A simulation-based study evaluating the preparedness of interns' post-anaesthesia rotation in managing a failed obstetric intubation scenario: Is our training good enough?

BACKGROUND: Difficult or failed intubation of obstetric patients may be up to 8 times higher than in general surgical patients. A decline in obstetric intubation opportunities may be a contributing factor, resulting in reduced training opportunities for junior doctors, who therefore do not acquire airway management skills. OBJECTIVES: To assess post-anaesthesia rotation interns' preparedness to manage a difficult/failed obstetric airway scenario. METHODS: We recruited 49 interns, obtained informed consent and individually assessed them on a simulation-based scenario using a high-fidelity manikin. Two independent assessors scored participants using a checklist assessment and a global rating scale. After the simulation-based scenario, participants completed a questionnaire on their internship training, rated the simulation experience and received debriefing. The borderline regression method was used to determine the checklist pass mark. RESULTS: Analysis showed that 40% of interns passed. Correlation between assessors was strong for checklist scores and global ratings. The main reasons for failing were repeated attempts at intubation and failure to optimise the intubating position or conditions. There was concern regarding the infrequent use of a supraglottic airway device as a rescue. Twenty-eight interns had performed <5 general obstetric anaesthetic procedures. CONCLUSIONS: There are concerns regarding adequate anaesthetic preparation for interns to manage a difficult/failed intubation scenario in a full-term pregnancy. Despite the Essential Steps in Managing Obstetric Emergencies (ESMOE) airway module training, which all interns should receive, a high rate of success was not achieved in this study. Simulation-based training and assessment may be a valuable tool to improve intern training and preparedness.

Managing women who decline HIV testing in pregnancy and their infants? A multidisciplinary team guideline.

OBJECTIVES: The management of women at high risk of HIV infection who repeatedly decline HIV testing in pregnancy is not covered in any national guideline. In Leeds, we had a case which prompted us to consider maternal rights plus our duty of care to the infant once born. METHODS: Leeds has an established HIV and Syphilis in Pregnancy Multidisciplinary Team (MDT). The main issues pertaining to a pregnant woman persistently declining HIV testing were discussed within the MDT: identification of pregnant women declining testing; universal testing versus testing by risk stratification of their infants; calculation of vertical transmission risk; definition of unacceptable risk; timing of the decision to request court authority to test the infant; advanced preparation of court authority request papers. RESULTS: It was decided that an HIV transmission risk > 1 in 1000 justified testing an infant at birth. The MDT decision to request court authority for infant HIV testing would be made at 32-34 weeks of gestation, allowing the court papers to be prepared in advance of delivery. The Leeds Obstetrics and Paediatric Guidelines were reviewed, amended and approved by the Trust Guideline Group, Risk Management team and legal team. These guidelines are outlined within the article. The Neonatal guideline also is accessible via this link: http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=177 CONCLUSIONS: If a woman at high risk declines HIV testing in pregnancy, it remains possible to significantly reduce the risk of vertical transmission once the child is born, but the window of opportunity is small. Therefore, it is vital to have pathways already in place to address this prior to delivery.

Shorter preparation to procedure interval for colonoscopy improves quality of bowel cleansing.

BACKGROUND: The timing of bowel preparation for colonoscopy influences the quality of bowel cleansing and the success of the procedure. AIM: We aimed to determine whether the interval between the end of bowel preparation and the start of colonoscopy influences preparation quality. METHODS: We retrospectively analysed 1785 colonoscopies performed between January 2010 and January 2011. The quality of bowel cleansing was compared between those who had a less than 8-h interval between the end of bowel preparation to the start of the procedure versus those who had a greater than 8-h interval. Univariate and multivariate logistic regression analyses evaluated quality of bowel cleansing, preparation to procedure time, age, gender, hospital inpatient or outpatient status, indication for colonoscopy, caecal intubation rate, and segmental polyp detection. RESULTS: Fifty-three per cent of the cohort was male. Eighty-nine per cent were outpatients. Bowel cleansing was reported as satisfactory/good in 87% and poor in 13%. A <8-h preparation to procedure time was associated with a higher rate of satisfactory/good cleansing than a >8-h interval (odds ratio (OR) 1.3, P = 0.04). In a multivariate analysis, female gender (OR 1.4, P = 0.02), outpatient status (OR 3.1 P = 0.001) and indication for procedure (P < 0.01) were significant predictors of adequate bowel preparation. Adequate bowel preparation was associated with a significant increase in caecal intubation rates (OR 5.3, P = 0.001). CONCLUSIONS: A shorter (<8 h) interval between end of bowel preparation and start of colonoscopy yielded better bowel cleansing than a longer (>8 h) interval. Adequate bowel preparation led to improved caecal intubation rates.

