Prevention of mother-to-child transmission of HIV programme: low vertical transmission in KwaZulu-Natal, South Africa

Objective. To describe the operational effectiveness of the PMTCT programme at McCord hospital during the period from 1 March 2004 to 31 August 2005 Design. Observational cohort study Setting. McCord hospital, Durban, South Africa Subjects. Antenatal patients attending the PMTCT clinic Measurements and results. During the 18 months all 2624 women (100%) attending the antenatal clinic received HIV counselling resulting in 91% (2388) being tested for HIV. The prevalence of HIV in this cohort was 12.9% (95% confidence interval (CI) 11.6 to 14.2). Of the 302 (89%) HIV positive mothers who completed their pregnancy at the hospital, there were 3 intra-uterine deaths, 1 miscarriage, 1 maternal death (with baby in utero) and 297 live births with one early neonatal death. Only 11% (36 out of 338) were lost to follow-up. Of all women attending the antenatal clinic, a quarter (668) of partners was tested for HIV. Delivery in 70% (209) of live births was by caesarean section. Nevirapine was administered to 98% (290) of live babies and 76% (224) received AZT as well. The six week PCR baby test uptake was 81% (239 out of 296 live babies). Out of those tested 2.9% (95% CI 1.3-6.2) tested HIV positive. Conclusion. Despite the challenges faced by PMTCT providers in a resource constrained setting this state-aided hospital provides a comprehensive and integrated service and has achieved outcomes which compare favourably with those in the developed world

The Mock Trial: Revisiting a Valuable Training Strategy

The number of forensic psychiatrists has increased dramatically over the past 40 years. With this welcome development has also come some challenges for educating future generations of practitioners, specifically the greater demands on training programs and the need to divide practice hours among a larger pool of individuals. Junior trainees and experienced practitioners alike can benefit by supplementing work experience with welldesigned, theoretically informed simulations. In this article, the theoretical perspectives of simulation, deliberate practice, and experiential education are discussed and linked to the design of mock trials, a form of simulation used to teach the essential skill of expert testimony. My argument is that, by explicitly linking the mock trial to learning theory, its efficacy and range of application can be increased. I provide recommendations for effective design and application

A Clinical Comparison of Orally Administered Aspirin, Dextropropoxyphene and Pentazocine in the Treatment of Post-Operative Pain

A double-blind between-patient study involving 225 aduh patients was carried out to compare the efficacy of oral aspirin (650 mg), dextropro poxyphene (65 mg) and pentazocine (50 mg) in post-operative pain. All the patients were initially in moderate or severe pain and all three drugs produced some degree of pain relief. The onset of action of pentazocine was significantly more rapid than that of aspirin or dextropropoxyphene. The analgesia provided by dextropropoxyphene was significantly inferior to that achieved with aspirin or pentazocine and the duration of action, assessed by patient demand for further analgesic drugs, was aho significantly shorter than that of the other two drugs. The incidence and severity of side-effects was greatest in the dextropropoxyphene group and it is concluded from these results that pentazocine should be the oral analgesic of choice in the treatment of post-operative pain

Evaluation of the use of BioGlue â in neurosurgical procedures

Summary Objective: Post-operative cerebrospinal fluid (CSF) fistula following neurosurgery is associated with increased morbidity and mortality. This prospective study evaluates the efficacy of a new bioadhesive -BioGlue, as a dural sealant in preventing CSF fistula. The complications associated with its use are investigated and the literature regarding dural closure reviewed. Methods: BioGlue was applied to the dura mater as a sealant in 210 patients undergoing 216 neurosurgical procedures over a period of 22 months at the Royal Melbourne Hospital. It was used where watertight closure of the dura mater could not be ensured by primary suture alone and for reconstruction of the sellar floor following transsphenoidal adenohypophysectomy. It was used in 114 supratentorial (52.7%), 53 infratentorial (24.5%) craniotomies, 41 (18.9%) transsphenoidal adenohypophysectomies and 8 spinal (3.7%) procedures. The incidence of CSF fistula as a complication of surgery with intradural exposure was analysed. Results: The incidence of CSF fistula post-operatively was significantly low. Two patients (0.93%), both having undergone posterior fossa craniotomy -for evacuation of a cerebellar haematoma and redo excision of a metastasis respectively and both complicated by hydrocephalus, developed CSF fistula. There were no complications associated with the use of BioGlue. Conclusion: BioGlue reduced the incidence of complications associated with neurosurgery. It is an effective adjunct in dural closure to prevent CSF fistula with enhanced bonding properties and is simple to use. In this study there were no complications associated with its use.

Prevention of shoulder subluxation after stroke with electrical stimulation. Stroke

Background and Purpose-Subluxation is a significant problem in poststroke hemiplegia, resulting in pain and loss of function. Current treatments are not proved and not considered effective. It has been demonstrated that cyclical electrical stimulation of the shoulder muscles can reduce existing subluxation. The purpose of this study was to determine whether electrical stimulation could prevent subluxation in both the short and long terms. Methods-A prospective, randomized controlled study was used to determine the efficacy of electrical stimulation in preventing shoulder subluxation in patients after cerebrovascular accidents. Forty patients were selected and randomly assigned to a control or treatment group. They had their first assessment within 48 hours of their stroke, and those in the treatment group were immediately put on a regimen of electrical stimulation for 4 weeks. All patients were assessed at 4 weeks after stroke and then again at 12 weeks after stroke. Assessments were made of shoulder subluxation, pain, and motor control. Results-The treatment group had significantly less subluxation and pain after the treatment period, but at the end of the follow-up period there were no significant differences between the 2 groups. Conclusions-Electrical stimulation can prevent shoulder subluxation, but this effect was not maintained after the withdrawal of treatment. (Stroke. 1999;30:963-968.

