The barriers and facilitators to initiation of telephone-assisted bystander cardiopulmonary resuscitation for patients experiencing out-of-hospital cardiac arrest in a private emergency dispatch centre in South Africa.

Background: The incidence of cardiovascular diseases, and with it out-of-hospital cardiac arrest (OHCA), is on the increase in low- to middle-income countries (LMICs), like South Africa. Interventions such as mass public cardiopulmonary resuscitation (CPR) training campaigns and public access defibrillators are expensive and out of reach for many LMICs. Telephone-assisted CPR (tCPR) is a cost-effective, scalable alternative. This study explored the barriers and facilitators to tCPR uptake in OHCA in a private South African emergency dispatch centre. Methods: This qualitative study applied inductive dominant content analysis to emergency call recordings of OHCA cases into a private emergency dispatch centre. Calls were analysed to the latent level to identify barriers and facilitators. Cases were sampled randomly, until data saturation. Results: Saturation occurred after the analysis of 25 recordings. A further three recordings were analysed to confirm saturation of the facilitators; yielding a final sample size of 28 calls. Overall, t-CPR was offered in 23 (82.1%) cases, but only initiated in 8 (34.8%) of these calls. Five barriers ("Poor Communication"; "Lack of Support"; "Caller Hesitance or Uncertainty;" "Emotionality"; and "Practical Barriers") and three facilitators ("Caller Willingness"; "Support" and "CPR in Progress") were extracted. Conclusion: Numerous barriers limit the initiation of tCPR in the South African private sector EMS. It is crucial to address these barriers and leverage the facilitators in order to improve tCPR uptake. This study highlights the importance of using specific language techniques and developing tailored tCPR algorithms to overcome these barriers, which is underpinned by standardised training of call-takers.

Developing a South African curriculum for education in neonatal critical care retrieval: An initial exploration.

BACKGROUND: Owing to limited or centralised neonatal critical care resources, the interfacility transfer of neonates is inevitable. In many high-income settings, dedicated Critical Care Retrieval Services (CCRS) with additional education and training undertake neonatal critical care retrieval (CCR). In South Africa, however, these transfers are mostly conducted by advanced paramedics with limited education in neonatal care, and this may lead to high adverse event rates. In SA, a shortage of skilled neonatal interfacility transport services has been identified as one of the top ten avoidable causes of under-5 mortality. In order to address this gap in neonatal transfer education for paramedics in South Africa, the aim of this study is to develop a curriculum for neonatal critical care retrieval in South Africa. METHODS: Using Kern's approach to curriculum development, a general and targeted needs assessment was conducted through semi-structured interviews with experts in the field and a focus group discussion with a prospective student group. Interviews were preceded and informed by a literature review and retrospective chart review of neonates who underwent CCR in SA over a one-year period. Audio recordings of interviews were transcribed verbatim and subjected to inductive-dominant content analysis. Finally, qualitative codes were expanded into course outcome and a curriculum map was developed. RESULTS: Six experts in neonatal critical care and retrieval participated in semi-structured interviews with a mean duration of 59 minutes. Following transcription and analysis, 372 codes were developed. Seven prehospital providers (prospective students) who are involved in neonatal transfers in South Africa participated in a focus group discussion with a duration of 91 minutes. The audio recording was transcribed and analysed with 97 codes extracted. The main categories were: Current status of neonatal CCR in South Africa; learning and education in neonatal CCR; and proposed curriculum structure. The proposed curriculum structure described 13 broad course outcomes to be delivered as a blended postgraduate programme. Participants noted that funding, employer buy-in and internet resources would be required. The targeted prospective student group should be all Advanced Life Support (ALS) providers with a change in their scope of practice on completion. CONCLUSION: This study described the need for additional education in neonatal critical care retrieval due to the limitations in the current and past education systems. This study provides a curriculum structure with course outcomes that can be used as a basis for the development of a complete curriculum for education in neonatal CCR, with the potential to greatly reduce adverse event rates.

The lived experiences of emergency care personnel in the Western Cape, South Africa during the COVID-19 pandemic: A longitudinal hermeneutic phenomenological study.

