Farm-level emission intensities of smallholder cattle (Bos indicus; B. indicus-B. taurus crosses) production systems in highlands and semi-arid regions.

Ruminants are central to the economic and nutritional life of much of sub-Saharan Africa, but cattle are now blamed for having a disproportionately large negative environmental impact through emissions of greenhouse gas (GHG). However, the mechanism underlying excessive emissions occurring only on some farms is imperfectly understood. Reliable estimates of emissions themselves are frequently lacking due to a paucity of reliable data. Employing individual animal records obtained at regular farm visits, this study quantified farm-level emission intensities (EIs) of greenhouse gases of smallholder farms in three counties in Western Kenya. CP was chosen as the functional unit to capture the outputs of both milk and meat. The results showed that milk is responsible for 80-85% of total CP output. Farm EI ranged widely from 20 to >1 000 kg CO2-eq/kg CP. Median EIs were 60 (Nandi), 71 (Bomet), and 90 (Nyando) kg CO2-eq/kg. Although median EIs referenced to milk alone (2.3 kg CO2-eq/kg milk) were almost twice that reported for Europe, up to 50% of farms had EIs comparable to the mean Pan-European EIs. Enteric methane (CH4) contributed >95% of emissions and manure ∼4%, with negligible emissions attributed to inputs to the production system. Collecting data from individual animals on smallholder farms enabled the demonstration of extremely heterogeneous EI status among similar geographical spaces and provides clear indicators on how low EI status may be achieved in these environments. Contrary to common belief, our data show that industrial-style intensification is not required to achieve low EI. Enteric CH4 production overwhelmingly drives farm emissions in these systems and as this is strongly collinear with nutrition and intake, an effort will be required to achieve an "efficient frontier" between feed intake, productivity, and GHG emissions.

The Role of Alcohol and Drug Intoxication in Fire-Related Incidents in Africa: A Systematic Review.

Fire-related burns contribute significantly to the global burden of burn injury and mortality. Alcohol and/or drug intoxication poses a risk to burn and fire-related injury, whether intentional or unintentional, but such evidence is scarce in the African context. This review aimed to fill the knowledge gap on health determinants of fire-related morbidity and mortality regionally by investigating the role of alcohol and drug intoxication in such events. Using key concepts, an extensive search was performed on 25 databases for relevant publications. Eligible articles were critically appraised using the appraisal tool for cross-sectional studies (AXIS tool), adapted to the review's objectives and outcomes. A total of 42 articles were included, of which less than half were solely investigating burn/fire-related events. Others indirectly mentioned burn injuries as part of larger health burdens such as injury, trauma, violence and other diseases. The measurement of alcohol and/or drug intoxication was inconsistent between studies with varying results. Alcohol and drug impairment in burn incidents in Africa requires evidence-based epidemiological research, and this review illustrated the limited scope of this topic in current literature. Routine toxicological results from post-mortem examinations were identified as important data sources and several research recommendations were provided.

Les atteintes lors d'un incendie représentent une partie non négligeable de l'ensemble des brûlures. Qu'elle soit intentionnelle ou non, l'intoxication alcoolique et/ou par stupéfiant en augmente le risque. Mais les données à ce sujet sont rares en Afrique. Nous avons effectué une revue systématique sur 25 banques de données. Les 42 articles sélectionnés, dont moins de la moitié exploraient les brûlures lors d'un incendie (les autres comprenaient les brûlures dans un cadre traumatique plus général- blessure, traumatisme, violence, etc.), ont été étudiés selon la méthode AXIS. La mesure de l'alcoolémie et les recherches de toxiques étaient variablement reprises dans les articles, le diagnostic d'intoxication reposant essentiellement sur la clinique en Afrique et il y a donc peu de données basées sur des chiffres, les plus fréquentes étant celles provenant de prélèvements autopsiques. Il s'agit donc d'améliorer le diagnostic de ces intoxications en cas de brûlure lors d'un incendie.

Cretaceous origins of the vibrotactile bill-tip organ in birds.