Breastfeeding and Weaning Practices in Saudi Arabia

Summary A National Child Health Survey was conducted during 1987 for which a stratified multi-stage sampling was done. Out of the 8482 mothers interviewed 6131 had at least one live birth 5 years or less before the survey. Eighty-two per cent of the currently breastfed children, were less than 6 months of age, but only 55 per cent of the infants up to 1 month of age were breastfed without supplementation. The mean interval between supplementation and weaning for all age groups of mothers was 7.7 months. The predominant causes of weaning were child reaching suitable age and mother not having enough milk. This study establishes base line information about feeding practice on a nationwide basis in Saudi Arabia

THE HUMAN BIOLOGY OF OBESITY, AND ITS RELEVANCE TO INSURERS

No human community functions without its insurance industry. People everywhere "insure their lives" by seeking marriage partners, or surrounding themselves with family members, with the longest possible life expectancy. Everybody concludes social and economic deals that take the mortality risks of the contractors into account. Age, sex, and body build have probably always constituted the corner stones of such risk assessments. The present review deals with one of these attributes--body build, especially obesity--and examiners its value as a predictor of mortality to modern underwriters, in the light of what is presently known about its biology. Causes of obesity That Obesity is the result of food intake having exceeded the metabolic energy expenditure of an individual is a truism. It is also a platitude of singular uninformativeness. A person's every physical feature is a result of positive energy balance: one's muscle mass, bones and skin, the existence of limbs, the displacement of one's brain and the volume of the packed blood cells. These self-evident truths contribute as much to the understanding of obesity, as they do about the prevention of phocomelia, the treatment of polio deformities, or the management of prostatic hypertrophy. The human neonate converts about 10% of its solid food intake into tissue. This value decreases very rapidly, however, to less than 1% during the first 2 years of life. It remains at approximately 0.8% during most of the rest of childhood. To conclude from this that the energy budget will balance, and growth will stop, when the food intake of a child is reduced by 0.8% is clearly erroneous. Much greater reductions than 0.8% can be brought about merely by substituting brown for white bread in a child's diet, or by withdrawing a favorite cool drink or condiment from the menu. In fact, most children in the world probably eat about 80 -90% of what their counterparts in the U.S.A. eat, yet they grow. Nor are they obviously less active than American children. Often the contrary. Children in many Third World environments have to walk large distances to school, frequently after having first attended to a variety of arduous domestic chores, such as carrying water and firewood, or herding the cattle to distant pastures. But they remain in positive energy balance. Food-energy intake probably needs to be reduced to less than 20% or 30% of that eaten by Western middle class children before growth will stop in childhood. The apportionment of the energy budget under various types of nutritional stress is, therefore, clearly a great deal more subtle and versatile than is generally appreciated. Humans are unusual among land vertebrates in that they have considerable fat deposits under the skin. The human baby is born with it, and at 9-12 months it constitutes, on average, about 25% of the infant's mass. 1 Relative fat mass decreases during the second year of life, to average about 10% of total body mass through most of childhood The fat organ increases in size during puberty in both sexes, but, more importantly, it changes shape. 1 In boys it tends to thin out on the limbs and the limb girdles, while thickening in the loins to produce the torso of a typical young man. In girls there is an overall increase in the thickness of the subcutaneous fat layer during puberty, with particular emphasis on the hips, thighs, and, of course, the breasts. Interestingly, the fat layer in the loins tends to be thinner than it is in boys. When growth in height ceases at the age of 18 years adipose tissue constitutes, on average, 12% of the mass of boys (the normal, 95% probability limit, range is from 3% to 28%), and 24% of the mass of girls (normal range: 17% to 34%). The remodelling of the body does not cease at 18 years. In both men and women fat and muscle continue to accumulate well into middle age. Connective tissue and skin probably never stops growing, except terminally. Indeed, the growth of the nose and ears, and skin of the face with age is well recognized by cartoonists, who invariably depict older people (especially women) with larger noses and ears than they depict younger people. But the hands and feet also grow, as does the skin all over the bod)~ causing the characteristic creases and wrinkles of old age. In men the fat organ hypertrophies on the trunk, especially in the abdomen. In women the remodelling of this organ occurs particularly on the proximal portions of the limbs, the breasts, and, to a lesser extent, in the abdomen. All of these changes are associated with a positive energy balance of, on average, 0.5%, which tails off, in men, to zero at about the age of 50 years 2 (though isoenergetic remodelling of the body continues unabated into old age). Most women remain in positive energy balance for an additional 20 years. 2 The average 25 year-old therefore weight 4 -5% more than the average 20 year-old. At the age of 45 years the average weight of both men and women, on a wide variety of nutritional regimens, worldwide, is 20% higher than it is at 20 years. 2-5