The signs and symptoms of Ernest Shackleton.

Ernest Shackleton, an accomplished Antarctic explorer, developed a life-threatening illness during the Discovery Antarctic expedition of 1901-4. His documented signs and symptoms included inflamed gums attributed to scurvy, severe dyspnea, and exercise intolerance, presenting in a setting of nutritional deficiency. Physical examinations at a later date, also following a prolonged diet of limited fresh food, revealed a pulmonary systolic murmur. Thiamine deficiency with cardiomyopathy, either alone or subsequently exacerbated by advanced scurvy, may have been a prominent cause of Shackleton's condition.

International Collaboration in the Time of COVID-19: The World Hospice and Palliative Care Social Work Network.

In the context of widespread loss, isolation, and grief due to COVID-19, palliative social workers came together in the fall of 2020 to form an international group named the World Hospice and Palliative Care Social Work Network (WHPCSW). This emerging global network is committed to amplifying the innovative work, nuanced skills, research, and education and training provided by palliative social workers across different settings around the world. This article highlights some of the novel interventions developed by social workers in response to the pandemic and describes this coalescing WHPCSW network along with information about its mission and membership.

Comparative assessment of methicillin resistant Staphylococcus aureus diagnostic assays for use in resource-limited settings.

BACKGROUND: The rise of methicillin-resistant Staphylococcus aureus (MRSA) is a global health concern. Paucity of data on MRSA carriage prevalence and diagnostic methods in resource-limited settings hampers efforts to define the problem and plan an appropriate response. Additionally, high variability in cost and logistical characteristics of MRSA screening methods may impede infection control efforts. We compared the performance of locally-available chromogenic agar BD CHROMagar MRSA II and two PCR-based assays (Hain GenoQuick MRSA and Cepheid Xpert SA Complete) for the detection of asymptomatic MRSA carriage in nasal swabs. RESULTS: During 2015, we enrolled 500 patients from five hospital wards at a Ugandan regional referral hospital. We found 30% prevalence of methicillin-sensitive Staphylococcus aureus (MSSA) nasal carriage, and 5.4% MRSA nasal carriage prevalence. Compared to a composite reference standard defined as a positive test result on any one of the three assays, Hain GenoQuick MRSA demonstrated the highest sensitivity (96%) followed by direct plating on CHROMagar at (70%), with the lowest sensitivity observed with Xpert SA Complete (52%). Cepheid Xpert provided the most rapid results (< 1 h) but was the most expensive (US $45-50/test). Substantially more labor was required for the Hain GenoQuick MRSA compared to Xpert SA Complete or CHROMagar tests. CONCLUSION: MRSA nasal carriage prevalence rates were low, and high diagnostic sensitivity was achieved using Hain GenoQuick MRSA. Chromogenic media had significantly lower sensitivity, but may represent a viable local option given its lower cost compared to PCR-based assays.

The analgesic effects of intrathecal morphine in comparison with ultrasound-guided transversus abdominis plane block after caesarean section: a randomised controlled trial at a Ugandan regional referral hospital.