Chronic genital ulceration: a 'topical' issue.

We report a case of a chronic non-healing penile ulcer due to repeated topical application of crushed paracetamol tablets. To our knowledge, there are no such reports in the literature.

Primary Health Care Facility Infrastructure and Services and The Nutritional Status of Children 0 to 71 Months Old and Their Caregivers Attending These Facilities in Four Rural Districts in The Eastern Cape and Kwazulu-Natal Provinces; South Africa

Objective: To assess primary health care (PHC) facility infrastructure and services; and the nutritional status of 0 to 71-month-old children and their caregivers attending PHC facilities in the Eastern Cape (EC) and KwaZulu-Natal (KZN) provinces in South Africa. Design: Cross-sectional survey. Setting: Rural districts in the EC (OR Tambo and Alfred Nzo) and KZN (Umkhanyakude and Zululand). Subjects: PHC facilities and nurses (EC: n = 20; KZN: n = 20); and 0 to 71-month-old children and their caregivers (EC: n = 994; KZN: n = 992). Methods: Structured interviewer-administered questionnaires and anthropometric survey. Results: Of the 40 PHC facilities; 14 had been built or renovated after 1994. The PHC facilities had access to the following: safe drinking water (EC: 20; KZN: 25); electricity (EC: 45; KZN: 85); flush toilets (EC: 40; KZN: 75); and operational telephones (EC: 20; KZN: 5). According to more than 80of the nurses; problems with basic resources and existing cultural practices influenced the quality of services. Home births were common (EC: 41; KZN: 25). Social grants were reported as a main source of income (EC: 33; KZN: 28). Few households reported that they had enough food at all times (EC: 15; KZN: 7). The reported prevalence of diarrhoea was high (EC: 34; KZN: 38). Undernutrition in 0 to younger than 6 month-olds was low; thereafter; however; stunting in children aged 6 to 59 months (EC: 22; KZN: 24) and 60 to 71 months (EC: 26; KZN: 31) was medium to high. Overweight and obese adults (EC: 49; KZN: 42) coexisted. Conclusion: Problems regarding infrastructure; basic resources and services adversely affected PHC service delivery and the well-being of rural people; and therefore need urgent attention

Adverse Social; Nutrition and Health Conditions in Rural Districts of Kwazulu-Natal and the Eastern Cape Provinces; South Africa

Objective: This study determined the socio-demographic; nutritional and health status of children and their caregivers in two rural districts in KwaZulu-Natal (KZN) and one rural district in the Eastern Cape (EC); South Africa. Design: A cross-sectional survey was conducted. Setting: The study population resided in Umkhanyakude (sub-district Jozini) and Zululand (sub-district Pongola) in KZN; and in OR Tambo (sub-district Nyandeni) in the EC province. Subjects: Children 0 to 59 months old (Umkhanyakude n = 398; Zululand n = 303; OR Tambo n = 364) and their caregivers were included.Methods: Structured interviewer-administered questionnaires were conducted and height and weight were measured.Results: Households in OR Tambo had less access to services (tap water 3; toilets 33); compared to Umkhanyakude (tap water 50;toilets 82) and Zululand (tap water 74; toilets 98). Wood was the main energy source used to cook food in all three districts ( 75).Grants were a main source of income (Umkhanyakude and Zululand 61; OR Tambo 55). Many households obtained vegetables from their own garden (Umkhanyakude and Zululand 30; OR Tambo 70). The households that reportedly had enough food available at all times (Umkhanyakude and Zululand 25; OR Tambo 17); were in the minority. The diarrhoea prevalence reported by the caregivers was high (Umkhanyakude 35; Zululand 24; OR Tambo 24). The prevalence of stunting was higher for children older than 12 months and varied between 22 and 26. The prevalence of overweight among children 0 to 23 months exceeded the prevalence of underweight. The prevalence of overweight and obesity among caregivers was high (Umkhanyakude 42; Zululand 60; OR Tambo 56).Conclusion: Concerted efforts are needed to address the adverse social; nutrition and health conditions in these districts

A genetic analysis of post-weaning feedlot performance and profitability in Bonsmara cattle.

