis of tuberculous pericarditis is associated with a high mortality in sub-Saharan Africa. Attention to rapid aetiological diagnosis of pericardial effusion and treatment of concomitant HIV infection may reduce the high mortality associated with the disease.

Hyperglycaemic emergency admissions to a secondary-level hospital - an unnecessary financial burden

BACKGROUND AND OBJECTIVES

Diabetes affects approximately 1 million South Africans. Hospital admissions, the largest single item of diabetes expenditure, are often precipitated by hyperglycaemic emergencies. A recent survey of a 200- bed hospital, serving approximately 1.3 million Cape Town residents, showed that hyperglycaemic emergencies comprised 25.6% of high-care unit admissions. A study was undertaken to determine the reasons for, and financial cost of, these admissions.

METHODS

All hyperglycaemic admissions during a 2-month period (1 September - 31 October 2005) were surveyed prospectively. Admissions were classified using the American Diabetes Association classification of hyperglycaemic emergencies. Demographic data, and the reason for, duration of and primary outcome of admission, were recorded. The following costs per admission were calculated using publicsector pricing: (i) total costs; (ii) patient-specific costs; (iii) nonpatient- specific costs; and (iv) capital costs.

RESULTS

Sepsis (36%), non-compliance with therapy (32%) and a new diagnosis of diabetes (11%) were the predominant reasons for admission of 53 hyperglycaemic emergency cases. Mean duration of hospital stay was 4 days, with an in-hospital mortality of 7.5%. Mean cost per admission was R5 309. Clinical staff (25.8%), capital (25.6%) and overhead (34%) costs comprised 85.4% of expenditure.

DISCUSSION AND RECOMMENDATIONS

Hyperglycaemic admissions, costing more than R5 300 per patient, represent a health burden that has remained unchanged over the past 20 years. Urgently required primary care preventive strategies include early diagnosis of diabetes, timely identification and treatment of precipitating causes, specifically sepsis, and education to improve compliance.

Performance of academically at-risk medical students in a problem-based learning programme: a preliminary report

INTRODUCTION

Racially segregated schooling, a legacy of Apartheid policies, continues to hamper education in South Africa. Students entering university from suboptimal circumstances are at significant risk of demonstrating poor academic performance and dropping out of their programmes. Attempts to address the educational needs of these students have included the introduction of extended medical programmes at several universities. Such a programme, the Academic Development Programme (ADP), was implemented at the University of Cape Town in 1991. Over the past decade the programme has graduated more than 100 students. Upon implementation of a new problem-based learning (PBL) programme in 2002, the ADP was discontinued and all students were entered directly into the new PBL programme. Students who demonstrate a need for additional academic support by the end of the first semester enter the Intervention Programme for 1 year before proceeding to the second semester of the PBL programme. An interim analysis was performed to compare the retention rates and academic performance of academically at-risk students in the new PBL programme and the ADP.

METHODS

The records of all academically at-risk students entering the ADP (1991-2000) and the new PBL programme (2002) were reviewed. Retention rates for all years of study, and academic performance in the fourth year clerkship courses of the respective programmes were compared.

RESULTS

A total of 239 academically at-risk students in the ADP and 43 at-risk students in the new PBL programme were studied. The median retention rates, per year of study, for at-risk students in the PBL programme was significantly better than for at-risk students in the ADP (p<0.02). Academic performance of the at-risk students in all the fourth year clinical clerkship courses of the PBL programme was significantly better than the mean performance over 10 years for at-risk students in the same fourth year courses in the ADP.

CONCLUSION

The introduction of PBL at the University of Cape Town has not had a deleterious effect on the performance of academically at-risk medical students. Interim analysis suggests that retention rates and academic performance in the PBL programme are better than those achieved in the extended traditional programme.

Accreditation of undergraduate medical training programs: practices in nine developing countries as compared with the United States

CONTEXT AND OBJECTIVES

Undergraduate medical training program accreditation is practiced in many countries, but information from developing countries is sparse. We compared medical training program accreditation systems in nine developing countries, and compared these with accreditation practices in the United States of America (USA).

METHODS

Medical program accreditation practices in nine developing countries were systematically analyzed using all available published documents. Findings were compared to USA accreditation practices.