In March 2020, the World Health Organisation declared COVID-19 a global pandemic. Shortly after the first case of COVID-19 was reported in South Africa, the Western Cape province experienced a rapid growth in the number of cases, establishing it as the epicentre of the disease in South Africa. The aim of this study was to explore emergency care personnel's lived experiences and their perceptions thereof within the context of the COVID-19 pandemic in the Western Cape province. This study followed a longitudinal hermeneutic phenomenological approach. The convenience sample included prehospital and emergency centre medical personnel. Data were collected over a 4-month period using both one-on-one interviews and participant recorded voice recordings. Data were analysed following Ricoeur's theory of interpretation. Four themes were generated during the data analysis: 1) In the beginning, waiting for the unknown; 2) Next, change and adaptation in the workplace; 3) My COVID-19 feelings; 4) Support and connection. Participants discussed the uncertainty associated with responding to an unknown threat and a need to keep up with constant change in an overburdened work environment. Results showed high levels of uncertainty, restriction, fear, anxiety, and exhaustion. Despite these difficulties, participants demonstrated resilience and commitment to caring for patients. A need for support was also highlighted. Results indicated that change, over time, resulted in adaptation to a new way of practising and keeping safe. Healthcare workers experienced intersecting consequences as frontline healthcare workers and members of the public, all of which impacted their well-being. The importance of compassion and encouragement as forms of support was highlighted in the study. Robust and sustained support structures in a time of change, low mood, and exhaustion are essential.

A national retrospective review of neonatal critical care transfers in dedicated critical care transport services in the private sector.

BACKGROUND: South Africa (SA) has a shortage of dedicated neonatal critical care services, which are mostly concentrated in urban areas, thus illustrating the need for neonatal critical care transport (CCT) services. Neonates who are transported by teams without the requisite experience and knowledge in neonatal care are at risk of severe adverse events during transport. This has led to the development of dedicated CCT teams by some emergency medical services. There is a paucity of national literature describing the neonatal population who undergo CCT in dedicated services. OBJECTIVES: To describe a sample of neonates who underwent CCT transfer by dedicated CCT services in the private sector in SA. METHODS: This observational cohort study with a retrospective descriptive design sampled all neonatal transfers completed during 1 year (1 January 2017 - 31 December 2017) from the dedicated CCT of the two largest national emergency medical services in SA. Data were extracted from patient report forms by trained data extractors, and subjected to descriptive analysis. RESULTS: A total of 444 neonates were transferred between the two services. A total of 760 diagnoses were recorded, yielding an average of ~2 diagnoses per patient. The most prevalent diagnosis was respiratory distress syndrome (n=139, 31%), followed by congenital heart defects (n=123, 28%) and prematurity (n=81, 18%). Patients had an average of ~4 attachments, with the most prevalent being patient monitoring (n=677, 152%). Just under half (n=182, 41%) of patients required ventilatory support. A total of 422 medications were required during transport, yielding a rate of ~1 medication or infusion per neonate transported. The most common infusion was maintenance (n=199, 45%), while almost 1 in 10 neonates required inotropic support (n=33, 7%). CONCLUSIONS: This study provides insight into the demographics, most prevalent diagnoses, and interfacility transfer monitoring needs of neonates being transported in SA by two private dedicated CCT services. The results of this study should be used to inform future specialised neonatal CCT courses and qualifications, as well as the scopes of practice of providers transporting neonates.

Using fresh frozen plasma as an emergency treatment modality for hypertriglyceridaemic acute pancreatitis in a resource-constrained environment: A case report and review of literature.

Hypertriglyceridaemia is associated with severe disease such as coronary disease, cerebral vascular accidents and acute pancreatitis. Severe hypertriglyceridaemia is defined as a serum triglyceride value of >55 mmol/L. Hypertriglyceridaemic acute pancreatitis, often found in pregnancy, has a higher mortality rate than the other causes of acute pancreatitis. The cornerstone of treatment is to lower the triglyceride level as quickly as possible. In a resource-constrained environment, plasma exchange is not a viable option. Therefore, exploring the possible efficacity of directly infusing fresh frozen plasma is applicable to rural emergency medicine and may lead to more definitive research. In our case study, we used fresh frozen plasma to enhance the removal of triglyceride because it contains lipoprotein lipase.

The molecular basis of an avian plumage polymorphism in the wild: a melanocortin-1-receptor point mutation is perfectly associated with the melanic plumage morph of the bananaquit, Coereba flaveola.

