Investigating the experience of parents who have given their infants enoxaparin at home.

INTRODUCTION: Enoxaparin is a common anticoagulant used in infants for the prevention and treatment of thrombosis. When administered with the purpose of treating a thrombosis, the duration of treatment is six to twelve weeks. Enoxaparin must be injected subcutaneously, either by direct injection or via an indwelling subcutaneous catheter (Insuflon™). Once discharged from hospital, parents/caregivers of infants and small children take responsibility for the safe preparation and administration of the enoxaparin which can be difficult and confronting. Whilst there is documented evidence about the benefits of targeted education for warfarin anticoagulation and the impact this has on the quality of life for children and their families, this has not been investigated in a cohort of children requiring enoxaparin anticoagulation. We therefore explored the educational needs of parents whose infants require enoxaparin anticoagulation after discharge to inform future practice to optimise delivery of care as well as improve patient safety and outcomes. MATERIALS & METHODS: A qualitative, descriptive methodology was employed using focus groups to generate rich descriptive data. RESULTS: Our results show that parents were traumatised by the process of managing their infant's enoxaparin, and that they may benefit from a formal, more structured educational program to facilitate this treatment in the future. CONCLUSION: It is recognised that enoxaparin therapy in infants may be a traumatic experience for parents and caregivers. The availability of an educational resource for families to refer to once discharged, as well as ongoing communication with the treating medical team is vital.

HIV self-screening distribution preferences and experiences among men who have sex with men in Mpumalanga Province: Informing policy for South Africa.

Current research suggests that HIV self-screening (HIVSS) is a feasible and acceptable approach to increase HIV testing among men who have sex with men (MSM). However, few data are available to shape policy around dissemination and implementation. Gaps in knowledge include preferences for distribution of HIVSS kits, potential social harms and benefits of their use, and how much test users would be willing to pay for the kits. The aim was to inform policy recommendations to optimise distribution of HIVSS kits to MSM in South Africa (SA), where there is a high HIV incidence and unmet testing needs. MSM in the high-HIV-prevalence Gert Sibande and Ehlanzeni districts of Mpumalanga Province, SA, were enrolled between October 2015 and May 2017. Participants were provided with their choice of blood or oral fluid HIVSS test kits, receiving 5 kits at enrolment and 4 additional kits at the 3-month follow-up visit. Questionnaires were administered at enrolment, 3 months and 6 months. We analysed participants' reported social benefits and harms, and their preferences for kit distribution and pricing. Among 127 MSM screened and enrolled, 114 responded to follow-up questionnaires regarding distribution preferences, 49.3% preferred to acquire HIVSS kits at a community-based organisation (CBO) and 42.7% at a clinic, with 8% preferring a pharmacy. Participants with higher education preferred CBO sites for distribution; in other respects preferences were similar by demographic characteristics. Reported social benefits were common, including knowing one's status, prevention knowledge gained and improved communication with partners. Despite ubiquitous interest in using the kits, the majority of MSM could not afford to purchase test kits. SA guidelines have integrated HIVSS into HIV and testing policy, but little has been published regarding distribution channels of the kits for MSM and other key populations. There is a partnership between the National Department of Health and CBOs that specialise in key population programming to ensure MSM and other populations with unmet testing needs can access affordable test kits. We observed no social harms, and there were multiple social benefits. Consequently, we recommend immediate free or low-cost distribution of HIVSS kits to MSM through community-based initiatives. Future research should continue to assess optimised linkage to care.

An evaluation of the effect of altering nutrition and nutritional strategies in early lactation on reproductive performance and estrous behavior of high-yielding Holstein-Friesian dairy cows.