The aim of this study was to identify factors influencing profitability in a feedlot environment and to estimate genetic parameters for and between a feedlot profit function and productive traits measured in growth tests. The heritability estimate of 0.36 for feedlot profitability shows that this trait is genetically inherited and that it can be selected for. The genetic correlations between feedlot profitability and production and efficiency varied from negligible to high. The genetic correlation estimate of -0.92 between feed conversion ratio and feedlot profitability is largely due to the part-whole relationship between these two traits. Consequently, a multiple regression equation was developed to estimate a feed intake value for all performance-tested Bonsmara bulls, which were group fed and whose feed intakes were unknown. These predicted feed intake values enabled the calculation of a post-weaning growth or feedlot profitability value for all tested bulls, even where individual feed intakes were unknown. Subsequently, a feedlot profitability value for each bull was calculated in a favorable economic environment, an average economic environment and in an unfavorable economic environment. The high Pearson and Spearman correlations between the estimate breeding values based on the average economic environment and the other two environments suggested that the average economic environment could be used to calculate estimate breeding values for feedlot profitability. It is therefore not necessary to change the carcass, weaned calf or feed price on a regular basis to allow for possible re-rankings based on estimate breeding values.

The Clinical Spectrum and Financial Burden of HIV Infected Children in a Regional Hospital in South Africa

Background: HIV infection has become a common risk factor for hospital admission and a major contributor to childhood morbidity in South Africa. There remains a paucity of data describing the cost of hospitalisation of HIV-infected children in South Africa. The aim of this study was to describe basic demographics and clinical patterns as well as cost implications of the hospitalisation of HIV-infected children in the Karl Bremer Hospital; Cape Town; South Africa. Methods: A prospective descriptive longitudinal study of HIV-positive paediatric admissions; matched with HIV-negative controls; was conducted. Patients were matched according to age; socio-demographic area and presenting symptoms. Questionnaires were used to elicit demographic and clinical information. Worksheets were used to record any costs incurred; which were calculated at rates applicable to 2001. This was done daily during admission. Data was statistically analysed in MS Excel and MS Access. Thirty HIV-positive children were identified; of which 23 could be matched with 23 HIV-negative children. HIV-positive children had a higher admission rate (2.09 versus 0.26 previous admissions; p = 0.000) and were also younger at the time of first admission to hospital (7.52 versus 13.78 months; p = 0.005). There is a statistically significant difference in duration of hospitalisation in the HIV-positive group when compared to the control group - duration of hospitalisation being longer in the HIV-positive group (7.91 versus 4.96 days; p = 0.005). Despite being treated for the same condition; there is a statistically significant difference in the cost incurred by children in the HIV-positive group (R6 203.16) when compared to the HIV-negative group (R3 901.96); p = 0.000. Conclusion: This study shows a clear and statistically significant difference between the HIV-positive group and HIV-negative control group of children with regard to admission rate; age at first admission; duration of hospitalisation and cost incurred during hospitalisation. HIV-infected children in the pre-HAART (highly active anti-retroviral therapy) era were hospitalised more frequently and for longer periods than their HIV-uninfected counterparts. These findings seem to suggest that the cost of hospitalising HIV-positive children is significantly more than HIV-negative controls; which will increase the financial burden on already restricted health resources

The targeting of nutritionally at-risk children attending a primary health care facility in the Western Cape Province of South Africa.

