On being agents of change: a qualitative study of elective experiences of medical students at the faculty of health sciences; university of cape town; south Africa

Background. Student electives during the 5th year of the University of Cape Town (UCT) medical curriculum provide a 4-week work experience in the health system. The reflective reports of past students indicate that the electives may significantly shape their developing identities as health professionals and agents of change. Objective. To better understand how 5th-year medical elective students perceive themselves as agents of change to strengthen the elective programme in the Faculty of Health Sciences; UCT. The hypothesis was that the more choice that students are given over their learning; the greater is their sense of agency. Methods. Thirteen 5th-year student volunteers participated in four focus group discussions soon after completing their electives in district; regional or tertiary health facilities in the South African health system. Thematic analysis of the transcripts was performed independently by two of the authors. Results. Key themes were the importance of providing holistic patient-centred care; becoming a competent health professional; working within the health team and advocating for a better health system. The elective experience helped students to be more confident in their abilities and to better understand how to effect change at a clinical and health system level. Conclusion. This study supported the hypothesis that the more choice students have over their learning; the greater is their sense of agency. The electives are appreciated as opportunities to develop clinical skills and competencies and to better understand the role of future doctors within the health team and health system. The value of the UCT elective programme could be enhanced by greater promotion; funding for rural electives; and post-elective peer-topeer feedback sessions. This study will inform planning for an extended 2016 medical elective programme in the Faculty

The Retention of Community Service Officers at District Hospitals in KwaZulu Natal; Eastern Cape and Limpopo Provinces

Background: Community service (CS) is an effective recruitment strategy for underserved areas; using legislation as the driver; however it is not a retention strategy. By the end of each year; most CS officers working in district hospitals (DH) are skilled; valued and valuable members of the health team; able to cope with the demands of working in the public health service within the resources available at DHs. Their exodus at the end of each annual cycle represents a net loss of valuable skills and experience by the public service; measured by the time and effort required to orientate and induct the following cohort of CS officers. This in turn has a negative effect on the level of service delivery and the quality of patient care. This study sought to understand the motivations of CS officers to continue working at the same DH for a subsequent year after their obligatory year was over. The objectives were to determine the number of CS officers who actually remained at the same DH after completing their CS in 2002; the major factors that influenced them to remain; and factors that would encourage the 2003 cohort of CS officers to remain for an additional year at the same DH. Methods: A descriptive cross- sectional study design was employed using qualitative methods with the cohort of CS officers who had completed their compulsory CS year in 2002 and who were still working at the same DH in July 2003. This was followed by a quantitative survey of CS officers doing their CS at DHs in KwaZulu-Natal (KZN); Eastern Cape (EC) and Limpopo Province (LP) in November 2003. Results: 22/278 (8) of the 2002 cohort of CS officers in KZN; EC and LP remained at the same DH in the year following their CS. The reasons given; in order of decreasing priority; were that they were close to home; had been allocated as part of their CS; were personally recruited; had bursary commitments; had heard about the hospital from friends; had visited the hospital prior to starting community service; and had visited as a medical student. Four others did not specify reasons. In the larger quantitative study 150 / 221 questionnaires were returned. More than 80of the respondents felt that there had been opportunities to develop confidence in their own ability to make independent decisions; that they had had good relations with the hospital staff; and that they had been able to make a difference in health care delivery. Between 67and 76of respondents felt that they were providing a good standard of care; that there were learning opportunities; that they were doing worthwhile work and saw CS as excellent work experience. However only 52of respondents felt that there had been opportunities for personal growth; 38felt that appropriate equipment was available; 37had a supportive mentor figure and 29felt that there were adequate levels of staffing at the hospital. In total 24 (16) of the 150 who responded to the questionnaire indicated a willingness to remain at the same DH after completion of their year of CS. The intention to continue for a further year was statistically significantly associated with the following factors: ethnic group; province; rural origin; allocation priority and bursary commitment. Conclusions: The retention in the same DH of only 8of the CS officer cohort in 3 rural provinces indicates a serious loss of skills on a recurrent annual basis. Local hospital management can do much to strengthen the factors that would attract CS officers to stay on by improving orientation; mentoring; teamwork; professional development opportunities; medical equipment and accommodation

