Obstetric anaesthesia at district and regional hospitals in KwaZulu-Natal: human resources, caseloads and the experience of doctors

Objectives: Suboptimal treatment as a result of lack of basic skills in anaesthesia and resuscitation contributes significantly to the continuing increase in anaesthetic-related maternal deaths in South Africa. This study aimed to determine the number of doctors providing obstetric anaesthesia at district and regional hospitals in KwaZulu-Natal, their level of experience and caseload, and to identify specific groups that could be targeted for support and training.Design: This was a prospective open cohort observational study of obstetric anaesthetic services in KwaZulu-Natal, which considered the human resources, caseloads and the experience of doctors.Setting and subjects: Two separate questionnaires, directed independently to medical managers and doctors providing operative obstetric services, were sent to 48 district and regional hospitals in KwaZulu-Natal. One third of the hospitals, selected by stratified randomisation, were visited to improve response rates.Outcome measures: Medical managers were asked for caseload and staffing data. Doctors were asked for details of their qualifications, experience and their current workload.Results: Thirty-eight (a 79% response rate) medical managers and 266 doctors (an estimated response rate of 65%) completed questionnaires. Community service medical officers (CSMOs) at rural district hospitals constituted 27% of fulltime staff. CSMOs at all responding district hospitals were expected to provide obstetric anaesthesia independently. Foreign medical graduates provided obstetric anaesthesia in 71% (27/38) of hospitals and constituted 27% of full-time staff at rural district hospitals. Twenty-four doctors (all foreign-trained) reported no anaesthesia training during their internship. District hospitals were more reliant on part-time (sessional) appointments. Fifty-eight per cent of all (22/38) hospitals reported that a number of sessional appointments provided obstetric anaesthesia. In October 2010, 58% (22/38 active during the month) of sessional appointments at district-level hospitals administered only one obstetric anaesthetic, whereas all 15 sessional appointments who were active at regional level administered two or more. Only 24% of responding doctors had more than five years’ experience in their current employment. Only 3% of responding doctors working in rural hospitals had a Diploma in Anaesthesia, compared to 26% in urban hospitals. Only one doctor with more than five years of employment history and a Diploma in Anaesthesia worked at district level.Conclusion: This study highlights the lack of training and experience of doctors in obstetric anaesthesia and documents workload patterns at district hospitals. It also identifies specific target groups for future support and training.Keywords: obstetric anaesthesia, human resources, caseloads, experience of doctorsSouth Afr J Anaesth Analg 2013;19(5):257-26

“Safe anaesthesia” for the South African rural obstetric patient in KwaZulu-Natal

Background: The South African National Committee for Confidential Enquiries into Maternal Deaths has shown that anaesthesia-related maternal deaths continue to increase at district hospitals. This has been attributed to substandard anaesthesia care and resuscitation. This study investigated the anaesthesia practices, work circumstances, support structure and access to training by doctors involved in obstetric anaesthesia in KwaZulu-Natal district and regional hospitals.Method: This was an observational study, which included 48 district and regional hospitals offering operative obstetrics in KwaZulu-Natal. Separate questionnaires were given to medical managers and doctors providing obstetric anaesthesia.Results: The authors assessed 254 doctors’ questionnaires.  Ninety-eight per cent were full-time appointments and 75% had been employed for less than five years. Almost all of the doctors routinely used spinal anaesthesia, 96% used uterine displacement and 77% measured blood pressure every 1–2 minutes. Appropriate vasopressors were used by 98% of the doctors to treat post-spinal hypotension. Thirteen per cent (32 of 254) of the doctors “frequently or always”  performed or assisted with surgery after anaesthetising the patient. Only 22% (54 of 248) of the doctors had an anaesthetic-trained nurse as usual assistance. Thirty per cent (35 of 115) of the doctors in the district hospitals reported feeling insecure or having experienced difficulties during general anaesthesia. Nine per cent (22) of the doctors reported not having after-hours supervision and 53% (134 of 253) did not receive any structured training at their base hospitals.Conclusion: The majority of doctors provided safe obstetric anaesthesia according to the indicators used. The unsafe practice of administering anaesthesia and then performing other theatre duties, thus leaving the mother without dedicated medical supervision, must be stopped. Efforts should be made to improve the supervision and support of district hospital doctors. Resources to optimise safe practices need to be improved.Keywords: district and regional hospitals, obstetric anaesthesia, supervision, training opportunitie

Membrane-bound β-catenin degradation is enhanced by ETS2-mediated Siah1 induction in Helicobacter pylori-infected gastric cancer cells.

