Culture/Power/History: Series Prospectus

Also CSST Working Paper #23.http://deepblue.lib.umich.edu/bitstream/2027.42/51154/1/386.pd

Availability of difficult airway equipment to rural anaesthetists in Queensland, Australia

Introduction: Since 1990 several airway devices have become available to assist in difficult intubation. Multiple surveys have assessed difficult airway equipment availability in international anaesthetic departments and emergency departments. The practice of GP anaesthetists is unique in both its multidisciplinary nature and geographical isolation. Objectives: General practitioners performing general anaesthesia in rural and remote Queensland, Australia were surveyed to assess their access to difficult airway equipment and whether this was related to the remoteness of their location or attendance at continuing professional development activities. Methods: Design: survey. Setting: proceduralists performing general anaesthesia in hospitals categorised as Rural, Remote and Metropolitan Area (RRMA) classification 4 to 7 inclusive were surveyed. Outcome measure: data collected included demographic information, availability of airway management equipment, and attendance at continuing professional development activities. The received data was entered into a Microsoft Excel spreadsheet and analysed in Statistical Package for Social Sciences (SPSS Inc; Chicago, IL, USA) using the frequencies and crosstabs functions. The Fisher’s exact test was used. A p-value of less than 0.10 was considered noteworthy and a p-value of less than 0.05 was considered to be significant. A statistical comparison was made between the known demographics of the target population and the survey responders. The known demographics were derived from the Health Workforce Queensland database and included age, gender, practice location and practitioner type. Results: Seventy-nine surveys were distributed and 35 returned (response rate 44%). This represented 21 hospitals. There was no statistical difference between the target population and the survey responders in terms of age and gender. There was no statistical difference in terms of practice location, although the small percentage responding from RRMA 6 was notable. There was a statistically significant difference between the groups in terms of practitioner type. Hospital-based practitioners were relatively under-represented in the responder group. Eighty-two per cent of practitioners felt they had access to appropriate equipment and this was not significantly related the remoteness of their location. There was wide variation in available equipment. Simple adjuncts such as the bougie and stylet were not universally available but cricothyroidotomy sets were more common. Practitioners in the more remote locations were less likely to have attended an educational activity such as conference, workshop or skills laboratory (p=0.05). Conclusions: We suggest standardisation of difficult airway equipment for rural practitioners. This could be supported by increased availability of airway management workshops in remote areas. Such an intervention would be in line with other initiatives to standardise medical equipment in rural and remote Queensland hospitals. Familiarity with infrequently used equipment may assist practitioners and their locums. Standardisation of equipment and practice is a recognised method of improving patient safety

Short-term treatment outcomes of children starting antiretroviral therapy in the intensive care unit, general medical wards and outpatient HIV clinics at Red Cross War Memorial Children’s Hospital, Cape Town, South Africa: A retrospective cohort study

Background: Many HIV-infected children are initiated on antiretroviral therapy (ART) during hospitalisation in South Africa (SA). No published data on these outcomes exist.Objectives: To assess the short-term outcomes of children initiated on ART in the intensive care unit (ICU), general medical wards (GMWs) and outpatient HIV clinics (OHCs) at Red Cross War Memorial Children’s Hospital (RCWMCH), Cape Town, SA.Methods: We conducted a retrospective cohort study of HIV-infected children aged <13 years commenced on first-line ART between January 2008 and December 2011. Outcomes included death, virological suppression and changes in CD4 count. Kaplan-Meier estimates, multivariate Cox proportional hazard ratios and logistic regression were used to estimate outcomes at 6 months.Results: One hundred and six children were commenced on ART in the ICU, 509 in the GMWs and 127 in the OHCs; 65.7% of all children were <12 months old. Of children qualifying for rapid ART initiation according to the 2013 national treatment guidelines, 182 (24.9%) started therapy within 7 days of diagnosis. Overall mortality was 6.4% (95% confidence interval (CI) 4.9 - 8.4). Of children remaining in care at RCWMCH, 51.0% achieved a CD4 percentage ≥25% and 62.3% a viral load ≤50 copies/mL 6 months after ART initiation. Mortality was higher in the ICU cohort (13.2%) than in the GMW and OHC cohorts (5.5% and 3.9%, respectively, log-rank p=0.004). Predictors of mortality included moderate underweight (adjusted hazard ratio (aHR) 2.4; 95% CI 1.1 - 5.2), severe underweight (aHR 3.2; 95% CI 1.6 - 6.5), absence of caregiver counselling sessions (aHR 2.9; 95% CI 1.4 - 6.0) and ART initiation in the ICU (aHR 2.6; 95% CI 1.4 - 4.9).Conclusion: These results highlight the importance of understanding the context in which children are initiated on ART, when comparing outcomes in different settings

Short-term outcomes of down-referral in provision of paediatric antiretroviral therapy at Red Cross War Memorial Children’s Hospital, Cape Town, South Africa: A retrospective cohort study

