How to write a research protocol

A research protocol is best viewed as a key to open the gates between the researcher and his/her research objectives. Each gate is defended by a gatekeeper whose role is to protect the resources and principles of a domain: the ethics committee protects participants and the underlying tenets of good practice, the postgraduate office protects institutional academic standards, the health authority protects provincial resources etc. The protocol must explicitly address the issues likely to be raised by these gatekeepers, demonstrating evidence of a clear understanding of the issues involved and that all components of the research plan have been addressed. The purpose of this paper is to add flesh to the skeleton provided in step six (‘write the protocol’) of the Biccard and Rodseth paper of 2014, orientated towards the first-time researcher working towards the MMed degree. Although occasional reference will be made to qualitative approaches, it is likely that the majority of these studies will be quantitative designs and these form the focus of this paper.Keywords: MMed, protocol, protocol design, research, research desig

Creating the perfect intern anaesthesia rotation: a survey using feedback from past interns

Background: Community service doctors (CSDs) are often expected to administer anaesthesia after minimal training and with very little support, especially in rural hospitals. This leads to unnecessary stress on these junior doctors and may lead to poor anaesthesia outcomes.Objectives: The aim of this study was to understand the experiences of CSDs administering anaesthesia. This feedback will be used to improve the current intern training programme for anaesthesia and to structure the rotation according to their needs.Methods: A questionnaire was sent to Pietermaritzburg (PMB) interns who completed their anaesthesia intern rotation between 2008 and 2010. Two data sets were collected: quantitative data (this will be reported on in another paper) and qualitative data. The qualitative data included five open-ended questions about the intern rotation in anaesthesia.Results: Between 2008 and 2010, 298 interns completed an anaesthetic rotation. The survey was sent to 259 doctors of whom 189 responded (73%). The first three questions were about the structure of the intern rotation in anaesthesia. The responses were analysed together. The following feedback was common: more autonomy, longer duration of the anaesthesia rotation and more practical exposure during the rotation. Questions 4 and 5 were about the impact of internship and community service on future career choice. Community service had a greater impact on career choice than internship.Conclusion: Intern training in anaesthesia is essential to create confident CSDs. Feedback from previous interns should be used to improve intern training programmes.Keywords: anaesthesia education, intern training, obstetric anaesthesia training, rural health car

The value of exercise stress testing in prediction of angiography amongst South African patients using quantitative scoring systems

Background: Accurate pre-test assessment of high risk patients may increase positive yield on angiography. Exercise stress testing (EST) prediction of angiography, may be evaluated by Duke Treadmill Score (DTS), and Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score, respectively. Aim: To investigate the value of EST in prediction of angiography amongst South African patients using quantitative scoring systems. Methods: The DTS and SYNTAX score were compared in patients with high risk pre-test assessments selected for angiography. Logistic regression modelling determined the odds ratio of abnormal angiograms using EST as a predictor. Results: Pre-test assessment of 525 suspected coronary artery disease patients, indicated angiography in 131 high risk individuals. The positive yield of abnormal angiograms was 58.0%, with no correlation between DTS and SYNTAX scores (Pearson’s correlation coefficient = 0.113, p=0.200). There was low predictive probability on receiver-operator-curve for DTS when compared to angiogram results (area under curve (AUC)=0.529, p=0.574), and SYNTAX categories (AUC=0.432, p=0.378). Chi-square tests had no significance between angiography and EST (all p-values >0.05). However DTS predicted abnormal angiograms with odds ratio of 1.92 when relevant cardiovascular risk factors (smoking, BMI, age) were added. Conclusion: Pre-test assessment of high risk patients represented a homogenous group with prevalent cardiovascular risk factors. However, the high risk group had no relationship between DTS and SYNTAX scores, indicating DTS alone discounts risk factors. Modelling accounted for DTS limitation by demonstrating an obese, elderly smoker with high risk category DTS is 1.92 times more likely to have an abnormal angiogram

Practising anaesthesia as a community service doctor: a survey-based assessment

Background: Anaesthesia-related maternal mortality remains unacceptably high, especially in district hospitals. Community service doctors (CSDs) play an important role in the provision of anaesthesia in these hospitals. The purpose of this study was to understand the experience of doctors providing anaesthesia during community service. Identifying deficiencies in the performance of anaesthesia by CSDs can lead to remedial actions.Methods: A prospective, questionnaire-based study was done of doctors who had done their anaesthesia rotation during their internship in Pietermaritzburg, between 2008 and 2010. Quantitative data were collected regarding their performance of anaesthesia during community service. The data included details concerning the provision of anaesthesia, supervision and training, and whether CSDs felt adequately prepared to perform anaesthesia during community service. Qualitative data were also collected, which will be reported in another article.Results: The study response rate was 72.9%. Roughly half of the respondents performed anaesthesia during community service, of which two-thirds did more than 50 cases. Obstetric anaesthesia was the most common procedure performed. CSDs worked largely unsupervised, 63% had very little supervision and 62% received no further training in anaesthesia during community service. CSDs felt adequately prepared to administer obstetric anaesthesia, but less well prepared to perform general anaesthesia for appendicectomies and ectopic pregnancies.Discussion: CSDs perform a large proportion of the anaesthesia in rural hospitals, where they work largely unsupervised. Furthermore, CSDs feel less well prepared to perform general anaesthesia than spinal anaesthesia. To meet the needs of patients in these areas, intern training needs to be aimed at improving anaesthesia delivery in rural hospitals and guidelines need to be established regarding the performance of anaesthesia by CSDs.Conclusion: The study showed that CSDs play an important role in provision of anaesthesia services, especially in rural areas. However, they work largely unsupervised and receive little further training or support. A large proportion do not feel comfortable in administering general anaesthesia. Intern training should be adjusted to meet the needs of CSDs.Keywords: Intern training in anaesthesia, community service doctors experienc

