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Background: Asthma medication prescription trends, including those of short-acting β 2 -agonists (SABAs), are not well documented for South Africa (SA)., Objectives: To describe demographics, disease characteristics and asthma prescription patterns in the SA cohort of the SABA use IN Asthma (SABINA) III study., Methods: An observational, cross-sectional study conducted at 12 sites across SA. Patients with asthma (aged ≥12 years) were classified by investigator-defined asthma severity, guided by the Global Initiative for Asthma (GINA) 2017 recommendations, and practice type (primary/ specialist care). Data were collected using electronic case report forms., Results: Overall, 501 patients were analysed - mean (standard deviation) age, 48.4 (16.6) years; 68.3% female - of whom 70.6% and 29.4% were enrolled by primary care physicians and specialists, respectively. Most patients were classified with moderate-to-severe asthma (55.7%; GINA treatment steps 3 - 5), were overweight or obese (70.7%) and reported full healthcare reimbursement (55.5%). Asthma was partly controlled/uncontrolled in 60.3% of patients, with 46.1% experiencing ≥1 severe exacerbations in the 12 months before the study visit. Overall, 74.9% of patients were prescribed ≥3 SABA canisters in the previous 12 months (over-prescription); 56.5% were prescribed ≥10 SABA canisters. Additionally, 27.1% of patients reported purchasing SABA over-the-counter (OTC); among patients with both SABA purchase and prescriptions, 75.4% and 51.5% already received prescriptions for ≥3 and ≥10 SABA canisters, respectively, in the preceding 12 months., Conclusion: SABA over-prescription and OTC purchase were common in SA, demonstrating an urgent need to align clinical practices with the latest evidence-based recommendations and regulate SABA OTC purchase to improve asthma outcomes., Study Synopsis: What the study adds. This study provides valuable insights into asthma medication prescription patterns, particularly SABAs, across SA. Collection of this real-world data in patients treated in primary and specialty care demonstrates that SABA over-prescription and SABA OTC purchase are common, even in patients with mild asthma. These findings will enable clinicians and policymakers to make targeted changes to optimise asthma outcomes across the country Implications of the findings. SABA over-prescription represents a major public health concern in SA. Healthcare providers and policymakers will need to work together to promote educational initiatives aimed at patients, pharmacists and physicians, align clinical practices with the latest evidence-based recommendations, improve access to affordable medications and regulate SABA purchase without prescription., Competing Interests: Conflicts of interest: CS received honoraria for talks and serves on advisory boards for numerous companies, including AstraZeneca. KL and RS are employees of AstraZeneca. MJHIB was an employee of AstraZeneca at the time this study was conducted. All other authors have no conflicts of interest to declare.

Background: Hernias are amongst the most common general surgical problems worldwide. In 2019, an estimated 800 000 inguinal hernias remain untreated in Tanzania. Furthermore, only 5% of hernias in Africa are repaired with mesh due to costs, resulting in high recurrence rates. We describe the establishment of a safe, sustainable and affordable mesh hernia programme in Tanzania., Methods: Hernia repairs were performed by a UK Consultant General Surgeon and two Tanzanian Surgical Assistant Medical Officers between November 2018 and April 2019. Tanzanian Assistant Medical Officers were taught in a modular fashion. Polyethylene 'mosquito net' mesh was sterilized using a steam autoclave on site. A standardized approach to intraoperative technique and perioperative care was adopted. Patients were followed up and a registry maintained., Results: A total of 50 mesh hernia repairs were performed on all-comers between November 2018 and April 2019. One additional hernia repair was carried out without mesh as the hernia contained perforated bowel with faecal contamination. Of the 50 patients, 47 were followed up. At 2 weeks, none were found to have recurrence, none had evidence of infection and none reported numbness. Of the 47 patients, nine reported low-grade discomfort. On further follow-up, the pain resolved in seven of the nine patients, and the remaining two reported persistent low-grade discomfort (both recurrent hernias with the reported pain less than preoperatively)., Conclusion: Proposals have been accepted for a Tanzania National Hernia Project, which aims to establish mesh repair as the gold-standard approach to inguinal hernia surgery across Tanzania. Through education and collaboration, this project hopes to address the major outstanding health issue of untreated hernias in Tanzania., (© 2020 Royal Australasian College of Surgeons.)

