Spinal clearance guideline for out-of hospital providers

IntroductionUnnecessary spinal cord immobilisation is a common problem in South Africa, even though out-of hospital spinal clearance is becoming standard of care in international emergency medical care (EMC) communities. Large numbers of unnecessary spinal immobilisations, in low risk trauma patients, result in an increased health and economic burden in both the in-hospital and out-of hospital settings. Currently, informal spinal clearance is being practiced in South Africa creating large practice variation, potential patient safety compromise and probable economic burden. An evidence-based out-of hospital spinal clearance algorithm would minimise the unnecessary hospitalisation of low risk spinal patients. Our objectives included: (i) To provide an accurate and reproducible algorithm to identify and correctly refer clinically relevant spinal injury in the out-of hospital setting and (ii) To inform policy makers of best practice for spinal cord clearance through evidence informed decision making and provide implementation and evaluation recommendations. This document provides recommendations for a spinal clearance guideline for South Africa and includes implementation strategies and evaluation criteria.MethodsA Population, Intervention, Professionals, Outcomes and Health Context (PIPOH) research question was designed to answer the guideline topic. The literature was systematically searched for spinal clearance guidelines or recommendations. These were screened, appraised and adapted by a specialist emergency care review group using the Appraisal of Guidelines Research and Evaluation (AGREE II) and ADAPTE tools recommended for guideline adaptation and development. The results were filtered by the primary author using pre-defined selection criteria.ResultsA total of 8 guidelines met the inclusion criteria. Each guideline was independently assessed by two emergency care specialists using the AGREE II tool. A forum discussion was held to adapt the included guidelines to the local out-of hospital needs. Emergency care policy stakeholders and operational and student paramedics were asked to review and comment on the adapted algorithm.ConclusionAn out-of hospital spinal clearance guideline was developed with evaluation and implementation strategies for the out-of hospital context. The author would like to acknowledge the South African Cochrane Centre and Dr Tamara Kredo for their support

Antifibrinolytic drugs for acute traumatic injury

In South Africa, trauma is a major concern, with violence and road traffic accidents being the fifth and seventh leading causes of death, respectively. Antifibrinolytic agents have been used in trauma and major surgery to prevent fibrinolysis and reduce blood loss. We highlight an updated Cochrane review investigating the effect of antifibrinolytic drugs in patients with acute traumatic injury. The review authors conducted  comprehensive literature searches in January 2015 with regard to all randomised  controlled trials comparing antifibrinolytic agents after acute traumatic injury. Three randomised controlled trials, of which two (n=20 451) assessed the effect of  tranexamic acid (TXA), were included. The authors concluded that TXA safely reduces  mortality in trauma with bleeding without increasing the risk of adverse events. TXA should be administered as early as possible, and within 3 hours of injury. There is still uncertainty with regard to the effect of TXA on patients with traumatic brain injury; however, ongoing randomised controlled trials should shed more light on this

Atmospheric aerosol and Doppler lidar studies

Experimental and theoretical studies were performed of atmospheric aerosol backscatter and atmospheric dynamics with Doppler lidar as a primary tool. Activities include field and laboratory measurement and analysis efforts. The primary focus of activities related to understanding aerosol backscatter is the GLObal Backscatter Experiment (GLOBE) program. GLOBE is a multi-element effort designed toward developing a global aerosol model to describe tropospheric clean background backscatter conditions that Laser Atmospheric Wind Sounder (LAWS) is likely to encounter. Two survey missions were designed and flown in the NASA DC-8 in November 1989 and May to June 1990 over the remote Pacific Ocean, a region where backscatter values are low and where LAWS wind measurements could make a major contribution. The instrument complement consisted of pulsed and continuous-wave (CW) CO2 gas and solid state lidars measuring aerosol backscatter, optical particle counters measuring aerosol concentration, size distribution, and chemical composition, a filter/impactor system collecting aerosol samples for subsequent analysis, and integrating nephelometers measuring visible scattering coefficients. The GLOBE instrument package and survey missions were carefully planned to achieve complementary measurements under clean background backscatter conditions

Analysis of airborne Doppler lidar, Doppler radar and tall tower measurements of atmospheric flows in quiescent and stormy weather