FINDINGS

Accreditation systems with explicitly defined criteria, standards and procedures exist in all nine countries studied: Argentina, India, Kenya, Malaysia, Mongolia, Nigeria, Pakistan, Philippines and South Africa. Introduction of accreditation processes is relatively recent, starting in 1957 in India to 2001 in Malaysia. Accrediting agencies were set up in these countries predominantly by their respective governments as a result of legislation and acts of Parliament, involving Ministries of Education and Health. As in the USA, accreditation: (1) serves as a quality assurance mechanism promoting professional and public confidence in the quality of medical education, (2) assists medical schools in attaining desired standards, and (3) ensures that graduates' performance complies with national norms. All nine countries follow similar accreditation procedures. Where mandatory accreditation is practiced, non-compliant institutions may be placed on probation, student enrollment suspended or accreditation withdrawn.

CONCLUSION

Accreditation systems in several developing countries are similar to those in the developed world. Data suggest the trend towards instituting quality assurance mechanisms in medical education is spreading to some developing countries, although generalization to other areas of the world is difficult to ascertain.

Formative assessment promotes learning in undergraduate clinical clerkships

INTRODUCTION

Clinical clerkships, typically situated in environments lacking educational structure, form the backbone of undergraduate medical training. The imperative to develop strategies that enhance learning in this context is apparent. This study explored the impact of longitudinal bedside formative assessment on student learning in a medical clerkship.

METHODS

We studied a class of 4th-year students completing a 14-week medical clerkship at the University of Cape Town in South Africa. Clinician educators assessed student performance during weekly bedside teaching sessions using blinded patient encounters (in which students had no prior knowledge of the patient's diagnosis or access to the clinical records). Student feedback was standardised using performance rating scales. The impact of formative assessment on student learning was determined from questionnaire responses.

RESULTS

A total of 575 formative assessments took place during the study period. Students perceived blinded patient encounters to be a valuable learning activity that improved their clinical reasoning skills and assessed progress fairly. They reported that feedback helped inform them of their level of competence and learning needs, motivated them to read more, and significantly improved their participation in patient-centred learning activities. Participating clinicians agreed that this formative assessment strategy enhanced the learning potential of bedside teaching sessions.

CONCLUSIONS

Longitudinal formative assessment, using blinded patient encounters, was successfully integrated into undergraduate clerkship bedside teaching. According to both students and staff this assessment strategy enhanced bedside learning and improved student participation in patient-centred learning activities during the clerkship.

Clinical characteristics and initial management of patients with tuberculous pericarditis in the HIV era: the Investigation of the Management of Pericarditis in Africa (IMPI Africa) registry

BACKGROUND

The incidence of tuberculous pericarditis has increased in Africa as a result of the human immunodeficiency virus (HIV) epidemic. However, the effect of HIV co-infection on clinical features and prognosis in tuberculous pericarditis is not well characterised. We have used baseline data of the Investigation of the Management of Pericarditis in Africa (IMPI Africa) registry to assess the impact of HIV co-infection on clinical presentation, diagnostic evaluation, and treatment of patients with suspected tuberculous pericarditis in sub-Saharan Africa.

METHODS

Consecutive adult patients in 15 hospitals in three countries in sub-Saharan Africa were recruited on commencement of treatment for tuberculous pericarditis, following informed consent. We recorded demographic, clinical, diagnostic and therapeutic information at baseline, and have used the chi-square test and analysis of variance to assess probabilities of significant differences (in these variables) between groups defined by HIV status.

RESULTS

A total of 185 patients were enrolled from 01 March 2004 to 31 October 2004, 147 (79.5%) of whom had effusive, 28 (15.1%) effusive-constrictive, and 10 (5.4%) constrictive or acute dry pericarditis. Seventy-four (40%) had clinical features of HIV infection. Patients with clinical HIV disease were more likely to present with dyspnoea (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.4 to 7.4, P = 0.005) and electrocardiographic features of myopericarditis (OR 2.8, 95% CI 1.1 to 6.9, P = 0.03). In addition to electrocardiographic features of myopericarditis, a positive HIV serological status was associated with greater cardiomegaly (OR 3.89, 95% CI 1.34 to 11.32, P = 0.01) and haemodynamic instability (OR 9.68, 95% CI 2.09 to 44.80, P = 0.0008). However, stage of pericardial disease at diagnosis and use of diagnostic tests were not related to clinical HIV status. Similar results were obtained for serological HIV status. Most patients were treated on clinical grounds, with microbiological evidence of tuberculosis obtained in only 13 (7.0%) patients. Adjunctive corticosteroids were used in 109 (58.9%) patients, with patients having clinical HIV disease less likely to be put on them (OR 0.37, 95% CI 0.20 to 0.68). Seven patients were on antiretroviral drugs.

CONCLUSION

Patients with suspected tuberculous pericarditis and HIV infection in Africa have greater evidence of myopericarditis, dyspnoea, and haemodynamic instability. These findings, if confirmed in other studies, may suggest more intensive management of the cardiac disease is warranted in patients with HIV-associated pericardial disease.

