Praxis-Informed Pointers: A Student Guide for Optimizing Clinical Learning in a Resource-Constrained Setting.

Issue: Health professions education (HPE) is intimately linked with teaching and learning in the clinical environment. While the value of authentic clinical experiences is acknowledged, whether learning actually occurs is to a large extent dependent on students' behaviors and attitudes. The kinds of student behaviors and attitudes that are necessary to optimize learning in the clinical environment thus becomes relevant. Evidence: Tips and recommendations to maximize clinical learning in a variety of settings have been well documented. There is, however, a dearth of literature which takes a narrative-based praxis approach focused on resource-constrained environments. We developed this praxis-orientated article as a means to translate the available literature and theory into a simple, practical guide, focused on optimizing clinical learning from a student perspective, remaining cognizant of the particular challenges present in a resource-constrained setting. Implications: Based on the resource-constrained environments our students are exposed to, we outline the following six key aspects: student-driven learning, integration into the community of practice, student engagement, empathy, interprofessional learning opportunities, and feedback for learning. These aspects provide useful pointers for students in general. Furthermore, exploration into what strategies students may utilize in resource-constrained clinical contexts is addressed.

COVID-19 and medical educator perceptions: Sense-making during times of crisis

Background. Although crises are generally considered uncommon, health professions education (HPE) literature gives evidence of repeated and ongoing crises. This has been most recently demonstrated by the global impact of COVID-19. Crisis management literature proposes that such recurrent crises are opportune moments for learning. While there has been much literature published that describes changes made to the format of HPE amid COVID-19, there has been little attention given to the perceptions of medical educators. Medical educators' experiences may serve as a resource to uncover lessons that may have been learnt during this period. Objective. To address the gap in the literature, by analysing the perceptions of medical educators at the University of Cape Town (UCT) during the COVID-19 pandemic of 2020-2021. Methods. A qualitative case-study approach was adopted. Rich data were collected from four medical educators using semi-structured interviews and a focus group discussion, and then analysed using a reflexive thematic approach. Results. The data indicated that educators grappled with a multitude of struggles during the COVID-19 pandemic. These were analysed thematically as: tensions with technology, balancing expectations, and the distribution of support. However, surface-level challenges faced by educators seem to belie a much deeper personal struggle. Conclusion. The data suggest that whe the rany learning occurs and what is learnt are embedded within the process of sense-making. If institutions of higher education aim to adopt proactive responses to crises, then further research ­ as well as support for these sense-making processes during crises ­ should form a critical part of overall institutional preparedness.

A pilot study of women's experiences after being offered late termination of pregnancy for severe fetal anomaly.

OBJECTIVE: We investigated the attitudes and experiences of women pregnant with an anomalous fetus after being offered late termination of pregnancy (LTOP) before and after delivery or TOP. METHODS: This was a pre- and post-intervention structured interview questionnaire-based study. Pregnant women with severe fetal abnormalities (lethal and nonlethal) diagnosed after 24 weeks gestation were recruited. All were managed according to standard protocol. Interviews were conducted by the researcher over a 3 months period (August-October 2010). Experiences, demographic profile, and sociocultural characteristics were compared between the groups that accepted and declined LTOP. RESULTS: Fifteen pregnant women with severe fetal anomalies were enrolled. Around 5 (33.3%) requested termination, and 10 (66.6%) continued the pregnancy. Those who continued their pregnancies were significantly younger (mean age 25 years, range 20-32 years) than those who requested termination (mean age 31 years, range 22-35 years) (P < 0.05). Mean parity was one (range 0-3) in the patients who continued the pregnancy, and 2 (1-3) in those who terminated it. Partners and immediate family members influenced decision making. All women reported a positive experience of the treatment protocol. CONCLUSION: The decision to continue or terminate a pregnancy for severe fetal abnormalities diagnosed after viability is complex and variable. Younger primigravidas were more likely to continue with the pregnancy in the hope that the baby would be born normal. Good support from partners and family, after delivery, was associated with less regret about the decision that had been made.

