A 10-Year Prospective Evaluation of Balloon Tube Tamponade and Emergency Injection Sclerotherapy for Actively Bleeding Oesophageal Varices

During a 10 year study period 234 patients were admitted on 371 occasions with a total of 566 acute variceal bleeding episodes. Of these, 173 patients had 343 variceal bleeds which required balloon tamponade to achieve initial control of bleeding during 229 admissions and were then referred for emergency injection sclerotherapy. Sixty-eight percent of these patients had alcoholic cirrhosis and 42% were poor risk Grade C patients. Injection sclerotherapy was performed initially using the rigid Negus oesophagoscope under general anaesthesia and later using the fibreoptic endoscope under light sedation. Definitive control of variceal bleeding was achieved with sclerotherapy during 197 hospital admissions (92%). Of the 17 failures of emergency sclerotherapy, 4 patients died from uncontrolled bleeding and 13 patients underwent major surgical intervention. Definitive control of variceal bleeding was achieved with a single injection treatment in 138 hospital admissions (70%). Complications were mostly of a minor nature and occurred at a rate of 6% per injection treatment. The overall hospital admission mortality was 36%. The majority of patients died due to liver failure. The mortality in patients who required 4 injection treatments to control variceal bleeding was 71%. Injection sclerotherapy is proposed as the emergency treatment of choice for patients whose variceal bleeding continues or recurs after initial conservative management. Patients whose variceal bleeding is not controlled by 2 injection treatments require more major emergency surgery

Environmental challenges to operationalisation of South African rainfall enhancement

Most of the atmospheric moisture in systems moving across South Africa leaves the sub-continent as the weather systems move out over the ocean, only a tenth of it falls on the landmass as rain. An increase in the efficiency of the atmospheric moisture delivery system by means of rainfall enhancement is therefore an attractive concept. Rainfall enhancement functions by either providing additional Cloud Condensation Nuclei or Ice forming Nuclei that will beneficially influence the precipitation formation process, improving the efficiency of moisture to rainfall conversion. Systematic South African research into rainfall enhancement started in the 1970s. The South African Rainfall Enhancement Programme (SAREP), initiated in the late 1990\'s, is the most recent in a series of studies and was the first semi-operational rainfall enhancement project to occur in South Africa as a response to drought conditions. In a recent study (DWAF, 2004 in prep) to finalise SAREP and provide guidance on operationalising rainfall enhancement, it was recommended that environmental impact assessment must be undertaken before this technology is implemented further. Rainfall enhancement falls specifically within the jurisdiction of the National Water Act (NWA) and the National Environmental Management Act (NEMA). A licence to undertake rainfall enhancement activities is required from the Minister of Water Affairs and Forestry after an appropriate environmental impact assessment has been undertaken to inform his decision. This paper proposes an approach to fulfil the legal requirements for operationalising future rainfall enhancement. The interaction between the science of rainfall enhancement and the ability of scientific disciplines to determine relevant environmental impacts, to appropriately inform the decision-making process, is specifically highlighted. The data requirements identified by scientists during the study varies in duration and resource needs and does not differentiate between ongoing scientific research and the requisite information required for informed decision making. This paper contemplates an approach which provides for holistic and co-ordinated investigation of South African rainfall enhancement into the future. Water SA Vol. 30 (5) 2005: pp.88-9

Statin therapy in critical illness : an international survey of intensive care physicians' opinions, attitudes and practice

Background Pleotropic effects of statins on inflammation are hypothesised to attenuate the severity of and possibly prevent the occurrence of the host inflammatory response to pathogen and infection-related acute organ failure. We conducted an international survey of intensive care physicians in Australia, New Zealand (ANZ) and United Kingdom (UK). The aims of the survey were to assess the current prescribing practice patterns, attitudes towards prescribing statin therapy in critically ill patients and opinions on the need for an interventional trial of statin therapy in critically ill patients. Methods Survey questions were developed through an iterative process. An expert group reviewed the resulting 26 items for face and content validity and clarity. The questions were further refined following pilot testing by ICU physicians from Australia, Canada and the UK. We used the online Smart SurveyTM software to administer the survey. Results Of 239 respondents (62 from ANZ and 177 from UK) 58% worked in teaching hospitals; most (78.2%) practised in ‘closed’ units with a mixed medical and surgical case mix (71.0%). The most frequently prescribed statins were simvastatin (77.6%) in the UK and atorvastatin (66.1%) in ANZ. The main reasons cited to explain the choice of statin were preadmission prescription and pharmacy availability. Most respondents reported never starting statins to prevent (65.3%) or treat (89.1%) organ dysfunction. Only a minority (10%) disagreed with a statement that the risks of major side effects of statins when prescribed in critically ill patients were low. The majority (84.5%) of respondents strongly agreed that a clinical trial of statins for prevention is needed. More than half (56.5%) favoured rates of organ failure as the primary outcome for such a trial, while a minority (40.6%) favoured mortality. Conclusions Despite differences in type of statins prescribed, critical care physicians in the UK and ANZ reported similar prescription practices. Respondents from both communities agreed that a trial is needed to test whether statins can prevent the onset of new organ failure in patients with sepsis