The cost of treating serious abdominal firearm-related injuries in South Africa

INTRODUCTION

Firearms, the leading external cause of non-natural deaths in South Africa, claim approximately 15,000 lives annually. Up to 127,000 firearm-injured victims seek state health care assistance per annum. The fiscal burden of treating these injuries is not known.

METHODS

All serious abdominal firearm-related injuries (requiring admission to hospital and emergency surgery) presenting to a state hospital over a 6-month period were reviewed. A cost analysis using five variables was performed: operating theatre time, duration of hospital and high-care unit stay, pharmaceutical and blood products used, laboratory services used and diagnostic imaging studies performed.

RESULTS

Twenty-three patients with serious abdominal gunshot injuries were admitted, of whom 21 (91%) were treated at the hospital from admission until discharge. Each admission cost approximately US dollars 1,467. Hospital stay (47%) and operating theatre (30%) costs accounted for most of the total cost. Pharmaceuticals and blood products (20%), laboratory services (2%) and imaging studies (1%) contributed less than 25% to the total cost.

CONCLUSION

Serious abdominal gunshot injuries cost at least 13-fold more than the annual per capita South African government expenditure on health. This fiscal burden of approximately US dollars 2.9 million, almost 4% of the annual health budget, does not include the cost of treating other serious gunshot injuries. These findings highlight the need for successful violence prevention strategies in South African.

A structured assessment of newly qualified medical graduates

INTRODUCTION

While there is extensive published experience with the assessment of procedural skills in undergraduate students, this is limited in newly qualified medical graduates at the time of entry to the pre-registration (internship) year. The few studies that have been published suggest that these skills are frequently deficient when objectively tested. We therefore chose to assess the competence of a group of South African medical graduates on entry to their pre-registration year.

METHODS

A total of 58 graduates of South African medical schools were assessed. Each subject participated in a 7-station objective structured clinical examination (OSCE); 6 of these assessed individual competence in phlebotomy, intramuscular injection, female pelvic examination, bladder catheterisation, tracheal intubation and prescription writing, while competence in cardiopulmonary resuscitation was assessed in a seventh station in randomly allocated teams of 3 candidates. Candidates' opinions of their own competence was sought by questionnaire.

RESULTS

There was a wide variation in competence between subjects and across the range of tasks studied. Mean scores ranged from 85.4% for phlebotomy to 55.3% for prescription writing. The average score across all stations was 67.5%, and no student obtained an overall cut-off score of 85% or more, which was established using a modified Angoff method. Subjects' assessment of their own performance was unduly optimistic; most believed that they had demonstrated competence despite clear shortcomings in technique. Objective scores for subjects who had been exposed to a structured skills laboratory programme were not significantly higher than for those who had not, although their self-assessed performance was indeed higher.

DISCUSSION

Most of the South African medical graduates who participated in this study were unable to satisfactorily perform technical procedures appropriate to the house officer on entry to the pre-registration year. This is in line with the conclusions of the few studies published in other countries. We suggest that the learning outcomes of undergraduate medical programmes should include an explicit statement of the competencies required for practice in the pre-registration year, and that these should be adequately taught and rigorously assessed before graduation.

Single-cell cytokine analysis allows detection of cervical T-cell responses against human papillomavirus type 16 L1 in women infected with genital HPV

Specific types of human papillomavirus (HPV) are known to play a causal role in the development of cervical cancer, with human papillomavirus type 16 (HPV-16) identified as the predominant type. Despite this, little is known about cervical immune responses to this pathogen. The aim of this study was to assess the feasibility of cervical cytobrush sampling and single-cell cytokine staining to investigate cervical lymphocyte-specific cytokine responses to HPV-16 antigens. Of eighteen women recruited into the study, five were HPV DNA positive at the cervix (current exposure) and a further five had circulating antibodies to HPV-16 (previous exposure). Cervical lymphocytes, isolated from the five HPV DNA-positive women, two HPV DNA-negative controls, and one woman with circulating HPV-16 antibodies were assessed for HPV-specific responses using intracellular staining for interferon-gamma (IFN-gamma) and interleukin-4 (IL-4). We demonstrate that both CD4(+) and CD8(+) cervical T lymphocytes, harvested from noninfected and infected subjects, produce these cytokines in response to nonspecific stimulation. However, antigen-specific (HPV-16 L1) IFN-gamma production by CD4(+) and CD8(+) cervical T lymphocytes is only detectable in women exposed currently or previously to HPV-16. This is the first time that antigen-specific cytokine responses of mucosal lymphocytes, obtained from a site of HPV infection, have been demonstrated. This finding clearly illustrates the use of intracellular cytokine staining for investigation of low precursor frequency single-cell antigen-specific responses in lymphocytes harvested from mucosal sites with HPV infection.