Utility of the Robson Ten Group Classification System to determine appropriateness of caesarean section at a rural regional hospital in KwaZulu-Natal, South Africa.

BACKGROUND: High caesarean section (CS) rates are not only costly but associated with significant perinatal and maternal morbidity and mortality. It has recently been suggested that structured auditing of CSs may identify those groups in the obstetric population that contribute substantially to the high rates and for which focused interventions may bring about change. OBJECTIVE: To evaluate the utility of the Robson Ten Group Classification System (RTGCS) in determining appropriateness of CS at a regional rural hospital in KwaZulu-Natal Province, South Africa. METHODS: A retrospective review of the hospital records of women delivered by CS over a 3-month period was performed. The RTGCS was used to categorise women according to parity, age, past obstetric history, singleton or multiple pregnancy, fetal presentation, gestational age and mode of onset of labour/delivery. RESULTS: There were 2 553 hospital births over the 3-month study period. The CS rate was 42.4% (1 082/2 553). According to the RTGCS, groups 1 (n = 296, 27.4%), 5 (n = 186, 17.2%) and 10 (n = 253, 23.4%) were substantial contributors to the overall CS rate. The main indications for CS were fetal distress (36.5%) and cephalopelvic disproportion (26.8%). CONCLUSION: The RTGCS is a useful tool with which to identify patient groups warranting interventions to reduce high CS rates in a rural regional hospital setting. Group 1 (nullipara: single cephalic term pregnancy; spontaneous labour) warrants the most attention. Applying stricter criteria and due diligence in decision-making for primary CS may decrease the high CS rates.

Otolaryngological, head and neck manifestations in HIV-infected patients seen at Steve Biko Academic Hospital in Pretoria, South Africa.

BACKGROUND: Sub-Saharan Africa has the highest incidence of HIV infection. According to recent census statistics, 5.6 million people in South Africa (SA) are HIV-positive, the highest number of infected individuals worldwide. Over 80% of HIV-infected individuals will present with ear, nose and throat (ENT) manifestations. Previous studies show that oral diseases seem to be the most common ENT-related manifestation, reported in about 40 - 50% of HIV-infected patients. In SA, there is lack of local information regarding the otolaryngological and head and neck manifestations in HIV-infected individuals. OBJECTIVE: To ascertain our local trends of ENT and head and neck manifestations in HIV-infected patients seen at our specialised ENT-HIV Clinic, Steve Biko Academic Hospital, Pretoria, Gauteng Province, SA. METHODS: A 1-year prospective study involving 153 HIV-infected patients was conducted in the clinic from January to December 2011. Patient history was taken and examinations were performed based on the World Health Organization (WHO) HIV/AIDS classification system. Data analysis was performed using Epi Info 7 software. RESULTS: The most common manifestations were adenoid hypertrophy/hyperplasia followed by cervical lymphadenopathy, chronic suppurative otitis media, otitis media with effusion and sensory-neural hearing loss. CONCLUSION: Patients typically presented with early manifestations during symptomatic WHO stages I and II in contrast to results reported in similar developing world studies from Iran, Nigeria and India. A possible explanation may lie in the SA government HIV Counselling and Testing campaign and the antiretroviral rollout programme, the effectiveness of which is becoming evident.

Views and Attitudes of Pregnant Women Regarding Late Termination of Pregnancy for Severe Fetal Abnormalities at a Tertiary Hospital in KwaZulu-Natal

