Doctors' views of working conditions in rural hospitals in the Western Cape

There has been a lively debate in the media about working conditions in rural South African Hospitals, with a particular focus on staffing and quality of care. From a medical perspective, it has been stated that poorly equipped and managed hospitals, inappropriate training and an excessive workload are significant contributors to the problem. This study was conducted to investigate the experiences of medical practitioners in performing their professional duties in rural district hospitals in the Western Cape. Twenty in-depth, free-attitude interviews were conducted. Three major themes became apparent from the data, namely the importance of situational factors, knowledge and skills, and support structures. Two conceptual frameworks emerged from the themes that describe the impact of working conditions on the quality of care, and captured positive and negative factors influencing performance. This study provides evidence that substantial after-hour duties, an excessive workload and a perceived lack of management support impact negatively on doctors' views of working in district hospitals. Unless these are addressed, the problem of retaining medical staff in rural hospitals will continue, and equity of access to health services for rural communities will remain an unfulfilled obligation. Recommendations are made on how these issues can be addressed. Key words: district hospitals, working conditions For full text, click here: SA Fam Prac 2004;46(3):21-2

The knowledge and skills gap of medical practitioners delivering district hospital services in the Western Cape, South Africa

IntroductionDistrict (community) hospitals play an important role in the delivery of health services at community level, especially in rural areas. These hospitals provide comprehensive level-one health services to their communities, and serve as a resource for the whole health district. Most district hospitals are situated in rural areas, with medical services in these hospitals being rendered by generalist medical practitioners.The education and training of generalist practitioners for rural practice needs specific attention. Firstly, the unique nature of rural practice makes it necessary for doctors to undergo relevant and focused instruction. Rural family practice requires that doctors have the knowledge and skills to practise in settings where high technology and specialist resources are not available, while at the same time requiring that they be able to perform a wide range of advanced functions and procedures.Secondly, it is argued that appropriate education and training for rural practice can positively influence the recruitment and retention of medical practitioners in rural areas.5 The teaching of the knowledge and skills required for rural practice should take place in an appropriate setting that promotes interest in rural practice and familiarises the student with its particular challenges. There is a paucity of data in South Africa on medical practitioners staffing district hospitals, especially in terms of their knowledge and skills levels. Such information is critical if rural hospitals are to deliver equitable and quality health services, and also for guiding appropriate undergraduate, postgraduate and continuing professional education for rural practice.With this as background, health service managers in the Western Cape requested a skills audit of medical officers in district hospitals to identify a possible gap in competencies that may impact on service delivery. The aim of this study was thus to identify the knowledge and skills of medical practitioners delivering these services in the Western Cape and to compare them with service needs in order to make recommendations for education and training. This article reports on the results of the knowledge and skills gap analysis, while the results of the district hospital performance data and in-depth interviews are reported elsewhere.Method The competencies of medical practitioners working in 27 district hospitals were explored by using a self-administered questionnaire containing a competency rating of proxy markers. The data were analysed using the SAS statistical package. Variables were examined for statistically significant differences.ResultsA response rate of 75% (110/147) was achieved. Part-time (older) medical officers regarded themselves as more experienced and more competent than full-time (younger) employees in most areas, except when managing problems relating to HIV/AIDS. Termination of pregnancy was the procedure most frequently not performed despite practitioners being competent to do so. A substantial need for supervision was identified for managing less common emergency conditions, as well as for some outpatient problems, including preventative, promotive and rehabilitation activities.ConclusionsThe knowledge and skills gaps varied considerably according to the individuals' education, training and experience, as well as their circumstances and working conditions. The superior competencies of the older practitioners reinforce the importance of the recruitment and retention of more experienced practitioners. The uneven skill and knowledge base in aspects of HIV/AIDS management should be addressed urgently by initiatives such as the internet-based course on HIV/AIDS developed by the Family Medicine Education Consortium (FaMEC). Departments of Family Medicine should urgently re-orientate their curricula to meet the training needs for level-one hospital practice.Keywords:Skills gap; education; family practitioners; survey; knowledgeFor full text, click here:SA Fam Pract 2006;48(2):16-16