Both transversus abdominis plane block and intrathecal morphine may produce prolonged postoperative analgesia, but the respective clinical outcomes of these anaesthetic techniques in resource-limited settings are not well described. We randomly assigned patients undergoing caesarean section to receive a hyperbaric bupivacaine (10 mg) spinal anaesthetic followed by an ultrasound-guided transversus abdominis plane block, or a hyperbaric bupivacaine (10 mg) spinal anaesthetic with 100 mcg intrathecal morphine, followed by a postoperative sham block. Supplemental postoperative analgesia included self-administered oral diclofenac 50 mg and paracetamol 1 g every 8 h. Numerical pain rating scores, the need for rescue medication, side-effects and patient satisfaction were recorded at 8, 16 and 24 h. We enrolled a total of 130 patients, with 65 women in each group. The mean numerical rating score for intrathecal morphine vs. transversus abdominis plane blocks at 8 h were: at rest, 2.5 vs. 3.1 (p = 0.04); with coughing, 4.3 vs. 4.8 (p = 0.07); and with movement, 3.6 vs. 4.2 (p = 0.06). At 16 h, respective scores were: 2.9 vs. 3.1 (p = 0.40) at rest; 4.0 vs. 4.3 (p = 0.19) with coughing; and 4.8 vs. 5.0 (p = 0.33) with movement. At 24 h, the respective scores were: 2.9 vs. 2.3 (p = 0.01); 4.6 vs. 4.2 (p = 0.04) with coughing; and 3.9 vs. 3.4 (p = 0.02) with movement. The need for rescue medication and the incidence of pruritis, sedation and nausea and vomiting were similar in both groups. Patient satisfaction with pain control was similar in both groups, with the majority of patients reporting satisfaction as good or excellent. Intrathecal morphine and transversus abdominis plane block provided clinically similar outcomes for pain relief after caesarean section.

The Quality and Utility of Surgical and Anesthetic Data at a Ugandan Regional Referral Hospital.

BACKGROUND: There are little primary data available on the delivery or quality of surgical treatment in rural sub-Saharan African hospitals. To initiate a quality improvement system, we characterized the existing data capture at a Ugandan Regional Referral Hospital. METHODS: We examined the surgical ward admission (January 2008-December/2011) and operating theater logbooks (January 2010-July 2011) at Mbarara Regional Referral Hospital. RESULTS: There were 6346 admissions recorded over three years. The mean patient age was 31.4 ± 22.3 years; 29.8 % (n = 1888) of admissions were children. Leading causes of admission were general surgical problems (n = 3050, 48.1 %), trauma (n = 2041, 32.2 %), oncology (n = 718, 11.3 %) and congenital condition (n = 193, 3.0 %). Laparotomy (n = 468, 35.3 %), incision and drainage (n = 188, 14.2 %) and hernia repair (n = 90, 6.8 %) were the most common surgical procedures. Of 1325 operative patients, 994 (75 %) had an ASA I-II score. Of patients undergoing 810 procedures booked as non-elective, 583 (72 %) had an ASA "E" rating. Records of 41.3 % (n-403/975) of patients age 5 years or older undergoing non-obstetric operations were missing from the ward logbook. Missing patients were younger (25 [13,40] versus 30 [18,46] years, p = 0.002) and had higher ASA scores (ASA III-V 29.0 % versus 18.9 %, p < 0.001) than patients recorded in the logbbook; there was no diffence in gender (male 62.8 % versus 67.0 %, p = 0.20). CONCLUSIONS: The hospital records system measures surgical care, but improved data capture is needed to determine outcomes with sufficient accuracy to guide and record expansion of surgical capacity.

Age-dependency of sevoflurane-induced electroencephalogram dynamics in children.

BACKGROUND: General anaesthesia induces highly structured oscillations in the electroencephalogram (EEG) in adults, but the anaesthesia-induced EEG in paediatric patients is less understood. Neural circuits undergo structural and functional transformations during development that might be reflected in anaesthesia-induced EEG oscillations. We therefore investigated age-related changes in the EEG during sevoflurane general anaesthesia in paediatric patients. METHODS: We analysed the EEG recorded during routine care of patients between 0 and 28 yr of age (n=54), using power spectral and coherence methods. The power spectrum quantifies the energy in the EEG at each frequency, while the coherence measures the frequency-dependent correlation or synchronization between EEG signals at different scalp locations. We characterized the EEG as a function of age and within 5 age groups: <1 yr old (n=4), 1-6 yr old (n=12), >6-14 yr old (n=14), >14-21 yr old (n=11), >21-28 yr old (n=13). RESULTS: EEG power significantly increased from infancy through ∼6 yr, subsequently declining to a plateau at approximately 21 yr. Alpha (8-13 Hz) coherence, a prominent EEG feature associated with sevoflurane-induced unconsciousness in adults, is absent in patients <1 yr. CONCLUSIONS: Sevoflurane-induced EEG dynamics in children vary significantly as a function of age. These age-related dynamics likely reflect ongoing development within brain circuits that are modulated by sevoflurane. These readily observed paediatric-specific EEG signatures could be used to improve brain state monitoring in children receiving general anaesthesia.