BACKGROUND: Evolution depends on natural selection acting on phenotypic variation, but the genes responsible for phenotypic variation in natural populations of vertebrates are rarely known. The molecular genetic basis for plumage color variation has not been described in any wild bird. Bananaquits (Coereba flaveola) are small passerine birds that occur as two main plumage variants, a widespread yellow morph with dark back and yellow breast and a virtually all black melanic morph. A candidate gene for this color difference is the melanocortin-1 receptor (MC1R), a key regulator of melanin synthesis in feather melanocytes. RESULTS: We sequenced the MC1R gene from four Caribbean populations of the bananaquit; two populations of the yellow morph and two populations containing both the yellow morph and the melanic morph. A point mutation resulting in the replacement of glutamate with lysine was present in at least one allele of the MC1R gene in all melanic birds and was absent in all yellow morph birds. This substitution probably causes the color variation, as the same substitution is responsible for melanism in domestic chickens and mice. The evolutionary relationships among the MC1R haplotypes show that the melanic alleles on Grenada and St. Vincent had a single origin. The low prevalence of nonsynonymous substitutions among yellow haplotypes suggests that they have been under stabilizing selection, whereas strong selective constraint on melanic haplotypes is absent. CONCLUSIONS: We conclude that a mutation in the MC1R is responsible for the plumage polymorphism in a wild bird population and that the melanic MC1R alleles in Grenada and St. Vincent bananaquit populations have a single evolutionary origin from a yellow allele.

Bacteraemia in shock. A prospective study.

Previous studies showed that bacteraemia occurs in shocked dogs and rats. The present study shows that it also occurs in shocked patients and that Gram-positive bacteria, especially staphylococci, feature prominently. Gram-positive bacteraemia may constitute an important link between shock and sepsis. Antibiotic prophylaxis covering Gram-positive bacteria is suggested for patients with severe shock.

Morphological characterisation of the cell-growth inhibitory activity of rooperol and pharmacokinetic aspects of hypoxoside as an oral prodrug for cancer therapy.

Hypoxoside is the major diglucoside isolated from the corms of the plant family Hypoxidaceae. It contains an unusual E-pent-1-en-4-yne 5-carbon bridging unit with two distal catechol groups to which the glucose moieties are attached. It is non-toxic for BL6 mouse melanoma cells in tissue culture on condition that the fetal calf serum in the medium is heat-inactivated for 1 hour at 56 degrees C in order to destroy endogenous beta-glucosidase activity. The latter catalyses hypoxoside conversion to its cytotoxic aglucone, rooperol, which, when tested as a pure chemical, caused 50% inhibition of BL6 melanoma cell growth at 10 micrograms/ml. Light and electron microscopy revealed that the cytotoxic effect of rooperol manifested as vacuolisation of the cytoplasm and formation of pores in the plasma membrane. Indications of apoptosis were also found. Pharmacokinetic studies on mice dosed intragastrically with hypoxoside showed that it was deconjugated by bacterial beta-glucosidase to form rooperol in the colon. Surprisingly, no hypoxoside or rooperol was detectable in the serum. Only phase II biotransformation products (sulphates and glucuronides) were present in the portal blood and bile. In contrast, however, in human serum after oral ingestion of hypoxoside, the metabolites can reach relatively high concentrations. Rooperol metabolites isolated from human urine were non-toxic for BL6 melanoma cells in culture up to a concentration of 200 micrograms/ml. In the presence of beta-glucuronidase, which released rooperol from the metabolites, 50% growth inhibition was achieved at a 75 micrograms/ml metabolite concentration. The supernatant of a human melanoma homogenate could also cause deconjugation of the metabolites to form rooperol.(ABSTRACT TRUNCATED AT 250 WORDS)

A phase I trial of hypoxoside as an oral prodrug for cancer therapy--absence of toxicity.