Reproductive performance in the high-yielding dairy cow has severely decreased in the last 40 yr. The aim of this study was to compare the effectiveness of 4 nutritional strategies in improving the reproductive performance of high-yielding dairy cows. It was hypothesized that offering cows a high-starch ration in early lactation would enhance the onset of luteal activity, and that decreasing the severity of negative energy balance in the early postcalving period would improve reproductive parameters. Nutritional regimens aimed at improving fertility were applied to 96 Holstein-Friesian dairy animals. Upon calving, animals were allocated in a balanced manner to one of 4 dietary treatments. Primiparous animals were balanced according to live weight, body condition score and calving date. Multiparous animals were balanced according to parity, previous lactation milk yield, liveweight, body condition score and calving date. Treatment 1 was based on an industry best practice diet (control) to contain 170 g of crude protein/kg of dry matter. Treatment 2 was an individual cow feeding strategy, whereby the energy balance (EB) of individual animals was managed so as to achieve a predetermined target daily EB profile (±10 MJ/d). Treatment 3 was a high-starch/high-fat combination treatment, whereby an insulinogenic (high-starch) diet was offered in early lactation to encourage cyclicity and followed by a lipogenic (low-starch, high-fat) diet to promote embryo development. Treatment 4 was a low-protein diet, containing 140 g of crude protein/kg of dry matter, supplemented with protected methionine at an inclusion level of 40 g per animal per day. The nutritional strategies implemented in this study had no statistically significant effects on cow fertility measures, which included the onset of luteal activity, conception rate, in-calf rate, and the incidence of atypical cycles. The individual cow feeding strategy improved EB in early lactation but had no benefit on conception rate to first insemination. However, conception rate to second insemination, 100-d pregnancy rate (from the commencement of breeding), and overall pregnancy rate tended to be higher in this group. The high-starch/high-fat treatment tended to decrease the proportion of delayed ovulations and increase the proportion of animals cycling by d 50 postcalving. Animals that failed to conceive to first insemination had a significantly longer luteal phase in the first cycle postpartum and a longer inter-ovulatory interval in the second cycle postpartum. With regards to estrous behavior, results indicate that as the size of the sexually active group increased, the intensity of estrus and the expression of mounting or attempting to mount another cow also increased. Furthermore, cows that became pregnant displayed more intense estrous behavior than cows that failed to become pregnant.

A randomised trial of rigid stump dressing following trans-tibial amputation for peripheral arterial insufficiency.

BACKGROUND: A multicentre randomised controlled trial to determine the effect of a rigid plaster dressing applied at the time of trans-tibial amputation on the number of days to casting for a prosthesis, and the incidence of post-operative stump infection. METHODS: Patients requiring trans-tibial amputation were randomised to one of 2 groups: In Group 1 (intervention) a rigid above-knee plaster dressing was applied at operation and patients were managed according to a standard protocol. Group 2 (control) had the individual surgeons' usual non-rigid dressing regime. Rehabilitation data were extracted from the national physiotherapy database. On completion of the trial a questionnaire was sent to all participants. RESULTS: 14 surgeons in 7 centres enrolled 154 patients, with 96 ultimately cast for a prosthesis. Patients who received a rigid dressing (n = 78) had reduced days to casting (median 36, confidence interval 30-47) when compared with other dressings (n = 76) (median 42, confidence interval 36-45), these differences did not reach statistical significance. There was no significant difference in post-operative infection rates in the two groups. 64% of surgeons, and all physiotherapists and vascular nurses responding to the post-trial questionnaire felt that the rigid dressing was an improvement on their normal regime and wished to continue with the technique. CONCLUSIONS: Despite a median reduction of 6 days in time to casting in patients treated with a rigid post-operative dressing this failed to reach statistical significance. The majority of participants who replied to the post-trial questionnaire expressed a wish to continue using the rigid dressing technique. To confirm that the trends shown in this trial are statistically valid a larger trial is needed.

Peyote use during pregnancy.

Peyote is a substance with varied potential. Used properly it may be a spiritual aid but used in excess, it can be a hallucinogenic agent with teratogenic potential. There is a growing community of devout people who use it as part of their religious observance. The active ingredient, mescaline, has been linked to a specific group of fetal abnormalities when the substance is used inappropriately.

Acetazolamide and furosemide for posthemorrhagic hydrocephalus of the newborn.