The maintenance of competence of rural district hospital medical practitioners

BackgroundThe maintenance of competence by rural district hospital medical practitioners is a challenge faced by all countries and, most acutely, by resource-poor nations. It is a vital element in addressing the disparity between rural and urban health care in South Africa. The wide scope of rural-district hospital practice demands updating in a variety of content areas. District hospital doctors are likely to have educational needs covering surgery, emergency and trauma, in-patient as well as out-patient care at primary service level, an understanding of the rural context and role of other health workers, public-health skills, and teamwork. Given such a broad curriculum, some prioritisation needs to be made for the content of their CPD. Rural practitioners generally use CPD activities that are most readily available to them, namely reading journals, meeting with pharmaceutical representatives and attending lectures sponsored by the pharmaceutical industry. These are not, however, the most appropriate or effective methods of acquiring the knowledge and skills that doctors define as being useful to them. Educational strategies that have been most effective in changing clinical behaviour are: an assessment of learning needs, interactive tuition sessions with the opportunity to practice the skills learned and sequenced multifaceted activities. It is equally important to have rural practitioners engage in educational activities that can be performed within their work environment. The aim of this study was to define expert consensus on the content and methods most suitable for the maintenance of competence by rural district hospital practitioners in the Western Cape province of South Africa. The study was carried out as a follow-up to an analysis of knowledge and skills of doctors in Western Cape district hospitals.MethodA study was therefore designed to investigate the content and methods used for the maintenance of competence of rural district hospital practitioners in the Western Cape province of South Africa. Expert opinion was sought to evaluate the topics requiring updating and the validity of the learning methods to maintain competence in practice. This was achieved by employing the Delphi technique to reach consensus on content and methodology. Categorical data analysis and a principal factor analysis were also performed. The qualitative data were then developed into themes and presented as a conceptual framework.Results Consensus was reached on the principal content areas requiring updating. Methods that were found most useful were inservice learning under supervision, structured courses, small group discussions and practical workshops. Rotations in tertiary hospitals, specialist lectures, journal reading and internet learning were less supported.ConclusionsThe study provides a practical model for continuing instruction plus self-directed learning in context. Three content domains were established, namely commonly encountered areas of practice, identified gaps, and needs specific to the practitioner and setting. It was concluded that the implementation of external updating programmes should be tailored to suit practitioners, while self-directed aspects should include reflective practice. Priority areas were identified and classified, as were educational methods that could contribute towards the maintenance of competence of rural practitioners.For full text, click here:SA Fam Pract 2006;48(3):18-18

Pregnancy- and lactation-associated osteoporosis

Pregnancy-and lactation-associated osteoporosis is a rare syndrome of spontaneous fractures occurring in late pregnancy or lactation. Early diagnosis and management is essential, because of the severity of the morbidityassociated with these fractures. Prior to therapy, other reversible causes of osteoporosis should be excluded through adequate investigation. Treatment includes cessation of breastfeeding, the provision of adequate pain relief,and the use of specific osteoporosis drugs, preferably those with short-term bone retention. Although there is no persuasive evidence that calcium and vitamin D requirements increase during pregnancy or lactation comparedto the non-pregnant woman of childbearing age, it is advisable to ensure that women are vitamin D replete during pregnancy and lactation

Impact and cost-effectiveness of hepatitis B virus prophylaxis in pregnancy: a dynamic simulation modelling study

BACKGROUND: In 2020, WHO recommended the addition of peripartum antiviral prophylaxis (PAP) to hepatitis B birth dose vaccination (HepB-BD) and hepatitis B infant vaccination (HepB3) to reduce mother-to-child transmission of hepatitis B virus (HBV) infection in pregnant women who have a marker of high infectivity (ie, HBV DNA ≥200 000 international units per mL or HBeAg-positive). We aimed to evaluate the impact and cost-effectiveness of this recommendation and of a theoretical simplified strategy whereby PAP is given to all pregnant women who are HBsAg-positive without risk stratification. METHODS: This modelling study used a dynamic simulation model of the HBV epidemic in 110 countries in all WHO regions, structured by age, sex, and country. We assessed three strategies of scaling up PAP for pregnant women: PAP for those with high viral load (PAP-VL); PAP for those who are HBeAg-positive (PAP-HBeAg); and PAP for all pregnant women who are HBsAg-positive (PAP-universal), in comparison with neonatal vaccination alone (HepB-BD). We investigated how different diagnostic and antiviral drug costs affected the cost-effectiveness of the strategies evaluated. Using a health-care provider perspective, we calculated incremental cost-effectiveness ratios in cost (US$) per disability-adjusted life-year (DALY) averted in each country's population and compared these with country-specific cost-effectiveness thresholds. We also calculated new neonatal infections averted for each of the strategies. FINDINGS: Adding PAP-VL to HepB-BD could avert around 1·1 million (95% uncertainty interval 1·0 million-1·2 million) new neonatal infections by 2030 and around 3·2 million (95% uncertainty interval 3·0 million-3·4 million) new neonatal infections and approximately 8·8 million (7·8 million-9·7 million) DALYs by 2100 across all the countries modelled. This strategy would probably be cost-effective up to 2100 in 28 (26%) of 106 countries analysed (which included some of the countries that have the greatest HBV burden) if costs are as currently expected to be, and in 74 (70%) countries if diagnostic and monitoring costs were lowered (by about 60-75%). The relative cost-effectiveness of PAP-VL and PAP-HBeAg was finely balanced and depended on the respective diagnostic and monitoring costs. The PAP-universal strategy could be more cost-effective than either of these strategies in most countries, but the use of antiviral treatment could be five times as high than with PAP-VL. INTERPRETATION: PAP can provide substantial health benefits, and, although the current approach might already be cost-effective in some high-burden settings, decreased diagnostic costs would probably be needed for PAP to be cost-effective in most countries. Therefore, careful consideration needs to be given about how such a strategy is implemented, and securing reduced costs for diagnostics should be a priority. The theoretical strategy of offering PAP to all women who are HBsAg-positive (eg, if diagnostic tests to identify mothers at risk of transmission are not available) could be a cost-effective alternative, depending on prevailing costs of diagnostics and antiviral therapy. FUNDING: UK Medical Research Council, UK National Institute for Health and Care Research, and the Vaccine Impact Modelling Consortium

Microstructural evolution in solution heat treatment of gas- atomised Al alloy (7075) powder for cold spray

Cold gas dynamic spray is being explored as a repair technique for high-value metallic components, given its potential to produce pore and oxide-free deposits of between several micrometers and several millimeters thick with good levels of adhesion and mechanical strength. However, feedstock powders for cold spray experience rapid solidification if manufactured by gas atomization and hence can exhibit non-equilibrium microstructures and localized segregation of alloying elements. Here, we used sealed quartz tube solution heat treatment of a precipitation hardenable 7075 aluminum alloy feedstock to yield a consistent and homogeneous powder phase composition and microstructure prior to cold spraying, aiming for a more controllable heat treatment response of the cold spray deposits. It was shown that the dendritic microstructure and solute segregation in the gas-atomized powders were altered, such that the heat-treated powder exhibits a homogeneous distribution of solute atoms. Micro-indentation testing revealed that the heat-treated powder exhibited a mean hardness decrease of nearly 25% compared to the as received powder. Deformation of the powder particles was enhanced by heat treatment, resulting in an improved coating with higher thickness (* 300 lm compared to * 40 um for untreated feedstock). Improved particle–substrate bonding was evidenced by formation of jets at the particle boundaries

Characterization of Novel Cutaneous Human Papillomavirus Genotypes HPV-150 and HPV-151

DNA from two novel HPV genotypes, HPV-150 and HPV-151, isolated from hair follicles of immuno-competent individuals, was fully cloned, sequenced and characterized. The complete genomes of HPV-150 and HPV-151 are 7,436-bp and 7,386-bp in length, respectively. Both contain genes for at least six proteins, namely E6, E7, E1, E2, L2, L1, as well as a non-coding upstream regulatory region located between the L1 and E6 genes: spanning 416-bp in HPV-150 (genomic positions 7,371 to 350) and 322-bp in HPV-151 (genomic positions 7,213 to 148). HPV-150 and HPV-151 are phylogenetically placed within the Betapapillomavirus genus and are most closely related to HPV-96 and HPV-22, respectively. As in other members of this genus, the intergenic E2-L2 region is very short and does not encode for an E5 gene. Both genotypes contain typical zinc binding domains in their E6 and E7 proteins, but HPV-151 lacks the regular pRb-binding core sequence within its E7 protein. In order to assess the tissue predilection and clinical significance of the novel genotypes, quantitative type-specific real-time PCR assays were developed. The 95% detection limits of the HPV-150 and HPV-151 assays were 7.3 copies/reaction (range 5.6 to 11.4) and 3.4 copies/reaction (range 2.5 to 6.0), respectively. Testing of a representative collection of HPV-associated mucosal and cutaneous benign and malignant neoplasms and hair follicles (total of 540 samples) revealed that HPV-150 and HPV-151 are relatively rare genotypes with a cutaneous tropism. Both genotypes were found in sporadic cases of common warts and SCC and BCC of the skin as single or multiple infections usually with low viral loads. HPV-150 can establish persistent infection of hair follicles in immuno-competent individuals. A partial L1 sequence of a putative novel HPV genotype, related to HPV-150, was identified in a squamous cell carcinoma of the skin obtained from a 64-year old immuno-compromised male patient

