Worlds apart: training in rural South Africa.

Background: Reforms in the delivery of surgical and anaesthetic services in the UK have reduced the opportunity for trainees to acquire 'hands-on' training. These problems are seen in other European countries and in North America.

Context: Surgical and anaesthetic services within developed health care systems tend to be specialised, and are often consultant led.

Pneumocystis jiroveci pneumonia and pneumomediastinum in an anti-TNFalpha naive patient with ulcerative colitis.

We report the case of a 21-year-old man who was noted to have pneumomediastinum during an admission for an acute flare of ulcerative colitis. At that time, he was on maintenance treatment with azathioprine at a dose of 1.25 mg/kg per day, and had not received supplementary steroids for 9 mo.