Northern Ireland and 'The Troubles', outlining an innovative approach to nursing/midwifery student teaching and module evaluation.

This discussion paper outlines an approach to developing and evaluating an educative programme primarily delivered by lay `citizen trainers' in educating student nurses, and student midwives to the impact of and experience of extended and extensive civil unrest within their communities (`the Troubles' ). This is drawn from experience within the Northern Ireland `Troubles' and all of the citizen trainers were directly affected physically/psychologically. The programme was intended to both educate but primarily to help facilitate student nurses and student midwives to better understanding to experience and context and to more effective care delivery to those affected by/damaged by `the Troubles'. Evaluation of the teaching and learning by the students was significantly positive.

Return to contact sports following infectious mononucleosis: the role of serial ultrasonography.

Splenic rupture is a rare but potentially fatal complication of infectious mononucleosis. Athletes returning to contact sports following infectious mononucleosis are at potential risk of splenic rupture secondary to abdominal trauma. No clear consensus exists as to when it is safe to allow these athletes to return to contact sports. Suggested periods of abstinence have ranged from 2 weeks to 6 months. We outline our experiences with the use of abdominal ultrasonography at 1 month after the diagnosis of infectious mononucleosis as a means of determining when athletes can safely return to contact sports. Our study group was made up of 19 such patients (mean age: 16.7 yr). We found that 16 of these patients (84%) had normal splenic dimensions on ultrasonography 1 month after diagnosis, and they were therefore allowed to return to contact sports. While the remaining 3 patients had an enlarged spleen at 1 month, their splenic dimensions had all returned to normal when ultrasonographic examination was repeated at 2 months postdiagnosis. We conclude that serial abdominal ultrasonography allows for informed decision making in determining when athletes can safely return to contact sports following infectious mononucleosis.

Laryngotracheoplasty to avoid tracheostomy in neonatal and infant subglottic stenosis.

OBJECTIVE: To outline the authors' experiences with performing laryngotracheoplasty as an alternative to tracheostomy in neonates and infants with symptomatic subglottic stenosis (SGS). STUDY DESIGN: Case series with chart review. SETTING: A tertiary referral pediatric hospital. SUBJECTS AND METHODS: Patients younger than 12 months undergoing single-stage laryngotracheoplasty for SGS at the authors' institution over a 3-year period. RESULTS: Ten patients (8 boys and 2 girls) underwent single-stage laryngotracheoplasty during the study period. There were 9 cases of acquired SGS and 1 case of congenital SGS. Eight patients had grade III SGS, and 2 patients had grade II SGS. In 9 of 10 patients, the procedure performed was an anterior cricoid split (ACS) and posterior cricoid split (PCS), with the placement of an anterior thyroid ala cartilage graft. One patient underwent ACS and PCS with the placement of a posterior rib cartilage graft, in combination with a right vocal cord lateralization. The mean period of intubation after surgery was 6.8 days (range, 5-9 days). Nine of 10 patients had a complete resolution of their airway symptoms following airway surgery, with a mean duration of follow-up of 305 days (range, 30-780 days). One patient required the placement of a tracheostomy tube 69 days postoperatively due to a failure to wean from ventilation in the setting of multiple comorbidities. CONCLUSION: Laryngotracheoplasty is a safe and effective alternative to long-term tracheostomy in infants and neonates with symptomatic SGS.

Safe surgery, the human factors approach.

Studies estimate that a degree of error occurs in 5-15% of all hospital admissions, with 45% of errors occurring in the operating theatre. Staffing limitations, high turnover rates, site and side-specific surgical procedures, make operating theatres a high-risk environment. Valuable lessons may be learned from the aviation experience with error management. With over 70% of air-crashes occurring due to human rather than technical error, the Human Factors Approach to error recognises the potential for errors occurring due to human limitations, such as stress and fatigue. It encourages error reporting in a non-punitive environment, where it is seen as a valuable source of information, facilitating education and future error prevention. Errors in healthcare and surgery however, have been traditionally associated with secrecy and embarrassment, often reaching an unsatisfactory endpoint with no resultant education. Application of the Human Factors Approach to error management in healthcare, can only serve to improve safety standards in our hospitals and satisfy ever-increasing public expectations.

