Practicing medicine on the high seas: a review of South African doctors’ careers in cruise ship medicine

Background: There has been an increase in the number of South African doctors working in the field of maritime medicine on board cruise ships. Despite this, there is a paucity of literature available addressing the epidemiology, level of expertise and continued medical education (CME) activities of cruise ship medicine. We aim to describe the demographics, qualifications and level of experience of South African doctors embarking on a career as a cruise ship doctor and assess ongoing CME and the future careers of doctors post cruise ship medicine. Materials and methods: A survey was distributed to doctors either currently employed or previously employed as a cruise ship doctor from July 2012 to June 2017. The data obtained was used to describe the characteristics of South African doctors working in the field of cruise ship medicine. Results: Of the 65 respondents, 61.5% were female. The majority of doctors were aged between 25 and 40 years. All South African doctors held a Bachelor of Medicine and Bachelor of Surgery degree, or equivalent, as a primary medical qualification and 46% held a Diploma in Primary Emergency Care prior to working at sea. The majority of doctors obtained certification in Basic Life Support, Advanced Cardiac Life Support, Paediatric Advanced Life Support and Advanced Trauma Life Support prior to joining cruise ship medicine. A wide range of courses and diplomas were undertaken by these doctors whilst working at sea. The majority of doctors opted for short to medium term contracts before returning to South Africa to pursue a land-based career, often by enrolling in postgraduate specialist training programmes. Conclusions: Maritime medicine is an emerging field of emergency medicine in South Africa and requires a high standard of competence. A robust CME programme exists whilst working at sea. Most South African doctors return to South Africa to pursue a land based career, alleviating the potential concern that South Africa is permanently losing doctors to cruise ship medicine

Hypoxaemia on arrival in a multidisciplinary intensive care unit

Background. Transport of the critically ill patient poses the risk of numerous complications. Hypoxaemia is one such serious adverse event and is associated with potential morbidity and mortality. It is, however, potentially preventable.Objective. To determine the incidence of hypoxaemia on arrival in a tertiary multidisciplinary intensive care unit (ICU) and to identify risk factors for this complication.Method. A retrospective observational study was conducted at King Edward VIII Hospital, Durban, South Africa, from May 2013 to February 2014.Results. Hypoxaemia occurred in 15.5% of admissions sampled. Statistically significant risk factors for hypoxaemia on univariate analysis (p<0.05) included lack of peripheral capillary oxygen saturation (SpO2) monitoring, transfer by an intern as opposed to other medical/paramedical staff, and transfer from internal medicine. Use of neuromuscular blockers and transfer from theatre were protective. Binary logistic regression analysis revealed lack of SpO2 monitoring to be the only significant independent predictor of hypoxaemia (odds ratio 6.1; 95% confidence interval 1.5 - 24.5; p=0.02).Conclusion. Hypoxaemia is common on admission to the ICU and may be prevented by simple interventions such as appropriate transport monitoring

Fabrication of a Large, Ordered, Three-Dimensional Nanocup Array

Metallic nanocups provide a unique method for redirecting scattered light by creating magnetic plasmon responses at optical frequencies. Despite considerable development of nanocup fabrication processes, simultaneously achieving accurate control over the placement, orientation, and geometry of nanocups has remained a significant challenge. Here we present a technique for fabricating large, periodically ordered arrays of uniformly oriented three-dimensional gold nanocups for manipulating light at subwavelength scales. Nanoimprint lithography, soft lithography, and shadow evaporation were used to fabricate nanocups onto the tips of polydimethylsiloxane nanopillars with precise control over the shapes and optical properties of asymmetric nanocups

Validating the utilisation of venous bicarbonate as a predictor of acute kidney injury in crush syndrome from sjambok injuries

Background. Crush injury secondary to sjambok beatings is a well-described phenomenon in southern Africa. Owing to a number of factors, it can result in acute kidney injury (AKI). In 1992, Muckart et al. described a risk stratification system using venous bicarbonate (VB) that can be used in the management of these patients.Objective. To validate this score in the modern era of AKI risk stratification.Methods. A retrospective study was performed on a local trauma database from June 2010 to December 2012. All patients with crush injury from sjambok/blunt instrument beatings were included in the analysis. VB was compared with the Kidney Disease Improving Global Outcomes scoring system for AKI. Serum base excess (BE) and creatine kinase were also examined as biomarkers. The endpoints were the need for renal replacement therapy (RRT) and mortality.Results. Three hundred and ten patients were included. The overall mortality rate was 1.9%, 14.8% of patients had AKI, and 3.9% required RRT. Both VB and BE performed well in RRT prediction, with areas under the receiver operating characteristic curve of 0.847 (95% confidence interval (CI) 0.756 - 0.938; p<0.001) and 0.871 (95% CI 0.795 - 0.947; p<0.001), respectively. The sensitivity and specificity of BE were 83.3% and 80.2% at an optimal cut-point of –7.25 mmol/L, while those of VB were 83.3% and 79.5% at an optimal cut-point of 18.85 mmol/L. VB was significantly different across the AKI risk groups (p<0.001), in keeping with the original Muckart risk stratification system.Conclusion. The risk stratification score using VB is valid and should continue to be used as a tool in the management of patients with sjambok injuries. BE performs well in predicting the need for RRT, with a value of <–7.25 mmol/L indicating severe injury.

