BackgroundSouth Africa has high burdens of tuberculosis (TB) and TB-HIV, yet the quality of patient care in the private sector is unknown. We describe quality of TB and TB-HIV care among private general practitioners (GPs) in two South African cities using standardised patients (SPs).MethodsSixteen SPs presented one of three cases during unannounced visits to private GPs in selected high-TB burden communities in Durban and Cape Town: case 1, typical TB symptoms, HIV-positive; case 2, TB-specified laboratory report, HIV-negative and case 3, history of incomplete TB treatment, HIV-positive. Clinical practices were recorded in standardised exit interviews. Ideal management was defined as relevant testing or public sector referral for any reason. The difference between knowledge and practice (know-do gap) was assessed through case 1 vignettes among 25% of GPs. Factors associated with ideal management were assessed using bivariate logistic regression.Results511 SP visits were completed with 212 GPs. Respectively, TB and HIV were ideally managed in 43% (95% CI 36% to 50%) and 41% (95% CI 34% to 48%) of case 1, 85% (95% CI 78% to 90%) and 61% (95% CI 73% to 86%) of case 2 and 69% (95% CI 61% to 76%) and 80% (95% CI 52% to 68%) of case 3 presentations. HIV status was queried in 35% (95% CI 31% to 39%) of visits, least with case 1 (24%, 95% CI 18% to 30%). The difference between knowledge and practice was 80% versus 43% for TB and 55% versus 37% for HIV, resulting in know-do gaps of 37% (95% CI 19% to 55%) and 18% (95% CI −1% to 38%), respectively. Ideal TB management was associated with longer visit time (OR=1.1, 95% CI 1.1 to 1.2), female GPs (3.2, 95% CI 2.0 to 5.1), basic symptom inquiry (2.0, 95% CI 1.7 to 2.3), HIV-status inquiry (OR=11.2, 95% CI 6.4 to 19.6), fewer medications dispensed (OR=0.6, 95% CI 0.5 to 0.7) and Cape Town (OR=2.2, 95% CI 1.5 to 3.1). Similar associations were observed for HIV.ConclusionsPrivate providers ideally managed TB more often when a diagnosis or history of TB was implied or provided. Management of HIV in the context of TB was less than optimal.

Magnetic resonance images of 44 patients who had varying degrees of supratentorial signal abnormalities compatible with subcortical arteriosclerotic encephalopathy (SAE) were reviewed for posterior fossa findings. Brain stem lesions frequently accompanied supratentorial SAE and were seen as multiple, fairly symmetric areas of poorly defined, increased signal intensity on axial T2-weighted images. Involvement was generally confined to the central portions of the mid and upper pons. The typical appearance of brain stem involvement by SAE and its probable pathogenesis are reviewed.

Objectives: Invasive meningococcal disease (IMD) is a severe bacterial infection that displays wintertime seasonality in temperate countries. Mechanisms driving seasonality are poorly understood and may include environmental conditions and/or respiratory virus infections. We evaluated the contribution of influenza and environmental conditions to IMD risk, using standardized methodology, across multiple geographical regions. Methods: We evaluated 3276 IMD cases occurring between January 1999 and December 2011 in 11 jurisdictions in Australia, Canada, France and the United States. Effects of environmental exposures and normalized weekly influenza activity on IMD risk were evaluated using a case-crossover design. Metaanalytic methods were used to evaluate homogeneity of effects and to identify sources of betweenregion heterogeneity. Results: After adjustment for environmental factors, elevated influenza activity at a 2-week lag was associated with increased IMD risk (adjusted odds ratio (OR) per standard deviation increase 1.29; 95% confidence interval, 1.04e1.59). This increase was homogeneous across the jurisdictions studied. By contrast, although associations between environmental exposures and IMD were identified in individual jurisdictions, none was generalizable. Conclusions: Using a self-matched design that adjusts for both coseasonality and case characteristics, we found that surges in influenza activity result in an acute increase in population-level IMD risk. This effect is seen across diverse geographic regions in North America, France and Australia. The impact of influenza infection on downstream meningococcal risk should be considered a potential benefit of influenza immunization programmes.

Background Nigeria has one of the highest rates of maternal mortality in the world (576/100,000 births), with a significant proportion of death attributed to hypertensive disorders in pregnancy (HDPs). High quality antenatal care (ANC) plays a crucial role in early detection and management of HDPs. We conducted an assessment of quality of antenatal care, and its capacity to detect and manage HDPs, in two tiers of Nigerian facilities, with the aim of describing the state of service delivery and identifying the most urgent gaps. Methods Quality of antenatal care was assessed and compared between primary healthcare centers (PHCs) ( n = 56) and hospitals (secondary + tertiary facilities, n = 39) in seven states of Nigeria. A cross-sectional design captured quality of care using facility inventory checklists, semi-structured interviews with healthcare providers and clients, and observations of ANC consultations. A quality of care framework and scoring system was established based on aspects of structure, process, and outcome. Average scores were compared using independent sample t-tests and measures of effect were assessed by multivariate linear regression. Results All domains of quality except provider interpersonal skills scored below 55%. The lowest overall scores were observed in provider knowledge (49.9%) and provider technical skill (47.7%). PHCs performed significantly worse than hospitals in all elements of quality except for provider interpersonal skills. Provider knowledge was significantly associated with their level of designation (i.e., obstetrician vs. other providers). Conclusions In order to provide high quality care, ANC in Nigeria must experience massive improvements to inventory, infrastructure and provider knowledge and training. In particular, ANC programs in PHCs must be revitalized to minimize the disparity in quality of care provided between PHCs and hospitals. The relatively low quality of care observed may be contributing to Nigeria’s high rate of maternal mortality and burden of disease attributed to HDPs. Electronic supplementary material The online version of this article (10.1186/s12913-019-4217-8) contains supplementary material, which is available to authorized users.