Some probe-foraging birds locate their buried prey by detecting mechanical vibrations in the substrate using a specialized tactile bill-tip organ comprising mechanoreceptors embedded in densely clustered pits in the bone at the tip of their beak. This remarkable sensory modality is known as 'remote touch', and the associated bill-tip organ is found in probe-foraging taxa belonging to both the palaeognathous (in kiwi) and neognathous (in ibises and shorebirds) clades of modern birds. Intriguingly, a structurally similar bill-tip organ is also present in the beaks of extant, non-probing palaeognathous birds (e.g. emu and ostriches) that do not use remote touch. By comparison with our comprehensive sample representing all orders of extant modern birds (Neornithes), we provide evidence that the lithornithids (the most basal known palaeognathous birds which evolved in the Cretaceous period) had the ability to use remote touch. This finding suggests that the occurrence of the vestigial bony bill-tip organ in all modern non-probing palaeognathous birds represents a plesiomorphic condition. Furthermore, our results show that remote-touch probe foraging evolved very early among the Neornithes and it may even have predated the palaeognathous-neognathous divergence. We postulate that the tactile bony bill-tip organ in Neornithes may have originated from other snout tactile specializations of their non-avian theropod ancestors.

HIV-associated and idiopathic-acquired haemophilia A: A single-centre case series from Cape Town, South Africa.

Acquired haemophilia A is a rare coagulation disorder, which can lead to life-threatening haemorrhages if not identified and treated promptly. It is characterised by the presence of autoantibodies (inhibitors) to factor VIII. Acquired haemophilia A associated with HIV is a rare but well described phenomenon with limited directions to its management. We comparatively describe four patients - two with HIV and two without - that presented with unusual bleeding episodes with a prolonged activated partial thromboplastin time secondary to factor VIII inhibitors. An empiric observation is that the patients with acquired haemophilia A associated with HIV had higher antibody titres at presentation, that required more prolonged immunosuppressive therapy to induce remission.

Cold Disinfestation of "Hass" Avocado (Persia americana) of Three Species of Fruit Fly (Diptera: Tephritidae)-Ceratitis capitata, Ceratitis rosa, and Ceratitis cosyra.

The avocado industry is important in South Africa, but access to certain markets is impeded by the presence of phytosanitary pests. One of the ways of securing entry to these markets is to demonstrate that a mitigating treatment will result in there being a negligible chance of accidental importation. In cold treatment comparative studies at 0 °C and 2 °C of immature stages of Ceratitis capitata (Wiedemann), Ceratitis rosa Karsch, and Ceratitis cosyra (Walker) in "Hass" avocado, the third instar of C. cosyra was shown to be the most cold tolerant. This larval life stage was used in a large-scale trial to test treatment efficacy at 2 °C, a temperature known to be the better for fruit quality. There were no survivors from the 49,795 individual fruit fly larvae subjected to the cold treatment at 2 °C for 20 d. It is argued that, although this level of assessment falls short of the Probit 9 level normally required for fruit fly, they are rarely found in avocado fruit and that the level of disinfestation obtained is more than sufficient to achieve quarantine security.

Comparison of corticosteroid, autologous blood or sclerosant injections for chronic tennis elbow.

OBJECTIVES: To compare three different ultrasound-guided injections for chronic tennis elbow. DESIGN: Assessor-blinded, randomized controlled comparative trial. METHODS: 44 patients with clinically diagnosed tennis elbow, confirmed by Doppler ultrasound, received under ultrasound guidance, a single corticosteroid injection (n=14), or two injections (separated by 4 weeks) of either autologous blood (n=14) or polidocanol (n=16). Clinical and ultrasound examination was performed at baseline, 4, 12 and 26 weeks. RESULTS: Complete recovery or much improvement was greater for corticosteroid injection than autologous blood and polidocanol at 4 weeks (p<0.001, number needed to treat 1 (95% CI 1-2)). In contrast, at 26 weeks corticosteroid was significantly worse than polidocanol (p=0.004, number needed to harm 2 (1-6)). Recurrence after corticosteroid injection was significantly higher than autologous blood or polidocanol (p=0.007, number needed to harm 2 (1-4)). Corticosteroid injection produced greater reduction in tendon thickness and vascularity than autologous blood at 4 weeks only. Compared to autologous blood, polidocanol reduced tendon thickness at 4 and 12 weeks and reduced echogenicity and hyperaemia after 12 or 26 weeks respectively. CONCLUSIONS: Injections of corticosteroid cannot be recommended over polidocanol or autologous blood, because despite beneficial short-term effect there were inferior long-term effects. Whether polidocanol or autologous blood injections are effective is unknown, especially as their global effect profiles are not unlike previously reported for wait-and-see.

False Codling Moth, Thaumatotibia leucotreta (Lepidoptera: Tortricidae), Cold Disinfestation Treatment Using Grapes as the Test Medium.