Background: Given the lack of hospital-wide ownership and shortage of nurses, the ideal model for large-scale implementation of hand hygiene (HH) behaviour change in low- and middle-income countries is unknown., Aim: The aim of the multi-modal strategy was to engender hospital accountability for HH compliance., Methods: The quasi-experimental study was conducted in 50 South African hospitals (November 2015 to July 2017) and involved five overlapping phases: executive governance and corporate behaviour change; group-wide systematic situational analysis; development of an electronic-assisted direct-observed data collection and analysis application; launch and implementation; and accountable governance. Measurement of intra- and inter-hospital variance to six HH opportunities was calculated and data compliance dashboards were e-mailed weekly to hospital leadership teams to provide feedback of recorded HH compliance and behaviour to frontline teams. Baseline comparison (July 2016) of compliance was compared versus post-implementation (July 2017)., Findings: Baseline HH compliance of ≤60% was documented for 16% (8/50) of hospitals, whereas overall, 48% (24/50) of hospitals demonstrated a significant improvement (P < 0.01). Over the 13-month observation period, 523,422 observations were recorded with a mean rate of 277 ± 223 observations per 1000 patient-days. The group mean composite compliance improved by 7.8% (P < 0.01) from 77.4% ± 12.8 to 85.2% ± 8.8 between July 2016 and July 2017, respectively., Conclusion: Implementation of a multi-faceted HH model in a large, diverse group of South African hospitals translated into changes in the organizational systems and accountability, standardized HH compliance management and feedback that led to HH proprietorship., (Copyright © 2019 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Summary: Access to neurosurgical care in South Africa is influenced by prevailing inequities in healthcare. It is generally perceived that the public sector performs mainly emergencies relating to trauma, and the private sector performs mainly elective spinal surgery. In March 2015, emergencies constituted 51% of cases in the public sector compared to 8% in the private sector. Trauma, paediatric hydrocephalus and intracranial sepsis constituted nearly 75% of the operative workload in the public sector. Cranial surgery accounted for the majority (95%) of operations in the public sector, whereas the majority in the private sector was spinal (75%). There is considerable disparity in the type of neurosurgery being performed in the public and private sectors in KwaZulu-Natal and with the current financial constraints, there is a potential unmet need for elective spinal surgery in the public sector., (Copyright© Authors.)

Glioblastoma multiforme (GBM) is extremely rare in the pineal region, with only 19 previously reported cases. We report a unique case of a teenage girl with a pineal tumour with markedly raised beta-human chorionic gonadotropin (BHCG) levels, thought to be a germ-cell tumour. However, the raised BHCG was due to pregnancy, and biopsy revealed a pineal GBM.

Objective: To assess the role of point-of-care (PoC) assessment of C-reactive protein (CRP) and white blood cell (WBC) count to identify bacterial illness in Tanzanian children with non-severe non-malarial fever., Methods: From the outpatient department of a district hospital in Tanzania, 428 patients between 3 months and 5 years of age who presented with fever and a negative malaria test were enrolled. All had a physical examination and bacterial cultures from blood and urine. Haemoglobin, CRP and WBC were measured by PoC devices., Results: Positive blood cultures were detected in 6/428 (1.4%) children and urine cultures were positive in 24/401 (6.0%). Mean WBC was similar in children with or without bacterial illness (14.0 × 10 9 , 95% CI 12.0-16.0 × 109 vs. 12.0 × 10 9 , 95% CI 11.4-12.7 × 109), while mean CRP was higher in children with bacterial illness (41.0 mg/l, 95% CI 28.3-53.6 vs. 23.8 mg/l, 95% CI 17.8-27.8). In ROC analysis, the optimum cut-off value for CRP to identify bacterial illness was 19 mg/l but with an area under the curve of only 0.62. Negative predictive values exceeded 80%, while positive predictive values were under 40%., Conclusion: WBC and CRP levels had limited value in identifying children with bacterial infections. The positive predictive values for both tests were too low to be used as single tools for treatment decisions., (© 2016 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.)

Introduction: The functional significance of coronary artery collateral (CAC) vasculature in humans has been debated for decades and this has been compounded by the lack of a standard, systematic, objective method of grading and documenting CAC flow in man. CACs serve as alternative conduits for blood in obstructive coronary artery disease. This study aimed to evaluate the impact of CACs on left ventricular function in the presence of total coronary arterial occlusion., Methods: The study group included the coronary angiographic records of 97 patients (mean age: 59 ± 8 years). CACs were graded from 0-3 based on the collateral connection between the donor and recipient arteries. Left ventricular function was computed from the ventriculogram and expressed as ejection fraction (EF)., Results: The mean EF of the patients with grades 0, 1, 2 and 3 CACs were calculated as 50.4, 47, 60.5 and 70%, respectively. A significant difference was recorded in the mean EF calculated for the different CAC grades (p = 0.001). There was a significant positive correlation (p < 0.001; r = 0.478) between the mean EF and the CAC grades., Conclusion: The patients with better coronary collateral grades had a higher mean EF. Therefore, as the grade of CACs increased, there was an improvement in their ability to preserve left ventricular function.