The first experiment to combine airborne Doppler Lidar and ground-based dual Doppler Radar measurements of wind to detail the lower tropospheric flows in quiescent and stormy weather was conducted in central Oklahoma during four days in June-July 1981. Data from these unique remote sensing instruments, coupled with data from conventional in-situ facilities, i.e., 500-m meteorological tower, rawinsonde, and surface based sensors, were analyzed to enhance understanding of wind, waves and turbulence. The purposes of the study were to: (1) compare winds mapped by ground-based dual Doppler radars, airborne Doppler lidar, and anemometers on a tower; (2) compare measured atmospheric boundary layer flow with flows predicted by theoretical models; (3) investigate the kinematic structure of air mass boundaries that precede the development of severe storms; and (4) study the kinematic structure of thunderstorm phenomena (downdrafts, gust fronts, etc.) that produce wind shear and turbulence hazardous to aircraft operations. The report consists of three parts: Part 1, Intercomparison of Wind Data from Airborne Lidar, Ground-Based Radars and Instrumented 444 m Tower; Part 2, The Structure of the Convective Atmospheric Boundary Layer as Revealed by Lidar and Doppler Radars; and Part 3, Doppler Lidar Observations in Thunderstorm Environments

Building capacity for development and implementation of clinical practice guidelines

Robust, reliable and transparent methodologies are necessary to ensure that clinical practice guidelines (CPGs) meet international criteria. In South Africa (SA) and other low- and middle-income countries, upskilling and training of individuals in the processes of CPG development is needed. Since de novo CPG development is time-consuming and expensive, new emerging CPG-development approaches (adopting, contextualising, adapting and updating existing good-quality CPGs) are potentially more appropriate for our context. These emerging CPG-development methods are either not included or sparsely covered in existing training opportunities. The SA Guidelines Excellence (SAGE) team has responded innovatively to the need for CPG training in SA. We have revised an existing SA course and developed an online, open-access CPG-development toolkit. This Guideline Toolkit is a comprehensive guideline resource designed to assist individuals who are interested in knowing how to develop CPGs. Findings from the SAGE project can now be implemented with this innovative CPG training programme. This level of CPG capacity development has the potential to influence CPG knowledge, development, practices and uptake by clinicians, managers, academics and policy-makers around the country

Viewership footprint for a low-resource, student-centred collaborative video platform to teach orthopaedics in southern Africa

Background. Institutions are increasingly using technology to augment the class learning experience of medical students. Especially in Africa, local content is key to allow insights and knowledge to emerge and build transformative capacity for students and patients. There is currently no peer-reviewed video content produced by students with the aim of providing education on orthopaedic topics for medical students and patients in this region.Objectives. To evaluate the demographic and geographical viewership as well as video-specific statistics of orthopaedic teaching videos for medical students on a YouTube channel, with the expressed aim of informing future content production.Methods. Videos were produced by South African (SA) medical students as a problem-based collaborative project. Student-owned smartphones and various types of free video editing software were used to produce these videos, which were then assessed by a group of orthopaedic specialists and uploaded onto a YouTube channel (UCTeach). The analytical reports of this channel generated by Google and YouTube were analysed regarding watch time per day (minutes), average view duration (minutes), most watched videos, top geographies, age and gender.Results. A total of 83 videos were uploaded to the UCTeach Ortho channel during a 2-year period, with a total watch time of 857 062 minutes and 337 983 views. The majority of viewers were between the ages of 18 and 34 years (85%). India had the most views (n=69 089), followed by the USA (n=66 257) and SA (n=21 882). Most of the videos were watched on mobile phones (n=183 299) and computers (n=128 228). The most watched video, produced in April 2016, was on physiological and pathological gait, with 51 314 views.Conclusions. Our study provides proof of concept for a new educational material creation and dissemination strategy. A low-cost local collaborative orthopaedic video project by medical students for medical students can lead to high view counts and watch time on YouTube. It is accessible to audiences in low-, middle- and high-income countries. The students’ educational videos also reached a global audience consistently over a 3-year period

