An electronic colonoscopy record system enables detailed quality assessment and benchmarking of an endoscopic service

Background. Competence in colonoscopy, which is a technically difficult procedure, requires adequate exposure to it and the maintenance of a detailed logbook. Without an electronic record this is difficult to  achieve. By implementing an electronic medical record system we aimed to perform a detailed quality assessment audit of colonoscopy, to benchmark our results and generate accurate logbooks for individual endoscopists.Methods. We reviewed the prospectively maintained Hybrid Electronic Medical Registry (HEMR).  Colonoscopies performed between March 2013 and March 2014 were reviewed, and for competency, quality metrics were derived from the guidelines of the American Society of Gastroenterology.Results. A total of 843 colonoscopies were performed. Seven hundred and seventy procedures were  performed by three staff endoscopists who each performed over the required 150 procedures annually (n=197, 338 and 235). The remaining 73 (8.7%) were performed by other staff. In 105 cases (12.5%), bowel preparation was deemed to be inadequate, which caused the procedure to be abandoned in 34 cases. A total of 64 cases were deemed to be incomplete because of obstructing lesions (n=26), extensive diverticulosis (n=4), technical difficulty (n=31) and patient discomfort (n=3). There were two complications recorded: perforation (n=1) and bleeding (n=1).Conclusions. The HEMR system enabled the audit of experiences with colonoscopy in our institution. Our results are broadly compatible with the international literature and with a number of guidelines. The  development of an electronic record system is a major advance, as it enables meaningful benchmarking and the generation of accurate procedural logbooks

Pan computed tomography for blunt polytrauma: Are we doing too many?

Background. Pan computed tomography (CT) is widely used in the evaluation of  patients with blunt polytrauma, but there is growing concern about the radiation risks imposed.Objectives. To ascertain whether we were possibly overutilising pan CT in our  trauma service, and whether we could safely cut down on scans without missing significant injuries.Methods. We audited all pan scans performed in the Metropolitan Trauma Service, Pietermaritzburg, South Africa, during the 12-month period 1 January - 31  December 2012. An analysis was done to determine what injuries were identified and how these findings influenced our management.Results. Of the 140 pan scans, 108 (77.1%) influenced management. These  included the following components: 62 brain scans (44.3%), 16 cervical spine scans (11.4%), 50 chest scans (35.7%) and 31 abdominal scans (22.1%). The remaining 32 pan scans (22.9%) did not influence management. However, it turned out that many of these ‘clinically negative’ scans were in fact clinically important, ruling out injury in patients in whom clinical assessment was regarded as unreliable: 3 patients (2.1%) were hypoxic and had to be sedated, intubated and ventilated; 14 (10.0%) had a Glasgow Coma Score (GCS) of <15; and 9 (6.4%) had major  distracting injuries. This left only 6 pan scans (4.3%) that were not regarded as clinically helpful.Conclusion. In our setting, the majority of pan scans influence management. By  ruling out significant injuries, clinically negative scans are valuable in patients who are obtunded, intubated and ventilated, or have major distracting injuries. In  patients with a GCS of 15, not sedated and ventilated and with no major distracting injuries, clinical assessment and alternative imaging modalities may suffice

Empirical antimicrobial therapy for probable v. directed therapy for possible ventilator-associated pneumonia in critically injured patients

