A review of paediatric anaesthetic-related mortality, serious adverse events and critical incidents

Anaesthetists increasingly face questions from parents on the long-term outcomes of anaesthesia, and yet more immediate anaesthetic risks are not understood, nor explained to families. This review focused on paediatric anaesthetic-related mortality, cardiac arrest and anaesthetic-related serious adverse events and critical incidents during general anaesthesia, and within 24 hours of anaesthesia ending. Anaesthetic-related mortality is rare in the developed world, and is approximately 1 per 10 000 anaesthetics, but increases in high-risk children. Serious anaesthetic-related adverse events occur in 1.4 per 1 000 anaesthetics in the developed world. Data are lacking from the developing world but anaesthetic mortality is 2–3 times higher in middle-income countries and may be up to 100-fold greater in low-income countries. A critical incident occurs in 3–8% of anaesthetics and this figure is double that in low-income countries. Anaesthetic-related events are predominantly preventable. Brief recommendations on preventative strategies are made and research goals outlined.Keywords: mortality, outcomes, paediatric anaesthesia, perioperative, risk

Identifying flies used for maggot debridement therapy

To the Editor: The use of maggots to clean necrotic wounds, known as maggot debridement therapy (MDT), has long been known to the scientific world. Its use has been recorded since the 1500s when soldiers’ wounds were often infested with maggots. Napoleon’s surgeon, Baron Dominic Larrey, reported that wounds that were infested with maggots appeared to heal faster than those without maggots.1 William Baer is considered to be the founder of modern MDT. While treating soldiers in World War I, he noted the good condition of wounds that had been infested with maggots, and was the first doctor on record to experiment with the use of maggots in treating infections.1 MDT even featured in the recent version of the film ‘Spartacus’. Various species of flies have been used for MDT,1 the most commonly used being Lucilia sericata, a greenbottle blowfly (Figs 1 and 2). This fly is closely related to another greenbottle, L. cuprina, but L. cuprina feeds on live as well as necrotic tissue, which is undesirable in MDT. L. cuprina is commonly named the ‘sheep blowfly’ because it is responsible for fly-strike in sheep, a form of massive, usually rectal myiasis that can kill sheep. A recent article2 suggested that L. cuprina was being used successfully for MDT at the Eugene Marais Hospital Wound Care Centre (EMHWCC). As this would be inconsistent with international experience in MDT and at odds with the usual biology of L. cuprina, it was decided to check the identity of these flies

Colorectal cancer in South Africa: A heritable cause suspected in many young black patients

Background. Colorectal carcinoma (CRC) has a low incidence among the black African population. Largely unrecognised in the scientific literature is the fact that a disproportionately large number of young black patients

A comprehensive analysis of carotenoids metabolism in two red-fleshed mutants of Navel and Valencia sweet oranges (Citrus sinensis)

Kirkwood Navel and Ruby Valencia are two spontaneous bud mutations of the respective parental lines of sweet orange (Citrus sinensis) Palmer Navel and Olinda Valencia, showing an atypical red pigmentation of the pulp. These red-fleshed varieties are commercially available and highly attractive for consumers but their carotenoid metabolism and the basis of the mutation have not been investigated. The red colour of Kirkwood and Ruby pulp was observed from the very early stages of fruit development until full maturity and associated with an altered carotenoid profiling. The red-fleshed varieties accumulated from 6- up to 1000-times more total carotenoids compared to the standard oranges. Specifically, the pulp of Kirkwood and Ruby accumulated large amounts of phytoene and phytofluene, and moderate contents of lycopene. Moreover, the red-fleshed oranges contained other unusual carotenes as δ-carotene, and lower concentrations of downstream products such as β,β-xanthophylls, abscisic acid (ABA) and ABA-glucosyl ester. This peculiar profile was associated with chromoplasts with lycopene crystalloid structures and round vesicles likely containing colourless carotenes. The flavedo and leaves of Kirkwood and Ruby showed minor changes in carotenoids, mainly limited to higher levels of phytoene. The carotenoid composition in Kirkwood and Ruby fruits was not explained by differences in the transcriptional profile of 26 genes related to carotenoid metabolism, covering the main steps of biosynthesis, catabolism and other processes related to carotenoid accumulation. Moreover, sequence analysis of the lycopene cyclase genes revealed no alterations in those of the red-fleshed oranges compared to the genes of the standard varieties. A striking event observed in Kirkwood and Ruby trees was the reddish coloration of the inner side of the bark tissue, with larger amounts of phytoene, accumulation of lycopene and lower ABA content. These observation lead to the conclusion that the mutation is not only manifested in fruit, affecting other carotenogenic tissues of the mutant plants, but with different consequences in the carotenoid profile. Overall, the carotenoid composition in the red-fleshed mutants suggests a partial blockage of the lycopene β-cyclization in the carotenoid pathway, rendering a high accumulation of carotenes upstream lycopene and a reduced flow to downstream xanthophylls and ABA

Daily or weekly? The role of treatment frequency in the effectiveness of grammar treatment for children with specific language impairment.