A comparison of coronary angiography and myocardial perfusion studies, using quantitative scoring systems

Background: Results of myocardial perfusion for screening coronary artery disease (CAD), and angiography for diagnosing CAD, can be quantified using summed difference score (SDS) and Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score, respectively. Aim: The aim is to quantitatively compare myocardial perfusion studies with angiography amongst South African patients using scoring systems. Methods: SDS on myocardial perfusion and SYNTAX score on angiography were compared. Regional scores within each vessel (left anterior descending (LAD), circumflex and right coronary artery (RCA)) were also compared. Scores were further risk categorised and evaluated. Results: The weak correlation between SDS and SYNTAX score (rs=0.210, p=0.015), became slightly negative when SYNTAX scores were stratified into low and intermediate-high risk groups. Regionally, LAD had very slight positive correlation (rs=0.171, p=0.048), circumflex (rs=0.164, p=0.058), and RCA (rs=0.116, p=0.184) no correlation. Conversely, comparison of scores categories was signifi cant (p=0.001). Conclusions: Inherent differences in the design of 2 scoring systems that evaluate the LAD territory may explain these findings. These differences were dominance, regional blood flow distribution and significant luminal diameter reduction. This study highlights the need to interpret myocardial perfusion results contextually during CAD screening

University level genetics students’ competencies in selected science process skills

Science process skills are essential for all practicing scientists. These skills include various practices that are needed to glean new knowledge as well as to represent existing knowledge. For example, an ability to use mathematics to represent relationships between variables is important in any scientific discipline. Furthermore, understanding scientific method is imperative in any research field. In addition, being literate with tabulated and graphical data is not only important for the scientist’s understanding of data, but also for the representation of data in a coherent manner for peer review and knowledge dissemination. Unfortunately these skills are often not explicitly taught in science discipline courses, but instead many course designers assume that students already have these skills. Research has shown however, that this can be a wrong assumption as graduate students sometimes display a shortfall in science process skills. The research presented in this thesis focused on assessing genetics student competencies in some of the science process skills required by practicing geneticists. The research questions sought to investigate the status of students’ abilities in some science process skills, whether they improve throughout the undergraduate careers of the students and which factors might impact on student performance in the skills. The study is introduced in the first chapter with a rationale for the study along with a statement of the significance of the research goals. The term ‘science process skills’ is expounded and examples are given. Chapter two contains a review of the literature on science process skills. The historical development of science and the inclusion of science process skills as an integral part of the scientific discipline are related in order to emphasise the importance of science process skills. The current status of the science process skills literature is examined and it is shown that there is a gap in the literature, pertaining to our understanding of the status of undergraduate and graduate student science process skills, which requires investigation by research. The general research method and design developed for the study is explicated in chapter three. The nature of the study required that both quantitative and qualitative data be gleaned from a large number of students. The complexity of the study required many research processes to be carried out in a linear procedure, from interviewing experts, to designing and implementing a test instrument, to statistical and qualitative analysis of the student scores for the items in the instrument. All of these processes are explained in chapter 3 while the development of the instrument is specifically dealt with in chapter four. Chapters five to seven report on the specific methods used to address each research question, the results obtained and the implications of the study. Quantitative analysis of the items in the instrument was executed in order to get a snapshot of the student capacities in the science process skills tested (Chapter five). The results achieved for each group from first year through to honours were compared to infer whether students increase their skill level as they progress through the years (Chapter six). Data from student records were used in addition to their test scores in an effort to find indicators of performance (Chapter seven). Chapter seven includes a model for predicting student performances in science process skills. This model could prove useful when selecting students for admission into science courses The final chapter provides an overall synthesis of the study with reflective critique and suggestions for further research. An important inference of the study was that in spite of their overall successful completion of the instrument, many students have some specific problems with some science process skills. Furthermore, it appears that students’ abilities with science process skills improve significantly from first year through to honours. This study was conducted in one department at a single university and therefore the results cannot be taken as indicative of all science departments nationally or internationally. However, the method designed and used for this work may be transferred in order to establish the status of students’ similar skills at other department and institutions. It is also with this regard that the findings of this thesis may be useful in the future. Copyright 2005, University of Pretoria. All rights reserved. The copyright in this work vests in the University of Pretoria. No part of this work may be reproduced or transmitted in any form or by any means, without the prior written permission of the University of Pretoria. Please cite as follows: Aldous, CM 2005, University level genetics students’ competencies in selected science process skills, MSc dissertation, University of Pretoria, Pretoria, viewed yymmdd Dissertation (MSc)--University of Pretoria, 2007.GeneticsUnrestricte

