Restoration of Anal Sphincter Tone by Graciloplasty: A Report of Five Cases

Stool incontinence can be as a result of congenital or acquired anal sphincter problems. It is a devastating state for a patient not to be able to control stools resulting into continued feacal soiling. It reduces an individual to a dejected and depressed person who becomes a social misfit. Hence any procedure that can alleviate this state is normally highly appreciated. Various techniques have been quoted in literature and use of gracilis muscle to form a neosphincter is one of them. Dynamic graciloplasty, is a technique whereby electrodes have been implanted into gracilis muscle and is connected to an implantable pulse generator which provides progressive levels of stimulation to convert the fast twitch, fatigue prone muscle fibres to a slow twitch, fatigue resistant firbres over eight week training period (1,2,3). This has shown improved efficacy over the static graciloplasty (3). In this case report, five patients with stool incontinence from different aetiologies are presented, all having been managed by static graciloplasty and intense physiotherapy with good outcomes reported

Neonatal Ebstein’s Anomaly: Surgical Decision Making

Ebstein’s Anomaly (EA) is a rare form of congenital heart disease. Surgical decision-making in neonates is controversial. In developing countries, neonates with Ebstein’s anomaly requiring surgical intervention rarely present to health institutions capable of providing intervention. We present a 2.2 kg term female neonate who presented with Ebstein’s anomaly. Data was obtained retrospectively from clinical case notes. We describe our surgical decision-making process and outcome in relation to prevailing thought regarding the management of this condition and we make a recommendation on what we consider to be the best surgical option for these patients.Key words: Ebstein's anomaly, Neonatal, Treatmen

Patient satisfaction with out-of-hours primary care in the Netherlands

BACKGROUND: In recent years out-of-hours primary care in the Netherlands has changed from practice-based to large-scale cooperatives. The purpose of this study is to determine patient satisfaction with current out-of-hours care organised in general practitioner (GP) cooperatives, and gain insight in factors associated with this satisfaction. METHODS: From March to June 2003, 2805 questionnaires were sent to patients within three weeks after they had contacted the GP cooperative in their region. The study was conducted in the province of Limburg in the South of the Netherlands. One-third of these questionnaires was sent to patients who had only received telephone advice, one-third to patients who attended the GP cooperative for consultation, and one-third to patients who received a home visit. Four weeks after the first reminder, a non-respondents telephone interview was performed among a random sample of 100 patients. Analyses were performed with respect to the type of consultation. RESULTS: The total response was 42.4% (1160/2733). Sixty-seven percent of patients who received telephone advice only reported to be satisfied with out-of-hours care. About 80% of patients who went to the GP cooperative for consultation or those receiving a home visit, reported to be satisfied. Factors that were strongly associated with overall satisfaction included, the doctor's assistant's attitude on the phone, opinion on GP's treatment, and waiting time. CONCLUSION: Patients seem generally satisfied with out-of-hours primary care as organised in GP cooperatives. However, patients who received telephone advice only are less satisfied compared to those who attended the GP cooperative or those who received a home visit

Poor availability of context-specific evidence hampers decision-making in conservation

Evidence-based conservation relies on reliable and relevant evidence. Practitioners often prefer locally relevant studies whose results are more likely to be transferable to the context of planned conservation interventions. To quantify the availability of relevant evidence for amphibian and bird conservation we reviewed Conservation Evidence, a database of quantitative tests of conservation interventions. Studies were geographically clustered, and few locally conducted studies were found in Western sub-Saharan Africa, Russia, South East Asia, and Eastern South America. Globally there were extremely low densities of studies per intervention - fewer than one study within 2000 km of a given location. The availability of relevant evidence was extremely low when we restricted studies to those studying biomes or taxonomic orders containing high percentages of threatened species, compared to the most frequently studied biomes and taxonomic orders. Further constraining the evidence by study design showed that only 17–20% of amphibian and bird studies used reliable designs. Our results highlight the paucity of evidence on the effectiveness of conservation interventions, and the disparity in evidence for local contexts that are frequently studied and those where conservation needs are greatest. Addressing the serious global shortfall in context-specific evidence requires a step change in the frequency of testing conservation interventions, greater use of reliable study designs and standardized metrics, and methodological advances to analyze patchy evidence bases

Whipworm and roundworm infections

Trichuriasis and ascariasis are neglected tropical diseases caused by the gastrointestinal dwelling nematodes Trichuris trichiura (a whipworm) and Ascaris lumbricoides (a roundworm), respectively. Both parasites are staggeringly prevalent, particularly in tropical and subtropical areas, and are associated with substantial morbidity. Infection is initiated by ingestion of infective eggs, which hatch in the intestine. Thereafter, T. trichiura larvae moult within intestinal epithelial cells, with adult worms embedded in a partially intracellular niche in the large intestine, whereas A. lumbricoides larvae penetrate the gut mucosa and migrate through the liver and lungs before returning to the lumen of the small intestine, where adult worms dwell. Both species elicit type 2 anti-parasite immunity. Diagnosis is typically based on clinical presentation (gastrointestinal symptoms and inflammation) and the detection of eggs or parasite DNA in the faeces. Prevention and treatment strategies rely on periodic mass drug administration (generally with albendazole or mebendazole) to at-risk populations and improvements in water, sanitation and hygiene. The effectiveness of drug treatment is very high for A. lumbricoides infections, whereas cure rates for T. trichiura infections are low. Novel anthelminthic drugs are needed, together with vaccine development and tools for diagnosis and assessment of parasite control in the field