This study compared the effectiveness of a school-based treatment for expressive grammar in 5-year-olds with specific language impairment delivered in two different dose frequencies: eight sessions delivered daily over 8 consecutive school days or eight sessions delivered weekly over 8 consecutive weeks. Eighteen children received treatment daily and 13 children received treatment weekly. In both groups, treatment consisted of eight 1-hour sessions of small group activities in a classroom setting. Techniques included explicit instruction, focused stimulation, recasting, and imitation. Results were analysed at the group level and as a case series with each child as their own control in a single-subject design. The 8-weeks group showed significantly greater gain in test scores over the treatment period than in an equal time period prior to treatment, whereas the 8-days group did not (Cohen's d = 1.64 for 8-weeks group). Single-subject analyses indicated that 46% of children in the 8-week group and 17% of children in the 8-day group showed a significant treatment effect. It is concluded that expressive grammar treatment was most effective when dose frequency was weekly over 8 weeks rather than daily over 8 days for 5-year-old children with specific language impairment.13 page(s

Avoiding philosophy as a trump-card in sociological writing. A study from the discourse of evidence-based healthcare

In this article I explore a situation where health sociologists encounter pure-philosophical reasoning in the fabric of social life. Accounts of the relationship between philosophy and sociology tend to be framed in abstract theory, so there is a need for practical ways to anchor philosophical reasoning in sociological writing. I consider the use of philosophies as strategic tools for socially grounded understanding, rather than rhetorical trump-cards which bypass socio-political questions. I present my understanding in two stages: first, I discuss my example topic of Evidence-Based Healthcare (EBHC), reviewing some philosophical contributions by writers in that discourse. These niche-writings I contextualise briefly in relation to other academic meetings between philosophy and sociology. Second, I offer three philosophical perspectives on the topic of EBHC, and outline their significance for understanding it sociologically. I conclude that to navigate the difficult ground where philosophy and sociology meet, sociologists can entrain pure-philosophical argumentation to the purpose of critical, socially situated understandings.PostprintPeer reviewe

Caffeine intake, plasma caffeine level, and kidney function: a Mendelian randomization study

Caffeine is a psychoactive substance widely consumed worldwide, mainly via sources such as coffee and tea. The effects of caffeine on kidney function remain unclear. We leveraged the genetic variants in the CYP1A2 and AHR genes via the two-sample Mendelian randomization (MR) framework to estimate the association of genetically predicted plasma caffeine and caffeine intake on kidney traits. Genetic association summary statistics on plasma caffeine levels and caffeine intake were taken from genome-wide association study (GWAS) meta-analyses of 9876 and of >47,000 European ancestry individuals, respectively. Genetically predicted plasma caffeine levels were associated with a decrease in estimated glomerular filtration rate (eGFR) measured using either creatinine or cystatin C. In contrast, genetically predicted caffeine intake was associated with an increase in eGFR and a low risk of chronic kidney disease. The discrepancy is likely attributable to faster metabolizers of caffeine consuming more caffeine-containing beverages to achieve the same pharmacological effect. Further research is needed to distinguish whether the observed effects on kidney function are driven by the harmful effects of higher plasma caffeine levels or the protective effects of greater intake of caffeine-containing beverages, particularly given the widespread use of drinks containing caffeine and the increasing burden of kidney disease

Earth Through the Eyes of NAPA-1: Commissioning Results and the Next Steps in CubeSat Earth Observation