Some countries consider false codling moth, Thaumatotibia leucotreta (Meyrick) (Lepidoptera: Tortricidae), a phytosanitary pest and may require the application of a mitigation treatment before accepting T. leucotreta-susceptible produce. This research reports on cold treatments that provide the phytosanitary security that this pest would not be accidentally imported alive. More than 35,000 individuals were treated for 20 d at 0.8 °C and >30,000 individuals subjected to - 0.6 °C for 18 d, with no survivors. The adoption of these treatments in international fruit trade protocols is recommended.

Role of dung beetle feeding mechanisms in limiting the suitability of species as hosts for the nematode Spirocerca lupi.

Various species of dung beetle serve as intermediate hosts after ingesting the embryonated eggs (11-15 × 30-37 µm) of Spirocerca lupi (Spirurida: Spirocercidae) in dog faeces. The feeding mechanisms of coprophagous dung beetles restrict the size of the food particles they can ingest and hence may determine which species can be efficient vectors for S. lupi. In this study, we aimed to exclude certain dung beetle species as possible hosts of S. lupi based on whether or not they ingested latex beads of known diameters mixed into fresh cattle dung. We found that the majority (11/14) of species tested can potentially serve as intermediate hosts of S. lupi because their mouthparts allow the passage of food particles larger than the minimum size range of the eggs of this parasite.

Cold tolerance and disinfestation of Bactrocera invadens (Diptera: Tephritidae) in 'Hass' avocado.

Bactrocera invadens (Diptera: Tephritidae) has spread rapidly across Africa and currently poses a phytosanitary threat to the fruit industry of South Africa. In reaction a cold mitigating treatment to provide phytosanitary security to importing countries was developed in Nairobi, Kenya. Using laboratory reared fruit flies, the rate of development in 'Hass' avocado (Persea americana Miller) was determined at 28 degrees C. Fruit ripeness or softness was found to be a factor improving larval fruit fly survival. Using this information the egg and larval developmental stages were subjected to 2 degrees C cold treatment and it was found that the third instars were the most cold tolerant life stage and that it was expected that between 16 and 17 d treatment would provide phytosanitary security. There were no survivors in the treatment of an estimated 153,001 individuals in four replicates at an average fruit pulp temperature of 2 degrees C satisfying the Probit 9 level of efficiency at a confidence of >95%. These data provide evidence that a continuous cold treatment of 1.5 degrees C or lower for 18 d would provide phytosanitary security in that any consignment entering an importing country poses no risk of accidental importation of B. invadens.

Reduced-intensity conditioning for severe aplasia using fludarabine and CY followed by infusion of ex vivo T-cell-depleted grafts leads to excellent engraftment and absence of GVHD.

We studied the outcome of individuals with aplastic anaemia (AA) who received reduced-intensity conditioning followed by the infusion of stem cell grafts that had been T-cell depleted ex vivo with alemtuzumab. Consecutive patients with AA who had an HLA-identical sibling received conditioning with fludarabine 30 mg/m(2) daily for 5 days followed by CY 60 mg/kg on 2 consecutive days. Cytokine-mobilized blood grafts were incubated ex vivo with alemtuzumab 'in the bag' and infused without washing. CYA was prescribed until day +90. Engraftment rate, GVHD, EFS and overall survival were studied. Fifteen patients received PBPC grafts. It was the second graft in one of the patients. Ten patients were male and their median age was 23.5 years. The toxicity of the conditioning was minimal. One patient received 1 x 10(7)/kg donor lymphocytes for rising chimerism. At a median of 1107 (294-1778) days, all of them survived with normal blood parameters. None of them developed acute or chronic GVHD. In patients with AA the combination of purine analogue and alkylator leads to rapid engraftment despite T-cell depletion of grafts. This strategy of reduced-intensity conditioning has low toxicity, does not compromise engraftment and seems effective for prevention of GVHD.

Diagnostic accuracy of power Doppler ultrasound in patients with chronic tennis elbow.