Background. The large scale-up of paediatric HIV care necessitated down-referral of many children receiving antiretroviral therapy (ART) from Red Cross War Memorial Children’s Hospital (RCWMCH), Cape Town, South Africa. Few published data exist on the outcomes of these children.Objectives. To assess outcomes of children receiving ART in the first 12 months after down-referral to primary healthcare (PHC) clinics and identify determinants of successful down-referral.Methods. A retrospective cohort study of children <15 years of age who initiated ART at RCWMCH and were subsequently down-referred to one of two PHC clinics between January 2006 and December 2012 was completed. Baseline characteristics of patients and caregivers as well as CD4+ counts, viral loads (VLs) and weights were collected 6 and 12 months after down-referral. Outcomes included retention in care and viral suppression.Results. Of 116 children down-referred to the two study PHC clinics, 81.9% arrived at the designated PHC clinic and a further 8.6% continued care at other clinics, the remaining 9.5% being lost to follow-up. Of those successfully down-referred, 11.4% took >8 weeks to present, possibly experiencing treatment interruption. At 12 months after down-referral, only 81.0% remained in care. No factors were associated with retention in care in multivariable analysis. For children who remained in care at the designated PHC clinics, the clinical and immunological gains achieved prior to down-referral were sustained through 12 months of follow-up, and 54.7% of this cohort had documented viral suppression at 12 months. However, if only children with VL results are considered, 75.9% (41/54) were virally suppressed 12 months after down-referral.Conclusions. Down-referral of children on ART is complex, with risk of loss to follow-up and treatment interruption

Increased vulnerability of rural children on antiretroviral therapy attending public health facilities in South Africa: a retrospective cohort study

BACKGROUND: A large proportion of the 340,000 HIV-positive children in South Africa live in rural areas, yet there is little sub-Saharan data comparing rural paediatric antiretroviral therapy (ART) programme outcomes with urban facilities. We compared clinical, immunological and virological outcomes between children at seven rural and 37 urban facilities across four provinces in South Africa. METHODS: We conducted a retrospective cohort study of routine data of children enrolled on ART between November 2003 and March 2008 in three settings, namely: urban residence and facility attendance (urban group); rural residence and facility attendance (rural group); and rural residents attending urban facilities (rural/urban group). Outcome measures were: death, loss to follow up (LTFU), virological suppression, and changes in CD4 percentage and weight-for-age-z (WAZ) scores. Kaplan-Meier estimates, logrank tests, multivariable Cox regression and generalized estimating equation models were used to compare outcomes between groups. RESULTS: In total, 2332 ART-naive children were included, (1727, 228 and 377 children in the urban, rural and rural/urban groups, respectively). At presentation, rural group children were older (6.7 vs. 5.6 and 5.8 years), had lower CD4 cell percentages (10.0% vs. 12.8% and 12.7%), lower WAZ scores (-2.06 vs. -1.46 and -1.41) and higher proportions with severe underweight (26% vs.15% and 15%) compared with the urban and rural/urban groups, respectively. Mortality was significantly higher in the rural group and LTFU significantly increased in the rural/urban group. After 24 months of ART, mortality probabilities were 3.4% (CI: 2.4-4.8%), 7.7% (CI: 4.5-13.0%) and 3.1% (CI: 1.7-5.6%) p = 0.0137; LTFU probabilities were 11.5% (CI: 9.3-14.0%), 8.8% (CI: 4.5-16.9%) and 16.6% (CI: 12.4-22.6%), p = 0.0028 in the urban, rural and rural/urban groups, respectively. The rural group had an increased adjusted mortality probability, adjusted hazards ratio 2.41 (CI: 1.25-4.67) and the rural/urban group had an increased adjusted LTFU probability, aHR 2.85 (CI: 1.41-5.79). The rural/urban group had a decreased adjusted probability of virological suppression compared with the urban group at any timepoint on treatment, adjusted odds ratio 0.67 (CI: 0.48-0.93). CONCLUSIONS: Rural HIV-positive children are a vulnerable group, exhibiting delayed access to ART and an increased risk of poor outcomes while on ART. Expansion of rural paediatric ART programmes, with future research exploring improvements to rural health system effectiveness, is required

Associations between diurnal preference, sleep quality and externalizing behaviours: a behavioural genetic analysis

Background - Certain aspects of sleep co-occur with externalizing behaviours in youth, yet little is known about these associations in adults. The present study: (1) examines the associations between diurnal preference (morningness versus eveningness), sleep quality and externalizing behaviours; (2) explores the extent to which genetic and environmental influences are shared between or are unique to these phenotypes; (3) examines the extent to which genetic and environmental influences account for these associations. Method - Questionnaires assessing diurnal preference, sleep quality and externalizing behaviours were completed by 1556 young adult twins and siblings. Results - A preference for eveningness and poor sleep quality were associated with greater externalizing symptoms [r=0.28 (95% CI 0.23–0.33) and 0.34 (95% CI 0.28–0.39), respectively]. A total of 18% of the genetic influences on externalizing behaviours were shared with diurnal preference and sleep quality and an additional 14% were shared with sleep quality alone. Non-shared environmental influences common to the phenotypes were small (2%). The association between diurnal preference and externalizing behaviours was mostly explained by genetic influences [additive genetic influence (A)=80% (95% CI 0.56–1.01)], as was the association between sleep quality and externalizing behaviours [A=81% (95% CI 0.62–0.99)]. Non-shared environmental (E) influences accounted for the remaining variance for both associations [E=20% (95% CI −0.01 to 0.44) and 19% (95% CI 0.01–0.38), respectively]. Conclusions - A preference for eveningness and poor sleep quality are moderately associated with externalizing behaviours in young adults. There is a moderate amount of shared genetic influences between the phenotypes and genetic influences account for a large proportion of the association between sleep and externalizing behaviours. Further research could focus on identifying specific genetic polymorphisms common to both sleep and externalizing behaviours