β-catenin has two different cellular functions: intercellular adhesion and transcriptional activity. The E3 ubiquitin ligase Siah1 causes ubiquitin-mediated degradation of the cytosolic β-catenin and therefore, impairs nuclear translocation and oncogenic function of β-catenin. However, the effect of Siah1 on the cell membrane bound β-catenin has not been studied. In this study, we identified that the carcinogenic bacterium H. pylori increased ETS2 transcription factor-mediated Siah1 protein expression in gastric cancer cells (GCCs) MKN45, AGS and Kato III. Siah1 protein level was also noticeably higher in gastric adenocarcinoma biopsy samples as compared to non-cancerous gastric epithelia. Siah1 knockdown significantly decreased invasiveness and migration of H. pylori-infected GCCs. Although, Siah1 could not increase degradation of the cytosolic β-catenin and its nuclear translocation, it enhanced degradation of the membrane-bound β-catenin in the infected GCCs. This loss of membrane-bound pool of β-catenin was not associated with the proteasomal degradation of E-cadherin. Thus, this work delineated the role of Siah1 in increasing invasiveness of H. pylori-infected GCCs

Allelopathic effect of Leucaena leucocephala on Pansy (Viola tricolor L.)

The present study on allelopahtic effect of L. leucocephala on pansy (V. tricolor L.) both laboratory and nursery conditions were undertaken. Leucaena which significantly reduced the seed germination in all treatments at 2% (43%), 3% (42%) and 4% (40%) over Control (Distilled water), except in treatment at 1% (55%) wheregermination was found to be maximum over Control (Distilled water), this result shows the stimulatory effect on germination at 1% concentration of leaf leachate under laboratory condition. Leucaena soil in combination with Field soil showed stimulatory effect on the growth parameters in Pansy. Highest germination percentage (82%), fresh shoot weight (2.82g), fresh root weight (0.22g), dry shoot weight (0.50g), dry root weight (0.05g), vigor index (99.36) were recorded in treatment amended with soil 50% Leucaena soil and 50% Field soil and inhibitory effect was seen in pansy when amended into with 100% Leucaena soil under nursery condition. From this study it appears that Leucaena produces allelopahtic substrates, increase in concentration exhibit adverse effect on germination and growth parameters. Hence it is suggested that pansy could be affected economically but this tree can very well adapt to diversified soil condition

Studies on some homo and hetero trinuclear complexes of nickel(II), cobalt(II) and copper(II) with 1,8-bis(2'-oxophenyl)2,3,6,7-tetraza-4,5-dimethyl-1,3,5,7-octatetraene (BTDO)

788-791A few homo/hetero trinuc1ear complexes of the type [MNiM(BTDO)2X2(H2O)4] nH2O [where M = nickel(II), cobalt(II) and copper(II), X = cr or NO, n = 0, or 0.5 and BTDO = 1,8-bis(2'-oxophenyl)-2,3,6, 7-tetraza4,5-dimethyl-1 ,3,5,7-octatetraene] have been isolated in a stepwise reaction from the precursor nickel bis(diacetyldihydrazone) complexes. These have been characterised on the basis of elemental analyses, spectral and magnetic properties, conductivity measurements and thermal analyses. All the complexes contain coordinated water. The metal centres have an octahedral environmental around them