Investigating the impact of extraneous distractions on consultations in general practice: Lessons learned

<p>Abstract</p> <p>Background</p> <p>Extraneous distractions may influence the flow of general practice consultations. This study piloted a methodology to examine the impact of interrupting general practitioners (GPs) while consulting actor-patients.</p> <p>Methods</p> <p>Six GPs were video recorded consulting six actor-patients each presenting a different clinical scenario in a simulated surgery. Five cases presented red flag cancer symptoms. Half the consultations were interrupted. Two independent assessors, blinded to the occurrence of interruptions, assessed consultation performance using the Leicester Assessment Package (LAP) for clinical competence.</p> <p>Results</p> <p>24 of 36 consultations were video recorded with sufficient audio-visual clarity to allow scoring. The association between LAP score and three variables could be studied: a variety of interruptions, different GPs and various scenarios. Agreement between assessors on GP performance was poor and showed an increased bias with increasing LAP score. Despite this, the interruption did not significantly impact on assessor LAP scores (Mean difference: 0.22, P = 0.83) even after controlling for assessor, different GPs and scenarios.</p> <p>Conclusion</p> <p>Extraneous distractions had no impact on GP performance in this underpowered pilot study, a conclusion which needs to be confirmed in a larger study. However several important lessons were learned. Recorded actor-patient clinical sessions are logistically challenging. GPs whose skills were not previously assessed were working in unfamiliar surroundings dealing with relatively straight forward diagnostic challenges and may have anticipated the interruptions. In a redesign of this experiment it may be possible to eliminate some of these limitations.</p

Investigating the impact of extraneous distractions on consultations in general practice: Lessons learned

<p>Abstract</p> <p>Background</p> <p>Extraneous distractions may influence the flow of general practice consultations. This study piloted a methodology to examine the impact of interrupting general practitioners (GPs) while consulting actor-patients.</p> <p>Methods</p> <p>Six GPs were video recorded consulting six actor-patients each presenting a different clinical scenario in a simulated surgery. Five cases presented red flag cancer symptoms. Half the consultations were interrupted. Two independent assessors, blinded to the occurrence of interruptions, assessed consultation performance using the Leicester Assessment Package (LAP) for clinical competence.</p> <p>Results</p> <p>24 of 36 consultations were video recorded with sufficient audio-visual clarity to allow scoring. The association between LAP score and three variables could be studied: a variety of interruptions, different GPs and various scenarios. Agreement between assessors on GP performance was poor and showed an increased bias with increasing LAP score. Despite this, the interruption did not significantly impact on assessor LAP scores (Mean difference: 0.22, P = 0.83) even after controlling for assessor, different GPs and scenarios.</p> <p>Conclusion</p> <p>Extraneous distractions had no impact on GP performance in this underpowered pilot study, a conclusion which needs to be confirmed in a larger study. However several important lessons were learned. Recorded actor-patient clinical sessions are logistically challenging. GPs whose skills were not previously assessed were working in unfamiliar surroundings dealing with relatively straight forward diagnostic challenges and may have anticipated the interruptions. In a redesign of this experiment it may be possible to eliminate some of these limitations.</p

Building a tool to overcome barriers in research-implementation spaces: The conservation evidence database

Conservation practitioners, policy-makers and researchers work within shared spaces with many shared goals. Improving the flow of information between conservation researchers, practitioners and policy-makers could lead to dramatic gains in the effectiveness of conservation practice. However, several barriers can hinder this transfer including lack of time, inaccessibility of evidence, the real or perceived irrelevance of scientific research to practical questions, and the politically motivated spread of disinformation. Conservation Evidence works to overcome these barriers by providing a freely-available database of summarized scientific evidence for the effects of conservation interventions on biodiversity. The methods used to build this database – a combination of discipline-wide literature searching and subject-wide evidence synthesis – have been developed over the last 15 years to address the challenges of synthesizing large volumes of evidence of varying quality and measured outcomes. Here, we describe the methods to enhance understanding of the database and how it should be used. We discuss how the database can help to expand multi-directional information transfers between research, practice and policy, which should improve the implementation of evidence-based conservation and, ultimately, achieve better outcomes for biodiversity

Ground Dwelling Ants as Surrogates for Establishing Conservation Priorities in the Australian Wet Tropics

This study aims to identify a set of areas with high biodiversity value over a small spatial scale within the Australian Wet Tropics. We identified sites of high biodiversity value across an altitudinal gradient of ground dwelling ant communities using three measures of biodiversity. The three measures considered were estimated species richness, complementarity between sites and evolutionary history. The latter measure was derived using the systematic nomenclature of the ants to infer a surrogate phylogeny. The goal of conservation assessments could then be achieved by choosing the most diverse site combinations. This approach was found to be valuable for identifying the most diverse site combinations across an altitudinal gradient that could ensure the preservation of terrestrial ground dwelling invertebrates in the Australian Wet Tropics