Safety guideline: neurological monitoring associated with obstetric neuraxial block 2020: A joint guideline by the Association of Anaesthetists and the Obstetric Anaesthetists' Association.

Serious neurological lesions such as vertebral canal haematoma are rare after obstetric regional analgesia/anaesthesia, but early detection may be crucial to avoid permanent damage. This may be hampered by the variable and sometimes prolonged recovery following 'normal' neuraxial block, such that an underlying lesion may easily be missed. These guidelines make recommendations for the monitoring of recovery from obstetric neuraxial block, and escalation should recovery be delayed or new symptoms develop, with the aim of preventing serious neurological morbidity.

Risks associated with oral deferiprone in the treatment of infratentorial superficial siderosis.

OBJECTIVE: Deferiprone is an iron chelator that has recently been used to treat patients with infratentorial superficial siderosis (iSS). It is considered to have a generally favourable safety profile but concerns have been raised due to the risk of agranulocytosis. We aimed to evaluate the safety and tolerability of oral deferiprone as a treatment for patients with iSS. METHODS: We present a case series of 10 consecutive patients presenting with classical iSS treated with deferiprone. RESULTS: Ten patients were followed up for a mean period of 2.3 years (range 0.5-5.5 years). Four patients (40%) were withdrawn from treatment because of treatment-related side effects. The reasons for treatment discontinuation were neutropenic sepsis (n = 3) and fatigue (n = 1). In 2 out of the 3 cases of neutropenic sepsis, patients initially developed neutropenia without sepsis. The mean time to neutropenic sepsis following deferiprone was 1.2 years (range 0.3-2.5) with mean neutrophil count of 0.4 (range 0.3-0.5). Six patients (60%) reported no change in neurological function while on treatment, and four patients (40%) reported that their condition deteriorated. CONCLUSIONS: Deferiprone was poorly tolerated, with 40% of patients withdrawing from treatment, most commonly due to neutropenic sepsis, after an average of 2 years on treatment. This study increases the number of reported cases of agranulocytosis in patients with iSS treated with deferiprone. Clinicians treating iSS patients with deferiprone should be aware that this drug has a potentially life-threatening side effect of neutropenic sepsis, and should ensure that appropriate haematological monitoring is in place.

Dietary composition and prey selectivity of juvenile porcupine rays Urogymnus asperrimus.

Fifty-five juvenile porcupine ray Urogymnus asperrimus were collected in the isolated St Joseph Atoll, Seychelles. Stomach contents were sampled using non-lethal gastric lavage to determine the dietary composition, degree of prey selectivity and whether sex or size affected their diet. Sediment samples were collected to quantify prey availability so that prey selectivity could be estimated. Two phyla (Sipuncula and Nemertea) and 11 polychaete and crustacean families were recorded in stomach contents. Juvenile U. asperrimus appeared to specialize on one polychaete family, Capitellidae, which was the most important prey item (index of importance = 35%). This polychaete family was also most abundant in the sediment samples and U. asperrimus are thus considered opportunistic predators. There was evidence of a size-related shift in the crustacean families consumed by juvenile U. asperrimus. Data collected at this remote location provides important baseline ecological information that may prove useful in developing conservation strategies for this ecologically important species.

Feeding ecology of silky sharks Carcharhinus falciformis associated with floating objects in the western Indian Ocean.

The silky shark Carcharhinus falciformis is commonly associated with floating objects, including fish aggregating devices (FADs), in the Indian Ocean. While the motives for this associative behaviour are unclear, it does make them vulnerable to capture in the tuna purse seine fishery that makes extensive use of FADs. Here, the diet of 323 C. falciformis, caught at FADs in the Indian Ocean, was investigated to test the hypothesis that trophic benefits explain the associative behaviour. A high proportion of stomachs with fresh contents (57%) suggested that extensive feeding activity occurred while associated with FADs. Multiple dietary indices showed that typical non-associative prey types dominated, but were supplemented with fishes typically found at FADs. While the trophic benefits of FAD association may be substantial, our results suggest that associative behaviour is not driven solely by feeding.

Tidal amplitude and fish abundance in the mouth region of a small estuary.

Using an acoustic underwater camera (Dual Frequency IDentification SONar, DIDSON), the abundance and direction of movement of fishes > 80 mm total length (LT ) in the mouth of a small South African estuary during spring and neap tidal cycles were observed. While the sizes of fishes recorded were consistent across both tide cycles, the number of fishes passing the camera was significantly greater during the smaller neap tides. Schooling behaviour was more pronounced for fishes that were travelling into the estuary compared to fishes swimming towards the ocean.

Injecting epidural and intra-articular triamcinolone in HIV-positive patients on ritonavir: beware of iatrogenic Cushing's syndrome.