Aim. To study the views and attitudes of pregnant women with severe fetal anomalies regarding late termination of pregnancy (LTOP). Methods. Data were collected over a 3-month period using semi-structured interviews of pregnant women with severe fetal anomalies (lethal and non-lethal) detected after 24 weeks' gestation at a single tertiary/quaternary fetal medicine unit in KwaZulu-Natal; South Africa. The interviews were conducted both during pregnancy and within 2 weeks after delivery. The women who underwent LTOP and those who continued with their pregnancies were compared in respect of a variety of demographic and socio-economic characteristics. Results. During the study period; 15 pregnant women with severe fetal anomalies were interviewed. Of these; 5 (33.3) requested termination and 10 (66.6) opted to continue the pregnancy. The women who continued their pregnancies were significantly younger (mean age 25 years; range 20 - 32 years) than those who requested termination (mean age 31 years; range 22 - 35 years) (p0.05). Mean parity was 1 (range 0 - 3) in the patients who continued the pregnancy and 2 (1 - 3) in those who terminated it. The majority of the women were Christians; and there was no significant difference between the groups in their choices. Many women indicated that their partners and immediate family members influenced decision making. All the women said that they were given sufficient time by the hospital staff to make their decision whether to terminate or continue the pregnancy after the options had been explained to them in a non-threatening manner. Before delivery; the common reasons for continuing with the pregnancy included fear of killing an unborn baby; that a baby is God's gift and the baby will be well after it is born; that nature should be allowed to take its course; and that there should be no interference with the pregnancy. The main reasons for opting for LTOP were the cost implications of raising an abnormal baby; that the baby would suffer during his or her life; and being unable to cope with a severely handicapped child. After delivery and seeing the baby; most women felt that they made the correct choice. Conclusion. Despite the small numbers from a single academic institution; this study illustrates that even while pregnant with an anomalous fetus; patients' views and attitudes regarding LTOP for severe fetal anomaly were variable. Younger primigravidas were more likely to continue the pregnancy in the hope that the baby would be born normal. Good support from partner and family after delivery was associated with less regret about the decision that had been made. Larger follow-up studies assessing long-term views and attitudes of women regarding LTOP will be important for comparison with the initial decision-making process and for future prenatal counselling

Late termination of pregnancy by intracardiac potassium chloride injection: 5 years' experience at a tertiary referral centre.

OBJECTIVES: To report our experience with intracardiac potassium chloride (KCl) injection as a method of feticide for severe congenital abnormalities beyond 24 weeks' gestation. METHOD: A retrospective chart review. Patient demographics and types of fetal anomalies were analysed according to the groups that accepted or declined late termination of pregnancy (LTOP, ≥24 weeks) for severe congenital abnormalities. RESULTS: Of 3 896 women referred to the Fetal Medicine Unit at Inkosi Albert Luthuli Central Hospital, KwaZulu-Natal, 2 209 (56.7%) were at ≥24 weeks' gestation at their first visit. LTOP for severe congenital abnormalities was offered to 253 (11.5%), of whom 191 (75.5%) accepted. Differences in maternal age, parity, race and religion were not statistically significant. The type of fetal abnormalities and gestational age at diagnosis influenced the decision-making process in >80% of the women. The most frequent indications for LTOP were brain and spinal abnormalities (53.0%), and aneuploidy (20.6%). Feticide by ultrasound-guided intracardiac KCl injection was performed in 138/191 cases (72.2%); 53 women who accepted LTOP did not undergo feticide for a variety of reasons. The mean interval between diagnosis and performance of feticide was 10 days (range 0 - 42 days). Fetal asystole was achieved in all cases within 2 minutes by a single-needle injection of intracardiac KCl; the mean duration of the procedure was 12 minutes (range 6 - 25 minutes). There were no maternal complications, and stillbirths occurred in all cases. CONCLUSION: Feticide by ultrasound-guided intracardiac KCl injection was an acceptable, safe and effective method for LTOP. Further studies are needed to determine the minimum dosage of KCl required to achieve the desired effect.

Validation of the Quintero staging system for twin-twin transfusion syndrome.