OBJECTIVE: To determine the diagnostic accuracy of power Doppler and grey scale ultrasonography, assess the relationship between severity measures and neovascularity, and describe the intra-tendon distribution of neovascularity in chronic tennis elbow. DESIGN: Between group cross sectional study. SETTING: Sports medicine clinic and radiology centre. PARTICIPANTS: 32 affected elbows (median and range of duration: 10; 3-120 months) and 18 unaffected contralateral elbows in 25 patients (mean age 50 years) with lateral elbow pain, and 38 unaffected elbows in 19 asymptomatic participants (mean age 45 years) underwent a clinical examination (reference standard test) and grey scale and power Doppler ultrasonographic examination. MAIN OUTCOME MEASURES: Ultrasound examination with power Doppler identified neovascularity and grey scale ultrasound changes (lateral epicondyle bony spurring or irregularity, maximum anterior-posterior thickness, and echo characteristics) of the common extensor tendon. RESULTS: Power Doppler had a strong positive likelihood ratio of 45.39, whereas a combined null finding in power Doppler and grey scale ultrasonography resulted in a robust negative likelihood ratio of 0.05. Grey scale changes were generally not as diagnostically accurate. Common extensor tendon neovascularity was equally distributed between the superficial and deep part of the tendon, and clinical severity measures did not correlate with neovascularity scores. CONCLUSIONS: Neovascularity identified with power Doppler ultrasonography when compared to grey scale changes (alone or in combination with Doppler) was diagnostically superior in identifying chronic tennis elbow. The lack of both neovascularity and grey scale changes on ultrasound examination also substantially increase the probability that the condition is not present and should prompt the clinician to consider other causes for lateral elbow pain.

Prevention of graft vs. host disease with alemtuzumab 'in the bag' decreases early toxicity of stem cell transplantation and in multiple myeloma is associated with improved long-term outcome.

BACKGROUND: Allogeneic stem cell transplantation in multiple myeloma (MM) is controversial because treatment-related mortality and relapse remain a substantial challenge. METHODS: Patients with symptomatic MM responsive to therapy received myeloablative conditioning with radiotherapy (n=12) or chemotherapy (n=10) followed by infusion of HLA-identical grafts from a sibling. Graft vs. host disease (GvHD) prophylaxis consisted of 'ex vivo' T-cell depletion with CAMPATH-1 antibody. The objective of the study was to determine transplant-related mortality (TRM), GvHD, overall survival (OS) and Disease free Survival (DFS). RESULTS: Twenty-two patients, median age 45 (range 37-56) years, had a median performance status of 1 (0-2). Patients received a median of 23.8 x 10(4)/kg CFU-GM and 4.31 x 10(6)/kg CD34. Median time to engraftment was 13 days. The day-100 and 1-year TRM was 9% and 20%, respectively. Ten patients suffered disease recurrence. Four of eight patients remained in remission after infusions of donor lymphocyte (DLI) containing a median total of 0.67 x 10(8)/kg CD3 cells. Three-year OS was 56%, and 50% remained disease free at a median of 1101 days (range 385-5309). Multiple regression analysis showed that bone marrow (vs. peripheral blood stem cell) (P=0.03), presentation of low albumin (P=0.02) and a higher dose of CAMPATH-1H (P=0.01) were adverse factors for survival. Cox analysis confirmed that a lower CAMPATH-1H dose was associated with improved outcome. DISCUSSION: In chemotherapy-responsive patients with myeloma, T-cell depletion of allogeneic grafts was associated with an acceptable 1-year TRM and seemed to have a favorable impact on long-term survival.

Prevalence of the dog nematode Spirocerca lupi in populations of its intermediate dung beetle host in the Tshwane (Pretoria) Metropole, South Africa.

Spirocerca lupi (Spirurida: Spirocercidae) is a cosmopolitan parasite, principally of domestic dogs and dung beetles are its main intermediate hosts. In South Africa there has recently been growing concern over the upsurge of reported cases of clinical spirocercosis in dogs, while little is known or understood about the dynamics of the host-parasite associations between dung beetles and this nematode. We determined and compared the prevalence of infection in dung beetles between rural, urban and peri-urban areas of Tshwane (Pretoria) Metropole. Dung beetles were sampled during April and October 2006, at various localities in each of these areas. Localities were selected on the basis of being focal areas of high infection with S. lupi in dogs. Pig, dog and cow dung-baited pitfall traps were used for sampling the beetles. Trap contents were collected 48 h after the traps had been set and only dung beetles were collected from the traps. In total, 453 specimens belonging to 18 species were collected from 63 pitfall traps in all three areas. The numbers of species that were collected varied among the three areas. Dung beetles, irrespective of species (18) and numbers (447), predominantly preferred pig dung. The prevalence of dung beetles infected with the larvae of S. lupivaried considerably in the three areas. In the urban area 13.5% of the dung beetles dissected were infected, while the prevalence of S. lupi in dung beetles in the rural area was 2.3%. All the dung beetles that were infected with this nematode showed a preference for omnivore (pig and dog) dung.

Increasing dose intensity of anthracycline antibiotics improves outcome in patients with acute myelogenous leukemia.