Background. Ventilator-associated pneumonia (VAP) has recently been classified as possible or probable. Although direct attributable mortality has been difficult to prove, delay in instituting appropriate therapy has been reported to increase morbidity and mortality. Recent literature suggests that in possible VAP, instituting directed therapy while awaiting microbiological culture does not prejudice outcome compared with best-guess empirical therapy.Objectives. To ascertain outcomes of directed v. empirical therapy in possible and probable VAP, respectively. Methods. Endotracheal aspirates were obtained from patients with suspected VAP. Those considered to have possible VAP were given directed therapy following culture results, whereas patients with more convincing evidence of VAP were classed as having probable VAP and commenced on empirical antimicrobials based on microbiological surveillance.Results. Pneumonia was suspected in 106 (36.8%) of 288 patients admitted during January - December 2014. Of these, 13 did not fulfil the criteria for VAP. Of the remaining 93 (32.2%), 31 (33.3%) were considered to have probable and 62 (66.7%) possible VAP. The former were commenced on empirical antimicrobials, with 28 (90.3%) receiving appropriate therapy. Of those with possible VAP, 34 (54.8%) were given directed therapy and in 28 (45.2%) no antimicrobials were prescribed. Of the latter, 24 recovered without antimicrobials and 4 died, 3 from severe traumatic brain injury and 1 due to overwhelming intra-abdominal sepsis. No death was directly attributable to failure to treat VAP. No significant difference in mortality was found between the 34 patients with possible VAP who were commenced on directed therapy and the 31 with probable VAP who were commenced on empirical antimicrobials (p=0.75).Conclusions. Delaying antimicrobial therapy for VAP where clinical doubt exists does not adversely affect outcome. Furthermore, this policy limits the use of antimicrobials in patients with possible VAP following improvement in their clinical condition despite no therapy

Hanging-related injury in Pietermaritzburg, South Africa

BACKGROUND: Hanging is a common form of self-harm, and emergency care physicians will not infrequently be called upon to manage a survivor.Despite the relative frequency of the injury, there is a paucity of literature on the topic and the spectrum and incidence of associated injuries are poorly described. OBJECTIVES: To review experience with management of victims of hanging at a major trauma centre in South Africa. METHODS: All patients treated by the Pietermaritzburg Metropolitan Trauma Service following a hanging incident between December 2012 and December 2018 were identified from the Hybrid Electronic Medical Registry. Basic demographics were recorded, and the management and outcome of each patient were noted. RESULTS: During the 6-year period under review, a total of 154 patients were seen following a hanging incident. The mean age was 29.4 years. There were 24 females (15.6%) and 130 males (84.4%). The vast majority (n=150; 97.5%) had attempted suicide, and only 4 hangings (2.5%) were accidental. A total of 92 patients (60.9%) had consumed alcohol prior to the incident. There were 23 patients with a Glasgow Coma Score (GCS) 12 (mild TBI). A total of 7 patients (4.5%) required intensive care unit admission, and 25 (16.2%) required intubation. The following extracranial injuries were documented on computed tomography scans: hyoid bone fractures (n=2), cervical spine fracture (n=10), mandible fracture (n=4) and oesophageal injury (n=1). Intracranial pathology was evident on 27.0% of scans, with the most common finding being global cerebral ischaemia. The mortality rate was 2.5% (4/154). CONCLUSIONS: Hanging is a common mechanism of self-harm. It is associated with significant injuries and mortality. The acute management of hanging should focus on airway protection followed by detailed imaging of the head and neck. Further work must attempt to include mortuary data on hanging

Discrepancy in clinical outcomes of patients with gunshot wounds in car hijacking: a South African experience

INTRODUCTION: Discrepancy in outcomes between urban and rural trauma patients is well known. We reviewed our institutional experience with the management of gunshot wounds (GSWs) in the specific setting of car hijacking and focused on clinical outcome between rural and urban patients. METHODS: A retrospective review was conducted at a major trauma centre in South Africa over an 8-year period for all patients who presented with any form of GSWs in car hijacking settings. Specific clinical outcomes were compared between rural and urban patients. RESULTS: A total of 101 patients were included (74% male, mean age 34 years). Fifty-five per cent were injured in rural areas and the remaining 45% (45/101) were in the urban district. Mean time from injury to arrival at our trauma centre was 11 hours for rural and 4 hours for urban patients (p < 0.001). Seventy-six per cent (76/101) sustained GSWs to multiple body regions. Sixty-three of the 101 (62%) patients required one or more operative interventions. In individual logistic regressions adjusted for sex and number of regions injured, rural patients were 9 (95% CI: 1.9-44.4) and 7 (95% CI: 2.124.5) times more likely than urban patients to have morbidities or required admissions to intensive care respectively. The risk of death in rural patients was 36 (95% CI: 4.5-284.6) times higher than that of urban patients. CONCLUSIONS: Patients who sustained GSWs in carjacking incidents that occurred in rural areas are associated with significantly greater morbidity and mortality compared with their urban counterparts. Delay to definitive care is likely to be the significant contributory factor, and improvement in prehospital emergency medical service is likely to be beneficial in improving patient outcome

A review of blunt pelvic injuries at a major trauma centre in South Africa.