Role of micronutrients in HIV infection

More than 60% of the estimated 40 million persons with HIV/AIDS worldwide live in sub-Saharan Africa, where poverty, social insecurity, food shortages and malnutrition are major problems.1 In children under the age of 5 years, who live in developing countries, malnutrition has been associated with 50% of the 10.8 million deaths mainly caused by neonatal disorders, diarrhoea, pneumonia, malaria and HIV/AIDS.2 Likewise micronutrient deficiencies are widespread and are associated with increased morbidity and mortality particularly in relation to infectious diseases.3 This review focuss on the interaction between micronutrients and HIV/AIDS and discusses recent research findings that may have important public health implications in terms of the case management of persons with HIV/AIDS Southern African Journal of HIV Medicine Vol. 6 (2) 2005: pp. 18-2

eNOS plays essential roles in the developing heart and aorta linked to disruption of Notch signalling

\ua9 2024. Published by The Company of Biologists Ltd. eNOS (NOS3) is the enzyme that generates nitric oxide, a signalling molecule and regulator of vascular tone. Loss of eNOS function is associated with increased susceptibility to atherosclerosis, hypertension, thrombosis and stroke. Aortopathy and cardiac hypertrophy have also been found in eNOS null mice, but their aetiology is unclear. We evaluated eNOS nulls before and around birth for cardiac defects, revealing severe abnormalities in the ventricular myocardium and pharyngeal arch arteries. Moreover, in the aortic arch, there were fewer baroreceptors, which sense changes in blood pressure. Adult eNOS null survivors showed evidence of cardiac hypertrophy, aortopathy and cartilaginous metaplasia in the periductal region of the aortic arch. Notch1 and neuregulin were dysregulated in the forming pharyngeal arch arteries and ventricles, suggesting that these pathways may be relevant to the defects observed. Dysregulation of eNOS leads to embryonic and perinatal death, suggesting mutations in eNOS are candidates for causing congenital heart defects in humans. Surviving eNOS mutants have a deficiency of baroreceptors that likely contributes to high blood pressure and may have relevance to human patients who suffer from hypertension associated with aortic arch abnormalities

A decade of Australian Rural Clinical School graduates: Where are they and why?

Introduction: The Australian Rural Clinical School (RCS) initiative has been addressing the rural medical workforce shortage at the medical education level for over a decade. A major expectation of this initiative is that it will improve rural medical workforce recruitment and subsequent retention through a rurally based undergraduate clinical training experience. The longitudinal nature of these workforce initiatives means that definitive evidence of its impact on the shortage of rural doctors is yet to be provided; however, to date cross-sectional studies are accumulating a measure of efficacy for these initiatives by monitoring early career factors such as internship location choice and speciality choice of RCS graduates. This article reports on a study in one RCS that is monitoring the impact of rural undergraduate clinical training on trends in workforce participation patterns of its graduates as long as 9 years in the workforce. Career location and speciality choice are reported as well as perspectives on early career intentions and the reality of making career and life decisions as a doctor in the medical workforce

Invasive carbapenem-resistant Enterobacteriaceae infection at a paediatric hospital: A case series

Background. There are no paediatric reports of invasive infection caused by carbapenem-resistant Enterobacteriaceae (CRE) from Africa. Objectives. To document a series of cases of CRE infections at a tertiary children’s hospital in Cape Town, South Africa, describing the clinical and microbiological findings in these children.Methods. A retrospective, descriptive study was completed using data from a series of children with invasive CRE infection between 2010 and 2015, sourced from their clinical notes and microbiology results.Results. The first of 10 invasive CRE infections during the study period occurred in November 2012. Nine CRE infections were caused by Klebsiella pneumoniae, and one by both K. pneumoniae and Escherichia coli. The median age was 25 months (interquartile range (IQR) 5 - 60). All 10 CRE infections were hospital acquired. The median length of hospitalisation before CRE infection was 28.5 days (IQR 20 - 44). Eight of the children were exposed to carbapenems during the 12-month period prior to invasive CRE infection. Six were treated with colistin and carbapenem combination therapy, of whom 2 died, including 1 of a non-CRE event. The other 4 children received colistin monotherapy. All these children died, including 2 from non-CRE events.Conclusions. Children with invasive CRE infection and severe underlying disease must be treated with combination antibiotic therapy. Strict infection control practice and antibiotic stewardship are necessary to contain the spread of CRE and limit the number of new infections