Handmaidens and pioneers: Three female anaesthetists and their contribution to anaesthesia in South Africa.

The period during and after World War II saw enormous changes in the practice and status of anaesthesia, as well as in female participation. This article offers an account of three South African (SA) women who trained in anaesthetics before and during the War and participated in these changes. By the mid-1960s, they presided over the three independent anaesthetic departments at Johannesburg's three main teaching hospitals, teaching generations of junior doctors. The first woman to register as a specialist anaesthetist in SA, Miriam (Mollie) Barlow, broke the glass ceiling in her own career by lobbying for the professional rights of medical women, although working within the constraints of the medical and political establishment. She also contributed to important SA research on malignant hyperthermia. Hilde Ginsberg collaborated with Barlow in the 1950s, reducing intraoperative and perioperative mortality at Coronation Hospital, and fought for key interventions in anaesthetic practice and policy through the South African Society of Anaesthetists (SASA), becoming its most long-serving and honoured female member. Kathleen Barbara Vetten's exemplary career in academic medicine, including pioneering animal research (developing anaesthetic techniques for open-heart surgery in dogs and protocols for liver transplantation in primates) and a successful operation to separate craniopagus twins, shows both the achievement of and limits to female achievement at the end of this period. This article also offers a short account of factors that hindered black women from entering anaesthesia training, contributing to this history before the 1990s.

Surgery and anaesthesia in art: the contribution of Dorothy Kay.

Dorothy Kay, the acclaimed Irish-born Port Elizabeth artist, married Dr Hobart Kay, FRCSI, in Cape Town, South Africa, in 1910. She was an exceptional portrait painter, whose astute observation of detail and ability to empathise with her subject and convey character brought her much important work. Her traditional British realist-school style of painting, and ability to depict mechanical equipment accurately, led to several industrial commissions. In 1937 these skills combined to produce her largest painting, 'Surgery' which depicts a patient undergoing an abdominal operation in a Port Elizabeth hospital. The painting graphically captures the skill and care exhibited by the anaesthetist, together with the anaesthetic equipment used at that time. During the war Dorothy became an accredited war artist. Eight of her wartime paintings were purchased by the Union Government and are now housed in the Ditsong National Museum of Military History in Saxonwold, Johannesburg. Two of these paintings of medical interest are discussed. The first, entitled 'Operation in a Base Hospital, depicts surgery being performed in a base hospital and is very similar in composition to 'Surgery' The second, entitled 'Blood to Save Lives, portrays a volunteer donating blood.

Drug administration errors: a prospective survey from three South African teaching hospitals.

This prospective study was undertaken to determine the incidence of drug administration errors by anaesthetists at three tertiary South African hospitals. Hospitals A and C treat adults predominantly, whereas Hospital B is a paediatric hospital. Anaesthetists completed an anonymous study form for every anaesthetic performed over a six-month period. They were asked to indicate whether or not an error or near-miss had occurred and if so, the details thereof. A total of 30,412 anaesthetics were administered during the study period. The response rate and combined incidence of errors and near-misses was as follows: Hospital A 48.8% (1:320), B 81.3% (1:252) and C 48.1% (1:250). The overall response rate was 53% and the combined incidence was 1:274. Neither the experience of the anaesthetist nor emergency surgery influenced whether an error occurred or not. Most errors occurred during the maintenance phase of anaesthesia. The most common errors were those of substitution. At the paediatric hospital, incorrect dose was as frequent an error as substitution. Of all errors, 36.9% were due to drug ampoule misidentification; of these the majority (64.4%) were due to similar looking ampoules. Another 21.3% were due to syringe identification errors. No major complication attributable to a drug administration error was reported. Despite an increasing awareness of the problem together with suggestions in the literature to reduce the incidence, drug administration errors remain fairly common in South Africa. Failure to institute suggested solutions will continue to compromise patient safety.

Drug administration errors by South African anaesthetists--a survey.

OBJECTIVES: To investigate the incidence, nature of and factors contributing towards wrong drug administrations by South African anaesthetists. DESIGN: A confidential, self-reporting survey was sent out to the 720 anaesthetists on the database of the South African Society of Anaesthesiologists. RESULTS: A total of 133 questionnaires were returned for analysis (18.5% response rate). Of the respondents, 125 (94%) admitted to having inadvertently administered a wrong drug. Thirty respondents (22.6%) said they had made errors on at least four occasions. A total of 303 specific wrong drug administrations were described. Nearly 50% involved muscle relaxants. A further 43 incidents (14%) involved the erroneous administration of vasoactive drugs. Five deaths and 3 nonfatal cardiac arrests were reported. In 9.9% of incidents the anaesthetic time was prolonged by more than 30 minutes. Contributory causes identified included syringe swaps (40%), misidentification of drugs (27.1%), fatigue (14.1%), distractions (4.7%), and mislabelling of syringes (4.7%). Only 19% of respondents regularly use colour-coded syringe labels complying with the national standard. CONCLUSIONS: Most anaesthetists experienced at least one drug error. The incidence of wrong drug administrations by South African anaesthetists appears to be similar to that in Australasia and Canada. The commonest error was a 'syringe swap' involving muscle relaxants. Most drug errors are inconsequential. An important minority of incidents result in severe morbidity or death. The study supports efforts to improve ampoule labelling, to encourage the use of syringe labels based on the international colour code and to develop a national reporting system for such incidents.

Decreasing blood product requirements after orthotopic liver transplantation.

OBJECTIVES: To document the changing blood product transfusion requirements over time during the first 50 orthotopic liver transplantation (OLT) operations performed at Groote Schuur Hospital. DESIGN: The first 50 OLT operations were divided into three groups chronologically and blood transfusion requirements were compared across the three groups. SETTING: Groote Schuur Hospital, Cape Town. SUBJECTS: Forty-seven patients undergoing 50 OLT operations between October 1988 and September 1999. The majority of patients had end-stage chronic liver disease. Patients were divided chronologically into three groups of 16, 17 and 17 patients. OUTCOME MEASURES: The number of units of blood products transfused in each group was quantified. RESULTS: During the study period there was a significant decrease in the number of units of packed red cells, fresh frozen plasma (FFP) and platelets (but not cryoprecipitate) transfused intraoperatively. The median number of units of packed cells decreased from 13.5 in our first 16 patients (group 1) to 5.0 in our last 17 (group 3). The median number of units of platelets transfused was 9 in group 1 and 0 in groups 2 and 3. No platelets were transfused in our last 22 patients. The average cost of blood products transfused intraoperatively per patient in the three groups decreased from R13 034 in group 1 to R11 389 in group 2 to R7 396 in group 3. CONCLUSION: The number of units of blood products transfused during OLT operations has decreased since the programme started 13 years ago. The reasons include increased experience, the use of aprotinin to block fibrinolysis and the selective use of the thromboelastogram to monitor coagulation intraoperatively. OLT need no longer be regarded as wasteful of blood resources. Use of platelets to treat thrombocytopenia need not be empirical.

Memory interference during language processing.

The authors studied the operation of working memory in language comprehension by examining the reading of complex sentences. Reading time and comprehension accuracy in self-paced reading by college students were studied as a function of type of embedded clause (object-extracted vs. subject-extracted) and the types of noun phrases (NPs) in the stimulus sentences, including relative clauses and clefts. The poorer language comprehension performance typically observed for object-extracted compared with subject-extracted forms was found to depend strongly on the mixture of types of NPs (descriptions, indexical pronouns, and names) in a sentence. Having two NPs of the same type led to a larger performance difference than having two NPs of a different type. The findings support a conception of working memory in which similarity-based interference plays an important role in sentence complexity effects.

Ability in perceiving nonnative contrasts: performance on natural and synthetic speech stimuli.

The perception of the distinction between /r/ and /l/ by native speakers of American English and of Japanese was studied using natural and synthetic speech. The American subjects were all nearly perfect at recognizing the natural speech sounds, whereas there was substantial variation among the Japanese subjects in their accuracy of recognizing /r/ and /l/ except in syllable-final position. A logit model, which additively combined the acoustic information conveyed by F1-transition duration and by F3-onset frequency, provided a good fit to the perception of synthetic /r/ and /l/ by the American subjects. There was substantial variation among the Japanese subjects in whether the F1 and F3 cues had a significant effect on their classifications of the synthetic speech. This variation was related to variation in accuracy of recognizing natural /r/ and /l/, such that greater use of both the F1 cue and the F3 cue in classifying the synthetic speech sounds was positively related to accuracy in recognizing the natural sounds. However, multiple regression showed that use of the F1 cue did not account for significant variance in natural speech performance beyond that accounted for by the F3 cue, indicating that the F3 cue is more important than the F1 cue for Japanese speakers learning English. The relation between performance on natural and synthetic speech also provides external validation of the logit model by showing that it predicts performance outside of the domain of data to which it was fit.

Excision of a giant hydatid cyst of the lung under thoracic epidural anaesthesia.

We present a patient with a large pulmonary hydatid cyst compressing underlying lung, with previous pulmonary tuberculosis, who presented in respiratory failure. After institution of thoracic epidural anaesthesia employing 0.25% bupivacaine, 1% lignocaine and fentanyl, the patient was placed in the sitting position and the hydatid cyst excised and drained after a limited rib resection. An air leak persisted until the 16th postoperative day. A marked improvement in symptoms as well as in spirometly and arterial blood gases occurred, and the patient was discharged on the 20th day. Thoracic epidural anaesthesia may be a safer method than general anaesthesia for removal of a hydatid cyst in a patient with severe respiratory compromise.

The processing of coreference for reduced expressions in discourse integration.

Three reading-time experiments in Chinese are reported that test contrasting views of how pronominal coreference is achieved. On the one hand, studies of reading time and eye tracking suggest that reduced expressions, such as the pronoun he, serve as critical links to integrate separate utterances into a coherent model of discourse. On the other hand, probe-word recognition studies indicate that full anaphoric expressions, such as a repeated name, are more readily interpreted than reduced expressions due to their rich lexical information, which provides effective cues to match the representation of the appropriate referent in memory. The results indicate that the ease of integrating the critical referent into a model of discourse is a function of the congruence of lexical, semantic, and discourse features conveyed by a syntactically prominent reduced expression within linguistic input. This pattern supports the view that a reduced expression is interpreted on-line and indeed plays a critical role in promoting discourse coherence by facilitating the semantic integration of separate utterances.

Language comprehension and probe-list memory.

Experiments were performed using probe-word recognition methodology in which participants read sentences that were presented 1 word at a time and were then shown a probe word and had to make a speeded response indicating whether the word had occurred in the sentence. One experiment showed that response times to probe words increased with the size of the set of candidate probes. The other experiments showed that the effects caused by name repetition in circumstances in which the repeated name was co-referential also occurred when the repeated name was not co-referential and when the order of words in a sentence was scrambled. The results suggest that responses in the task can be based on probe-list memory, a mental representation created to keep track of those words that the participant believes are likely to be probed, and that the use of the task to make inferences about language comprehension should be accompanied by controls ruling out such strategies.

Myocardial stunning in hyperthyroidism.

The cases of two patients with hyperthyroidism and acute left ventricular (LV) dysfunction with segmental wall motion abnormalities resulting in heart failure are reported. Both had electrocardiographic changes mimicking ischemic coronary artery disease. Treatment with antithyroid medications, beta blockers, and angiotensin-converting enzyme inhibitors rapidly restored LV function. The rapid reversibility suggests a role for myocardial stunning, an important entity to recognize in hyperthyroidism since this form of LV dysfunction can be reversed with appropriate treatment.

Acute and nine-month clinical outcomes after "suboptimal" coronary stenting: results from the STent Anti-thrombotic Regimen Study (STARS) registry.