Disruptive CubeSat technology has brought scientific missions within reach that were previously only achievable through larger spacecraft. Satellite Earth Observation is now the new frontier for governments, private industry, and academia. With the recent launch of the Napa-1 satellite the Royal Thai Airforce (RTAF) has joined the ranks by having its first ever Earth Observation CubeSat in space. Its design, launch, early operations (LEOPS), and commissioning have been carried out by ISISpace, supporting the market’s need for imagery from space. Napa-1, meaning firmament in Thai, is a 6U CubeSat with the Gecko Imager from SCS Space as its primary payload, capable of taking RGB snapshot images with a 39-meter ground sampling distance (GSD) from 500 km altitude. In addition, the TriScape camera from Simera Sense flies onboard as an in-orbit technology demonstrator and is capable of delivering high-quality images with a GSD of 5 meter in the RGB bands. With well over 200 images taken by the primary payload this paper will look back on this exciting first period of Napa-1’s operational life and proudly present the very first images taken by the satellite and the lessons learnt throughout this turnkey mission. With that many images taken and that much data generated, the implemented onboard- and on ground data handling systems have been put to the test. ISISpace has made use of KUBOS’ Major Tom for command and control and having integrated a low-level processing tool, also for image data preview and delivery. Insight is provided into the systems and tools in place for image target planning, image acquisition, satellite command and control, and data delivery to the customer. How is it ensured targets are successfully captured? How is the usefulness of the image data efficiently validated? Subsequently, how is knowledge transfer to the customer accomplished to ensure successful routine operations? ISISpace will share the valuable lessons learnt from the mission planning, data handling, operations, and training points of view and show relevant in-orbit data on, for example, attitude behavior and temperature. In parallel, ISISpace has taken the next step in CubeSat Earth observation by using Napa-1 as a baseline while accommodating larger data streams and leveraging a higher level of automation. Together with the companies Simera Sense and Pinkmatter Solutions, multispectral images with automated on ground data processing (L0 up to L3) are to be delivered by the follow-up mission, Napa-2, to be launched in the summer of 2021. Details on this mission, including a further outlook at how CubeSat imagery and on ground processing will be shaped in the next few years will be provided

National priorities for perioperative research in South Africa

Background. Perioperative research is currently unco-ordinated in South Africa (SA), with no clear research agenda.Objective. To determine the top ten national research priorities for perioperative research in SA.Methods. A Delphi technique was used to establish consensus on the top ten research priorities.Results. The top ten research priorities were as follows: (i) establishment of a national database of (a) critical care outcomes, and (b) critical care resources; (ii) a randomised controlled trial of preoperative B-type natriuretic peptide-guided medical therapy to decrease major adverse cardiac events following non-cardiac surgery; (iii) a national prospective observational study of the outcomes associated with paediatric surgical cases; (iv) a national observational study of maternal and fetal outcomes following operative delivery in SA; (v) a steppedwedge trial of an enhanced recovery after surgery programme for (a) surgery, (b) obstetrics, (c) emergency surgery, and (d) trauma surgery; (vi) a stepped-wedge trial of a surgical safety checklist on patient outcomes in SA; (vii) a prospective observational study of perioperative outcomes after surgery in district general hospitals in SA; (viii) short-course interventions to improve anaesthetic skills in rural doctors; (ix) studies of the efficacy of simulation training to improve (a) patient outcomes, (b) team dynamics, and (c) leadership; and (x) development and validation of a risk stratification tool for SA surgery based on the South African Surgical Outcomes Study (SASOS) data.Conclusions. These research priorities provide the structure for an intermediate term research agenda

A meta-analysis of the efficacy of preoperative surgical safety checklists to improve perioperative outcomes

Background. Meta-analyses of the implementation of a surgical safety checklist (SSC) in observational studies have shown a significant decrease in mortality and surgical complications.Objective. To determine the efficacy of the SSC using data from randomised controlled trials (RCTs).Methods. This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with PROSPERO (CRD42015017546). A comprehensive search of six databases was conducted using the OvidSP search engine.Results. Four hundred and sixty-four citations revealed three eligible trials conducted in tertiary hospitals and a community hospital, with a total of 6 060 patients. All trials had allocation concealment bias and a lack of blinding of participants and personnel. A single trial that contributed 5 295 of the 6 060 patients to the meta-analysis had no detection, attrition or reporting biases. The SSC was associated with significantly decreased mortality (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.42 - 0.85; p=0.0004; I2=0%) and surgical complications (RR 0.64, 95% CI 0.57 - 0.71; p<0.00001; I2=0%). The efficacy of the SSC on specific surgical complications was as follows: respiratory complications RR 0.59, 95% CI 0.21 - 1.70; p=0.33, cardiac complications RR 0.74, 95% CI 0.28 - 1.95; p=0.54, infectious complications RR 0.61, 95% CI 0.29 - 1.27; p=0.18, and perioperative bleeding RR 0.36, 95% CI 0.23 - 0.56; p<0.00001.Conclusions. There is sufficient RCT evidence to suggest that SSCs decrease hospital mortality and surgical outcomes in tertiary and community hospitals. However, randomised evidence of the efficacy of the SSC at rural hospital level is absent