Prevalencia de infección cervical por Chlamydia trachomatis en mujeres de la Región Metropolitana / Prevalence of cervical infection by Chlamydia trachomatis among Chilean women living in the Metropolitan Región

Background: Chlamydia trachomatis is the most common bacterial sexually transmitted infection (STI) worídwide. In women, chlamydia infections are 75 percent asymptomatic and can lead to pelvic inflammatory disease, infertility, and ectopic pregnancy. Infants exposed to the microorganism at birth also have a high risk to develop conjunctivitis and pneumonía. Aim: To determine the prevalence of C trachomatis in women in the Metropolitan área of Santiago (Chile). Patients and methods: Cervical specimens were collected from 403 women attending three gynecological outpatient settings from Apríl 2003 to June 2005. These included one public hospital (n =100), a prívate medical center (n =268), and a clinic for adolescents (n =35). Mean ages ofeach group of patients were 35.6±8,2, 33.4±8.1 and 16.9±4.2 years, respectively. The diagnosis of C trachomatis was performed by the amplification byPCRofa 517-base pair segment of the cryptic plasmid on specimens extracted by a commercial procedure. Positive specimens were conñrmed by nested PCRs targeting the ompl gene. The presence of vaginal infections and its association with C trachomatis was investigated in a subset of 223 women ofthe prívate center. Residís: C trachomatis was detected in the cervix of 19 out of 403 women, resulting in a prevalence of 4.7 percent. The distribution of positive cases among different age groups was not significantly different. Women presenting with bacterial vaginosis had a significantly higher prevalence of C trachomatis infection (p <0.01). Conclusions: This study found a high prevalence of C trachomatis among gynecologic patients that should prompt preventive strategies.

The community involvement of nursing and medical practitioners in KwaZulu-Natal

Background: The basis of the health system in South Africa is purported to be primary health care (PHC); as defined by the Alma Ata Declaration of 1978. This approach emphasises community involvement in all health-related activities; but it would appear that a very limited or selective PHC approach is actually being pursued in South Africa; without meaningful community participation or ownership. This study explores the involvement of exemplary medical and nursing clinical practitioners in non-clinical community-wide activities in terms of the primary health care approach; which demands a broader scope of practice than primary medical care. Methods: The objectives of the study were to identify exemplary medical and nurse practitioners in primary health care; to document their practices and perceptions with regard to their community involvement; to analyse the common themes arising from the findings; and to present recommendations based on the findings. Seventeen primary care clinicians in KwaZulu-Natal; half of whom were professional nurses and the rest medical practitioners; were purposively selected through their district managers. A team of four medical students was trained to collect the data and interviewed the subjects in their places of work using open-ended questions. The interviews were recorded; translated where necessary; and transcribed. Content analysis was carried out as a team; with the identification of major and minor themes.Results: The findings of this study were consistent with studies from other countries; with some interesting differences. The major themes that emerged from the data included the wide range of activities that subjects were involved in; the importance of relationships; the context of poverty; the frustrations of this kind of work; and the respondents' motivations. These are illustrated by numerous verbatim quotes from the respondents. Minor themes were the roles that the respondents play in the community; the difficulty of obtaining funding; and experiences in starting up. Significantly; the fact that the role of clinicians in the community emerged as only a minor theme rather than a major theme in this study indicates the absence of expectation and policy in this area of practice in South Africa. In the light of the supposed centrality of the primary healthcare approach in the national health system; this is a serious gap.Conclusion: The lack of a clearly defined role in the community outside of the clinical role that deals with the individual patient who presents for care is discussed in relation to the policy of the primary health care approach. The concept of community-oriented primary care provides a framework for a more systematic approach to community engagement; and this study serves as a basis for further research into the subject

Depression and its associated factors among patients attending chronic disease clinics in southwest Trinidad / La depresión y sus factores asociados entre los pacientes que asisten a las clínicas de enfermedades crónicas en el suroeste de Trinidad