Background: The burden of typhoid in sub-Saharan African (SSA) countries has been difficult to estimate, in part, due to suboptimal laboratory diagnostics. However, surveillance blood cultures at two sites in Nigeria have identified typhoid associated with Salmonella enterica serovar Typhi (S. Typhi) as an important cause of bacteremia in children., Methods: A total of 128 S. Typhi isolates from these studies in Nigeria were whole-genome sequenced, and the resulting data was used to place these Nigerian isolates into a worldwide context based on their phylogeny and carriage of molecular determinants of antibiotic resistance., Results: Several distinct S. Typhi genotypes were identified in Nigeria that were related to other clusters of S. Typhi isolates from north, west and central regions of Africa. The rapidly expanding S. Typhi clade 4.3.1 (H58) previously associated with multiple antimicrobial resistances in Asia and in east, central and southern Africa, was not detected in this study. However, antimicrobial resistance was common amongst the Nigerian isolates and was associated with several plasmids, including the IncHI1 plasmid commonly associated with S. Typhi., Conclusions: These data indicate that typhoid in Nigeria was established through multiple independent introductions into the country, with evidence of regional spread. MDR typhoid appears to be evolving independently of the haplotype H58 found in other typhoid endemic countries. This study highlights an urgent need for routine surveillance to monitor the epidemiology of typhoid and evolution of antimicrobial resistance within the bacterial population as a means to facilitate public health interventions to reduce the substantial morbidity and mortality of typhoid., Competing Interests: The authors have declared that no competing interests exist.

Objective: In sub-Saharan Africa, the use of malaria rapid diagnostic tests (mRDT) has raised awareness of alternative fever causes in children but few studies have included adults. To address this gap, we conducted a study of mRDT-negative fever aetiologies among children and adults in Tanzania., Methods: A total of 1028 patients aged 3 months to 50 years with a febrile illness and negative mRDT were enrolled from a Tanzanian hospital outpatient department. All had a physical examination and cultures from blood, nasopharynx/throat and urine. Patients were followed on Days 7 and 14 and children meeting WHO criteria for pneumonia were followed on Day 2 with chest radiology., Results: Respiratory symptoms were the most frequent presenting complaint, reported by 20.3% of adults and 64.0% (339/530) of children. Of 38 X-rayed children meeting WHO pneumonia criteria, 47.4% had a normal X-ray. Overall, only 1.3% of 1028 blood cultures were positive. Salmonella typhi was the most prevalent pathogen isolated (7/13, 53.8%) and S. typhi patients reported fever for a median of 7 days (range 2-14). Children with bacteraemia did not present with WHO symptoms requiring antibiotic treatment. Young children and adults had similar prevalences of positive urine cultures (24/428 and 29/498, respectively)., Conclusion: Few outpatient fevers are caused by blood stream bacterial infection, and most adult bacteraemia would be identified by current clinical guidelines although paediatric bacteraemia may be more difficult to diagnose. While pneumonia may be overdiagnosed, urinary tract infection was relatively common. Our results emphasise the difficulty in identifying African children in need of antibiotics among the majority who do not., (© 2015 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.)

A 65-year-old man with prolonged history of intermittent rectal bleeding due to a large hemangioma involving the distal colon underwent radiological evaluation. barium enema and computed tomography findings are illustrated and previous articles about this entity are briefly reviewed.

Effective collaboration between agencies is often difficult to achieve. Children and their families/carers, who have complex therapeutic needs, present particular difficulties in that agencies need to work together, if they are to produce a co-ordinated and integrated package of care. A Multi-Agency-Consultation-Team (MACT) was set up in an attempt to overcome some of these problems of inter-agency co-operation. This paper describes the protocol, types of children referred and the recommendations made by the team. Follow-up of these children at 4 months suggests that a MACT does have a role to play in developing high quality services.

The urine of 45 athletes, male and female, were studied after completing an ultra long-distance marathon race. Of these athletes, 24.4% were found on screening to have red blood cells in the urine. The urinary mean corpuscular volume (MCV) of red cells was used in an attempt to differentiate between lower and upper urinary tract haematuria. With the exception of 1 athlete, the red cells were not dysmorphic and had an MCV greater than 72 fl. This suggested that the haematuria had an origin from the lower urinary tract. The urinary changes disappeared within 7 days. No definite residual renal damage could be established.

A patient is described who had undergone bilateral nephrectomy for renal cell carcinoma and who had been maintained on hemodialysis for the last 2 years. A total of 3 months after acceptance into the program he was found histologically to have metastatic pleural lesions, which had regressed spontaneously 1 1/2 years ago. Repeat clinical and radiological assessment has shown no tumor recurrence.

The case of a young man who developed a remarkably regular and rapid cyclical affective illness following a subarachnoid haemorrhage is reported. A CT scan showed damage restricted to the brain-stem. The illness proved resistant to a variety of agents; carbamazepine and lithium combined proved effective.

The paper focuses on the psychological consequences of disaster work. The issue of identifying staff who may be more vulnerable to psychological distress is discussed as is the need for services to plan psychological screening and support for staff who will be exposed to the trauma of dealing with the aftermath of disasters. It is concluded that active steps need to be taken to incorporate psychological aspects into disaster planning. Specifically, attention should be paid to staff selection, training, use of resources, supervision, debriefing, counselling and feedback.