Synchronous distance anesthesia education by Internet videoconference between Uganda and the United States.

STUDY OBJECTIVE: We evaluated the effectiveness of anesthesia education delivered via Internet videoconferencing between the Massachusetts General Hospital, Boston, MA, and Mbarara Regional Referral Hospital, Uganda. DESIGN: This is a prospective educational study. SETTING: The setting is the education in 2 hospitals in Uganda and the United States. SUBJECTS: The subjects are anesthesia residents. INTERVENTIONS: The interventions are anesthesia education lectures delivered in person and via Internet videoconferencing. MEASUREMENTS: The average pre-lecture and post-lecture scores of the local, remote, and combined audiences were compared. MAIN RESULTS: Post-lecture test scores improved over pre-lecture scores: local audience, 59% ± 22% to 81% ± 16%, P = .0002, g = 1.144; remote audience, 51% ± 19% to 81% ± 8%, P < .0001, g = 2.058; and combined scores, 56% ± 14% to 82% ± 8%, P < .0001, g = 2.069). CONCLUSIONS: Transfer of anesthetic knowledge occurs via small group lectures delivered both in person and remotely via synchronous Internet videoconferencing. This technique may be useful to expand educational capacity and international cooperation between academic institutions, a particular priority in the growing field of global health.

Effect of the first GnRH and two doses of PGF2α in a 5-day progesterone-based CO-Synch protocol on heifer pregnancy.

The objectives were (1) to determine the effects of gonadorelin hydrochloride (GnRH) injection at controlled internal drug release (CIDR) insertion on Day 0 and the number of PGF2α doses at CIDR removal on Day 5 in a 5-day CO-Synch + CIDR program on pregnancy rate (PR) to artificial insemination (AI) in heifers; (2) to examine how the effect of systemic concentration of progesterone and size of follicles influenced treatment outcome. Angus cross beef heifers (n = 1018) at eight locations and Holstein dairy heifers (n = 1137) at 15 locations were included in this study. On Day 0, heifers were body condition scored (BCS), and received a CIDR. Within farms, heifers were randomly divided into two groups: at the time of CIDR insertion, the GnRH group received 100 µg of GnRH and No-GnRH group received none. On Day 5, all heifers received 25 mg of PGF2α at the time of CIDR insert removal. The GnRH and No-GnRH groups were further divided into 1PGF and 2PGF groups. The heifers in 2PGF group received a second dose of PGF2α 6 hours after the administration of the first dose. Beef heifers underwent AI at 56 hours and dairy heifers at 72 hours after CIDR removal and received 100 µg of GnRH at the time of AI. Pregnancy was determined approximately at 35 and/or 70 days after AI. Controlling for herd effect (P < 0.06), the treatments had significant effect on AI pregnancy in beef heifers (P = 0.03). The AI-PRs were 50.3%, 50.2%, 59.7%, and 58.3% for No-GnRH + PGF + GnRH, No-GnRH + 2PGF + GnRH, GnRH + PGF + GnRH, and GnRH + 2PGF + GnRH groups, respectively. The AI-PRs were ranged from 50% to 62.4% between herds. Controlling for herd effects (P < 0.01) and for BCS (P < 0.05), the AI pregnancy was not different among the treatment groups in dairy heifers (P > 0.05). The AI-PRs were 51.2%, 51.9%, 53.9%, and 54.5% for No-GnRH + PGF + GnRH, No-GnRH + 2PGF + GnRH, GnRH + PGF + GnRH, and GnRH + 2PGF + GnRH groups, respectively. The AI-PR varied among locations from 48.3% to 75.0%. The AI-PR was 43.5%, 50.4%, and 64.2% for 2.5 or less, 2.75 to 3.5, and greater than 3.5 BCS categories. Numerically higher AI-PRs were observed in beef and dairy heifers that exhibited high progesterone concentrations at the time of CIDR insertion (>1 ng/mL, with a CL). In addition, numerically higher AI-PRs were also observed in heifers receiving CIDR + GnRH with both high and low progesterone concentration (<1 ng/mL) initially compared with heifers receiving a CIDR only with low progesterone. In dairy heifers, there were no differences in the pregnancy loss between 35 and 70 days post-AI among the treatment groups (P > 0.1). In conclusion, GnRH administration at the time of CIDR insertion is advantageous in beef heifers, but not in dairy heifers, to improve AI-PR in the 5-day CIDR + CO-Synch protocol. In addition, in this study, both dairy heifers that received either one or two PGF2α doses at CIDR removal resulted in similar AI-PR in this study regardless of whether they received GnRH at CIDR insertion.