To understand the effect of dose concentration in the overall survival of AML, we conducted a study on the efficacy and toxicity of a drug combination where the dose of daunorubicin was intensified. For this analysis, the outcome of patients entered into two consecutive prospective trials was compared. Inclusion criteria in both arms were identical and consisted of primary AML in adults. Treatment protocol for Cape Town Regimen 4 (CTR-IV) comprised of cytarabine infusion (100 mg/m(2)) and etoposide (100 mg/m(2)), injection daily for 7 days in combination with daunorubicin (45 mg/m(2)) on days 1, 2, and 3. Patients achieving remission were given two further courses of the same chemotherapy and received allogeneic or autologous transplantation. CTR-V was a similar treatment program, except that daunorubicin was escalated on days 1, 2, and 3 to 75 mg/m(2) during induction and to 60 mg/m(2) during a single consolidation. Patients were also offered stem cell transplantation. Between 1990 and 1997, 78 patients (median age 33; range 13-67 years) fulfilled entry criteria and received CTR-IV. From 1998 onwards, 35 patients (median age 36; range 15-66 years) were prospectively enlisted into the CTR-V trial. The patient population in CTR-V had fewer Caucasian individuals (P = 0.02) and had significantly lower presentation hemoglobin (P = 0.0002). Following initiation of induction chemotherapy, 40 patients failed to respond. Among these, 10 patients demised before day 28. Another 30 (25/69 CTR-IV and 5/32 in CTR-V groups; P = 0.01) had leukemia that was resistant to chemotherapy, and all died. Remission was achieved in 59% of patients treated with CTR-IV and 77% of those receiving CTR-V (P = 0.03). CR occurred with a single course in 64% versus 88% (P = 0.02), respectively. There were no differences in the toxicity profile between these two combinations. Disease recurred in 50% and 28% (P = 0.07) of patients. For the 113 individuals, median follow up is 254 (range 19-4,451) and 304 (12-1,702; P = 0.03) days. Survival is 23% and 40%, respectively, favoring patients treated with CTR-V (log rank; P = 0.03). Cox regression analysis showed that treatment group (P < 0.001), FAB type, hemoglobin level, and platelet count were independent factors for response to chemotherapy. Older age and not undergoing myeloablative therapy were the only adverse factors for survival. We conclude that increase in the treatment dose of daunorubicin in patients with AML led to a higher remission rate, particularly with a single course of chemotherapy and had an equivalent toxicity profile. This therapeutic modification is also likely to result in substantial reduction in patient stay in hospital and in the overall expenditure.

Increased apoptosis of bone marrow cells and preserved proliferative capacity of selected progenitors predict for clinical response to anti-inflammatory therapy in myelodysplastic syndromes.

To determine the relation of apoptosis and clonal proliferation in the bone marrow (BM) to the effectiveness of a therapeutic protocol described to downmodulate monokine activity in patients with myelodysplastic syndromes (MDS). Prior to protocol therapy, BM stroma was cultivated and selected CD34(+) cells were studied in stroma and cytokine-dependent clonogenic assays. The TUNEL assay was used to establish the degree of apoptosis occurring in the marrow and CD34(+) population. The effectiveness of oral ciproloxacin 500 mg b. i.d., pentoxifylline 800 mg t.i.d., and dexamathasone 4 mg t.i.d. (CPD) antiinflammatory therapy was correlated with the intensity of cell apoptosis and proliferation of BM progenitor cells. Seventeen patients were studied. Twelve patients (10 transfusion dependent) received therapy for a median of 99 days (range 49-284). Toxicity caused four patients to discontinue the drug combination. Six patients fulfilled response criteria. Four patients became transfusion independent, and 50% reduction in the need for blood transfusions was noted in one patient. Blood parameters of one untransfused patient increased by >30%. Blood count remained unsupported in three patients, even at a median of 12 months after trial discontinuation. Apoptosis of marrow cells and selected CD34(+) progenitors was detected in a median of 49.5% (range 3. 6%-90%) and 10.6% (range 3.6%-100%; p < 0.01), respectively. In patients who responded to therapy, the median apoptosis rate in the bone marrow population was 71%, in contrast to the nonresponder's rate of 13% (p = 0.002). Overall clonogenic growth of selected precursors corresponded significantly with response to CPD protocol (p = 0.004). In some patients with MDS, ineffective hematopoiesis is related to high apoptotic index despite proliferation of the CD34(+) precursors. These patients seem to benefit from CPD cytokine modulatory therapeutic strategy.