We report two HIV-positive patients on highly active antiretroviral therapy (HAART) who developed clinical features in keeping with secondary adrenal suppression following epidural and subacromial triamcinolone. Both patients were on ritonavir-boosted protease inhibitor containing HAART and both required maintenance hydrocortisone therapy following diagnosis. This highlights the need for radiologists and clinicians practicing these injections to be aware of this complication, to elicit an accurate drug history, and to take adequate measures to minimize these adverse effects.

Effects of altered estuarine submerged macrophyte bed cover on the omnivorous Cape stumpnose Rhabdosargus holubi.

The ecological importance of submerged macrophyte beds to fishes within estuaries was investigated through the example of the ubiquitous Cape stumpnose Rhabdosargus holubi, an omnivorous, vegetation and estuary-dependent species, using stable-isotope techniques and long-term abundance (catch-per-unit-effort) data from the East Kleinemonde Estuary, South Africa. Outputs from a Bayesian mixing model using δ(13) C and δ(15) N signatures indicated that the submerged macrophytes Ruppia cirrhosa and Potamogeton pectinatus were not a primary source of nutrition for R. holubi, confirming previous work that revealed that macrophytes are consumed but not digested. Long-term seine netting data showed reduced abundance of R. holubi during a prolonged period of macrophyte senescence, suggesting that submerged macrophyte habitats provide shelter that reduces mortality (predation risk) and a food-rich foraging area.

Skeletal muscle MRI magnetisation transfer ratio reflects clinical severity in peripheral neuropathies.

MRI may provide treatment outcome measures in neuromuscular conditions. The authors assessed MRI magnetisation transfer ratios (MTRs) in lower-limb musculature as markers of pathology in peripheral neuropathies and compared the findings with associated clinical data. Ten patients with Charcot-Marie-Tooth disease type 1A (CMT1A) and nine patients with chronic inflammatory demyelinating polyneuropathy (CIDP) were compared with 10 healthy subjects. The MTR in the calf muscles was significantly lower than controls in the two patient groups (both p<0.001). The median MTRs (IQR) were 50.5(1.6) percentage units (p.u.) (control), 41.5(10.6) p.u. (CMT1A) and 39.3(8.7) p.u. (CIDP). Moreover, anterior lower leg MTR correlated strongly with strength of ankle dorsiflexion, measured with the Medical Research Council scale, in CIDP (ρ=0.88, p<0.001) and also in CMT1A (ρ=0.50, p<0.05), where MTR also showed an association with disease duration (ρ=-0.86, p<0.001). Short tau inversion recovery MRI of the same muscles showed abnormalities associated with regions of reduced MTR (p<0.001), and MTR was also reduced in other muscles otherwise deemed normal appearing (p<0.001), indicating that MTR may be more sensitive to muscle damaged by denervation than conventional MRI. The significant reductions in muscle MTR in peripheral neuropathies and the associated correlations with clinical measures indicate that MTR has potential as an imaging outcome measure in future therapeutic trials.

An assessment of the size structure, distribution and behaviour of fish populations within a temporarily closed estuary using dual frequency identification sonar (DIDSON).

The fish populations within the East Kleinemonde Estuary, South Africa, were studied using Dual frequency IDentification SONar (DIDSON) during March 2010 which allowed for direct comparisons of the abundance, distribution and behaviour of a wide size range of fishes along the length of the system. Small schooling fishes <100 mm in total length (L(T) ) were most abundant while larger size classes 100-300 and 300-500 mm were less abundant, but evenly distributed longitudinally within the estuary. Fishes <100 mm were most abundant within the mouth region which may reflect the feeding ecology of species that fall into these size classes and the effects of higher turbidities further up the estuary. Large fishes >500 mm were similarly most abundant near the mouth, and fishes of this size being mostly piscivorous, probably showed these distribution patterns due to the location of smaller prey fishes. Differential behaviour was observed among the longitudinal sections, with small fishes forming schools in areas of low turbidity and particularly in the presence of large predatory fishes. Results from this study present a snap-shot of the composition, distribution and behaviour of the ichthyofauna within a small temporarily closed estuary, and also show that abiotic factors and interactions of various size classes can influence their distribution. There is significant potential for DIDSON in future ecological research within these systems.

MRI shows increased sciatic nerve cross sectional area in inherited and inflammatory neuropathies.