OBJECTIVES: This registry collected the 30-day and 9-month clinical outcomes of patients whose coronary stent implantation was suboptimal, and compared them with the cohort of patients with "optimal" stenting in the randomized portion of the STent Anti-thrombotic Regimen Study (STARS) trial. BACKGROUND: Although "optimal" stenting combined with an aspirin and ticlopidine regimen carries a low (0.5%) incidence of subacute stent thrombosis, only limited data are available for patients in whom stents are deployed suboptimally. METHODS: In the STARS, 312 (15.9%) of 1,965 patients enrolled were excluded from participation in the randomized trial based on a perceived "suboptimal" result of coronary stenting. Of these, 265 patients met prespecified criteria for suboptimal stenting, and were followed in a parallel registry, which was compared with the randomized STARS optimal stenting cohort. The primary end point was a 30-day composite of death, emergent target lesion revascularization, angiographic thrombosis of the target vessel without revascularization and nonfatal myocardial infarction (MI) unrelated to direct procedural complications. RESULTS: Registry patients had a similar frequency of the primary end point compared with the overall randomized cohort (3.0% vs. 2.2%), with this end point correlating to use of multiple stents, smaller final lumen diameter and absence of ticlopidine from the poststent regimen. Overall 30-day mortality (1.1% vs. 0.06%, p = 0.009) and periprocedural non-Q wave MI (8.7% vs. 4.2%, p = 0.003) were more frequent in registry patients, and appeared to be related to acute procedural complications. Clinical restenosis was significantly higher for registry patients (26.8% vs. 16.0%, p = 0.001), relating to greater prevalence of independent predictors such as smaller final lumen diameter and multiple stent use. CONCLUSIONS: In the STARS registry, the inability to perform optimal stenting correlated with smaller final lumen diameter and longer stent length. With ticlopidine-containing regimens, the acute clinical results of "suboptimal" stent deployment are clinically acceptable, although they are not quite as good as those of optimal stenting using similar drug therapy.

The role of the College of Medicine of South Africa Diploma in Anaesthesia in southern Africa.

OBJECTIVE: To determine the role that the College of Medicine Diploma in Anaesthesia (DA) plays in health services in southern Africa. DESIGN: A postal questionnaire. MAIN INFORMATION SOUGHT: Reasons for doing the DA, percentage of diplomates still actively involved in anaesthesia, career pathways of diplomates, perceived value of the DA, geography and type of anaesthetic practice of diplomates, and participation in continuing medical education. SUBJECTS: The 1,096 candidates who passed the DA between 1974 and 1993. METHODS: Questionnaires were sent to all 861 diplomates with known addresses. RESULTS: The response rate was 62.1% (535/861). Over 70% of diplomates are still actively involved in anaesthesia. Approximately one-third of all diplomates specialize in anaesthesia. The majority of GP anaesthetists with the DA have trained in anaesthesia for more than 1 year. Thirty-three per cent of GP anaesthetists work in small towns or rural areas. Nearly 20% of GP anaesthetists spend more than 75% of their time in anaesthetic practice. Twenty-eight diplomates are working in southern African countries outside South Africa. The DA is perceived to have been of value by the majority of specialist and non-specialist diplomates. CONCLUSIONS: Diplomates are playing a valuable role in anaesthesia throughout the southern African region.

A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators.

BACKGROUND: Antithrombotic drugs are used after coronary-artery stenting to prevent stent thrombosis. We compared the efficacy and safety of three antithrombotic-drug regimens - aspirin alone, aspirin and warfarin, and aspirin and ticlopidine - after coronary stenting. METHODS: Of 1965 patients who underwent coronary stenting at 50 centers, 1653 (84.1 percent) met angiographic criteria for successful placement of the stent and were randomly assigned to one of three regimens: aspirin alone (557 patients), aspirin and warfarin (550 patients), or aspirin and ticlopidine (546 patients). All clinical events reflecting stent thrombosis were included in the prespecified primary end point: death, revascularization of the target lesion, angiographically evident thrombosis, or myocardial infarction within 30 days. RESULTS: The primary end point was observed in 38 patients: 20 (3.6 percent) assigned to receive aspirin alone, 15 (2.7 percent) assigned to receive aspirin and warfarin, and 3 (0.5 percent) assigned to receive aspirin and ticlopidine (P=0.001 for the comparison of all three groups). Hemorrhagic complications occurred in 10 patients (1.8 percent) who received aspirin alone, 34 (6.2 percent) who received aspirin and warfarin, and 30 (5.5 percent) who received aspirin and ticlopidine (P<0.001 for the comparison of all three groups); the incidence of vascular surgical complications was 0.4 percent (2 patients), 2.0 percent (11 patients), and 2.0 percent (11 patients), respectively (P=0.01). There were no significant differences in the incidence of neutropenia or thrombocytopenia (overall incidence, 0.3 percent) among the three treatment groups. CONCLUSIONS: As compared with aspirin alone and a combination of aspirin and warfarin, treatment with aspirin and ticlopidine resulted in a lower rate of stent thrombosis, although there were more hemorrhagic complications than with aspirin alone. After coronary stenting, aspirin and ticlopidine should be considered for the prevention of the serious complication of stent thrombosis.