Bone marrow transplantation depleted of T cells followed by repletion with incremental doses of donor lymphocytes for relapsing patients with chronic myeloid leukemia: a therapeutic strategy.

BACKGROUND: For patients with chronic myeloid leukemia (CML), long-term survival after stem cell transplantation requires adequate control of graft-versus-host disease (GVHD) and disease recurrence. Relapsing patients respond to donor lymphocyte infusion (DLI) but develop life-threatening complications. METHODS: Patients with CML in first chronic phase received bone marrow (n = 14) or peripheral blood progenitor cell transplants (n = 4) from HLA-identical siblings. GVHD prophylaxis was by ex vivo T-cell depletion with CAMPATH 1G. If disease recurred, donors' mononuclear cells were collected by apheresis, the CD3 samples commencing at 10(6)/kg were aliquoted at half-log increment intervals, cryopreserved, and infused until disease clearance. RESULTS: Eighteen patients (median age: 32.5 years) received transplants. All engrafted without procedure-related mortality. Fourteen patients relapsed, and 13 entered the DLI program. Two developed extensive GVHD after single schedule infusions ranging from 89x10(6) to 670x10(6) mononuclear cells/kg, and one survives in complete remission (CR). The rest, treated with incremental dose DLI, experienced no acute toxicities. One, who had developed grade III steroid-responsive GVHD, died in CR2 from opportunistic infections. Steroids reversed limited cutaneous GVHD and elevated liver enzymes in five patients. Three others developed pancytopenia, and two restored blood counts only after donor peripheral blood progenitor cell infusions. Molecular CR2 was established in 12/13 patients, occurring in 10/11 (91%) on the incremental program at a median accumulation of 67 (range: 5-166) x10(6) CD3 cells/kg. Sixteen of 18 (89%) survive at median of 854.5 days from bone marrow transplantation, 4 in CR1 and 10 in CR2 at a median disease-free survival (for remission 2) duration of 341 days. The median combined disease-free survival of the 14 patients in CR 1+2 is 660 days, with 99% average performance status. CONCLUSIONS: Escalating DLI leads to safe new molecular CR in most CML relapse patients. These results raise the possibility of using "safe" transplantation programs of T-cell depletion, that include graded DLI as prevention against disease recurrence.

A new technique of continuous interscalene nerve block.

PURPOSE: To describes a technique of indwelling interscalene catheter placement and to evaluate its complications. METHODS: One hundred and twenty patients undergoing major shoulder surgery received interscalene nerve block (ISNB) and were studied in three groups. Group 1 ISNB using Winnie's technique; group 2 by Winnie's technique with nerve stimulator and group 3 by epidural needle and catheter technique with nerve stimulator. All patients received 20 mL bupivacaine 0.5% and group 3 patients received an additional bupivacaine 0.25% infusion. Diaphragmatic movements were measured sonographically on emergence from anesthesia. Complications were noted. A visual analogue scale (0-10) was used to assess pain four hours postoperatively. RESULTS: Mean ipsilateral diaphragmatic movements were 4+/-8, 14+/-11 and 18+/-8 mm (mean +/- SD) in groups 1, 2 and 3 respectively. This was less than contralateral movements in all three groups (P < 0.05). None of the patients in groups 2 and 3 reported postoperative pain. The block failed in 10% of group 1 patients. Complete ipsilateral phrenic nerve block occurred in 85% of the patients in group 1, 35% of group 2 and 20% of group 3 (P < 0.05). Ipsilateral recurrent laryngeal nerve paralysis occurred in 20% of the patients in group 1, 5% of group 2 and in none of the patients in group 3 (P < 0.05). Horner's syndrome was noted in group 1 (30%), group 2 (12%) but not in group 3. None of the catheters in group 3 patients dislodged after an average use of 2.8+/-2.1 days. CONCLUSIONS: Indwelling catheter placement into the brachial plexus sheath as described in this communication was effective and associated with few complications.

The implications of early detection and pre-school habilitation of the hearing-impaired child. With special reference to the Provincial Paedo-audiological Centre, Tygerberg Hospital.

The basic handicap of deafness, viz. the lack lf natural communication skills, can be overcome by early detection of the defect and pre-school habilitation. In congenital deafness this dramatically improves the outlook for these children as regards the acquisition of normal speech, education in normal schools and emotional, social and economic integration into society. Planning for this is the responsibility of the Department of Health and Social Welfare and the provincial hospital administration.