Emergency medicine in Paarl, South Africa: a cross-sectional descriptive study

Background: Emergency Medicine (EM) in South Africa is in its earliest stages of development. There is a paucity of data about emergency department (ED) patient demographics, epidemiology, consultation and admission criteria and other characteristics. Aims: This information is absolutely necessary to properly guide the development of EM and appropriate emergency care systems. In order to provide this information, we performed a study in a rural hospital in Paarl, 60 km outside Cape Town. Methods: All patients who were seen in the ED between 1 January 2008 and 31 May 2008 were eligible for our research. We designed a cross-sectional descriptive study and retrieved information from a randomized sample of all consecutive patient charts seen during this period using a 40-point questionnaire (see Appendix 1). Results: We investigated 2,446 charts, of which 2,134 were suitable for our research The majority (88.2%) of these patients were self-referred. In our sample, 24.1% were children under 12 years old. Almost 20% of patients had a serious pathological condition or were physiologically unstable; 36.0% of all presentations were trauma related. Besides trauma-related problems, gastrointestinal- (21.9%) and respiratory tract- (12.4%) related problems were most common in the ED; 16.5% of the patients were admitted to a ward. Conclusion: This descriptive epidemiological study provides necessary data that will be used for further needs assessments and for future EM development in Paarl, and can be used as a template in other EDs and hospitals to provide similar data necessary for initial EM development strategy

Real world costs and cost-effectiveness of Rituximab for diffuse large B-cell lymphoma patients: a population-based analysis.

BackgroundCurrent treatment of diffuse-large-B-cell lymphoma (DLBCL) includes rituximab, an expensive drug, combined with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy. Economic models have predicted rituximab plus CHOP (RCHOP) to be a cost-effective alternative to CHOP alone as first-line treatment of DLBCL, but it remains unclear what its real-world costs and cost-effectiveness are in routine clinical practice.MethodsWe performed a population-based retrospective cohort study from 1997 to 2007, using linked administrative databases in Ontario, Canada, to evaluate the costs and cost-effectiveness of RCHOP compared to CHOP alone. A historical control cohort (n = 1,099) with DLBCL who received CHOP before rituximab approval was hard-matched on age and treatment intensity and then propensity-score matched on sex, comorbidity, and histology to 1,099 RCHOP patients. All costs and outcomes were adjusted for censoring using the inverse probability weighting method. The main outcome measure was incremental cost per life-year gained (LYG).ResultsRituximab was associated with a life expectancy increase of 3.2 months over 5 years at an additional cost of $16,298, corresponding to an incremental cost-effectiveness ratio of$61,984 (95% CI $34,087-$135,890) per LYG. The probability of being cost-effective was 90% if the willingness-to-pay threshold was $100,000/LYG. The cost-effectiveness ratio was most favourable for patients less than 60 years old ($31,800/LYG) but increased to $80,600/LYG for patients 60-79 years old and$110,100/LYG for patients ≥ 80 years old. We found that post-market survival benefits of rituximab are similar to or lower than those reported in clinical trials, while the costs, incremental costs and cost-effectiveness ratios are higher than in published economic models and differ by age.ConclusionsOur results showed that the addition of rituximab to standard CHOP chemotherapy was associated with improvement in survival but at a higher cost, and was potentially cost-effective by standard thresholds for patients <60 years old. However, cost-effectiveness decreased significantly with age, suggesting that rituximab may be not as economically attractive in the very elderly on average. This has important clinical implications regarding age-related use and funding decisions on this drug

The validity and reliability of continuous-wave near -infrared spectroscopy for the assessment of leg blood volume during an orthostatic challenge.

Near-infrared spectroscopy (NIRS) can potentially be used to assess the cardiovascular autonomic system by monitoring orthostatic challenge-induced shifts in lower limb blood volume. However, in order to be of clinical utility the test must be valid, reliable, and relatively simple to conduct. Purpose: To induce lower limb blood volume shifts using a 10min 70o head-up tilt, and: (1) in the soleus, determine the validity of an inexpensive continuous wave (cw)-NIRS device by comparing to a criterion frequency-domain (fd-) NIRS device, (2) determine the between-day reliability of soleus assessments obtained from cw-NIRS and fd-NIRS; and, (3) compare the between-day reliability for fd-NIRS assessments obtained at the soleus (standard) and gastrocnemius (simpler alternative). Methods: Fifteen non-smoking healthy adults were tested on 3 different mornings, under standardized conditions, separated by a maximum of 7 days. Total haemoglobin concentration (tHb) was continuously monitored bi-laterally in the medial soleus using cw-NIRS and fd-NIRS. For site comparison, tHb was measured in the medial gastrocnemius using fd-NIRS. Results: (1) The area under the curve (AUC) for cw-NIRS and fd-NIRS assessments at the soleus were not significantly different (p =.619). (2) The criterion (0.75) intra-class correlation coefficient (ICC) was exceeded for both cw-NIRS and fd-NIRS. (3) The criterion ICC was exceeded for both soleus and gastrocnemius assessments. Conclusion: Continuous-wave NIRS can be used to monitor orthostatic stress-induced shifts in lower leg blood volume with acceptable validity and reliability. This orthostatic test may present a relatively simple and inexpensive approach for assessing the cardiovascular autonomic nervous system

Mutational Analysis of the Nitrogenase Carbon Monoxide Protective Protein CowN Reveals That a Conserved C‑Terminal Glutamic Acid Residue Is Necessary for Its Activity