OBJECTIVE: To validate an established staging system for twin-twin transfusion syndrome. METHODS: Prospective observational study in a tertiary referral fetal medicine center of 52 consecutive cases of twin-twin transfusion syndrome. Each pregnancy was assessed longitudinally for a variety of prognostic factors including fetal biometry, amniotic fluid volume, arterial and venous Doppler sonogram abnormalities, and the presence of hydrops. Data were used to determine stage at diagnosis and first treatment, and worst stage throughout pregnancy. Perinatal outcome was assessed by stage. Management comprised serial amnioreduction, septostomy, selective reduction, or delivery, alone or in combination. RESULTS: Median gestation at presentation and first treatment were both 21 weeks (range 14-34 and 15-34), and at delivery it was 29 weeks (range 16-40). Sixty-three percent of pregnancies (33 of 52) were at least stage III at presentation. Forty-five percent of pregnancies (22 of 49) progressed to a more advanced stage. Overall survival was 47% (47 of 100), with no difference between donor and recipient fetuses (40% [20 of 50] versus 54% [27 of 50] [chi(2) P =.5]). Survival rates were 58% (15 of 26), 60% (six of ten), 42% (20 of 48), 43% (six of 14), and 0% (none of two) for stages I-V, respectively, with no significant influence of stage at presentation on survival. Survival was poorer where stage increased, versus decreased (27% [12 of 44] versus 94% [17 of 18] chi(2) P <.001). Kaplan-Meier survival curves indicated that staging at presentation identified pregnancies at greater risk of earlier rather than later gestational perinatal loss. CONCLUSION: The Quintero staging system did not distinguish good from bad outcome at presentation, and thus should be used with caution in guiding initial management of twin-twin transfusion syndrome. However, prognosis was influenced by a change in stage, and pregnancies progressing to higher stage disease were at increased risk of earlier perinatal loss. Staging may thus be more useful in monitoring disease progression.

Interstitial laser: a new surgical technique for twin reversed arterial perfusion sequence in early pregnancy.

Current treatments for twin reversed arterial perfusion sequence are associated with significant morbidity and most are not feasible in early gestation. We report the use of an interstitial laser in two pregnancies complicated by this sequence at 14 and 15 weeks, respectively. A 600 microm laser fibre was introduced via a 17 gauge needle into the abdomen of the perfused twin close to the vitelline artery and umbilical vein, which were occluded by neodymium:yttrium aluminium garnet (Nd:YAG) laser. Both pregnancies continued uneventfully and each resulted in the birth of a healthy baby at term.

Bacterial vaginosis and associated infections in pregnancy.

OBJECTIVE: To assess the role of bacterial vaginosis (BV) on pregnancy complications in a developing community where mixed cervico-vaginal infections are common. SETTING: The antenatal clinic at King Edward VIII Hospital (KEH), Durban, South Africa, which is a large urban tertiary hospital serving mainly a Black underprivileged population of KwaZulu/Natal. METHODS: Asymptomatic pregnant women < or = 30 weeks gestation were recruited at their first antenatal visit. Clinical data including the sexual history were recorded. Swab specimens were collected from the vagina and endocervix for diagnosing BV, trichomoniasis, candidiasis, gonorrhea and chlamydial infection. Venous blood specimens were tested for antibody to syphilis and human immunodeficiency virus (HIV). All women continued standard antenatal care and hospital records were reviewed following delivery to evaluate pregnancy outcome. RESULTS: BV was found in 52% of the women studied and was the commonest infection diagnosed. Mixed vaginal infections of BV and trichomoniasis were diagnosed in 14%. Only 29% of asymptomatic women did not have any microbiological evidence of a lower genital tract infection. A total of 46% of women studied had poor pregnancy outcome as measured by obstetrical complications, pregnancy loss and/or neonatal morbidity. There was a significant difference in outcome in women with BV (55 of 88) compared to those having infections other than BV (13 of 31), or no infection (5 of 9)-P = 0.005. This difference was for obstetrical complications of preterm delivery, premature rupture of membranes and intrauterine infection, but not for pregnancy losses and neonatal morbidity. CONCLUSIONS: The high prevalence of BV and concomitant lower genital tract infections among asymptomatic pregnant women and the resultant adverse pregnancy outcome associated with BV, confirms reports from developed countries of the need for screening for BV at the initial antenatal clinic visit. Whether pregnancy outcome was worse in the presence of BV and other infections than BV alone could not be determined. Future studies with appropriate interventions are needed to evaluate the unique problems of developing countries.