OBJECTIVE: To assess the toxicity of hypoxoside taken orally by 24 patients with lung cancer. DESIGN: Open study with patients taking 1,200-3,200 mg standardised Hypoxis plant extract (200 mg capsules) per day divided in 3 doses in order to maintain metabolite blood levels near 100 micrograms/ml. PARTICIPANTS AND SETTING: Patients with histologically proven squamous, large-cell or adenocarcinoma were hospitalised initially at the radiation oncology ward, Karl Bremer Hospital, Bellville, W. Cape. Thereafter they returned every 2 weeks for full clinical examinations. METHODS: Routine biochemical and haematological measurements were done. Patients underwent regular full clinical examinations including radiographs and computed tomography scanning according to the discretion of the principal investigator. RESULTS: Nineteen patients on hypoxoside therapy survived for an average of 4 months with progression of their primary tumours and metastases, while 5 survived for more than a year. One of them survived for 5 years and histological examination of the primary lesion showed absence of cancer. No toxic effects, in clinical examinations or biochemical or haematological measurements, were found that could be ascribed to the ingestion of hypoxoside. Only one occasion of possible drug intolerance, with anxiety, nausea, vomiting and diarrhoea, was noted. CONCLUSION: The absence of toxicity warrants further investigation of hypoxoside as an oral prodrug, especially in patients with slow-growing necrotising tumours that are inoperable and have high concentrations of beta-glucuronidase and sulphatase as well as a high sensitivity for rooperol.

beta-Glucosidase activity in fetal bovine serum renders the plant glucoside, hypoxoside, cytotoxic toward B16-F10-BL-6 mouse melanoma cells.

By using p-nitrophenyl-beta-D-glucopyranoside as substrate, beta-glucosidase activity was observed in fetal bovine serum (FBS). This activity could be inhibited by heat inactivation of the serum. Gel chromatography of FBS indicated the presence of beta-glucosidase activity with an apparent molecular mass of 29 kDa. In McCoy's 5A medium supplemented with non-heat inactivated FBS, the diglucoside hypoxoside ([E]-1,5-bis[4'beta-D-glucopyranosyloxy-3'-hydroxyphenyl]pent-4-en - 1-yne) showed cytotoxicity toward B16-F10-BL-6 mouse melanoma cells. In incubations where the media were supplemented with FBS previously heat inactivated at 56 degrees C for 1 h or more, no cytotoxicity was observed in the presence of hypoxoside. The aglucone of hypoxoside, rooperol ([E]-1,5-bis[3',4'-dihydroxyphenyl]pent-4-en-1-yne), showed cytotoxicity regardless of whether the serum was heat inactivated or not. The kinetics of the heat inactivation of the beta-glucosidase activity in FBS coincided with the loss of apparent cytotoxicity of hypoxoside. High performance liquid chromatography analysis showed that rooperol could be generated by incubation of hypoxoside in non-heat inactivated FBS, but that this ability was lost in serum that was heat inactivated for 1 h or longer. Newborn bovine serum did not contain any beta-glucosidase activity whereas it was found in three different commercial sources of FBS. This observation is of practical importance because conventional heat inactivation of FBS at 56 degrees C for 30 min was not sufficient to inactivate the beta-glucosidase activity completely.

Interaction of the di-catechols rooperol and nordihydroguaiaretic acid with oxidative systems in the human blood. A structure-activity relationship.

The effects of the di-catechols rooperol [(E)-1,5-bis(3',4'- dihydroxyphenyl)pent-4-en-1-yne; P2] and nordihydroguaiaretic acid (NDGA) on oxidative systems in the human blood were investigated. P2 and NDGA gave comparable results in the inhibition of leukotriene synthesis in the polymorphonuclear leukocyte and prostaglandin synthesis in platelet microsomes. The oxidation states of myeloperoxidase in the presence of H2O2 were also similarly affected by both P2 and NDGA. In these systems, the 4'4'-beta-D-diglucopyranoside of rooperol, hypoxoside [(E)-1,5-bis(4' beta-D-glucopyranosyloxy-3'- hydroxyphenyl) pent-4-en-1-yne; P2A] had no effect. The only system which showed significant differences in the effects of the catechols was the red blood cell. NDGA in the presence of H2O2 had a pronounced haemolytic effect, which did not correlate with its ability to induce methaemoglobin formation, while P2 had a much lower haemolytic effect, but stimulated the oxidation of haemoglobin to a greater extent than NDGA. NDGA is more hydrophobic than P2 which would result in a greater membrane effect. The pent-4-en-1-yne chain which links the catechol moieties in P2 can take part in the resonance structures of the semiquinone free radical, thus assisting in its stabilization and leading to increased methaemoglobin formation. This stabilization is also demonstrated by the fact that P2A affected the oxidation of haemoglobin to nearly the same extent as NDGA.

