The obstetric caseload of a physician-based helicopter emergency medical service: case review and recommendations for retrieval physician training.

BACKGROUND: The Greater Sydney Area Helicopter Emergency Medical Service provides physicians for undertaking prehospital and inter-hospital critical care. We quantified the obstetric caseload of our service with respect to primary diagnosis and interventions in order to provide targeted physician training. MATERIALS AND METHODS: Retrieval records over a 4-year period were searched to identify keywords associated with pregnancy or obstetric complications. The data collected related to gestation, diagnosis, nature of transfer and interventions. RESULTS AND DISCUSSION: Of 66 pregnant or postpartum cases, 38 were transported by road and 28 by air. 33 had obstetric-related conditions, and 33 had non-obstetric medical conditions. 61 patients required mechanical ventilation, 23 of whom were intubated by the retrieval physicians prior to transport. 33 patients required vasoactive circulatory support, and arterial and/or central venous access was established in 48 and 30 patients, respectively. The only obstetric interventions provided by retrieval physicians were intravenous tocolytic therapy (two cases) and one case of resuscitative hysterotomy (peri-mortem caesarean section). CONCLUSIONS: A half of all peri-partum patients in our critical care transport service are retrieved for non-obstetric diagnoses. Obstetric interventions by retrieval physicians are rare, but resuscitative hysterotomy may be required. Most interventions are general critical care procedures. Exhaustive training in obstetric emergencies may not reflect the learning needs of retrieval physicians in services such as ours. Educational resources should prioritise general critical care of the pregnant woman rather than specific obstetric procedures. We have used these findings to construct a targeted obstetric module as part of our retrieval physician training programme.

Training needs assessment for clinicians at antiretroviral therapy clinics: evidence from a national survey in Uganda.

BACKGROUND: To increase access to antiretroviral therapy in resource-limited settings, several experts recommend "task shifting" from doctors to clinical officers, nurses and midwives. This study sought to identify task shifting that has already occurred and assess the antiretroviral therapy training needs among clinicians to whom tasks have shifted. METHODS: The Infectious Diseases Institute, in collaboration with the Ugandan Ministry of Health, surveyed health professionals and heads of antiretroviral therapy clinics at a stratified random sample of 44 health facilities accredited to provide this therapy. A sample of 265 doctors, clinical officers, nurses and midwives reported on tasks they performed, previous human immunodeficiency virus training, and self-assessment of knowledge of human immunodeficiency virus and antiretroviral therapy. Heads of the antiretroviral therapy clinics reported on clinic characteristics. RESULTS: Thirty of 33 doctors (91%), 24 of 40 clinical officers (60%), 16 of 114 nurses (14%) and 13 of 54 midwives (24%) who worked in accredited antiretroviral therapy clinics reported that they prescribed this therapy (p<0.001). Sixty-four percent of the people who prescribed antiretroviral therapy were not doctors. Among professionals who prescribed it, 76% of doctors, 62% of clinical officers, 62% of nurses and 51% of midwives were trained in initiating patients on antiretroviral therapy (p=0.457); 73%, 46%, 50% and 23%, respectively, were trained in monitoring patients on the therapy (p=0.017). Seven percent of doctors, 42% of clinical officers, 35% of nurses and 77% of midwives assessed that their overall knowledge of antiretroviral therapy was lower than good (p=0.001). CONCLUSION: Training initiatives should be an integral part of the support for task shifting and ensure that antiretroviral therapy is used correctly and that toxicity or drug resistance do not reverse accomplishments to date.

Advancing drug availability-experiences from Africa.

International health and drug regulatory authorities acknowledge that analgesics (especially opioids) are insufficiently available for pain management in many countries. In Africa, reported morphine consumption is far below the global mean, with multiple factors hampering opioid supply. Since 2006, the African Palliative Care Association has hosted three regional drug availability workshops across the continent to address this issue. Using an interactive format, the workshops have identified country-specific barriers to opioid and other essential medication accessibility before supporting participants to develop action plans to address recognized impediments. Despite multiple challenges, a number of successes have arisen from the implementation of the plans. However, key issues remain, including the introduction of supportive policy environments, effective educational initiatives, and measures to address supply-chain obstacles impeding drug availability.

Development and testing of particulate formulations for the nasal delivery of antibodies.

Therapeutic antibodies offer a potential treatment for, or means of protection against, airborne infections. For this application, it may be desirable to deliver the antibody directly into the nasal cavity, one of its potential sites of action, since this would be more efficient and convenient than systemic administration. Formulations of a model antibody (human IgG) were developed using albumin, sodium chloride and disaccharides. A combination of these excipients allowed the efficient spray-drying (yield>70%) of the antibody into a microparticulate (1-15 microm) dry powder that was rapidly soluble in aqueous media. The water content and crystallinity of the formulations were also measured, with both properties being affected by the substitution of some of the sodium chloride in the formulation, with lactose. The antibody was found to be stable following the formulation process, as determined by gel-electrophoresis, field-flow-fractionation and enzyme-linked immunosorbent assay. Incubation of an in vitro epithelial cell line in the presence of solutions of the formulations (at concentrations of up to 2500 microg/mL) was found not affect cell viability. The aerosolisation properties of the formulations were tested using Bespak's "Unidose-DP", dry-powder nasal device. The powder aerosol was analysed by laser diffraction, high-speed video and dose deposition in Bespak's nasal cast model. For the latter experiment, a range of additional excipients were either dissolved in the spray-drying liquid feed (leucine), or blended with the spray-dried powder formulation (magnesium stearate, Aerosil and lactose). The major dose deposition site of the standard spray-dried formulation was the nasal vestibule (approximately 55%). The addition of leucine and Aerosil resulted in a 10% increase in the deposition beyond the nasal vestibule, with approximately 45% of the delivered dose being deposited in the turbinates, olfactory region, and nasal-pharynx.

Simultaneously manufactured nano-in-micro (SIMANIM) particles for dry-powder modified-release delivery of antibodies.

Simultaneously Manufactured Nano-In-Micro (SIMANIM) particles for the pulmonary delivery of antibodies have been prepared by the spray-drying of a double-emulsion containing human IgG (as a model antibody), lactose, poly(lactide-co-glycolide) (PLGA) and dipalmitoylphosphatidylcholine (DPPC). The one-step drying process involved producing microparticles of a diameter suitable for inhalation that upon contact with aqueous media, partially dissolved to form nanoparticles, approximately 10-fold smaller than their original diameter. Continuous release of the model antibody was observed for 35 days in pH 2.5 release media, and released antibody was shown to be stable and active by gel electrophoresis, field-flow fractionation and enzyme linked immunosorbent assay. Adding 1% L-leucine to the emulsion formulation, and blending 'SIMANIM' particles with 1% magnesium stearate, achieved a fine particle fraction of approximately 60%, when aerosolised from a simple, capsule-based, dry powder inhaler device. 'SIMANIM' particles could be beneficial for the delivery of antibodies targeted against inhaled pathogens or other extracellular antigens, as well as having potential applications in the delivery of a wide range of other biopharmaceuticals and certain small-molecule drugs.