Measurements of the cross sectional area of the sciatic nerve are described in a group of 10 patients with genetically confirmed Charcot-Marie-Tooth disease type 1A (CMT1A), nine patients with chronic inflammatory demyelinating polyneuropathy (CIDP) and 10 healthy controls using MRI. One mid-thigh of each individual was imaged using a short tau inversion recovery sequence and the nerve appearance evaluated radiologically with respect to the signal intensity and visibility of the internal neural structure. The cross sectional area of the sciatic nerve of each individual was measured by defining irregular enclosing regions of interest on the MRI images. The sciatic nerve area was enlarged in both CMT1A (p<0.001) and CIDP (p=0.008) compared with controls and in CMT1A compared with CIDP (p<0.001). Median (interquartile range) areas were 67.6 (16.2) mm(2) for the CIDP group, 135.9 (46.5) mm(2) for the CMT1A group and 43.3 (19.9) mm(2) for the control group. The critical upper value for discriminating pathologically enlarged nerves from normal controls with p<0.05 was 64.4 mm(2). Quantification of sciatic nerve hypertrophy on MRI may be of assistance in cases where the diagnosis is still in doubt, providing an objective pathological marker complimenting other clinical investigations.

The status of fish conservation in South African estuaries.

Estuary-dependent fish species are defined as those taxa whose populations would be adversely affected by the loss of estuarine habitats. Of the 155 species regularly recorded in South African estuaries, only 32 (21%) are completely dependent on these systems, but this figure increases to 103 species (66%) if partially dependent taxa are included in the analysis. The conservation of fishes in estuaries on the subcontinent is threatened by a number of factors, including habitat degradation, disruption of essential ecological processes, hydrological manipulations, environmental pollution, overexploitation due to fishing activities and, more recently, climate change and the effects of introduced aquatic animals. Although major threats to fishes are usually linked to environmental degradation, there is increasing evidence that the stocks of certain fish species are overexploited or collapsed. Fish conservation and fisheries management does not depend on the implementation of a single action, but rather the co-ordination of a detailed plan, often in a multidisciplinary context. Some examples of innovative means of contributing to estuarine fish conservation in a South African context include the determination and implementation of the ecological freshwater requirements for estuaries, the zoning of estuaries for different uses and the recognition that the maintenance of ecological processes are vital to aquatic ecosystem health. Apart from the designation of protected areas, the main direct means of conserving fish species and stocks include habitat conservation, controls over fishing methods, effort, efficiency and seasonality, pollution control and the prevention of artificial manipulation of estuary mouths. Since becoming a democracy in 1994, environmental legislation, policy and institutional arrangements in South Africa have undergone some major changes, which, if fully implemented, will be very positive for fish conservation in estuaries on the subcontinent.

Pulsatile tinnitus from reversal of flow in an aberrant occipital artery: resolved after carotid artery stenting.

Carotid artery stent placement, performed for correction of an asymptomatic severe stenosis, leads to the resolution of persistent and troublesome pulsatile tinnitus. Tinnitus has been reported as a consequence of severe carotid stenoses on previous occasions. This case highlights how an aberrant occipital artery originating above a carotid artery stenosis can result in flow reversal and be a mechanism by which tinnitus may develop.

Efficacy of instability resistance training.

The use of the stability ball as a platform for upper-body resistance training has gained much attention in recent years. However, the efficacy of such training regimens remains largely unstudied. The purpose of this study was to evaluate the influence of platform (unstable vs. stable, stability ball vs. flat bench) on strength and work capacity during barbell chest-press exercise. We also sought to determine the effects of a barbell chest-press training program performed on a stability ball or flat bench on strength, work capacity, and abdominal power. Fourteen young women (20 - 23 yr) performed a 1 repetition maximum (1RM) barbell chest-press and the YMCA bench press test (YBT) on a stability ball and flat bench, as well as two field tests measuring abdominal power. The women were then assigned to perform 3 weeks of barbell chest-press training on a stability ball (SB group) or flat bench (FB group); assignment was balanced based on 1RM strength. Barbell chest-press training included 3 sets of 3 - 5 repetitions at loads greater or equal to 85 % of 1RM. The 1RM barbell chest-press, YBT, front abdominal power test (FAPT), and side abdominal power test (SAPT) were used to evaluate changes in strength, work capacity, and abdominal power, respectively. The chest-press tests were completed on both platforms following the training program. Platform (stability ball vs. flat bench) had no influence on strength, but work capacity was initially 12 % lower on the stability ball compared to the flat bench. In response to training, both groups significantly increased strength and work capacity, and there were no group differences. The increase in 1RM strength was 15 % and 16 % on the stability ball and flat bench for the SB group, and 16 % and 19 % for the FB group, respectively. The increase in work capacity was 32 % and 13 % on the stability ball and flat bench for the SB group, and 27 % and 26 % for the FB group, respectively. Both groups significantly improved on the FAPT, and there were no group differences. Performance on the FAPT improved by 5 % for the SB group, and 22 % for the FB group. Performance on the SAPT did not change. Barbell chest-press training performed on either the stability ball or flat bench increased strength and work capacity, and these changes were transferable across platforms. Thus, the stability ball is an effective platform for barbell chest-press training in untrained women over a short duration.