Primary care management of otitis media among Australian children.

Acute otitis media (AOM) is diagnosed on the basis of acute onset of pain and fever; a red, bulging tympanic membrane; and middle ear effusion. AOM is managed with analgesia (paracetamol or non-steroidal anti-inflammatory drugs). Antibiotic therapy is minimally effective for most patients; it is most effective for children < 2 years with bilateral otitis media and for children with discharging ears. National guidelines recommend antibiotic therapy for Indigenous children with AOM. Evidence for corticosteroids, topical analgesia and xylitol are scant. Otitis media with effusion (OME) is diagnosed as the presence of middle ear effusion (type B tympanogram or immobile tympanic membrane on pneumatic otoscopy) without AOM criteria. Well children with OME with no speech and language delays can be observed for the first 3 months; perform audiological evaluation and refer to an ear, nose and throat (ENT) specialist if they have bilateral hearing impairment > 30 dB or persistent effusion. Children with effusions persisting longer than 3 months can benefit from a 2-4-week course of amoxycillin. Chronic suppurative otitis media is a chronic discharge through a tympanic membrane perforation. It is managed with regular ear cleaning (dry mopping or povidone-iodine [Betadine] washouts) until discharge resolves; topical ear drops (eg, ciprofloxacin); audiological evaluation; and ENT review.

Complications of otitis media in Indigenous and non-Indigenous children.

In Australia, three to five children die each year because of otitis media complications, and 15 children will suffer permanent hearing loss each year as a result of otitis media. Extracranial complications occur most commonly, and include mastoiditis, cholesteatoma and otitis media with perforation. Intracranial complications are less common, and include meningitis, brain abscess and lateral sinus thrombosis. In Australia, approximately 60% of extracranial and intracranial complications of otitis media occur in children. The contrasting rates of childhood otitis media among Indigenous and non-Indigenous children have implications for the frequency and types of complications occurring in both groups. Otitis media with effusion and acute otitis media predominate among non-Indigenous children, whereas chronic suppurative otitis media (CSOM) occurs most commonly among Indigenous children. The incidence of mastoiditis in Australia is low by international standards (2/100,000 children), but cholesteatoma rates among Indigenous children in Australia are higher than previously estimated (up to 10% in CSOM). A high rate of chronic tympanic membrane perforation occurs among Indigenous children, estimated to be as high as 80%. Intracranial complications of otitis media are uncommon, but are potentially life-threatening and are more likely to occur among Indigenous than non-Indigenous children. Reduced access to medical care, lower socioeconomic status and remote living conditions mean that levels of early childhood hearing loss among Indigenous children are likely to be underestimated. This has implications for early childhood speech and language development and education.

Objective assessment of supraglottoplasty outcomes using polysomnography.

OBJECTIVE: Supraglottoplasty is well documented as an effective procedure in the management of moderate to severe laryngomalacia. Traditionally assessed outcomes in the treatment of laryngomalacia include: reduced stridor, improved feeding and a resumption of weight-gain. Previous authors have documented the use of polysomnography in assessing the severity of paediatric laryngeal abnormalities. The aim of the current study was to objectively assess the efficacy of supraglottoplasty for laryngomalacia by comparing data from pre- and post-operative polysomnography. METHODS: A retrospective review was performed of patients undergoing supraglottoplasty for laryngomalacia at a tertiary referral paediatric hospital over a 35-month period. Patients were required to have undergone full overnight polysomnography both before and after supraglottoplasty. Pre- and post-operative polysomnographic results were compared and the statistical significance between mean values was determined. RESULTS: From a total of 46 patients, 10 were suitable for inclusion into the study. Mean age at first presentation was 2 months and 19 days (range 30-134 days). The surgical procedure performed was bilateral division of aryepiglottic folds alone in 1 patient (1/10), bilateral division of aryepiglottic folds and bilateral trimming of arytenoid mucosa in 5 patients (5/10) and bilateral aryepiglottic fold division, bilateral arytenoid mucosal trimming and epiglottic trimming or epiglottopexy in 4 patients (4/10). Statistically significant improvements occurred in mean values for Total Sleep Time (TST) (P=0.049), Lowest Oxygen Saturation Levels (SpO2 nadir) (P=0.006), Obstructive Apnoea Hypopnoea Index (OAHI) (P=0.009) and Respiratory Disturbance Index (RDI) (P=0.002), following supraglottoplasty. An improvement in mean Transcutaneous Carbon Dioxide (TcCO2) value occurred, but did not achieve statistical significance (57.1 vs. 52.8) (P=0.259). The mean age at which post-operative polysomnography confirmed a reversal of abnormal respiratory parameters following surgery was 5 months and 18 days. CONCLUSIONS: Polysomnography is an effective method for objectively assessing the efficacy of supraglottoplasty for laryngomalacia. Supraglottoplasty effectively reverses the abnormal respiratory parameters occurring in moderate to severe laryngomalacia.