This study determined the prevalence of depression and associated factors, among patients attending chronic disease clinics in Southwest Trinidad. This was a cross-sectional survey using a sample of consecutive patients at four large clinics. To determine the presence of depression, an interviewer-applied modified Zung Scale was validated The modified Zung scale, at the cut-off index of 60, has a sensitivity of 60and a specificity of 94. Seven hundred and thirty-four completed questionnaires were received, a response rate of 76. The patients were primarily Indo-Trinidadian (70), over 50 years (76.4) and female (72.3). The prevalence of depression was 28.3. There were statistically significant differences in the level of depression by age, gender, educational level achieved and occupation (p < 0.05). There were also statistically significant differences in the level of depression by the number of presenting complaints, the number of chronic diseases, the presence of arthritis, the presence of diabetes mellitus with another chronic disease and the presence of ischaemic heart disease (p < 0.05). No significant differences were found with respect to ethnicity (p = 0.97) or the presence of diabetes mellitus by itself (p = 0.34). Results of logistic regression indicate that the independent predictors of depression (p < 0.05) were the level of education achieved, those with higher levels of education had less depression; the number of presenting complaints, those with more presenting complaints were more likely to be depressed and the presence of arthritis and female gender. It is imperative that policy be developed to address the mental health problems of patients attending these chronic disease clinics.

Este estudio determinó la prevalencia de la depresión y los factores asociados con ella, entre los pacientes que asisten a las clínicas en el suroeste de Trinidad. El mismo consistió en una encuesta transversal que utiliza una muestra de pacientes consecutivos en cuatro clínicas grandes. A fin de determinar la presencia de la depresión, validamos una escala de depresión de Zung modificada y aplicada por un entrevistador. La escala de Zung modificada, a un índice límite de 60, tiene una sensibilidad de 60% y una especificidad de 94%. Se recibieron setecientos treinta y cuatro cuestionarios respondidos, lo que equivale a una tasa de respuesta de 76%. Los pacientes fueron fundamentalmente indotrinitenses (70%), mayores de 50 años (76.4%) y mujeres (72.3%). La prevalencia de la depresión fue 28.3%. Hubo diferencias estadísticas significativas en el nivel de depresión por edad, sexo, nivel educacional alcanzado, y ocupación (p < 0.05). Hubo también diferencias estadísticamente significativas en el nivel de depresión por el número de quejas que se presentaban, el número de enfermedades crónicas, la presencia de artritis, la presencia de diabetes mellitus junto con otras enfermedades crónicas, y la presencia de cardiopatías isquémicas (p < 0.05). No se hallaron diferencias significativas en relación con la etnicidad (p = 0.97) o la presencia de diabetes mellitus por sí sola (p = 0.34). Los resultados de la regresión logística indican que los predictores independientes de la depresión (p < 0.05) fueron: el nivel educacional alcanzado, poseyendo aquellos con niveles de educación más altos, menos depresión; el número de quejas, presentándose en aquellos con más quejas, una mayor probabilidad de sentirse deprimidos; la presencia de artritis y género femenino. Es imprescindible desarrollar una política encaminada a abordar los problemas de salud mental de los pacientes que asisten a estas clínicas de enfermedades crónicas.

HIV seroprevalence and risk factors in female substance abusers seeking rehabilitation in Trinidad and Tobago

Crack cocaine use, especially among females, is associated with risky sexual behaviour. Data from 122 female substance abusers admitted to a rehabilitation centre in Trinidad and Tobago between 1996 and 2002 were retrospectively reviewed to determine Human Immunodeficiency Virus (HIV) seroprevalence and other associated risk factors. HIV seroprevalence was 19.7, eight times higher than in the general population. Factors significantly associated with HIV infection were use of crack cocaine, low educational attainment and diagnosis of a sexually transmitted infection. Other factors associated with risky sexual behaviour were common--use of cocaine in combination with alcohol (65.6), psychiatric illness (28.7) and a history of sexual abuse (83). Female substance abusers, especially female crack addicts are at high risk of acquiring and transmitting HIV. Rehabilitation programmes should include HIV prevention interventions which specifically target all risk factors including trauma counselling, skills development and screening for sexually transmitted infections

Serotipos y susceptibilidad antimicrobiana de Streptococcus agalactiae / Serotypes and antimicrobial susceptibility of Streptococcus agalactiae

