Surgery in the time of Ebola: how events impacted on a single surgical institution in Sierra Leone.

INTRODUCTION: The mortality and morbidity of Ebola extends far wider than those contracting the disease. Surgical activity in Sierra Leone has been severely disrupted by the epidemic. METHOD: This is a retrospective study examining the effect of the 2014-2015 Ebola virus epidemic on surgical activity in a Sierra Leone's main teaching hospital. RESULTS: The impact of national and local events on surgical provision is illustrated by the experience of Connaught Hospital, Freetown Sierra Leone. Surgical activity fell dramatically in August 2014, the month when the most health care workers died and continued to fall to just 3% of expected activity. Two of eight surgeons at Connaught Hospital died of Ebola. DISCUSSION: The example of Connaught Hospital serves as a graphic and poignant illustration of the difficulties faced by surgeons in low resource settings when dealing with the acute effects of a natural disaster. In any future epidemic, high levels of preparedness, training and protection, in addition to liaison with public health teams early in an epidemic, may allow surgeons to carry out at least some of their duties without the very high levels of personal risk seen here.In a country with so few specialists the loss of 25% is disastrous and will result in long term capacity reduction.

Pancolonic motor response to subsensory and suprasensory sacral nerve stimulation in patients with slow-transit constipation.

BACKGROUND: Sacral nerve stimulation (SNS) is emerging as a potential treatment for patients with constipation. Although SNS can elicit an increase in colonic propagating sequences (PSs), the optimal stimulus parameters for this response remain unknown. This study evaluated the colonic motor response to subsensory and suprasensory SNS in patients with slow-transit constipation. METHODS: Patients with confirmed slow-transit constipation were studied. Either a water-perfused manometry catheter or a high-resolution fibre-optic manometry catheter was positioned colonoscopically to the caecum. A temporary electrode was implanted transcutaneously in the S3 sacral nerve foramen. In the fasted state, three conditions were evaluated in a double-blind randomized fashion: sham, subsensory and suprasensory stimulation. Each 2-h treatment period was preceded by a 2-h basal period. The delta (Δ) value was calculated as the frequency of the event during stimulation minus that during the basal period. RESULTS: Nine patients had readings taken with a water-perfused catheter and six with a fibre-optic catheter. Compared with sham stimulation, suprasensory stimulation caused a significant increase in the frequency of PSs (mean(s.d.) Δ value - 1·1(7·2) versus 6·1(4·0) PSs per 2 h; P = 0·004). No motor response was recorded in response to subsensory stimulation compared with sham stimulation. Compared with subsensory stimulation, stimulation at suprasensory levels caused a significant increase in the frequency of PSs (P = 0·006). CONCLUSION: In patients with slow-transit constipation, suprasensory SNS increased the frequency of colonic PSs, whereas subsensory SNS stimulation did not. This has implications for the design of therapeutic trials and the clinical application of the device.

A critical review of racial/ethnic variables in osteoporosis and bone density research.

UNLABELLED: Racial and ethnic variables are common in research on variation in bone density. This literature review describes some of the common flaws associated with the use of these variables and provides some suggestions for how bone density research may be able to better document and address skeletal health disparities. INTRODUCTION: Racial/ethnic differences in bone density have been commonly documented in the research literature. While effective identification of the specific factors underlying these trends might go a long way in informing treatment and screening for osteoporosis, this would require careful consideration of exactly what these variables are capturing. However, the basis and implications of what racial/ethnic variables represent have not carefully been examined in bone density research. METHODS: For this paper, we systematically reviewed 55 articles that included bone density and race/ethnicity as key variables. Our analysis reveals that racial/ethnic terminology in these articles is highly variable, and discussion of how race/ethnicity is determined is often vague and idiosyncratic. Racial/ethnic variables are being used for a wide range of analytical purposes in statistical tests, which may not be appropriate for such a complex and poorly defined variable. RESULTS: Many articles attribute racial/ethnic differences in bone mass/bone density to genetic causes, although few studies actually examine genetic data. CONCLUSION: This analysis indicates that more rigorous examination of what race/ethnicity actually captures, more careful definitions of group labels and the procedures for assigning them, and attention to the limitations of how such variables can reliably be used in data analyses is needed to help address the problems and issues outlined in this review.

Comparison of surgical skill acquisition by UK surgical trainees and Sierra Leonean associate clinicians in a task-sharing programme.