Expectant management of early onset of severe pre-eclampsia in Durban

Fifty patients with severe pre-eclampsia who presented before 32 weeks' gestation were managed conservatively (sedation, bed rest, antihypertensive therapy and intensive fetal and maternal monitoring) until intervention was indicated. Twelve patients presented before 26 weeks ofpregnancy and there were no fetal survivors in this group; 23 presented between 26 and 29 weeks and 8(34,8%) of the babies in this group survived. The rate of perinatal loss in those presenting between 30 and 32 weeks was 26,6% (N =4). Patients who had a history of a hypertensive disorder in their previous pregnancy(ies) had a higher perinatal mortality rate; 23 such mothers experienced 16 perinatal losses compared with 27 mothers who had no such history and who had only 8 perinatal losses. There was 1 maternal death, there were 2 cases of eclampsia, 3 of pulmonary oedema, 4 of abruptio placentae and 1 case of renal failure; 2 patients had disseminated intravascular coagulation. The local indigent and underprivileged black population have a more aggressive form of early onset of severe pre-eclampsia than that reported for other population groups. The high maternal complication rate of 30,8% and the low fetal survival rate before 26 weeks indicate that there is no place in our setting for expectant management of severe pre-eclampsia in patients presenting before 26 weeks. This applies particularly to those with a previous history ofhypertension in pregnancy

Silicon amendment induces synergistic plant defense mechanism against pink stem borer (Sesamia inferens Walker.) in finger millet (Eleusine coracana Gaertn.).

Silicon (Si) uptake and accumulation in plants can mitigate various biotic stresses through enhanced plant resistance against wide range of herbivores. But the role of silicon in defense molecular mechanism still remains to be elucidated in finger millet. In the present study, we identified three silicon transporter genes viz. EcLsi1, EcLsi2, and EcLsi6 involved in silicon uptake mechanism. In addition, the study also identified and characterized ten different Si transporters genes from finger millet through transcriptome assembly. The phylogenetic study revealed that EcLsi1 and EcLsi6 are homologs while EcLsi2 and EcLsi3 form another pair of homologs. EcLsi1 and EcLsi6 belong to family of NIP2s (Nod26-like major intrinsic protein), bona fide silicon transporters, whereas EcLsi2 and EcLsi3, an efflux Si transporter, belong to an uncharacterized anion transporter family having a significant identity with putative arsB transporter proteins. Further, the phylogenetic and topology analysis suggest that EcLsi1 and EcLsi2 co-evolved during evolution while, EcLsi2 and EcLsi3 are evolved from either EcLsi1 and/or EcLsi6 by fusion or duplication event. Moreover, these silicon transporters are predicted to be localized in plasma membrane, but their structural differences indicate that they might have differences in their silicon uptake ability. Silicon amendment induces the synergistic defense mechanism by significantly increasing the transcript level of silicon transporter genes (EcLsi1, EcLsi2 and EcLsi6) as well as defense hormone regulating genes (EcSAM, EcPAL and EcLOX) at 72 hpi (hours of post infestation) in both stem and roots compared to non-silicon treated plants against pink stem borer in finger millet plants. This study will help to understand the molecular defense mechanism for developing strategies for insect pest management

The enrichment of an alkaliphilic biofilm consortia capable of the anaerobic degradation of isosaccharinic acid from cellulosic materials incubated within an anthropogenic, hyperalkaline environment.

Anthropogenic hyper-alkaline sites provide an environment that is analogous to proposed cementitious geological disposal facilities (GDF) for radioactive waste. Under anoxic, alkaline conditions cellulosic wastes will hydrolyse to a range of cellulose degradation products (CDP) dominated by isosaccharinic acids (ISA). In order to investigate the potential for microbial activity in a cementitious GDF, cellulose samples were incubated in the alkaline (∼pH 12), anaerobic zone of a lime kiln waste site. Following retrieval, these samples had undergone partial alkaline hydrolysis and were colonised by a Clostridia dominated biofilm community, where hydrogenotrophic, alkaliphilic methanogens were also present. When these samples were used to establish an alkaline CDP fed microcosm, the community shifted away from Clostridia, methanogens became undetectable and a flocculate community dominated by Alishewanella sp. established. These flocs were composed of bacteria embedded in polysaccharides and protein stabilised by extracellular DNA. This community was able to degrade all forms of ISA with >60% of the carbon flow being channelled into extracellular polymeric substance (EPS) production. This study demonstrated that alkaliphilic microbial communities can degrade the CDP associated with some radioactive waste disposal concepts at pH 11. These communities divert significant amounts of degradable carbon to EPS formation, suggesting that EPS has a central role in the protection of these communities from hyper-alkaline conditions