Background : Streptococcus agalactiae or group B streptococcus, GBS, is the leading cause of neonatal and maternal infections and an opportunistic pathogen in adults with underlying disease. In the last decade, a dramatic increase in the resistance of this microorganism to erythromycin and clindamycin has been observed. Aim: To determine the serotype distribution and antimicrobial susceptibility of isolates of S agalactiae collected from infections and colonization and to assess the genetic mechanisms of macrolide and clindamycin resistance. Material and methods: A total of 100 GBS isolates were collected between 1998 and 2002, in Santiago, Chile. They were isolated from the amniotic fluid from patients with premature rupture of membranes (7 isolates), blood from neonatal sepsis (10 isolates), neonate colonizations (2 strains), skin and soft tissue infections (7 isolates), urinary tract infections (5 isolates), genital infections (3 isolates), articular fluid (one isolate), and 65 strains were recovered from vaginal colonization55. Results: Serotypes Ia, II and III were the predominant serotypes identified in our study, accounting for 90 (90 percent) of the strains. Five isolates belonged to serotypes Ib (5 percent) and two (2 percent) to serotype V respectively; no strains belonging to serotype IV were found. All strains were susceptible to penicillin G, ampicillin and cefotaxime, and four isolates (4 percent) were resistant to both erythromycin (MIC >64 µg/ml) and clindamycin (MIC >64 µg/ml). The strains had a constitutive macrolide-lincosamide-streptogramin (cMLSB) resistance phenotype and the erm(A) gene was present in the four isolates. Conclusions: Serotypes Ia, II and III were the predominant serotypes in this study. All strains were susceptible to penicillin G, ampicillin and cefotaxime, and four (4 percent) strains were resistant to both erythromycin and clindamycin. The cMLSB resistance phenotype, and the erm(A) gene was detected in resistant strains (Rev MÚd Chile 2004; 132: 549-55).

Substance abuse among first admissions to the psychiatric unit of a general hospital in Trinidad

Admissions for first episode of psychiatric illness provide information on service utilization which can be used to improve service delivery. The present study reviews the use of in-patient general psychiatric services in southern Trinidad using data from first admissions in one year, specifically to determine service utilization by substance-abusing patients. Case files of all admissions to the psychiatric unit of the San Fernando General Hospital in one year were reviewed and analyzed for demographic data, substance abuse, diagnosis and associated features of the admission. Significant rates of substance abuse were found among first admissions. Of 123 new patients, 43.1 were diagnosed with a substance abuse disorder, 56.6 of whom had a comorbid psychiatric disorder. Patients with substance abuse problems tended to be young males. The substance most commonly abused was alcohol (26.8) and alcohol abusers were more likely to be of East Indian descent. Management within this mental health catchment area needs to address identification, early intervention and prevention of substance abuse among psychiatric patients. It is proposed that both hospital and community-based substance abuse interventions should be employed in the management of acute psychiatric patients

Terapia con metformina y embarazo en pacientes con síndrome de ovario poliquístico / Metformin therapy for polycystic ovary syndrome during pregnancy

Estudio prospectivo de seguimiento de 15 pacientes con síndrome de ovario poliquístico (SOP) e hiperinsulinemia que se embarazaron con el uso de metformina, y que se siguieron hasta el parto. Diez continuaron metformina durante el embarazo, hasta las 14 semanas y cinco hasta las 32 semanas. Las 5 pacientes que usaron más tiempo el medicamento no desarrollaron diabetes gestacional a diferencia de las que lo tomaron hasta las 14 semanas que presentaron diabetes gestacional en tres de diez. No encontramos abortos en estas pacientes, y tampoco presentaron problemas con el medicamento. No hubo malformaciones en los recién nacidos.

Biotipos y susceptibilidad antimicrobiana de Gardnerella vaginalis / Biotypes and antimicrobial susceptibility of Gardnerella vaginalis

Se determinaron los biotipos y susceptibilidad a ampicilina, clindamicina, eritromicina, ciprofloxacina y tetraciclina de 63 cepas de Gardnerella vaginalis aisladas de pacientes con vaginosis bacteriana. Las cepas se distribuyeron en los 8 biotipos del esquema de clasificación de Piot, siendo los biotipos 1 y 2 los más frecuentes (44,4 por ciento). Todas las cepas fueron susceptibles a ampicilina y resistentes a ciprofloxacina. Cuatro cepas (6,4 por ciento) presentaron resistencia a clindamicina y dos (3,2 por ciento) a eritromicina. Treinta y una cepas (49,2 por ciento) fueron resistentes a tetraciclina. Se estudió la base genética de la resistencia a tetraciclina en ocho cepas resistentes, demostrándose la presencia del determinante tet (M) en todas ellas.