Activation-induced expression of CD56 by T cells is associated with a reprogramming of cytolytic activity and cytokine secretion profile in vitro.

A subset of human T lymphocytes expresses the natural killer (NK) cell-associated receptor CD56 and is capable of major histocompatibility complex (MHC)-unrestricted cytotoxicity against a variety of autologous and allogeneic tumor cells. CD56+ T cells have shown potential for immunotherapy as antitumor cytotoxic effectors, but their capacity to control adaptive immune responses via cytokine secretion is unclear. We have examined the inducibility of CD56+ T cells from human blood in vitro and compared the kinetics of Th1, Th2, and regulatory cytokine secretion by CD56+ T cells with those of conventional CD56- T cells. CD56 was induced on CD8+ and CD4- CD8- T cells by CD3/T-cell receptor (TCR)-mediated activation, particularly when grown in the presence of interleukin (IL)-2. Activation-induced CD56+ T cells proliferated less vigorously but displayed enhanced natural cytotoxicity compared with CD56- T cells. CD56+ T cells released interferon-gamma (IFN-gamma) and interleukin-13 (IL-13), but not IL-10, upon TCR stimulation. Flow cytometric analysis demonstrated that, compared with CD56- T cells, elevated proportions of CD56+ T cells expressed IFN-gamma, IL-4, and IL-13 within hours of activation. These acquired cytolytic and cytokine secretion activities of CD56+ T cells make them potential targets for immunotherapy for infectious and immune-mediated disease.

Expression of recombinant Plasmodium falciparum subtilisin-like protease-1 in insect cells. Characterization, comparison with the parasite protease, and homology modeling.

Serine proteases play crucial roles in erythrocyte invasion by merozoites of the malaria parasite. Plasmodium falciparum subtilisin-like protease-1 (PfSUB-1) is synthesized during maturation of the intraerythrocytic parasite and accumulates in a set of merozoite secretory organelles, suggesting that it may play a role in host cell invasion or post-invasion events. We describe the production, purification, and characterization of recombinant PfSUB-1 and comparison with the authentic protease detectable in parasite extracts. The recombinant protease requires high levels of calcium for optimum activity and has an alkaline pH optimum. Using a series of decapeptide and protein substrates, PfSUB-1 was found to have a relaxed substrate specificity with regard to the P1 position but is unable to efficiently cleave substrates with a P1 leucine residue. Similarly, replacement of a P4 valine with alanine severely reduced cleavage efficiency, whereas its replacement with lysine abolished cleavage. In all respects investigated, the recombinant protease was indistinguishable from parasite-derived enzyme. Three-dimensional homology modeling of the PfSUB-1 catalytic domain based on an alignment with closely related bacterial subtilisins and an orthologue from the rodent malaria Plasmodium yoelii suggests that the protease has at least three potential calcium ion-binding sites, three intramolecular disulfide bridges, and a single free cysteine within the enzyme S1 pocket. A predicted highly polar S1 pocket and a hydrophobic S4 subsite are in broad agreement with the experimentally determined substrate specificity.