AIM: The aim of this study was to determine the practices of primary health care (PHC) nurses in targeting nutritionally at-risk infants and children for intervention at a PHC facility in a peri-urban area of the Western Cape Province of South Africa. METHODOLOGY: Nutritional risk status of infants and children <6 years of age was based on criteria specified in standardised nutrition case management guidelines developed for PHC facilities in the province. Children were identified as being nutritionally at-risk if their weight was below the 3rd centile, their birth weight was less than 2500 g, and their growth curve showed flattening or dropping off for at least two consecutive monthly visits. The study assessed the practices of nurses in identifying children who were nutritionally at-risk and the entry of these children into the food supplementation programme (formerly the Protein-Energy Malnutrition Scheme) of the health facility. Structured interviews were conducted with nurses to determine their knowledge of the case management guidelines; interviews were also conducted with caregivers to determine their sociodemographic status. RESULTS: One hundred and thirty-four children were enrolled in the study. The mean age of their caregivers was 29.5 (standard deviation 7.5) years and only 47 (38%) were married. Of the caregivers, 77% were unemployed, 46% had poor household food security and 40% were financially dependent on non-family members. Significantly more children were nutritionally at-risk if the caregiver was unemployed (54%) compared with employed (32%) (P=0.04) and when there was household food insecurity (63%) compared with household food security (37%) (P<0.004). Significantly more children were found not to be nutritionally at-risk if the caregiver was financially self-supporting or supported by their partners (61%) compared with those who were financially dependent on non-family members (35%) (P=0.003). The weight results of the nurses and the researcher differed significantly (P<0.001), which was largely due to the different scales used and weighing methods. The researcher's weight measurements were consistently higher than the nurses' (P<0.00). The researcher identified 67 (50%) infants and children as being nutritionally at-risk compared with 14 (10%) by the nurses. The nurses' poor detection and targeting of nutritionally at-risk children were largely a result of failure to plot weights on the weight-for-age chart (55%) and poor utilisation of the Road to Health Chart. CONCLUSIONS: Problems identified in the practices of PHC nurses must be addressed in targeting children at nutritional risk so that appropriate intervention and support can be provided. More attention must be given to socio-economic criteria in identifying children who are nutritionally at-risk to ensure their access to adequate social security networks.

The inheritance of liability to epistaxis in the southern African Thoroughbred.

This study was carried out to estimate the heritability of liability to epistaxis in the southern African Thoroughbred population. Data of all horses that suffered epistaxis while racing in southern Africa and Mauritius from 1986 to 2002 and involving 1252 bleeders were analysed. Pedigree data covering the period 1960-1986 was used as required to calculate the incidence of bleeding amongst ancestors of the post-1986 era. Only pedigrees of horses that raced were included in this study as it was not possible to predict whether non-runners would have bled had they raced. Consequently all non-runners and also those that raced overseas in countries where bleeding occurrence was not recorded, were excluded. The heritability of liability method as described by Falconer (1989) was used to estimate the relative importance of heredity and environment. For the period investigated, the population incidence for epistaxis in southern African horses was 2.1%. The estimation of heritability of liability showed that 1st-degree relatives had a figure of 55.4%. Second-degree relatives had a heritability of 41.3% and 3rd-degree relatives came in at 30.4%. The heritability of liability shown in this study could be regarded as being at the lower end of the range but could be appreciably higher. The data depict horses that bled almost exclusively on race days, as only a small percentage (approximately 5%) was reported as having bled during exercise. Accordingly, the full extent of epistaxis amongst racing Thoroughbreds in southern Africa is difficult to gauge. It is clear that epistaxis in the racing Thoroughbred has a strong genetic basis. It is suggested that horses showing frankbleeding from the nostrils after racing or exercise be suspended, and not used for breeding purposes. This should result in relatively fast progress being made towards eradicating this costly scourge of the modern Thoroughbred racehorse.

Epistaxis related to exercise-induced pulmonary haemorrhage in south African Thoroughbreds.

This study investigated if environmental factors had an effect on the incidence of epistaxis related to exercise-induced pulmonary haemorrhage (EIPH) among racehorses in southern Africa. Data covering the period 1986-2001 and involving 778 532 race runs were analysed. This included the following information: date of race, age, sex, name of breeder, trainer, distance, jockey, state of going, weight carried, racing centre and altitude. Veterinarians employed by the Jockey Club suspended officially entered horses that presented with epistaxis (frank bleeding from the nostrils) after racing. On-course endoscopy is not performed as a standard practice at any southern African racetrack. Epistaxis was identified in 1287 horses (0.165%). More horses presented with EIPH-related epistaxis (a) at sea level, (b) from May to October, (c) when older (> 3 years), (d) after 1995, (e) on Fridays and Sundays, and (f) more in geldings than in mares or entire males. No association could be established between epistaxis and breeder, trainer, distance run, jockey, state of going and weight carried. It is concluded that the frequency of EIPH-related epistaxis is associated with altitude, winter and spring, sex and age. It is suggested that racing at lower altitudes may increase the probability of exercise-induced pulmonary haemorrhage.