Foundations of Black Hole Accretion Disk Theory

This review covers the main aspects of black hole accretion disk theory. We begin with the view that one of the main goals of the theory is to better understand the nature of black holes themselves. In this light we discuss how accretion disks might reveal some of the unique signatures of strong gravity: the event horizon, the innermost stable circular orbit, and the ergosphere. We then review, from a first-principles perspective, the physical processes at play in accretion disks. This leads us to the four primary accretion disk models that we review: Polish doughnuts (thick disks), Shakura-Sunyaev (thin) disks, slim disks, and advection-dominated accretion flows (ADAFs). After presenting the models we discuss issues of stability, oscillations, and jets. Following our review of the analytic work, we take a parallel approach in reviewing numerical studies of black hole accretion disks. We finish with a few select applications that highlight particular astrophysical applications: measurements of black hole mass and spin, black hole vs. neutron star accretion disks, black hole accretion disk spectral states, and quasi-periodic oscillations (QPOs).Comment: 91 pages, 23 figures, final published version available at http://www.livingreviews.org/lrr-2013-

Development of a portfolio of learning for postgraduate family medicine training in South Africa: a Delphi study

<p>Abstract</p> <p>Background</p> <p>Within the 52 health districts in South Africa, the family physician is seen as the clinical leader within a multi-professional district health team. Family physicians must be competent to meet 90% of the health needs of the communities in their districts. The eight university departments of Family Medicine have identified five unit standards, broken down into 85 training outcomes, for postgraduate training. The family medicine registrar must prove at the end of training that all the required training outcomes have been attained. District health managers must be assured that the family physician is competent to deliver the expected service. The Colleges of Medicine of South Africa (CMSA) require a portfolio to be submitted as part of the uniform assessment of all registrars applying to write the national fellowship examinations. This study aimed to achieve a consensus on the contents and principles of the first national portfolio for use in family medicine training in South Africa.</p> <p>Methods</p> <p>A workshop held at the WONCA Africa Regional Conference in 2009 explored the purpose and broad contents of the portfolio. The 85 training outcomes, ideas from the WONCA workshop, the literature, and existing portfolios in the various universities were used to develop a questionnaire that was tested for content validity by a panel of 31 experts in family medicine in South Africa, via the Delphi technique in four rounds. Eighty five content items (national learning outcomes) and 27 principles were tested. Consensus was defined as 70% agreement. For those items that the panel thought should be included, they were also asked how to provide evidence for the specific item in the portfolio, and how to assess that evidence.</p> <p>Results</p> <p>Consensus was reached on 61 of the 85 national learning outcomes. The panel recommended that 50 be assessed by the portfolio and 11 should not be. No consensus could be reached on the remaining 24 outcomes and these were also omitted from the portfolio. The panel recommended that various types of evidence be included in the portfolio. The panel supported 26 of the 27 principles, but could not reach consensus on whether the portfolio should reflect on the relationship between the supervisor and registrar.</p> <p>Conclusion</p> <p>A portfolio was developed and distributed to the eight departments of Family Medicine in South Africa, and the CMSA, to be further tested in implementation.</p

Inferring Phylogenies from RAD Sequence Data

Reduced-representation genome sequencing represents a new source of data for systematics, and its potential utility in interspecific phylogeny reconstruction has not yet been explored. One approach that seems especially promising is the use of inexpensive short-read technologies (e.g., Illumina, SOLiD) to sequence restriction-site associated DNA (RAD) – the regions of the genome that flank the recognition sites of restriction enzymes. In this study, we simulated the collection of RAD sequences from sequenced genomes of different taxa (Drosophila, mammals, and yeasts) and developed a proof-of-concept workflow to test whether informative data could be extracted and used to accurately reconstruct “known” phylogenies of species within each group. The workflow consists of three basic steps: first, sequences are clustered by similarity to estimate orthology; second, clusters are filtered by taxonomic coverage; and third, they are aligned and concatenated for “total evidence” phylogenetic analysis. We evaluated the performance of clustering and filtering parameters by comparing the resulting topologies with well-supported reference trees and we were able to identify conditions under which the reference tree was inferred with high support. For Drosophila, whole genome alignments allowed us to directly evaluate which parameters most consistently recovered orthologous sequences. For the parameter ranges explored, we recovered the best results at the low ends of sequence similarity and taxonomic representation of loci; these generated the largest supermatrices with the highest proportion of missing data. Applications of the method to mammals and yeasts were less successful, which we suggest may be due partly to their much deeper evolutionary divergence times compared to Drosophila (crown ages of approximately 100 and 300 versus 60 Mya, respectively). RAD sequences thus appear to hold promise for reconstructing phylogenetic relationships in younger clades in which sufficient numbers of orthologous restriction sites are retained across species