Background: Task-sharing in surgery is well established, with associate clinicians performing successful surgery in many countries. Little is known about the process of surgical skill acquisition by associate clinicians, or whether this differs from that of doctors. Methods: A blinded experimental study compared surgical skill acquisition by Sierra Leonean associate clinicians enrolled in an essential and emergency surgery training programme with that of a matched group of UK surgical trainees. After identical instruction, practice time and with identities disguised, trainees were videoed performing simulated surgery. Trainees were marked on 12 performance parameters and five behaviour characteristics using validated tools and qualitative comment. Results: The Sierra Leonean group comprised 19 associate clinicians and one doctor; the UK group comprised 20 doctors in their first 5 years of training. The UK group had significantly more surgical and postgraduate experience than the Sierra Leonean group. The Sierra Leonean trainees outperformed the UK trainees on three of the 12 performance parameters and four of the five behaviour characteristics. UK trainees did not outperform Sierra Leonean trainees on any parameter or characteristic. Qualitative differences in learning style were observed. Conclusion: Sierra Leonean associate clinicians demonstrated equal or superior skill in all objective parameters tested, despite having less experience than the UK doctors.

Genes, race and research ethics: who's minding the store?

BACKGROUND: The search for genetic variants between racial/ethnic groups to explain differential disease susceptibility and drug response has provoked sharp criticisms, challenging the appropriateness of using race/ethnicity as a variable in genetics research, because such categories are social constructs and not biological classifications. OBJECTIVES: To gain insight into how a group of genetic scientists conceptualise and use racial/ethnic variables in their work and their strategies for managing the ethical issues and consequences of this practice. METHODS: In-depth semi-structured interviews were conducted with a purposive sample of 30 genetic researchers who use racial/ethnic variables in their research. Standard qualitative methods of content analysis were used. RESULTS: Most of the genetic researchers viewed racial/ethnic variables as arbitrary and very poorly defined, and in turn as scientifically inadequate. However, most defended their use, describing them as useful proxy variables on a road to "imminent medical progress". None had developed overt strategies for addressing these inadequacies, with many instead asserting that science will inevitably correct itself and saying that meanwhile researchers should "be careful" in the language chosen for reporting findings. CONCLUSIONS: While the legitimacy and consequences of using racial/ethnic variables in genetics research has been widely criticised, ethical oversight is left to genetic researchers themselves. Given the general vagueness and imprecision we found amongst these researchers regarding their use of these variables, they do not seem well equipped for such an undertaking. It would seem imperative that research ethicist move forward to develop specific policies and practices to assure the scientific integrity of genetic research on biological differences between population groups.

An epidemiological study of myopathies in Warmblood horses.

REASON FOR PERFORMING STUDY: There are few detailed reports describing muscular disorders in Warmblood horses. OBJECTIVES: To determine the types of muscular disorders that occur in Warmblood horses, along with presenting clinical signs, associated risk factors and response to diet and exercise recommendations, and to compare these characteristics between horses diagnosed with polysaccharide storage myopathy (PSSM), those diagnosed with a neuromuscular disorder other than PSSM (non-PSSM) and control horses. METHODS: Subject details, muscle biopsy diagnosis and clinical history were compiled for Warmblood horses identified from records of biopsy submissions to the University of Minnesota Neuromuscular Diagnostic Laboratory. A standardised questionnaire was answered by owners at least 6 months after receiving the muscle biopsy report for an affected and a control horse. RESULTS: Polysaccharide storage myopathy (72/132 horses) was the most common myopathy identified followed by recurrent exertional rhabdomyolysis (RER) (7/132), neurogenic or myogenic atrophy (7/132), and nonspecific myopathic changes (14/132). Thirty-two biopsies were normal. Gait abnormality, 'tying-up', Shivers, muscle fasciculations and atrophy were common presenting clinical signs. Forty-five owners completed questionnaires. There were no differences in sex, age, breed, history or management between control, PSSM and non-PSSM horses. Owners that provided the recommended low starch fat supplemented diet and regular daily exercise reported improvement in clinical signs in 68% (19/28) of horses with a biopsy submission and 71% of horses diagnosed with PSSM (15/21). CONCLUSIONS: Muscle biopsy evaluation was a valuable tool to identify a variety of myopathies in Warmblood breeds including PSSM and RER. These myopathies often presented as gait abnormalities or overt exertional rhabdomyolysis and both a low starch fat supplemented diet and regular exercise appeared to be important in their successful management. POTENTIAL RELEVANCE: Warmbloods are affected by a variety of muscle disorders, which, following muscle biopsy diagnosis can be improved through changes in diet and exercise regimes.

