Snake bites in north east Sri Lanka.

INTRODUCTION: Snake bite is a major problem in Sri Lanka where recent decades of warfare and economic sanctions have complicated its management. RESULTS: A retrospective review of snake bites in north-east Sri Lanka was undertaken in 2005 to review management. Of 303 victims, 145 revealed a local response, 134 a prolonged clotting time, 46 ptosis and five respiratory failure. One died. Of 97 snakes identified: 42 were saw-scaled vipers, 14 Russell's vipers, 6 cobras and 6 kraits. Most bites occurred at the harvest and the median age of victims was 32 years. There was no difference in morbidity or mortality at any age. In total, 262 snake bite cases were treated within 3 hours of the bite, and 183 were given antivenom. Seventy victims reacted adversely, of whom 61 received hydrocortisone, chlorpheniramine and subcutaneous adrenaline. No significant side effects were noted. CONCLUSION: North-east Sri Lanka has endured two decades of civil disruption but public knowledge and an established protocol for management, including adrenaline, has compensated for shortages in medical staff and infrastructure. The resumption of economic sanctions in 2007 is likely to counter that success.

Low molecular weight heparin for neonatal thrombosis.

The clinical course of a term neonate (birthweight 3.14 kg) who developed thrombosis of the left common and internal iliac veins on day 21 following recovery from Streptococcus mitis septicemia, with shock diagnosed on day 13, is reported. Subcutaneous low molecular weight heparin (LMWH) was commenced (1.5 mg/kg 12 hourly for 10 days) after 13 h of standard heparin infusion, due to difficulties in securing a peripheral venous access. The inflammation of the left leg was completely resolved by day 5 of LMWH therapy. Prothrombin time, activated prothrombin time and fibrinogen levels were within normal limits during LMWH therapy. Treatment-related side effects, such as thrombocytopenia and bleeding tendency were not noted. Doppler studies 6 weeks after discharge home on day 33 revealed complete resolution of the thrombus. Apart from septicaemia and shock, the presence of an indwelling central venous catheter and a history of untreated maternal diabetes were additional risk factors for thrombosis. Because it is as effective as standard heparin, LMWH may be a therapeutic option for thrombosis in high-risk neonates, particularly given its ease of administration by the subcutaneous route, predictable pharmacokinetics and reduced incidence of adverse effects such as bleeding complications.

Intravenous rifampicin in neonates with persistent staphylococcal bacteraemia.

UNLABELLED: Addition of intravenous rifampin is reported to be useful in prompt clearance of persistent coagulase negative staphylococcal (CONS) bacteraemia in high-risk neonates. Four neonates (mean birthweight 823 g, mean gestation 25 wk) with persistent CONS bacteraemia for > 7-10 d (mean 11) were treated with i.v. rifampicin (10 mg/kg/12 h x 10 d) while continuing vancomycin (15 mg/kg/24 h). Their age at time of infection ranged from 2 to 11 d. The mean (range) vancomycin peak and trough concentrations were 29 (25-35) and 6 (4-10) microg/ml, respectively. The blood isolates were Staphylococcus epidermidis, S. hominis, and S. haemolyticus. Addition of rifampicin was associated with prompt clearance of bacteraemia within 48 h (n = 3) and 5 d (n - 1). Rifampicin-related adverse effects such as abnormal liver function tests and thrombocytopenia did not occur. CONCLUSION: Addition of i.v. rifampicin to vancomycin may optimize the outcome of persistent CONS bacteraemia and the risk of bacterial resistance related to prolonged exposure to vancomycin.

Sudden infant death syndrome risk factors in north Queensland: a survey of infant-care practices in Indigenous and non-Indigenous women.

OBJECTIVE: To assess the prevalence of sudden infant death syndrome (SIDS) risk factors in the Indigenous and non-Indigenous community of Townsville, a large remote urban centre in north Queensland, Australia. METHODS: Thirty Indigenous and 30 non-Indigenous women with young children were surveyed using sections of the West Australian Infancy and Pregnancy Survey 1997-1998. The prevalence of SIDS risk factors was compared between the two groups and medians and univariate associations were generated where appropriate. RESULTS: The Indigenous women were significantly younger and more likely to be single. The median age of the infants was 8 months (range 0.3-26 months) with no difference between the two groups. Thirty-seven per cent of Indigenous infants slept prone (cf. 17% of non-Indigenous infants; P = 0.03), and 77% shared a bed (cf. 13% of non-Indigenous infants; P < 0.001). The Indigenous households had significantly more members, with 57% including extended family members (cf. 20% non-Indigenous group; P = 0.003). Fifty-three per cent of the Indigenous women smoked during pregnancy (cf. 23% of non-Indigenous women; P = 0.017), 60% were smokers at the time of the interview, and smoking occurred inside 40% of Indigenous houses (cf. 20% and 20% for non-Indigenous women, respectively; P < 0.001, 0.09). CONCLUSION: This small survey suggests that the prevalence of SIDS risk factors is higher in the Indigenous population, and a new approach to education is needed urgently to promote SIDS awareness among Indigenous women.