Introducing a multifaceted approach to the management of diabetes mellitus in resource-limited settings

Globally diabetes mellitus (DM) and its complications are placing an enormous burden on individual patients and countries alike. South Africa is a developing country already under enormous pressure from communicable diseases such as HIV and tuberculosis. Added to this is DM, which serves to fuel the interactions between communicable and non-communicable diseases. Data from KwaZulu-Natal Province (KZN) have demonstrated that the majority of patients with DM in the public healthcare sector are diagnosed and started on treatment at their local resource-limited healthcare clinics. This article describes introduction of a multifaceted approach to the management of DM in a resource-limited clinic at Edendale Hospital, Pietermaritzburg, KZN. Strategies like this may help provide a blueprint for other resource-limited healthcare facilities in developing countries

Description of an internal medicine outreach consultant appointment in western KwaZulu-Natal, South Africa, 2007 to mid-2014

This is a description of an internal medicine outreach appointment in western KwaZulu-Natal Province (KZN), South Africa (SA), from 2007 to mid-2014, facilitated by the transport services of the Red Cross Air Mercy Service (AMS) and funded by the KZN Department of Health. The hospital visits represented ‘multifaceted’ as opposed to ‘simple’ outreach. The AMS database of outreach visits was analysed according to frequencies of visits, number of patient contacts and number of contacts with medical personnel. A brief history of the outreach visits is given and their nature described. From January 2007 to the end of June 2014, the outreach physician undertook 481 hospital visits and visited seven hospitals (out of 21) more than 40 times each. A total of 3 340 medical personnel contacts were made, and 5 239 patients were seen. Other internal medicine specialists undertook an additional 199 visits, during which they made 1 157 personnel contacts and saw 2 020 patients. The combined total was therefore 680 visits undertaken, 4 497 medical personnel contacts made and 7 259 patients seen. The appointment of a dedicated outreach consultant for a particular discipline together with a reliable air and road transport system was successful in providing access to specialist care in rural settings. This strategy could be recommended throughout SA. Further studies would be required in order to assess outcomes. Document type: Articl

A deadly combination - HIV and diabetes mellitus: Where are we now?

Background. The combination of HIV infection and diabetes mellitus (DM) represents a collision of two chronic conditions. Both HIV and DM increase the risk of developing tuberculosis (TB). Health resources in developing countries are already under strain as a result of the TB epidemic and poor diabetic control would further worsen this epidemic. Optimal diabetic control provides one avenue of curbing the TB epidemic in developing countries. Objectives. To establish if there is a difference in blood pressure, lipid and glycaemic control and complications between HIV-infected and uninfected diabetic patients; and to compare characteristics among HIV-infected diabetic patients between those with optimal and sub- optimal glycaemic control.Methods. This was a retrospective chart review of all patients who visited the Edendale Hospital diabetic clinic, Pietermaritzburg, from 1 October 2012 to 30 September 2013. Results. There were statistically significant differences noted in the following parameters between HIV-infected and uninfected diabetic patients: (i) mean HbA1c% (11.08% v. 10.14%, respectively); (ii) nephropathy defined by proteinuria (25.66% v. 15.43%); (iii) neuropathy (48.68% v. 42.10%); and (iv) Kidney Disease Outcomes Quality Initiative (KDOQI) stage ≥2 chronic kidney disease (30.87% v. 41.67%). There were no significant differences noted in the percentage of patients achieving the following target parameters between the two cohorts: (i) blood pressure (42.11% v. 35.62%); (ii) total cholesterol (36.84% v. 34.67%); and (iii) triglycerides (42.76% v. 40.19%). Within the HIV-infected diabetic cohort 85.23% displayed suboptimal glycaemic control. A significant percentage of HIV-infected diabetic patients on antiretroviral (ARV) therapy (89.36%) had suboptimal glycaemic control. HIV-infected female diabetic patients showed a significant increased waist circumference when compared with their HIV-uninfected counterparts. Conclusion. HIV-infected diabetic patients had significantly poorer blood sugar control and a higher incidence of neuropathy and nephropathy (when defined by overt proteinuria). There was a non-significant difference noted between the HIV-infected and uninfected diabetic patients with regard to blood pressure and lipid control. The majority of HIV-infected patients on ARVs failed to achieve target glycaemic control. Obesity remains a global challenge, as noted in both the HIV-infected and uninfected diabetic patients.