Artificial insemination at 56 h after intravaginal progesterone device removal improved AI pregnancy rate in beef heifers synchronized with five-day CO-Synch + controlled internal drug release (CIDR) protocol.

The objective was to determine whether timed artificial insemination (TAI) 56 h after removal of a Controlled Internal Drug Release (CIDR, 1.38 g of progesterone) insert would improve AI pregnancy rate in beef heifers compared to TAI 72 h after CIDR insert removal in a 5-days CO-Synch + CIDR protocol. Angus cross beef heifers (n = 1098) at nine locations [WA (5 locations; n = 634), ID (2 locations; n = 211), VA (one location; n = 193) and WY (one location; n = 60)] were included in this study. All heifers were given a body condition score (BCS; 1-emaciated; 9-obese), and received a CIDR insert and 100 µg of gonadorelin hydrochloride (GnRH) on Day 0. The CIDR insert was removed and two doses of 25 mg of dinoprost (PGF(2α)) were given, first dose at CIDR insert removal and second dose 6 h later, on Day 5. A subset of heifers (n = 629) received an estrus detector aid at CIDR removal. After CIDR removal, heifers were observed thrice daily for estrus and estrus detector aid status until they were inseminated. Within farm, heifers were randomly allocated to two groups and were inseminated either at 56 h (n = 554) or at 72 h (n = 544) after CIDR removal. All heifers were given 100 µg of GnRH at AI. Insemination 56 h after CIDR insert removal improved AI pregnancy rate compared to insemination 72 h (66.2 vs. 55.9%; P < 0.001; 1 - ß = 0.94). Locations, BCS categories (≤ 6 vs. > 6) and location by treatment and BCS by treatment interactions did not influence AI pregnancy rate (P > 0.1). The AI pregnancy rates for heifers with BCS ≤ 6 and > 6 were 61.8 and 60.1%, respectively (P > 0.1). The AI pregnancy rates among locations varied from 54.9 to 69.2% (P > 0.1). The AI pregnancy rate for heifers observed in estrus at or before AI was not different compared to heifers not observed in estrus [(65.4% (302/462) vs. 52.7% (88/167); P > 0.05)]. In conclusion, heifers inseminated 56 h after CIDR insert removal in a 5-days CO-Synch + CIDR protocol had, on average, 10.3% higher AI pregnancy rate compared to heifers inseminated 72 h after CIDR insert removal.

Prolongation of the corrected QT complex--a cause of sudden cardiac death in the mountain environment?

In the mountain environment sudden cardiac death (SCD) has been shown to be responsible for the deaths of up to 52% of downhill skiers and 30% of hikers. The majority of SCD's are precipitated by a ventricular arrhythmia. Although most are likely to result from structural abnormalities associated with conditions such as ischaemic heart disease, a small but significant number may be due to abnormalities in ion channel activity, commonly known as, "channelopathies". Channelopathies have the potential to lengthen the time between ventricular depolarisation and repolarisation that can result in prolongation of the corrected QT interval (QTc) and episodes of polymorphic ventricular tachycardia (PVT) and eventually, ventricular fibrillation. This review examines the factors that prolong the QTc interval in the mountain environment and outlines a practical framework for preventing the life threatening arrhythmias that are associated with this condition.