Forecasting Lightning Threat using Cloud-Resolving Model Simulations

Two new approaches are proposed and developed for making time and space dependent, quantitative short-term forecasts of lightning threat, and a blend of these approaches is devised that capitalizes on the strengths of each. The new methods are distinctive in that they are based entirely on the ice-phase hydrometeor fields generated by regional cloud-resolving numerical simulations, such as those produced by the WRF model. These methods are justified by established observational evidence linking aspects of the precipitating ice hydrometeor fields to total flash rates. The methods are straightforward and easy to implement, and offer an effective near-term alternative to the incorporation of complex and costly cloud electrification schemes into numerical models. One method is based on upward fluxes of precipitating ice hydrometeors in the mixed phase region at the-15 C level, while the second method is based on the vertically integrated amounts of ice hydrometeors in each model grid column. Each method can be calibrated by comparing domain-wide statistics of the peak values of simulated flash rate proxy fields against domain-wide peak total lightning flash rate density data from observations. Tests show that the first method is able to capture much of the temporal variability of the lightning threat, while the second method does a better job of depicting the areal coverage of the threat. Our blended solution is designed to retain most of the temporal sensitivity of the first method, while adding the improved spatial coverage of the second. Exploratory tests for selected North Alabama cases show that, because WRF can distinguish the general character of most convective events, our methods show promise as a means of generating quantitatively realistic fields of lightning threat. However, because the models tend to have more difficulty in predicting the instantaneous placement of storms, forecasts of the detailed location of the lightning threat based on single simulations can be in error. Although these model shortcomings presently limit the precision of lightning threat forecasts from individual runs of current generation models,the techniques proposed herein should continue to be applicable as newer and more accurate physically-based model versions, physical parameterizations, initialization techniques and ensembles of forecasts become available

Task-shifting from doctors to non-doctors for initiation and maintenance of antiretroviral therapy

'Cochrane Corner’ in the August SAMJ offers evidence relating to articles published in this issue, namely ‘Improving access to antiretrovirals in rural South Africa – a call to action’, ‘Multimorbidity, control and treatment of non-communicable diseases among primary healthcare attenders in the Western Cape, South Africa’ and ‘Prevalence of tobacco use among adults in South Africa: Results from the first South African National Health and Nutrition Examination Survey’, and the editorial by Yach and Alexander, ‘Turbo-charging tobacco control in South Africa’.

Electronic consent in a COVID-19 vaccine implementation trial in South Africa: Participant perspectives.

The COVID-19 pandemic has warranted modifications to clinical research implementation to ensure adherence to public health and safety measures. Often, this modification has necessitated a deviation from the traditional face-to-face approach to an electronic or hybrid consent process. We assessed the acceptability and preference for electronic consent and explored understanding of the electronic consent information – an outcome which is vital in providing reassurance that consent is provided with full appreciation of the risks and benefits of study participation. In this descriptive study, healthcare professionals (HCPs) were invited, through a database of HCP contacts, snowball sampling and advertisement, to participate in an online survey between 14 July 2021 and 17 September 2021, to explore their experiences of providing electronic consent for enrolment into the largest implementation trial of a COVID vaccine in South Africa (SISONKE Trial). Descriptive analysis was used to characterise respondents and categorical data were expressed as frequencies. The prevalence of recurring responses to open-ended questions allowed for the identification of themes. A total of 1025 HCPs completed the online survey. Access to a COVID-19 vaccine was the strongest motivating factor for enrolment (82.3%) into the SISONKE Trial. Over a third of participants (38.6%) were not able to discuss the study with research staff. While the majority of participants (85.2%) indicated that online consent was acceptable, it was recognised that acceptability was context specific. Although 64% indicated awareness that reporting both a positive COVID test and adverse events were requirements, a significant percentage (32%) did not recall that the reporting period was 2 years. The electronic consent process was easily navigated by educated HCPs with access to electronic devices and data. Vaccine access was the most important motivation for participation, thus raising questions about how voluntary the consent process was and the role of desperation in deciding to participate.Significance:• Navigation of the electronic consent process for participation in a COVID-19 vaccine implementation trial is not a challenge for educated healthcare professionals with access to electronic devices and data. However, technical skills and access to technology may impact the integrity of the informed consent process for lay research participants.• Motivation to join research studies for access to scarce resources impacts negatively on the authenticity of the consent processes, as participation may be informed but not truly voluntary, and is an issue that ethics committees and researchers should address