The effect of melatonin treatment on reproductive efficiency in an accelerated lambing system.

A trial, which involved 917 ewes, was conducted to examine whether reproductive traits could be improved in an accelerated lambing system with 3 lambing seasons per year by subcutaneous melatonin treatment. Fertility (ewes lambed per ewes put to the ram), litter size and the interval between melatonin application date and lambing date were not affected by treatment. However, in the first lambing season (15 February to 15 March), fertility was 16% higher in melatonin-treated ewes compared to untreated ewes (P > 0.05). Season or month of application therefore seems to be an important factor with regard to the response. It is concluded that melatonin treatment in accelerated lambing systems is further complicated by the presence of pregnant and lactating ewes, which makes the value of commercial use thereof doubtful.

Productivity of pure- and crossbred cattle in a subtropical environment.

The influence of different breeds of sire and dam types on cow productivity in an arid, subtropical environment was studied. Cows with calves sired by Simmentaler, Hereford and Bonsmara bulls were more (P less than 0.05) productive than those with calves sired by Afrikaner bulls. Simmentaler sires were superior (P less than 0.05) to Bonsmara sires. Crossbred cows of predominant (greater than 50%) Bos taurus breeding were generally superior to crossbreds of predominant B. indicus breeding and purebreds. Crossbreeding systems to utilize breed effects to optimise cow productivity within environmental constraints are discussed.

The influence of body mass and condition on ovulation rate in polyandroalbumin immunized S A mutton Merino ewes. / Die invloed van liggaamsmassa en kondisie op ovulasietempo van poliandro-albumien geïmmuniseerde S A vleismerino-ooie.

Two groups of 40 S A Mutton merino ewes were used to determine the effect of body mass and condition score on the response of immunisation against androstenedione. The effect of immunisation was significant (P less than 0.05) on ovulation rate (1.64 for non-immunised and 2.08 for immunised ewes) and higher body mass and condition scores acted complimentary to the effect of immunisation. The ovulation rate in control ewes was more closely related to condition score (r = 0.511) and body mass (r = 0.600) at the end of the experimental period than in the immunised ewe group (r = 0.302 and 0.235).

Biochemical polymorphisms in the South African springbok (Antidorcas marsupialis).

An attempt was made to use polymorphic markers in the genetic taxonomy of springbok populations. Three independent free ranging springbok populations could be identified on the basis of albumin and transferrin gene frequencies. Even if most of the enzyme markers appeared to be monomorphic it can be stated that in any comparative study of this kind, cryptic genetic markers are of greater use than other environmentally sensitive taxonomic criteria. From the given data and others mentioned it can be stated that little support exists for the continued application of the subspecific status in the species Antidorcas marsupialis. It is shown that the use of environmentally sensitive parameters in the springbok are both misleading and highly unsatisfactory. Biochemical polymorphism can be utilized better than other parametres but here also there are several limitations. Basically, only the albumin and transferrin types can be used when blood samples are available and only IDH and 6-PGD polymorphisms are of value when liver samples can be utilized for the genetic differentiation.

Biochemical polymorphisms in South African freshwater fish. Isoenzyme patterns in fish of the families Cyprinidae and Salmonidae.

Isoenzyme patterns were studied in local populations of the carp (Cyprinus carpio) and the bream (Sarotherodon mossambicus) of the Cyprinid family, and in the trout (Salmo giardneri) of the family Salmonidae. Homogenates of heart muscle extracts were used in the identification of PGI, NADP-IDH, PGM and 6-PGD. Polymorphisms found and gene frequencies obtained are discussed separately for each enzyme and species or population. In the bream, variation was found only at the PGI locus. In the carp only the PGM locus was polymorphic whereas both PGM and IDH showed variation in the trout. The variation at the PGM locus in the trout cannot support the three locus model suggested elsewhere and clearly indicates a single locus for the monomeric enzyme. The large variety of NADP-IDH types in trout not only illucidates the complexity of this locus but confirms a disomic mode of inheritance. Genetic differences in the trout populations could be related to possible advantages for management purposes.