BACKGROUND: The collective five-year experience with the acute management of pelvic trauma at a busy South African trauma service is reviewed to compare the usefulness and applicability of current grading systems of pelvic trauma and to review the compliance with current guidelines regarding pelvic binder application during the acute phase of resuscitation. METHODS: A retrospective review was conducted over a 5-year period from December 2012 to December 2017 on all polytrauma patients who presented with a pelvic fracture. Mechanism of injury and presenting physiology and clinical course including pelvic binder application were documented. Pelvic fractures were graded according to the Young- Burgess and Tile systems. RESULTS: There was a cohort of 129 patients for analysis. Eighty-one were male and 48 female with a mean age was 33.6 ± 13.1 years. Motor vehicle-related collisions (MVCs) were the main mechanism of injury (50.33%) and pedestrian vehicle collisions (PVCs) were the second most common (37.98%). The most common associated injuries were abdominal injuries (41%), chest injury (37%), femur fractures (21%), tibia fractures (15%) and humerus fracture (14.7%). Thirty patients in this cohort (23%) underwent a laparotomy. They were mainly in the Tile B (70%) and lateral compression (63%) groups. Nine patients underwent pelvic pre-peritoneal packing. Thirty-five (27%) patients were admitted to ICU. Fifteen (12%) patients died. The Young-Burgess classification had a greater accuracy in predicting death than the Tile classification. Forty per cent of deaths occurred in ICU, 33% died secondary to a traumatic brain injury (TBI). Twenty per cent died in casualty and 6.6% in the operating room from ongoing haemorrhage. A pelvic binder was not applied in 66% of patients. In the 34% of patients who had a pelvic binder applied, it was applied post CT scan in 24.8%, in the pre-hospital setting in 7.2%, and on arrival in 2.4% of patients. In 73% of deaths, a binder was not applied, and of those deaths, 54% showed signs of haemodynamic instability. CONCLUSION: It would appear that our application of pelvic binders in patients with acute pelvic trauma is ad hoc. Appropriate selection of patients, who may benefit from a binder and it's timely application, has the potential to improve outcome in these patients

Pulmonary function and fuel use: A population survey

BACKGROUND: In the backdrop of conflicting reports (some studies reported adverse outcomes of biomass fuel use whereas few studies reported absence of any association between adverse health effect and fuel use, may be due to presence of large number of confounding variables) on the respiratory health effects of biomass fuel use, this cross sectional survey was undertaken to understand the role of fuel use on pulmonary function. METHOD: This study was conducted in a village of western India involving 369 randomly selected adult subjects (165 male and 204 female). All the subjects were interviewed and were subjected to pulmonary function test. Analysis of covariance was performed to compare the levels of different pulmonary function test parameters in relation to different fuel use taking care of the role of possible confounding factors. RESULTS: This study showed that biomass fuel use (especially wood) is an important factor for deterioration of pulmonary function (particularly in female). FEV(1 )(p < .05), FEV(1 )% (p < .01), PEFR (p < .05) and FEF(25–75 )(p < .01) values were significantly lower in biomass fuel using females than nonusers. Comparison of only biomass fuel use vs. only LPG (Liquefied Petroleum Gas) use and only wood vs. only LPG use has showed that LPG is a safer fuel so far as deterioration of pulmonary function is concerned. This study observes some deterioration of pulmonary function in the male subjects also, who came from biomass fuel using families. CONCLUSION: This study concluded that traditional biomass fuels like wood have adverse effects on pulmonary function

Considering the Case for Biodiversity Cycles: Reexamining the Evidence for Periodicity in the Fossil Record