The authors evaluated the efficacy of acetazolamide (ACZ) and furosemide (FUR) in avoiding ventricular shunting procedures in preterm infants with posthemorrhagic hydrocephalus (PHH) and increased intracranial pressure (ICP). Preterm infants were screened for PHH (defined as ventriculomegaly [VM] and increased ICP measured with the Ladd fiberoptic monitor). PHH infants were randomized to ACZ and FUR treatment or serial lumbar puncture (LP) and monitored until not receiving medications or having undergone shunting. Of 69 infants with IVH screened for the study, 39 never developed VM, 14 developed VM, without increased ICP, and 16 developed PHH. Ten PHH infants were randomized to ACZ and FUR treatment and six to serial LP. Nine (90%) of the 10 infants assigned to the ACZ and FUR group avoided shunting. Nephrocalcinosis developed in a significant proportion of treated infants. Three (50%) of the six LP group infants did not require shunting procedures (P = 0.118). The authors conclude that ACZ and FUR therapy is useful in the treatment of preterm infants with PHH. Because a significant number of infants treated with both ACZ and FUR developed nephrocalcinosis, close monitoring for increased calcium excretion in the urine, or use of ACZ without FUR, is advised.

Supernumerary nipples and accessory breast tissue.

Supernumerary nipples and supernumerary breast tissue are often dismissed as cosmetic curiosities. These structures have the potential for pathologic degeneration and may be associated with significant congenital abnormalities. In a prospective comparison of 100 Native American women to 100 non-Native American women, these accessory organs were found much more commonly in Native American women. Careful attention should be given to thorough evaluation and long term follow-up of any patient in whom this anomaly is found.

An experience in missionary obstetrics and gynecology.

An extended visit at a small community hospital in Thailand provided an opportunity to observe and learn about rural health care in an emerging nation. Several aspects of gynecologic and obstetric care are compared.

Preparing faculty members for problem based, small group learning encounters.

In 1991, the University of South Dakota School of Medicine initiated the use of a problem based educational method for the junior students at the Yankton Campus. This program was innovative for both the students and the faculty. In order to prepare the faculty for their role in the management of the small group sessions, workshops were arranged. The students that made up the groups were chosen from the senior class at Yankton High School. Since these students needed appropriate prompting, the faculty gained experience in the management of a problem based small group learning session.

Nephrocalcinosis complicating medical treatment of posthemorrhagic hydrocephalus.

Furosemide and acetazolamide are often used concurrently to treat posthemorrhagic hydrocephalus in premature infants with intraventricular hemorrhage. Eleven premature infants with posthemorrhagic hydrocephalus were monitored for the development of hypercalciuria during treatment using urine calcium/creatinine (Ca/Cr) ratios (normal: less than or equal to 0.21). Seven of 11 infants (64%) developed hypercalciuria; 5 of those 7 infants had nephrocalcinosis on renal ultrasonography. Infants who developed nephrocalcinosis had urine Ca/Cr ratios of 0.5-4.0. In all 5 infants with nephrocalcinosis, renal calculi decreased and urine Ca/Cr improved after drug therapy was discontinued. The combined use of acetazolamide and furosemide as therapy for posthemorrhagic hydrocephalus places premature infants at high risk for nephrocalcinosis. It is suggested that urine Ca/Cr be monitored closely in infants receiving these drugs and that other treatment modalities be considered when the urine Ca/Cr ratio exceeds 0.21.

The Yankton Model Program.

Changes in medical education towards a student-centered, problem-based learning, with continuity care experience in ambulatory settings have been recommended. The University of South Dakota School of Medicine has developed such an educational model for third year medical students named the Yankton Model Program and is herein described.

Seizures in children with Down syndrome: etiology, characteristics and outcome.

Of 737 patients with Down syndrome, newborn to 22 years of age, 47 had a history of at least one seizure. Of those, 24 children had seizures with an identifiable etiology, usually related to a common medical complication of Down syndrome: neonatal hypoxia-ischemia, hypoxia from congenital heart disease, or infection. These acute medical illnesses may precipitate seizures in brains already predisposed to hyperexcitability because of abnormal neuronal development. It is recommended that all Down syndrome children with seizures undergo investigations to determine the etiology of the seizure.