NIDDM patients' fears and hopes about insulin therapy. The basis of patient reluctance.

OBJECTIVE: This study examines NIDDM patients' attitudes toward insulin injections, the basis of these attitudes, and how they may affect patients' willingness to take insulin. RESEARCH DESIGN AND METHODS: Forty-four low-income Mexican American NIDDM patients were interviewed using open-ended in-depth interviewing techniques. Transcripts were analyzed using techniques of content analysis. Data classification was cross-checked in analysis conferences and through a second researcher coding 50% of the cases, comparing the results, then resolving any discrepancies. RESULTS: Patients' positive attitudes toward insulin focus on its efficacy and efficiency, the avoidance of complications, and feeling better and more energetic. Negative attitudes were much more frequently discussed and include "technical concerns": anxiety about the pain, proper techniques, and general hassles of taking injections; about hypoglycemic symptoms; and about insulin causing serious health problems; and "experimental concerns": sensing that the disease has progressed into a serious phase, that past treatment efforts have failed, and that the patient has not taken proper care. Attitudes were based on personal experience, observation, what others say, and interactions with health care professionals. CONCLUSIONS: Results from the few published reports on NIDDM patients' attitudes about insulin from various cultural settings were consistent with our findings, indicating that these themes may be generally applicable to a wider population. It is recommended that health care providers take care to avoid unwitting promotion of negative attitudes toward insulin and actively elicit and respond to patient attitudes to reduce reluctance to take the medication.

Practicing oncology in provincial Mexico: a narrative analysis.

This paper examines the discourse of oncologists treating cancer in a provincial capital of southern Mexico. Based on an analysis of both formal interviews and observations of everyday clinical practice, it examines a set of narrative themes they used to maintain a sense of professionalism and possibility as they endeavored to apply a highly technologically dependent biomedical model in a resource-poor context. They moved between coexisting narrative frameworks as they addressed their formidable problems of translating between theory and practice. In a biomedical narrative frame, they drew on biomedical theory to produce a model of cellular dysfunction and of clinical intervention. However, limited availability of diagnostic and treatment techniques and patients inability or unwillingness to comply, presented serious constraints to the application of this model. They used a practical narrative frame to discuss the socio-economic issues they understood to be underlying these limitations to their clinical practice. They did not experience the incongruity between theory and practice as a continual challenge to their biomedical model, nor to their professional competency. Instead, through a reconciling narrative frame, they mediated this conflict. In this frame, they drew on culturally specific concepts of moral rightness and order to produce accounts that minimized the problem, exculpated themselves and cast blame for failed diagnosis and treatment. By invoking these multiple, coexisting narrative themes, the oncologists sustained an open vision of their work in which deficiencies and impotency were vindicated, and did not stand in the way of clinical practice.

Relativism in the diagnosis of hypoglycemia.

It is a common assumption in our medicalized society that diagnostic labels simply describe facts, rather than express the diagnostician's own concepts of anomaly and dysfunction. Variability among physicians in diagnosing reactive hypoglycemia illustrates some fundamental problems of reifying the concept of disease. Although most physicians consider the same three variables in this diagnosis, their interpretations of them may vary widely. The disagreement centers around the credibility given standardized, technological measures versus the individual patient's experiences. Most physicians consider lab tests definitive in diagnosing hypoglycemia, while bypassing patients' subjective reports. Some, however, rely more heavily on patient-generated criteria to diagnose the condition. This lack of agreement about the criteria for diagnosing hypoglycemia, coupled with the psychological nature of many of the symptoms, make hypoglycemia and psychological disorder reasonable alternative diagnoses. These diagnoses, in turn, have very different effects on patients. These variations in physicians' diagnostic criteria illustrate that diagnostic labels are cognitive constructs, subject to the influence of the physician's culture, expectations, values and interests.

Views of what's wrong: diagnosis and patients' concepts of illness.

A group of women were interviewed about their construction of their illness experiences before they saw a physician and subsequently over a period of several months following consultation. It was found that the physician's input was one of many components of their post-consultation understanding of their illnesses. The women built up their understandings in an interactive process, drawing significantly on their prior histories, ongoing experiences and social worlds. They continually tried out, adjusted and reworked the construction of their illnesses to adapt them to the exigencies of everyday life. We conclude that illness explanations are dynamic entities whose adequacy is determined by their usefulness within the extra-medical social environment.

Porque me tocó a mi? Mexican American diabetes patients' causal stories and their relationship to treatment behaviors.