Design and synthesis of a maximally diverse and druglike screening library using REM resin methodology.

A 3042 compound screening library was synthesized using a combination of two solid-phase technologies: REM resin methodology and Lewis acid promoted aminolysis. The exclusivity and structural diversity of the library were enhanced by using a highly divergent synthetic strategy involving 13 different scaffolds (9 of which were custom-made), five different types of resin-bound phenol derivatization chemistry (Mitsunobu, Suzuki, acylation, sulfonylation, and carbamoylation), and three different cleavage strategies (Hofmann elimination, AlCl(3)-promoted aminolysis, base-promoted esterolysis). This is the first example of a solid-phase Suzuki coupling involving a resin-bound aryl triflate being used for library synthesis. Computational analysis suggested that the compounds are likely to have favorable properties for CNS penetration. Analysis of the library by HPLC and MS suggested at least 90% of the sampled members were present in an average purity of approximately 70%. Encouragingly, hits have been identified from high-throughput screening of this library, such as compound 6, which has an affinity of 1.02 microM for the GlyT(2) transporter.

Uganda: improving maternal health care efficiency and financing.

PIP: This article presents the findings of the Partnerships for Health Reform on the efficiency and financing issues of maternal health services of the Ugandan Ministry of Health. A comparison was made between provider and consumer maternal health service expenditures provided by a public and a mission hospital and center, and by 17 private midwives and 20 traditional birth attendants (TBAs). The six areas covered by the study include antenatal care, normal deliveries, cesarean deliveries, postabortion care and postpartum hemorrhage and eclampsia complications. Greater health service cost was noted among mission hospitals compared with public hospitals and health centers, while prices for cesarean deliveries and treatment of obstetrical complications are higher compared with other maternal health services. Records show relative efficiency indications of the various providers, while quality of services were noted among midwives working in hospitals and centers compared with TBAs. Most consumer costs were observed to be lower compared with other care-related expenses except for mission health care cost. Thus, mission facilities recover more financially compared with public health centers and hospitals. Key actions suggested include: increasing health service utilization, streamlining staffing, improving the drug supply, employing midwives, assessing prescription practices, establishing specific times for check-ups, regulating consumer fees and provision of contracting arrangements, intensifying performance incentives, and evaluating user incomes and the ability of the public to pay for health care services.^ieng

Diseño, contenido y financiamiento de un paquete nacional de servicios de salud esenciales / Design content and financing of an essential national package of health services

En los países de bajos ingresos se podría ofrecer un paquete mínimo de intervenciones clínicas y de salud pública, muy efectivas en función del costo, destinadas a aliviar la carga ocasionada por las principales enfermedades, por unos US$ 12 anuales por persona, y en los de medianos ingresos, por cerca de $ 22. Al prestarse debidamente, este paquete permitiría eliminar de 21 a 38 por ciento de la carga de mortalidad prematura y discapacidad en niños menores de 15 años y de 10 a 18 por ciento de la que recae en los adultos. El costo excedería lo que los gobiernos gastan en salud en los países más pobres, pero estaría al alcance de los de medianos ingresos. Los gobiernos deberían asegurarse de que por lo menos la población pobre tenga acceso a esos servicios. El gasto público adicional debería destinarse entonces a ampliar la cobertura de la población solvente o a llevarla más allá de los servicios mínimos, para prestar un paquete nacional de servicios de salud esenciales, que incluya intervenciones algo menos efectivas en función del costo para tratar más enfermedades y trastornos

Diseño, contenido y financiamiento de un paquete nacional de servicios de salud esenciales / Design content and financing of an essential national package of health services

En los países de bajos ingresos se podría ofrecer un paquete mínimo de intervenciones clínicas y de salud pública, muy efectivas en función del costo, destinadas a aliviar la carga ocasionada por las principales enfermedades, por unos US$ 12 anuales por persona, y en los de medianos ingresos, por cerca de $ 22. Al prestarse debidamente, este paquete permitiría eliminar de 21 a 38 por ciento de la carga de mortalidad prematura y discapacidad en niños menores de 15 años y de 10 a 18 por ciento de la que recae en los adultos. El costo excedería lo que los gobiernos gastan en salud en los países más pobres, pero estaría al alcance de los de medianos ingresos. Los gobiernos deberían asegurarse de que por lo menos la población pobre tenga acceso a esos servicios. El gasto público adicional debería destinarse entonces a ampliar la cobertura de la población solvente o a llevarla más allá de los servicios mínimos, para prestar un paquete nacional de servicios de salud esenciales, que incluya intervenciones algo menos efectivas en función del costo para tratar más enfermedades y trastornos

Se pública en inglés en el Bull. WHO. Vol. 72(4), 1994