Christmas: Years Like This. Ingested foreign bodies and societal wealth: three year observational study of swallowed coins.

OBJECTIVE: To examine the relation between coins ingested by children and the Dow Jones Industrial Average. DESIGN: Observational study. Main outcome measures Total value of coins ingested and number of incidents of coins versus other objects swallowed, measured before and after the stock market crash of October 2008. RESULTS: Eighteen objects, including 11 coins, were ingested (NASDAQ (numismatic and sundry detritus acquired) composite of 18). The total value of the 11 coins swallowed was $1.03 (FTSE 100 (fraction of the US$ or 100 cents) index of 103). The pecuniary extraction ratio (PE ratio) was 0.57 (9/16). Comparing values for a period before and after October 2008, the mean monthly NASDAQ composite (0.41 (SD 0.67) v 0.5 (0.85), P=0.75), FTSE 100 index in cents (2.3 (6.8) v 3.1 (7.8), P=0.77), and PE ratio (0.54 (0.52) v 0.66 (0.29), P=0.50) did not change. The mean end-of-month closing value of the Dow Jones, however, decreased significantly (12 537 (841.4) v 8388 (699.8), P<0.001) CONCLUSION: There was no detectable difference in the total value of coins ingested, or ratio of coins to other objects swallowed, before or after a massive stock market crash.

Mountain mortality: a review of deaths that occur during recreational activities in the mountains.

The growing popularity of activities such as hiking, climbing, skiing and snowboarding has ensured that the number of visitors to mountain environments continues to increase. Since such areas place enormous physical demands on individuals, it is inevitable that deaths will occur. Differences in the activities, conditions and methods of calculation make meaningful mortality rates difficult to obtain. However, it is clear that the mortality rate for some mountain activities is comparable to hang gliding, parachuting, boxing and other pastimes that are traditionally viewed as dangerous. Deaths in the mountains are most commonly due to trauma, high altitude illness, cold injury, avalanche burial and sudden cardiac death. This review describes the mortality rates of those who undertake recreational activities in the mountains and examines the aetiology that lies behind them.

Anaesthesia and high altitude: a history.

During an expedition to climb Everest in 1933, expedition doctor Raymond Greene administered an open-drop chloroform anaesthetic to a Tibetan patient at an altitude of more than 14,000 feet. The patient's subsequent apparent cardiopulmonary arrest has long been attributed to the effects of altitude on anaesthetic delivery. However, anaesthetics can be safely administered at a wide variety of altitudes by adequately trained and experienced anaesthetists. The problems may have arisen from an inadequate depth of anaesthesia consequent to decreased chloroform vaporisation in a cold environment, Greene's concern about potential depression of ventilation and the contemporary lack of a precise approach to assessing depth of anaesthesia.

Patients and their families.