Medvedev and Melott (2007) have suggested that periodicity in fossil biodiversity may be induced by cosmic rays which vary as the Solar System oscillates normal to the galactic disk. We re-examine the evidence for a 62 million year (Myr) periodicity in biodiversity throughout the Phanerozoic history of animal life reported by Rohde & Mueller (2005), as well as related questions of periodicity in origination and extinction. We find that the signal is robust against variations in methods of analysis, and is based on fluctuations in the Paleozoic and a substantial part of the Mesozoic. Examination of origination and extinction is somewhat ambiguous, with results depending upon procedure. Origination and extinction intensity as defined by RM may be affected by an artifact at 27 Myr in the duration of stratigraphic intervals. Nevertheless, when a procedure free of this artifact is implemented, the 27 Myr periodicity appears in origination, suggesting that the artifact may ultimately be based on a signal in the data. A 62 Myr feature appears in extinction, when this same procedure is used. We conclude that evidence for a periodicity at 62 Myr is robust, and evidence for periodicity at approximately 27 Myr is also present, albeit more ambiguous.Comment: Minor modifications to reflect final published versio

Development and testing of Indoor Soundscape Questionnaire for evaluating contextual experience in public spaces

An Indoor Soundscape Questionnaire aiming at the evaluation of indoor public sound environments was designed, statistically tested and presented. It was established through initial pilot studies and three main factors under contextual experience variable are established as (1) psychological factors, (2) space usage factors and (3) demographical factors. In addition to the questions on demographical and space usage factors, detailed questions on psychological factors are designed and statistically tested for expectation, perception and reaction categories of the psychological factor. The questionnaire was applied as part of a case study in enclosed library foyer environments to a group of 270 participants through non-experimental survey data sampling. The reliability and validity scores of the Indoor Soundscape Questionnaire were statistically tested and confirmed. Furthermore, statistical tests were used to derive relationships between contextual experience variables of psychological, space usage and demographical factors. Chi-square test of goodness-of-fit results showed statistical significances of demographical and space usage factors with the psychological factors

How are falls and fear of falling associated with objectively measured physical activity in a cohort of community-dwelling older men?

BACKGROUND: Falls affect approximately one third of community-dwelling older adults each year and have serious health and social consequences. Fear of falling (FOF) (lack of confidence in maintaining balance during normal activities) affects many older adults, irrespective of whether they have actually experienced falls. Both falls and fear of falls may result in restrictions of physical activity, which in turn have health consequences. To date the relation between (i) falls and (ii) fear of falling with physical activity have not been investigated using objectively measured activity data which permits examination of different intensities of activity and sedentary behaviour. METHODS: Cross-sectional study of 1680 men aged 71-92 years recruited from primary care practices who were part of an on-going population-based cohort. Men reported falls history in previous 12 months, FOF, health status and demographic characteristics. Men wore a GT3x accelerometer over the hip for 7 days. RESULTS: Among the 12% of men who had recurrent falls, daily activity levels were lower than among non-fallers; 942 (95% CI 503, 1381) fewer steps/day, 12(95% CI 2, 22) minutes less in light activity, 10(95% CI 5, 15) minutes less in moderate to vigorous PA [MVPA] and 22(95% CI 9, 35) minutes more in sedentary behaviour. 16% (n = 254) of men reported FOF, of whom 52% (n = 133) had fallen in the past year. Physical activity deficits were even greater in the men who reported that they were fearful of falling than in men who had fallen. Men who were fearful of falling took 1766(95% CI 1391, 2142) fewer steps/day than men who were not fearful, and spent 27(95% CI 18, 36) minutes less in light PA, 18(95% CI 13, 22) minutes less in MVPA, and 45(95% CI 34, 56) minutes more in sedentary behaviour. The significant differences in activity levels between (i) fallers and non-fallers and (ii) men who were fearful of falling or not fearful, were mediated by similar variables; lower exercise self-efficacy, fewer excursions from home and more mobility difficulties. CONCLUSIONS: Falls and in particular fear of falling are important barriers to older people gaining health benefits of walking and MVPA. Future studies should assess the longitudinal associations between falls and physical activity