This paper reports findings from an ethnographic study of self-care behaviors and illness concepts among Mexican-American non-insulin dependent diabetes mellitus (NIDDM) patients. Open-ended interviews were conducted with 49 NIDDM patients from two public hospital outpatient clinics in South Texas. They are self-identified Mexican-Americans who have had NIDDM for at least 1 yr, and have no major impairment due to NIDDM. Interviews focused on their concepts and experiences in managing their illness and their self-care behaviors. Clinical assessment of their glucose control was also extracted from their medical records. The texts of patient interviews were content analyzed through building and refining thematic matrixes focusing on their causal explanations and treatment behaviors. We found patients' causal explanations of their illness often are driven by an effort to connect the illness in a direct and specific way to their personal history and their past experience with treatments. While most cite biomedically accepted causes such as heredity and diet, they elaborate these concepts into personally relevant constructs by citing Provoking Factors, such as behaviors or events. Their causal models are thus both specific to their personal history and consistent with their experiences with treatment success or failure. Based on these findings, we raise a critique of the Locus of Control Model of treatment behavior prevalent in the diabetes education literature. Our analysis suggests that a sense that one's own behavior is important to the disease onset may reflect patients' evaluation of their experience with treatment outcomes, rather than determining their level of activity in treatment.

Mismanaging prescription medications among rural elders: the effects of socioeconomic status, health status, and medication profile indicators.

PURPOSE: This study assessed the extent to which community-dwelling rural older adults mismanage their prescription medication regimens and predicted mismanagement of medications from selected socioeconomic, health status, and medication profile characteristics. DESIGN AND METHODS: Personal interviews with 499 community-dwelling adults aged 66 and over taking at least one prescription medication and living in a rural region of the Southeast. With approximately equal numbers of African American and white men and women, the SUDAAN multiple logistic regression procedure was used to predict the mismanagement of prescription medications. RESULTS: The mismanagement of prescribed medication regimens is relatively common among older adults. Those more likely than others to mismanage their regimens are African American, younger, in poorer mental health, with more acute care physician visits, and those who find payment for their medications to be problematic. IMPLICATIONS: The implications of the findings for what is known about the self-modification of drug regimens, targeting prescription drug cost benefits or interventions, and the limitations of the study are discussed.

Abnormal Pap screening among Mexican-American women: impediments to receiving and reporting follow-up care.

PURPOSE/OBJECTIVES: To understand impediments to receiving and reporting timely follow-up care for abnormal Pap tests among Hispanic women. DESIGN: Descriptive, qualitative. SETTING: A federally funded cancer screening clinic in urban South Texas. SAMPLE: 11 Mexican/Mexican-American women over 40 years old who appear in clinic records as "lapsed" in follow-up and 5 clinic staff members. METHODS: Semistructured, qualitative interviews regarding staff and patient concepts about cancer, cancer screening, and follow-up. Abstraction of patients' clinic charts. MAIN RESEARCH VARIABLES: Factors associated with women being classified as "lapsed" in follow-up care for abnormal Pap tests. FINDINGS: Only two patients had no follow-up, while nine eventually had follow-up, either elsewhere or after several missed appointments. Contrary to expectations, poor knowledge, lack of social support, and lack of availability of care were not factors impeding follow-up. Reluctance to be examined by a male practitioner, lack of flexibility in scheduling clinic appointments, and poor staff communication regarding appointments and the seriousness of the condition were all influences negatively affecting follow-up behavior. Nevertheless, these women went to significant lengths to comply with follow-up recommendations. CONCLUSIONS: The classification of patients' follow-up behavior as "lapsed" was not attributable to culturally based beliefs and attitudes, nor lack of knowledge and motivation, but was primarily the result of institutional features such as scheduling and record-keeping practices and policies. IMPLICATIONS FOR NURSING PRACTICE: More thorough evaluation of actual behaviors would ensure more accurate assessment of follow-up behavior in this group. More female practitioners, better communication of appointments and of the seriousness of the condition, and more flexible scheduling options would reduce the difficulty these Hispanic patients encountered in having timely follow-up care.

Effect of sheep breed and sex on accumulation and depletion of ronnel in fat.

When four breeds of sheep were dipped in .25% ronnel for control of sheep-biting lice, Bovicola ovis (Schrank), the differences in residues in the fat were highly significant for breed, sex, day X breed and day X sex interactions.

Disinfection of nitrous oxide inhalation equipment.