Nitrogenase is the only enzyme that catalyzes the reduction of nitrogen gas into ammonia. Nitrogenase is tightly inhibited by the environmental gas carbon monoxide (CO). Many nitrogen fixing bacteria protect nitrogenase from CO inhibition using the protective protein CowN. This work demonstrates that a conserved glutamic acid residue near the C-terminus of Gluconacetobacter diazotrophicus CowN is necessary for its function. Mutation of the glutamic acid residue abolishes both CowN’s protection against CO inhibition and the ability of CowN to bind to nitrogenase. In contrast, a conserved C-terminal cysteine residue is not important for CO protection by CowN. Overall, this work uncovers structural features in CowN that are required for its function and provides new insights into its nitrogenase binding and CO protection mechanism

Wintertime observations of Subtropical Mode Water formation within the Gulf Stream

Author Posting. © American Geophysical Union, 2009. This article is posted here by permission of American Geophysical Union for personal use, not for redistribution. The definitive version was published in Geophysical Research Letters 36 (2009): L02607, doi:10.1029/2008GL035918.We study the structure of Subtropical Mode Water (STMW) within the eastward-flowing Gulf Stream as it forms during strong winter cooling. Shipboard observations using SeaSoar and ADCP reveal that while active mixing by gravitational instabilities is common, large vertical and lateral shears of the Gulf Stream play a central role in determination of the modes of active mixing. Evidence is presented that low static stability and large vertical shear can combine to cause slantwise convection/symmetric instabilities, while the large anticyclonic shears to the south of the Gulf Stream core can cause low absolute vorticity and precondition the Ertel potential vorticity to be small and more susceptible to instabilities. The area of active mixing driven by surface forcing in the presences of shear occupies a swath 50–90 km wide immediately south of the Gulf Stream core at the northern edge of the Sargasso Sea.Support came from the National Science Foundation grants OCE-0424865 (TJ and FB) and OCE-0549699 (LT)

Proper Motions in Kapteyn Selected Area 103: A Preliminary Orbit for the Virgo Stellar Stream

We present absolute proper motions in Kapteyn Selected Area (SA) 103. This field is located 7 degrees west of the center of the Virgo Stellar Stream (VSS, Duffau et al. 2006), and has a well-defined main sequence representing the stream. In SA 103 we identify one RR Lyrae star as a member of the VSS according to its metallicity, radial velocity and distance. VSS candidate turnoff stars and subgiant stars have proper motions consistent with that of the RR Lyrae star. The 3D velocity data imply an orbit with a pericenter of 11 kpc and an apocenter of ~90 kpc. Thus, the VSS comprises tidal debris found near the pericenter of a highly destructive orbit. Examining the six globular clusters at distances larger than 50 kpc from the Galactic center, and the proposed orbit of the VSS, we find one tentative association, NGC 2419. We speculate that NGC 2419 is possibly the nucleus of a disrupted system of which the VSS is a part.Comment: ApJL accepte

Impact of tailored falls prevention education for older adults at hospital discharge on engagement in falls prevention strategies postdischarge: Protocol for a process evaluation

Introduction: Older adults recently discharged from hospital have greater incidence of adverse events, functional decline, falls and subsequent readmission. Providing education to hospitalised patients on how to prevent falls at home could reduce postdischarge falls. There has been limited research investigating how older adults respond to tailored falls prevention education provided at hospital discharge. The aim of this study is to evaluate how providing tailored falls prevention education to older patients at the point of, and immediately after hospital discharge in addition to usual care, affects engagement in falls prevention strategies in the 6-months postdischarge period, including their capability and motivation to engage in falls prevention strategies. Methods and analyses: This prospective observational cohort study is a process evaluation of a randomized controlled trial, using an embedded mixed-method design. Participants (n=390) who have been enrolled in the trial are over the age of 60 years, scoring greater than 7/10 on the Abbreviated Mental Test Score. Participants are being discharged from hospital rehabilitation wards in Perth, Western Australia, and followed up for 6 months postdischarge. Primary outcome measures for the process evaluation are engagement in falls prevention strategies, including exercise, home modifications and receiving assistance with activities of daily living. Secondary outcomes will measure capability, motivation and opportunity to engage in falls prevention strategies, based on the constructs of the Capability Opportunity Motivation Behaviour system. Quantitative data are collected at baseline, then at 6 months postdischarge using structured phone interviews. Qualitative data are collected from a purposive sample of the cohort, using semistructured in-depth phone interviews. Quantitative data will be analysed using regression modelling and qualitative data will be analysed using interpretive phenomenological analysis. Ethics and dissemination: Results will be presented in peer-reviewed journals and at conferences worldwide. This study is approved by hospital and university Human Research Ethics Committees

The Southern Proper Motion Program IV. The SPM4 Catalog

We present the fourth installment of the Yale/San Juan Southern Proper Motion Catalog, SPM4. The SPM4 contains absolute proper motions, celestial coordinates, and (B,V) photometry for over 103 million stars and galaxies between the south celestial pole and -20 deg declination. The catalog is roughly complete to V=17.5 and is based on photographic and CCD observations taken with the Yale Southern Observatory's double-astrograph at Cesco Observatory in El Leoncito, Argentina. The proper-motion precision, for well-measured stars, is estimated to be 2 to 3 mas/yr, depending on the type of second-epoch material. At the bright end, proper motions are on the International Celestial Reference System by way of Hipparcos Catalog stars, while the faint end is anchored to the inertial system using external galaxies. Systematic uncertainties in the absolute proper motions are on the order of 1 mas/yr.Comment: 34 pages, 8 figures, 3 tables; accepted for publication in AJ; note - modified author list and acknowledgements sectio