Insecticidal effect of essential oils from mediterranean plants uponAcanthoscelides Obtectus Say (Coleoptera, Bruchidae), a pest of kidney bean (Phaseolus vulgaris L.).

The bioactivity of 22 essential oils from aromatic and medicinal plants was tested uponAcanthoscelides obtectus Say (Coleoptera, Bruchidae), a pest of kidney bean (Phaseolus vulgaris L.). The insecticidal effect was evaluated by determination of 24- and 48-hr LC50 and LC50 (from 1.50 mg/ dm(3) to more than 1000 mg/dm(3)). Isoprenoids and phenylpropanoids were identified by gas chromatography. The most efficient essential oils were extracted from plants belonging to Labiatae.Origanum marjorana andThymus serpyllum essential oils were the most toxic.

The diagnosis of abdominal injuries in comatose patients.

The clinical course of 95 comatose trauma patients was prospectively evaluated. The role of clinical findings and diagnostic peritoneal lavage (DPL) combined with computed tomography (CT) were assessed in the diagnosis of abdominal injuries. Seven per cent of the patients were comatose due to hypoperfusion, and did not have a primary brain injury. Of the remaining 88 patients, 28% had an associated abdominal injury. Hypotension predicted an associated abdominal injury with an accuracy of 72%, and a haematocrit less than 30% had an accuracy of 82%. Clinical examination was 50% accurate. DPL was 93% accurate, with a false-positive rate of 10%. No abdominal injuries were present in the group in whom the lavage results were negative, while no unnecessary laparotomies were performed in the group with a 4+ or 5+ positive DPL (calorimetric method). In the group with 1+, 2+ and 3+ positive DPL, 3/15 laparotomies (12%) were done for minor abdominal injuries. Minimising unnecessary laparotomies was achieved by utilising CT to determine the nature and extent of the injury. By using DPL as a screening test, and CT to quantify the injury, unnecessary operations can be avoided, and all injuries can still be diagnosed.

Thermal injury in pregnancy--the neglected tragedy.

Thermal injury sustained during pregnancy presents special management problems for the gravid woman and her unborn child. Because of the reported high morbidity and mortality and lack of available data in South Africa, a multicentre retrospective review was undertaken by five burn centres. Thirty-three patients (average age 25,7 years) with mean 30% (range 1-80%) total body surface area burn were assessed. A review of the clinical material led to the following observations and conclusions. Pregnancy does not influence maternal outcome after thermal injury and maternal survival is usually accompanied by fetal survival in the absence of significant maternal complications. Maternal survival is less likely if the burn wound exceeds 50% total body surface area. Thermal injury does increase the risk of spontaneous abortion and premature labour, and fetal survival depends on fetal maturity. Early obstetric intervention is only indicated in the gravely ill patient where complications (hypoxia, hypotension, sepsis) jeopardize the life of a viable fetus. The mode of delivery should be determined by obstetric considerations.

Cross-contamination of human esophageal squamous carcinoma cell lines detected by DNA fingerprint analysis.

DNA "fingerprint" analysis has recently become known as a valuable technique for positive identification of any given individual. The chances for mistaken identity have been estimated to be 10(-6) for close siblings or as little as 10(-23) for randomly selected individuals. This methodology thus represents a significant improvement over previously established identification tests using protein or enzyme analysis techniques and has already found application in forensic medicine. One of the chief problems in tissue culture studies is the question of the unequivocal identity of the cultured cells used and the very real possibility of their being contaminated by cells of a similar morphological appearance. We report here the application of the DNA "fingerprint" technique to the genotypic analysis of cultured human squamous carcinoma cells. The results show that a number of lines, designation HCu, have become cross-contaminated. Lines SNO, HCu 10, and HCu 13 are genetically distinct, however lines HCu 10, 18, 33, 37, and 39 are genetically identical and are in fact subcultures of the same cells. In addition, a myocardial line known as Girardi is shown to be identical to HeLa cells. The introduction of this technique to tissue culture laboratories could therefore prevent contaminated cultures from being disseminated or used in research studies.