Efecto de la prueba de la caminata de seis minutos sobre la hiperinflación pulmonar en pacientes con enfermedad pulmonar obstructiva crónica avanzada / The six minute walking test elicits dynamic hyperinflation in severe COPD patients

Background: Exercise tolerance in patients with COPD is highly variable and poorly related to airways obstruction assessed by FEV1. These patients develop dynamic hyperinflation (DH) during an incremental exercise test which can be evaluated through a reduction in inspiratory capacity (IC). Aim: to evaluate: a) if the six minute walking test (6 MWD) induce DH reducing IC, b) if the reduction in IC is related to tidal expiratory flow limitation at rest (FL). Subjects and methods: Thirty eight stable COPD patients (28 FL and ten non FL during resting breathing, determined by the negative pressure technique). Inspiratory capacity was measured before and immediately after the 6 MWD test. Dyspnea, SpO2 and heart rate were measured before and after the test. Results: Inspiratory capacity was lower in FL patients as compared to patients without FL (p <0,005). Although no differences were found between groups in 6 MWD, dyspnea and HR, a significant reduction in IC after the walking test was observed only in FL patients (p <0,0001). In addition, SpO2 fell significantly (p <0,0001) after walking in the same group. Conclusions: Our results demonstrate that a moderate exercise such as the walking test induces DH and hypoxemia in patients with COPD and FL and stresses the importance of assessing DH by measuring IC in these patients

Pseudodementia in a twenty-one-year-old with bipolar disorder and vitamin B12 and folate deficiency

A twenty-one-year-old female known to suffer from bipolar type I disorder developed features of a pseudodementia. Following prompt initial response to treatment with antidepressants, there was an early recurrence of cognitive impairment. Blood investigations confirmed a macrocytic anaemia and vitamin B12 and folate deficiencies. There was dramatic resolution of cognitive impairment after vitamin replacement. This suggested the occurrence of a reversible nutritional dementia and reinforced the need to rule out secondary organic causes of psychiatric symptoms even in patients previously diagnosed with a primary psychiatric disorder.

Drug use, sexual behaviour and HIV risk of the homeless in Port-of-Spain, Trinidad

Data were collected from 88 homeless persons in Port-of-Spain, Trinidad to assess HIV risk. 68of the sample were engaging in unprotected sex with multiple partners, 25were exchanging sex for money, and 29.5were regularly smoking crack cocaine. Many had two or more of these behaviours that put them at high risk of HIV infection. Females were significantly more likely to be sex traders, to engage in bisexual behaviour and to have a history of psychiatric illness. The relationship between psychiatric illness and HIV risk behaviours among homeless female persons is explored. Educational interventions are suggested to reduce the public health risks in this population.

Streptococcus Beta hemolítico grupo B: colonización materna y neonatal / Beta-hemolytic Streptococcus group B: maternal and neonatal colonization

Streptococcus B hemolítico grupo B (SBHGB) es agente causal importante en infección del R.N. El reservorio principal es el tracto gastrointestinal de la madre originando colonización vaginal. El R.N. adquiere este microorganismo durante el parto o por vía ascendente en pacientes con ruptura de membranas. El objetivo de este estudio fue precisar tasa de colonización por SBHGB rectal y vaginal de embarazadas previo al parto así como de sus R.N. Se estudiaron, 102 embarazadas y 50 no embarazadas (grupo control) en las cuales se tomó muestra rectal y vaginal y a sus R.N. secreción nasal y umbilical. Se inocularon estas muestras en medio Todd Hewitt con antimicrobianos y en agar Columbia CNA. En 18 (17,6%) de las pacientes se aisló SBHGB correspondiendo a 10 muestras vaginales (9,8%), 7 vaginales y rectales (6,8%) y 1 solo rectal. El 38,9% (7/18) de los R.N. presentaron colonización y de ellos (42,9%) se asoció a infección grave