The focus of this chapter is on how clinicians can understand and communicate with the families of patients suffering from cancer. Most doctors and nurses do not have training in this area and are uncomfortable when conducting interviews with whole families. The need to extend our skills in the family context reflects the changes in the way care is provided to patients with a serious illness. We recognise the part families play in providing care and the subsequent effects on family life. The influence of systemic thinking and social construction theories has led to the acknowledgement that we are all part of systems which interact with each other and it is no longer appropriate to see the patient in isolation. The chapter will look at ideas from family therapy which can help us assess and intervene when necessary. The patient suffering from a life-threatening illness such as cancer looks to his family and friends for care and support. The management and course of the illness is affected by the involvement of the family and how they manage the stress and the effects of illness on a family member (Wright and Leahey 2000). Duhamel and Dupuis (2003) point out that there are three important factors in the management of the illness: the effects of family stress, the needs of the family as caregivers, and the effects of the role and how the family cope with the way the patient experiences his illness. This presents professionals working in the field with challenges they are often ill-equipped to deal with. Most healthcare workers have inadequate training in understanding family dynamics and even less knowledge about how to communicate effectively with whole families. Consequently, many healthcare professionals avoid couple and family interviews, feeling inadequate and helpless like the families themselves. I will address some of these issues in the chapter, firstly by examining what we now regard as the family and then by using ideas from systemic theory I will look at assessing families, the organisation of families and belief systems, concluding with communications which can bring about change in families needing our help. Families are complex, they have histories and are influenced by the past. Relationships within families have different meanings and significance not understood unless questions that we ask bring access to them; moreover, their journeys through the illness of the family member is different from that of the patients. However, the need for support/information/valuing/respect is the same. If we are to help, we need to know how to approach families, how to asses their needs, and learn about interventions that help so that we can offer holistic care which will ease the practical, physical, emotional, social and spiritual pain and suffering of the people who will go on living with the significance of the death.

A study examining inter- and intrarater reliability of three scales for measuring severity of psoriasis: Psoriasis Area and Severity Index, Physician's Global Assessment and Lattice System Physician's Global Assessment.

BACKGROUND: There is a lack of consensus as to the best way of monitoring psoriasis severity in clinical trials. The Psoriasis Area and Severity Index (PASI) is the most frequently used system and the Physician's Global Assessment (PGA) is also often used. However, both instruments have some drawbacks and neither has been fully evaluated in terms of 'validity' and 'reliability' as a psoriasis rating scale. The Lattice System Physician's Global Assessment (LS-PGA) scale has recently been developed to address some disadvantages of the PASI and PGA. OBJECTIVES: To evaluate the inter-rater and intrarater reliability of the PASI, PGA and LS-PGA. METHODS: On the day before the study, 14 dermatologists (raters), with varied experience of assessing psoriasis, received detailed training (2.5 h) on use of the scales. On the study day, each rater evaluated 16 adults with chronic plaque psoriasis in the morning and again in the afternoon. Raters were randomly assigned to assess subjects using the scales in a specific sequence, either PGA, LS-PGA, PASI or PGA, PASI, LS-PGA. Each rater used one sequence in the morning and the other in the afternoon. The primary endpoint was the inter-rater and intrarater reliability as determined by intraclass correlation coefficients (ICCs). RESULTS: All three scales demonstrated 'substantial' (a priori defined as ICC > 80%) intrarater reliability. The inter-rater reliability for each of the PASI and LS-PGA was also 'substantial' and for the PGA was 'moderate' (ICC 75%). CONCLUSIONS: Each one of the three scales provided reproducible psoriasis severity assessments. In terms of both intrarater and inter-rater reliability values, the three scales can be ranked from highest to lowest as follows: PASI, LS-PGA and PGA.

Anaesthesia for peculiar cells--a century of sickle cell disease.

Sickle cell disease is a congenital haemoglobinopathy with a high incidence of perioperative complications. Traditional anaesthetic management, based largely on extrapolation from biochemical models, has emphasized avoidance of red cell sickling to prevent exacerbations of the disease. This historical review outlines the evolution of the traditional approach to sickle cell pathology, assesses the validity of this model, describes the emergence of the concept of the disease as one defined by chronic inflammatory vascular damage, and outlines the practical implications of this new approach.

Management of multiple intracranial aneurysms: neuroanesthetic considerations of sickle cell disease.

Intracranial aneurysms are a common complication of sickle cell disease. The management of a patient with multiple intracranial aneurysms and sickle cell disease is described. The English language literature is reviewed. Neuroanesthetic management has traditionally been based on the avoidance of factors said to lead to erythrocyte sickling; however neuropathology typically arises from arterial intimal damage, not from venous sickling. Neuroanesthesia should be based on an appreciation of this pathophysiological model. Consideration of precipitants of vaso-occlusive crises, such as hypothermia, dehydration and possibly altered hemodynamics, should influence management.