Adjunctive corticosteroid treatment of clinical Pneumocystis jiroveci pneumonia in infants less than 18 months of age – a randomised controlled trial

Objectives. To determine the efficacy and safety of adjunctive corticosteroid therapy in clinical Pneumocystis jiroveci pneumonia (PCP) in infants exposed to HIV infection. Design. Double-blind randomised placebo-controlled trial. Methods. Infants with a clinical diagnosis of PCP, based on an ‘atypical' pneumonia with: (i) hypoxia out of proportion to the clinical findings on auscultation; (ii) C-reactive protein count less than 10 mg/l; (iii) lactate dehydrogenase level above 500 IU/l; (iv) compatible chest radiograph findings; and (v) positive HIV enzyme-linked immunosorbert assay (ELISA) were included in the study. Patients were randomised to receive either prednisone or placebo. The protocol provided for the addition of prednisone to the treatment at 48 hours if there was clinical deterioration or an independent indication for steroid therapy. Other treatment was carried out in accordance with established guidelines. The primary study endpoint was in-hospital survival. Secondary outcome was time from admission to the first day of mean oxygen saturation above 90% in room air. Results. One hundred patients were included, 47 in the prednisone and 53 in the placebo group. Patients in the prednisone group had a 43% better chance of survival than the placebo group (hazard ratio (HR) 0.57, 95% confidence interval (CI) 0.30 - 1.07, p=0.08). No significant differences could be demonstrated between groups with regard to other parameters of recovery. Conclusions. In HIV-exposed infants with clinical PCP, adjunctive corticosteroid treatment does not appear to add benefit regarding time to recovery or oxygen independency, but early administration may improve survival. A large multicentred trial is needed to confirm these findings.South African Medical Journal Vol. 98 (4) 2008: pp.287-29

Nutritional support of children with chronic liver disease

Anorexia, malabsorption and metabolic derangements contribute to the malnutrition that occurs in most children with chronic liverdisease. Nutritional support should be started early in the management of these children with the co-operation of a paediatric dietitian toimprove quality of life and decrease post-transplant mortality.Nutritional assessment entails a detailed dietary history, physical examination and anthropometry. Weight-based anthropometricmeasures are unreliable while mid-upper-arm circumference and skinfold thickness provide more reliable estimates of nutritional status.Special investigations such as serum vitamin levels and skeletal X-rays further guide management.High energy (130 - 150% of recommended daily intake (RDI)) and protein (3 - 4 g/kg/day) intakes are recommended. Diets are usuallyenriched with medium-chain fatty acids because of their better absorption in cholestatic liver disease. High-dose fat-soluble vitaminsupplements are given while care is taken to avoid toxicity. Initial doses are two to three times the RDI and then adjusted according to serumlevels or international normalised ratio (INR) in the case of vitamin K.Children with good appetites are fed orally. Feeds should be more regular than for other children to avoid prolonged periods of fastingand improve energy intake. Some children require supplementary nasogastric feeds to increase energy intake and avoid overnight fasting

The use of organisational network analysis as a diagnostic tool during team coaching

Orientation: Organisational network analysis (ONA) examines relationships between people and is a potential diagnostic tool to use during team coaching interventions.   Research purpose: The objective of this research was to investigate how ONA can be used during a team coaching intervention aimed at addressing business challenges.   Motivation for the study: The use of ONA as a diagnostic tool in individual coaching has been researched, but has not been applied in the emerging field of team coaching.   Research approach/design and method: An action research methodology employing both quantitative and qualitative methods was used in this research. A purposive sampling approach was used to select a leadership team of four people who received 11 team coaching sessions. Quantitative data were collected from the leadership team and their 18 direct reports, using pre- and post-test intervention ONA questionnaires. Qualitative data were collected after the coaching intervention using semi-structured interviews with the leadership team.   Main findings: Organisational network analysis helped to identify team coaching goals based on business challenges. It indicated the extent to which team coaching enhanced communication between the leadership team and their reports, enabling them to address business challenges. Organisational network analysis results taken out of context could, however, be misinterpreted.   Practical/managerial implications: Team coaches, ONA practitioners and leadership teams could use ONA as a diagnostic tool during team coaching interventions to identify team coaching goals based on business challenges, to gain insights into team dynamics and to assess the contribution of team coaching for addressing business challenges. Organisational network analysis should not be taken at face value and should ideally be triangulated with other data sources such as interviews.   Contribution/value-add: On a scholarly level, this research provides empirical evidence for the benefits of using ONA during a team coaching intervention. On a practice level, suggestions are provided for the manner in which ONA can guide team coaching interventions