Ethnicity and patterns of spondyloarthritis in South Africa--analysis of 100 patients

OBJECTIVE

To determine the spectrum and ethnic differences of spondyloarthritis disease patterns in patients attending the Rheumatic Diseases Unit, University of Cape Town, South Africa.

METHODS

A retrospective survey of case records of 100 patients with spondyloarthritis seen between January 1988 and January 1995.

RESULTS

Of these 100 patients, 71 were male, 53 were Colored [mixed race descendants of Khoisan (Hottentot and Bushmen), Whites, Malays and Black Africans], 40 White, 5 Black and 2 Indian (descendants of immigrants from the Indian subcontinent). Our results show that the prevalence and disease patterns of spondyloarthritis in this South African cohort are comparable to those seen in Europe and North America with respect to clinical and radiological features, as well as therapeutic and orthopedic surgical requirements. No major ethnic differences in disease patterns were observed in White and Colored patients studied.

CONCLUSION

The spectrum of spondyloarthritis in South Africa is similar to that seen elsewhere in the world. Our study confirmed the rarity of these conditions in Black South Africans.

Surgical treatment of severe autistic regression in childhood epilepsy

We report 2 children with partial epilepsy who manifested social and language regression and partial recovery after surgical treatment. One child had seizures since the first 2 weeks of life, caused by a right temporal dysembryoplastic neuroepithelial tumor and regression in the latter part of the first year; seizures were relieved and some functions were recovered after temporal lobe resection at 12 months of age. The second child developed epilepsy at 3 years 3 months, and between 5 years 9 months and 6 years 1 month he became aphasic (Landau-Kleffner syndrome) and lost social functioning, manifesting a very severe behavior disorder. He exhibited a significant improvement in communication, social functioning, and behavior after left multiple subpial transections. Both children manifested evidence of subclinical seizure activity in both temporal lobes. Their clinical picture was one of combined language and autistic regression, and the autistic features demonstrated a clear response to surgical treatment. We suggest that in pediatric epilepsy surgical programs, autistic regression should prompt urgent investigation if drug treatment is not effective.

Conn's syndrome due to adrenocortical adenoma--a rare but rewarding cause of curable hypertension

OBJECTIVE

To determine the characteristics of an aldosterone-producing adenoma (APA) as a cause of hypertension, its mode of presentation and investigation, as well as the outcome of surgical removal.

DESIGN

Retrospective survey with follow-up.

SETTING

Groote Schuur Hospital, Cape Town.

PATIENTS

18 patients who had an APA removed between 1975 and 1993.

OUTCOME MEASURES

Clinical and biochemical features, morbidity and mortality rates associated with adrenalectomy, and the degree of amelioration of hypertension.

RESULTS

Eighteen of 41 patients with primary hyperaldosteronism had an APA. Features of symptomatic hypokalaemia (muscular weakness 9, fatigue 7) were present for a mean of 60 (9 - 240) months. The mean systolic arterial pressure was 153 (117 - 200) mmHg. The mean potassium level was 2,2 mmol/l and the mean aldosterone level 1 639 (147 - 5 153) pmol/l, which, paradoxically, fell on ambulation in 12 patients. All renin levels were suppressed in the supine (mean 0,1 +/- 0,1 (0 - 0,6) ng/ml/h) and ambulatory positions (mean 0,4 +/- 0,5 (0 -1,8) ng/ml/h). Each of 17 tomographic and 6 iodocholesterol scans correctly identified the lesion. There was no surgical mortality, and all patients became normokalaemic. At 1 month or at the time of discharge, 12 (66%) patients were normotensive, 7 without medication. Age, length of history, severity of hypertension and evidence of target organ damage did not predict response to surgery.

CONCLUSIONS

An APA is a rare cause of hypertension and hypokalaemia, but it is important to identify as surgery may be beneficial in most cases.

Collagenous colitis--a rare cause of chronic watery diarrhoea. A case report

Collagenous colitis is a clinicopathological syndrome occurring predominantly in middle-aged females presenting with chronic watery diarrhoea. Histologically the disorder is characterised by a mononuclear cell mucosal inflammatory infiltrate and subepithelial collagen thickening. The condition was first described in 1976 and since then approximately 100 cases have been reported in the literature. We present here the first reported case of this rare disorder in South Africa.