Sudden infant death syndrome in Indigenous and non-Indigenous infants in north Queensland, 1990-1998.

OBJECTIVE: To compare the epidemiology of sudden infant death syndrome (SIDS) in Indigenous and non-Indigenous infants in north Queensland, and to assess the quality of data recorded for SIDS deaths. METHODS: Records were obtained for SIDS cases from all coronial courts in north Queensland from 1990 to 1998. Demographic characteristics, ethnicity, age at death, sleeping and feeding patterns, smoking incidences and autopsy findings were compared. Incidences, medians and univariate associations were generated where appropriate. RESULTS: There were 83 248 live births for the 9-year period; 71 389 non-Indigenous and 11 859 Indigenous births. There were 69 SIDS deaths (0.83 per 1000 live births). Overall, recording of demographic and death scene data was poor. Thirty-eight autopsies (55%) were performed by specialist pathologists. There were 22 (32%) non-Indigenous and 22 (32%) Indigenous SIDS deaths (25 ethnicity unknown), giving an estimated relative risk of 2.82 (95% CI 2, 4). Median age at death was 13.1 weeks (range 1-83 weeks) with 14% of deaths occurring in the neonatal period for both groups. Sleeping position was not recorded in 42% of cases and co-sleeping was not recorded in 27% of cases. Bed sharing was more common amongst Indigenous infants. Fifty-two per cent of SIDS cases occurred in the wet season and 48% in the dry season. CONCLUSIONS: Data recorded for SIDS deaths in north Queensland are poor, preventing specific conclusions concerning SIDS risk factors. However, SIDS rates may be up to three-fold higher in the Indigenous population. A uniform system of post-mortem and death scene data reporting is needed urgently.

Is being Aboriginal or Torres Strait Islander a risk factor for poor neonatal outcome in a tertiary referral unit in north Queensland?

OBJECTIVE: To compare perinatal outcomes for all births, and the morbidity and mortality patterns of babies admitted to neonatal intensive care, for non-Indigenous, Aboriginal and Torres Strait Islander (TSI) people in a major remote urban centre. METHODS: A prospective cohort study of all births and consecutive admissions to the Neonatal Intensive Care Unit/Special Baby Care Unit (NICU/SCBU) at Kirwan Hospital for Women (KWH), Townsville (a tertiary referral hospital) was conducted from January 1998 to June 1999. RESULTS: There were 2575 births, with 2392 (93%) booked into KWH for delivery. The Aboriginal group differed from the non-Indigenous group only in the prevalence of low-birthweight births. The TSI group had significantly higher perinatal mortality rates, preterm and low-birthweight births than the non-Indigenous group. Seven hundred and fifty-eight babies were admitted to NICU/SCBU: 586 (77%) non-Indigenous, 129 (17%) Aboriginal, 43 (6%) TSI. There were significantly more preterm, lower birthweight and longer stay length Aboriginal and TSI babies. Being Indigenous was not associated with neonatal death. Gestation of less than 28 weeks, congenital anomalies, and high-grade cerebral haemorrhage, but not ethnicity, were independent risk factors for neonatal death. Maternal risk factors, including poor antenatal care attendance, were more prevalent amongst Indigenous women. CONCLUSION: Neonatal outcomes for Aboriginal infants were better than expected from national and State reports. Outcomes for Torres Strait Islander infants were worse than expected. Ethnicity was not a risk factor for neonatal death. These findings suggest that outcomes may be further improved by programmes to increase access for Indigenous women to antenatal care services.

An ethics core curriculum for Australasian medical Schools.

Teaching ethics incorporates teaching of knowledge as well as skills and attitudes. Each of these requires different teaching and assessment methods. A core curriculum of ethics knowledge must address both the foundations of ethics and specific ethical topics. Ethical skills teaching focuses on the development of ethical awareness, moral reasoning, communication and collaborative action skills. Attitudes that are important for medical students to develop include honesty, integrity and trustworthiness, empathy and compassion, respect, and responsibility, as well as critical self-appraisal and commitment to lifelong education.

Hyperekplexia in neonates.

