RESUMEN
BACKGROUND: Maternal mortality in low- and middle-income countries (LMICs) is higher than in high-income countries (HICs), and poor anesthesia care is a contributing factor. Many anesthesia complications are considered preventable with adequate training. The Safer Anaesthesia From Education Obstetric Anaesthesia (SAFE-OB) course was designed as a refresher course to upgrade the skills of anesthesia providers in low-income countries, but little is known about the long-term impact of the course on changes in practice. We report changes in practice at 4 and 12-18 months after SAFE-OB courses in Madagascar and the Republic of Congo. METHODS: We used a concurrent embedded mixed-methods design based on the Kirkpatrick model for evaluating educational training courses. The primary outcome was qualitative determination of personal and organizational change at 4 months and 12-18 months. Secondary outcomes were quantitative evaluations of knowledge and skill retention over time. From 2014 to 2016, 213 participants participated in 5 SAFE-OB courses in 2 countries. Semistructured interviews were conducted at 4 and 12-18 months using purposive sampling and analyzed using thematic content analysis. Participants underwent baseline knowledge and skill assessment, with 1 cohort reevaluated using repeat knowledge and skills tests at 4 months and another at 12-18 months. RESULTS: At 4 months, 2 themes of practice change (Kirkpatrick level 3) emerged that were not present at 12-18 months: neonatal resuscitation and airway management. At 12-18 months, 4 themes emerged: management of obstetric hemorrhage, management of eclampsia, using a structured approach to assessing a pregnant woman, and management of spinal anesthesia. With respect to organizational culture change (Kirkpatrick level 4), the same 3 themes emerged at both 4 and 12-18 months: improved teamwork, communication, and preparation. Resistance from peers, lack of senior support, and lack of resources were cited as barriers to change at 4 months, but at 12-18 months, very few interviewees mentioned lack of resources. Identified catalysts for change were self-motivation, credibility, peer support, and senior support. Knowledge and skills tests both showed an immediate improvement after the course that was sustained. This supports the qualitative responses suggesting personal and organizational change. CONCLUSIONS: Participation at a SAFE-OB course in the Republic of Congo and in Madagascar was associated with personal and organizational changes in practice and sustained improvements in knowledge and skill at 12-18 months.
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Anestesia Obstétrica/normas , Competencia Clínica/normas , Evaluación Educacional/normas , Personal de Salud/educación , Personal de Salud/normas , Anestesia Obstétrica/economía , Anestesia Obstétrica/métodos , Congo/epidemiología , Evaluación Educacional/métodos , Femenino , Humanos , Madagascar/epidemiología , Pobreza/economía , Embarazo , Factores de TiempoRESUMEN
PURPOSE: Leptomeningeal disease (LMD) is an uncommon complication of advanced breast cancer. The prognosis is poor, and although radiotherapy (RT), systemic and intra-thecal (IT) chemotherapy are accepted treatment modalities, efficacy data are limited. This study was designed to evaluate potential predictors of survival in this patient group. METHODS: Breast cancer patients with LMD diagnosed by MRI in a 10-year period (2004-2014) were identified from electronic patient records. PFS and OS estimates were calculated using Kaplan-Meier method, with planned sub-group analysis by treatment modality. Cox regression was employed to identify significant prognostic variables. RESULTS: We identified 182 eligible patients; all female, median age at LMD diagnosis 52.5 years (range 23-80). Ninety patients (49.5%) were ER positive/HER2 negative; 48 (26.4%) were HER2 positive, and 27 (14.8%) were triple negative. HER2 status was unknown in 17 (9.3%). Initial management of LMD was most commonly whole or partial brain RT in 62 (34.1%), systemic therapy in 45 (24.7%) or supportive care alone in 37 (20.3%). Fourteen patients (7.7%) underwent IT chemotherapy, of whom two also received IT trastuzumab. From diagnosis of LMD, the median PFS was 3.9 months (95%CI 3.2-5.0) and median OS was 5.4 months (95%CI 4.2-6.6). Patients treated with systemic therapy had the longest OS (median 8.8 months, 95%CI 5.5-11.1), compared to RT; 6.1 months (95%CI 4.2-7.9 months), IT therapy; 2.9 months (95%CI 1.2-5.8) and supportive care; 1.7 months (95%CI 0.9-3.0). On multivariable analysis, triple negative histology, concomitant brain metastases, and LMD involving both the brain and spinal cord were associated with poor OS. CONCLUSIONS: Breast cancer patients with triple negative LMD, concomitant brain metastases or LMD affecting both the spine and brain have the poorest prognosis. Clinical trials to identify more effective treatments for these patients are urgently needed.
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Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias Encefálicas/secundario , Neoplasias de la Mama/patología , Carcinomatosis Meníngea/tratamiento farmacológico , Carcinomatosis Meníngea/radioterapia , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Antineoplásicos Inmunológicos/uso terapéutico , Protocolos de Quimioterapia Combinada Antineoplásica/administración & dosificación , Encéfalo , Neoplasias Encefálicas/metabolismo , Neoplasias de la Mama/metabolismo , Supervivencia sin Enfermedad , Femenino , Humanos , Infusiones Intravenosas , Infusión Espinal , Estimación de Kaplan-Meier , Carcinomatosis Meníngea/secundario , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Receptor ErbB-2/metabolismo , Receptores de Estrógenos/metabolismo , Receptores de Progesterona/metabolismo , Estudios Retrospectivos , Médula Espinal , Tasa de Supervivencia , Trastuzumab/uso terapéutico , Adulto JovenRESUMEN
An 85-year-old man presented to A&E department with a bleeding, pulsatile mass within the left antecubital fossa. He reported a 3-month history of an increasing, painless swelling. He had a history of end-stage renal failure secondary to antiglomerular basement membrane disease. 14â years prior, he had a left brachiocephalic fistula created, which was ligated shortly after its creation due to Steal syndrome. Examination revealed a 10×15×10â cm pulsatile, non-tender mass with overlying ulceration in the left antecubital fossa. Arterial duplex demonstrated a pseudoaneurysm arising from the left distal brachial artery with a 9â mm neck. The patient underwent surgical exploration and repair. At surgery, a large brachial artery pseudoaneurysm at the site of the previous fistula ligation was found. The overlying ulcerated skin and pseudoaneurysm were excised en mass, and the arterial defect repaired by transection and end-to-end anastomosis. This is the first reported case of a brachial artery pseudoaneurysm occurring following arteriovenous fistula ligation.
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Muñones de Amputación/patología , Aneurisma Falso/diagnóstico , Fístula Arteriovenosa/diagnóstico , Derivación Arteriovenosa Quirúrgica/efectos adversos , Arteria Braquial/patología , Anciano de 80 o más Años , Aneurisma Falso/cirugía , Fístula Arteriovenosa/cirugía , Humanos , Ligadura/efectos adversos , Masculino , Resultado del TratamientoRESUMEN
A new method for assessing the topology of metallosupramolecular assemblies using pyrene-appended ligands is reported. Two potentially tetradentate ligands containing one (L(1)) and two (L(2)) terminal pyrene moieties were synthesised and their complexes with Cu(+) and Cd(2+) were characterised. Photophysical measurements demonstrate that in [Cu(2)(L(1))(2)](2+), [CdL(1)](2+) and [Cu(2)(L(2))(2)](2+) the emission spectra are dominated by monomeric emission but in the cadmium complex of L(2) (where the pyrene units are in close proximity) a quenching of the luminescence coupled with weak emission at 540 nm is indicative of excimer formation.