Cross-infection by contaminated equipment is a potential hazard associated with conscious sedation with nitrous oxide and oxygen . Nosocomial infections have occasionally been linked wih the use of unsterile inhalation devices; microbial contamination of sterile nasal hoods routinely occurs during administration of nitrous oxide; and in vitro experiments indicate that subsequent use of contaminated nasal masks may lead to aspiration of microorganisms. Although the incidence of respiratory disease after such contamination is unknown, it is clear that disinfection of the nitrous oxide apparatus between patients is desirable. A simple cleaning method involving alkaline glutaraldehyde is described that provides adequate disinfection of the rubber goods used in the administration of gas. Superiority of this technique over previously recommended cleaning methods is shown.

Management of sexually transmitted disease by surgeons.

The management of 63 patients diagnosed by surgeons as having sexually transmitted disease (STD) was audited. A diagnosis of STD was made in 51 (81%) of patients without taking a sexual history. Only 2 (3%) patients were referred to genitourinary medicine (GUM). Appropriate microbiological specimens were obtained from only two of 52 (4%) patients diagnosed with either pelvic inflammatory disease (PID) or epididymo-orchitis. Reliance was placed on inappropriate specimens in 22 (42%). There was widespread use of inappropriate antibiotics. The management of sexually transmitted disease by surgeons was very poor. These patients should all be referred to genito-urinary medicine.

Contrasting patient and practitioner perspectives in type 2 diabetes management.

Studies of self-care behaviors in the management of type 2 diabetes often focus on patient knowledge and motivation, without considering the role of practitioner orientations. Using an exploratory descriptive design, we conducted open-ended interviews with 51 type 2 diabetes patients and 35 practitioners from clinics in San Antonio and Laredo, Texas. We found critical differences between patient and practitioner goals, evaluations, and strategies in diabetes management, especially regarding such key concepts as "control" and "taking care of self". Practitioners' perspectives are rooted in a clinical context, emphasizing technical considerations, whereas patients' perspectives exist within a life-world context and foreground practical and experiential considerations. These result in very different approaches to treatment. Practitioners, presuming failed treatment indicates uncooperativeness, try to inform and motivate patients. The patients we interviewed, however, understood and were committed to type 2 diabetes self-care, but lacked full access to behavioral options due to their poverty and limited social power.

Distribution and depletion of radioactivity in hens treated dermally with 14C-labeled permethrin.

The 25/75 cis-trans mixture of permethrin (BW21Z), one of the new broad-spectrum pyrethroid insecticides, was labeled with 14C in the alcohol methylene carbon moiety and mist sprayed at two rates (3.77 or 11.94 mg/hen) on 28 hens. Peak permethrin equivalents in both treatment groups were found in the skins, .414 and l.69 ppm, respectively. Total permethrin equivalents peaked 3 days after treatment, but permethrin equivalents in eggs peaked 5 days after treatment.

Moral reasoning and the meaning of cancer: causal explanations of oncologists and patients in southern Mexico.

Moral themes were a striking feature of the causal explanations for female cancers discussed by oncologists and patients in an ethnographic study of hospital-based cancer care in southern Mexico. These explanations integrate general biomedical explanations with everyday expectations and experiences, giving meaning to otherwise arbitrary events. Analysis of case examples shows that causal models incorporate local constructs about what constitutes a virtuous life, especially in terms of class-and gender-based values. Although patients and physicians draw on similar concepts of moral order, they apply these constructs in distinct ways. Because physicians' explanations are necessarily framed in terms of object, their causal stories employ generalized presumptions about how categories of persons behave (e.g., women, the lower class). In contrast, patients' explanations are framed in terms of subject; they are based on the specific details of their personal history. The article examines the distinct perspectives of physicians and patients, and provides an illustration of how biomedical culture articulates with the local moral constructs of a particular community.

An analytical framework for contrasting patient and provider views of the process of chronic disease management.

Medical anthropologists involved in clinical research are often asked to help explain patients' "noncompliance" with treatment recommendations. The clinical literature on "noncompliance" tends to problematize only the patient's perspective, treating the provider's perspective as an uncontroversial point of departure. Explicating the articulation between provider and patient assumptions, expectations, and perceptions in managing chronic illness is an area well suited to the unique perspective of medical anthropologists. In this article we present an analytical framework for contrasting patient and provider goals, strategies, and evaluation criteria in chronic illness management, using examples from research on type 2 diabetes care in South Texas. This approach goes beyond contrasting patient and provider concepts and explanations of the illness itself and examines their contrasting views within the dynamic process of long-term care. This approach may prove especially useful for research aimed at a clinical audience, since it maintains a clinically relevant focus while giving serious consideration to the patient's perspective.