Hyperekplexia (startle disease) is a rare non-epileptic disorder characterised by an exaggerated persistent startle reaction to unexpected auditory, somatosensory and visual stimuli, generalised muscular rigidity, and nocturnal myoclonus. The genetic basis is a mutation usually of the arginine residue 271 leading to neuronal hyperexcitability by impairing glycinergic inhibition. Hyperekplexia is usually familial, most often autosomal dominant with complete penetrance and variable expression. It can present in fetal life as abnormal intrauterine movements, or later at any time from the neonatal period to adulthood. Early manifestations include abnormal responses to unexpected auditory, visual, and somatosensory stimuli such as sustained tonic spasm, exaggerated startle response, and fetal posture with clenched fists and anxious stare. The tonic spasms may mimic generalised tonic seizures, leading to apnoea and death. Consistent generalised flexor spasm in response to tapping of the nasal bridge (without habituation) is the clinical hallmark of hyperekplexia. Electroencephalography may show fast spikes initially during the tonic spasms, followed by slowing of background activity with eventual flattening corresponding to the phase of apnoea bradycardia and cyanosis. Electromyography shows a characteristic almost permanent muscular activity with periods of electrical quietness. Nerve conduction velocity is normal. No specific computed tomography findings have been reported yet. Clonazepam, a gamma aminobutyric acid (GABA) receptor agonist, is the treatment of choice for hypertonia and apnoeic episodes. It, however, may not influence the degree of stiffness significantly. A simple manoeuvre like forced flexion of the head and legs towards the trunk is known to be life saving when prolonged stiffness impedes respiration.

Comparison of clinical characteristics and high-risk factors in Australian aboriginal and non-aboriginal neonates with necrotising enterocolitis.

In a five-year retrospective data analysis, incidence of > stage II necrotising enterocolitis (NEC) was four times higher in aboriginal (18/125) than non-aboriginal (11/306) neonates, all < or = 32 weeks' gestation. Stage III NEC occurred more frequently (10/18 vs 3/11) and related mortality was higher (44.4% vs 0%) in aboriginal than non-aboriginal neonates. Risk factors for NEC-prolonged rupture of membranes (50% vs 9.1%, p = 0.01), prematurity (median [range] gestational age: 25 (24-28.5) vs 30 [27-33]) weeks, p = 0.02), birth weight (< 1 kg 13 [72%] vs 2 [18%], p = 0.007) and intrauterine growth retardation (50% vs 0%, p = 0.01) occurred more frequently in aboriginal neonates. Though feed type and increments per day were similar, aboriginal neonates received higher volume of feeds/kg/day (median [range]: 154 [145-189] vs 106 [103-134] ml, p < 0.05). Condition at delivery and respiratory status before development of NEC were not significantly different.

Neonatal amniotic fluid aspiration syndrome underdiagnosed?

Aspiration of uncontaminated amniotic fluid as a cause of significant respiratory distress in neonates is not well documented. We report a term neonate who presented with severe respiratory distress soon after birth. The diagnosis of amniotic fluid aspiration was confirmed at autopsy. Implications of this diagnosis in the management of neonates with respiratory distress are discussed.

Benefits of a standardised feeding regimen during a clinical trial in preterm neonates.

The feeding regimen was standardised for a trial of erythromycin to reduce the time to reach full feeds (150 ml/kg/day) by 30% in neonates of < or = 32 weeks gestation. No significant improvement was noted in the primary outcome (median time: erythromycin 93.5 vs placebo 104 hours, p = 0.60). However, necrotising enterocolitis > or = stage II disappeared and the time to full feeds was reduced by over 50% in all neonates during the 18-month trial, and for more than two years after the trial, when the standardised feeding regimen was adopted as routine policy for feeding neonates of < or = 32 weeks (< 28 weeks: 13 vs 4.8 days, p < 0.05; > 28 weeks: 8 vs 3.9 days, p < 0.05). This was in contrast to an average of six cases of NEC per year with 45% mortality during the previous five years. The benefits of standardised feeding schedules--improved detection/treatment of signs/symptoms of feed intolerance--are emphasised.

Neonatal management at limits of viability: hypothesis based on review of literature and clinical observations.

Advances in the surfactant era have resulted in a dramatic rise in the survival of 23-26 week old neonates. For the group as a whole, survival is 50% with a 50% morbidity in survivors. Current literature includes a few 'small baby protocols' suggesting guidelines for management based on institutional experiences. Adopting these with or without any modifications may not be appropriate for other institutions due to the diversity of the patient population involved and the available resources. A review of literature on ELBW neonates reveals an interesting fact that almost all the management strategies and optimal goals in the most critical first few weeks of life involve two numbers--'fifty' and 'eight'! The relevance of these two numbers (or their multiples) in simplifying the management of ELBW neonates is highlighted.