Recommendations for improving integration in national end-to-end flood forecasting systems: an overview of the FFIR (flooding from intense rainfall) programme

Recent surface-water and flash floods have caused millions of pounds worth of damage in the UK. These events form rapidly and are difficult to predict due to their short-lived and localised nature. The interdisciplinary Flooding From Intense Rainfall (FFIR) programme investigated the feasibility of enhancing the integration of an end-to-end forecasting system for flash and surface-water floods to help increase the lead time for warnings for these events. Here we propose developments to the integration of an operational end-to-end forecasting system based on the findings of the FFIR programme. The suggested developments include methods to improve radar-derived rainfall rates and understanding of the uncertainty in the position of intense rainfall in weather forecasts; the addition of hydraulic modelling components; and novel education techniques to help lead to effective dissemination of flood warnings. We make recommendations for future advances such as research into the propagation of uncertainty throughout the forecast chain. We further propose the creation of closer bonds to the end users to allow for an improved, integrated, end-to-end forecasting system that is easily accessible for users and end users alike, and will ultimately help mitigate the impacts of flooding from intense rainfall by informed and timely action

Contribution of NOTCH1 genetic variants to bicuspid aortic valve and other congenital lesions

INTRODUCTION: Bicuspid aortic valve (BAV) affects 1% of the general population. NOTCH1 was the first gene associated with BAV. The proportion of familial and sporadic BAV disease attributed to NOTCH1 mutations has not been estimated. AIM: The aim of our study was to provide an estimate of familial and sporadic BAV disease attributable to NOTCH1 mutations. METHODS: The population of our study consisted of participants of the University of Leicester Bicuspid aoRtic vAlVe gEnetic research-8 pedigrees with multiple affected family members and 381 sporadic patients. All subjects underwent NOTCH1 sequencing. A systematic literature search was performed in the NCBI PubMed database to identify publications reporting NOTCH1 sequencing in context of congenital heart disease. RESULTS: NOTCH1 sequencing in 36 subjects from 8 pedigrees identified one variant c.873C>G/p.Tyr291* meeting the American College of Medical Genetics and Genomics criteria for pathogenicity. No pathogenic or likely pathogenic NOTCH1 variants were identified in 381 sporadic patients. Literature review identified 64 relevant publication reporting NOTCH1 sequencing in 528 pedigrees and 9449 sporadic subjects. After excluding families with syndromic disease pathogenic and likely pathogenic NOTCH1 variants were detected in 9/435 (2.1%; 95% CI: 0.7% to 3.4%) of pedigrees and between 0.05% (95% CI: 0.005% to 0.10%) and 0.08% (95% CI: 0.02% to 0.13%) of sporadic patients. Incomplete penetrance of definitely pathogenic NOTCH1 mutations was observed in almost half of reported pedigrees. CONCLUSIONS: Pathogenic and likely pathogenic NOTCH1 genetic variants explain 2% of familial and <0.1% of sporadic BAV disease and are more likely to associate with tetralogy of Fallot and hypoplastic left heart

A multinuclear solid state NMR, density functional theory and X-Ray diffraction study of hydrogen bonding in Group I hydrogen dibenzoates

An NMR crystallographic approach incorporating multinuclear solid state NMR (SSNMR), X-ray structure determinations and density functional theory (DFT) are used to characterise the H bonding arrangements in benzoic acid (BZA) and the corresponding Group I alkali metal hydrogen dibenzoates (HD) systems. Since the XRD data often cannot precisely confirm the proton position within the hydrogen bond, the relationship between the experimental SSNMR parameters and the ability of gauge included plane augmented wave (GIPAW) DFT to predict them becomes a powerful constraint that can assist with further structure refinement. Both the 1H and 13C MAS NMR methods provide primary descriptions of the H bonding via accurate measurements of the 1H and 13C isotropic chemical shifts, and the individual 13C chemical shift tensor elements; these are unequivocally corroborated by DFT calculations, which together accurately describe the trend of the H bonding strength as the size of the monovalent cation changes. In addition, 17O MAS and DOR NMR form a powerful combination to characterise the O environments, with the DOR technique providing highly resolved 17O NMR data which helps verify unequivocally the number of inequivalent O positions for the conventional 17O MAS NMR to process. Further multinuclear MAS and static NMR studies involving the quadrupolar 7Li, 39K, 87Rb and 133Cs nuclei, and the associated DFT calculations, provide trends and a corroboration of the H bond geometry which assist in the understanding of these arrangements. Even though the crystallographic H positions in each H bonding arrangement reported from the single crystal X-ray studies are prone to uncertainty, the good corroboration between the measured and DFT calculated chemical shift and quadrupole tensor parameters for the Group I alkali species suggest that these reported H positions are reliable

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy