Evaluation of competency-driven training for facilitators delivering a psychological intervention for children in Lebanon: a proof-of-concept study.

AIMS: The mounting evidence for effective delivery of psychological interventions by non-specialists in low- and middle-income settings has led to a rapid expansion of mental health and psychosocial support trainings globally. As such, there is a demand for strategies on how to train and implement these services to attain adequate quality. This study aims to evaluate the added value of a competency-driven approach to training of facilitators for a group intervention for children with severe emotional distress in Lebanon. METHODS: In a controlled before and after study, 24 trainees were randomly allocated to participate in either a competency-driven training (CDT) or training-as-usual (TAU) (1 : 1) for a psychological intervention for children with severe emotional distress. We assessed the change in demonstrated competencies, using standardised role-plays, before and after the training. Measures included the 13-item Working with children-Assessment of Competencies Tool (WeACT), the 15-item ENhancing Assessment of Common Therapeutic factors (ENACT) and the 6-item Group facilitation: Assessment of Competencies Tool (GroupACT). The trainer in the experimental arm used pre-training and during training competency assessment scores to make real-time adjustment to training delivery. Due to COVID-19 pandemic restrictions, all activities were done remotely. RESULTS: CDT resulted in significantly better outcomes on increasing competencies on the WeACT (repeated measures analysis of variance; F(1, 22) = 6.49, p < 0.018) and on the GroupACT (Mann-Whitney U = 22, p < 0.003), though not statistically significant on the ENACT. There is no significant between-group difference on the reduction of harmful behaviours, mainly because both forms of training appear equally successful in eliminating such behaviours. CONCLUSIONS: This proof-of-concept study demonstrates the potential of CDT, using standardised assessment of trainee competencies, to contribute to better training outcomes without extending the duration of training. CDT can result in up to 18% greater increase in adequate competency, when compared to TAU. The study also yields recommendations for further enhancing the benefits of competency-driven strategies. A fully powered trial is needed to confirm these findings.

The Pathophysiology of Myocardial Ischemia and Perioperative Myocardial Infarction.

Ischemic heart disease, the leading cause of death worldwide, may result in devastating perioperative ischemia and infarction. The underlying pathophysiology, precipitating factors, and approach to prevention differ between patients presenting for noncardiac surgery, developing acute coronary syndrome versus stable angina. The first half of this article reviews the pathophysiology of acute coronary syndrome and stable angina. Acute coronary syndrome, otherwise known as Type 1 myocardial infarction, includes unstable angina, non-ST segment elevated myocardial infarction and ST segment elevated myocardial infarction. Acute coronary syndrome occurs as a result of vulnerable plaque rupture with subsequent varying degrees of thrombus formation, arterial spasm, and thus coronary occlusion. Stable angina, on the other hand, results from a myocardial oxygen delivery and demand mismatch in the setting of fixed coronary stenosis. After this discussion, the review article considers how both apply to perioperative myocardial infarctions and myocardial injury after noncardiac surgery. This article furthermore argues why myocardial oxygen delivery demand mismatch (Type 2) myocardial infarction is the most likely underlying pathophysiology responsible for perioperative myocardial infarctions. Being aware of this and knowledgeable about Type 2 infarctions may enable anesthetic providers to better predict the majority of triggers contributing to, and thus decreasing the incidence of, perioperative myocardial infarctions.

An impedance-guided intra arterial catheter.

Under certain circumstances, the placement of arterial catheters can be difficult. In these instances, a form of guidance is preferred to avoid repeated insertions of the arterial catheter. Ultrasonic guidance is generally used in these instances, but the equipment required is expensive and cumbersome. This study produced an arterial catheter that is guided by the impedance of biological tissue encountered between the patient's skin and the lumen of the artery, with the aim of producing a cheaper and manageable alternative to ultrasonic guidance. Additionally, this study has inspected the impedance of human tissue in order to determine whether or not a sufficient and discernable difference between the impedance of the different tissue types could be identified and thus be used to guide an arterial catheter based on said impedance differences. The results indicate that the difference between subcutaneous tissue, fat tissue and skeletal muscle tissue are not clear enough to make accurate discrimination between tissue types. However, the study shows a clear difference between the impedance of arterial blood and the aforementioned tissue, allowing for the device to determine when accurate placement has been achieved. From the results obtained in the studies, the discrimination between blood and other intermediary tissue can be made with 99,4% confidence.

Implementation of a protocol facilitates evidence-based physiotherapy practice in intensive care units.

OBJECTIVES: To compare the physiotherapy service provided when therapists' decisions are guided by an evidence-based protocol with usual care (i.e. patient management based on therapists' clinical decisions). DESIGN: Exploratory, controlled, pragmatic sequential time block clinical trial. SETTING: Level 3 surgical unit in a tertiary hospital in South Africa. PARTICIPANTS: All patients admitted consecutively to the surgical unit over a 3-month period were allocated to usual or protocol care based on date of admission. INTERVENTIONS: Usual care was provided by clinicians from the hospital department, and non-specialised physiotherapists were appointed as locum tenens to provide evidence-based protocol care. MAIN OUTCOME MEASURES: Patient waiting time, frequency of treatment sessions, tasks performed and adverse events. RESULTS: During protocol-care periods, treatment sessions were provided more frequently (P<0.001) and with a shorter waiting period (P<0.001). It was more likely for a rehabilitation management option to be included in a treatment session during protocol-care periods (odds ratio 2.34, 95% confidence interval 1.66 to 3.43; P<0.001). No difference in the risk of an adverse event was found between protocol-care and usual-care periods (P=0.34). CONCLUSIONS: Physiotherapy services provided in intensive care units (ICUs) when the decisions of non-specialised therapists are guided by an evidence-based protocol are safe, differ from usual care, and reflect international consensus on current best evidence for physiotherapy in ICUs. Non-specialised therapists can use this protocol to provide evidence-based physiotherapy services to their patients. Future trials are needed to establish whether or not this will improve patient outcome.

The Pressure Flow Relationship of the Internal Mammary Artery after Offpump Anastomosis to the Left Anterior Descending Coronary Artery

Objective: To assess the pressure flow relationship of the internal mammary artery (IMA) in situ; after skeletonisation and after anastomosis to the left anterior descending (LAD) coronary artery; using either halothane; sevoflurane or propofol as an anaesthetic agent. Methods: 15 Pigs were used in total; five received halothane; five sevoflurane and five propofol as an anaesthetic agent. The flow in the internal mammary artery in each of the pigs; was measured at various arterial pressures. This was done with the IMA in situ; then after dissecting the artery off the chest wall using the skeletonisation technique and finally after offpump grafting to the left anterior descending coronary artery. Results: The pressure flow relationship of the internal mammary artery after skeletonisation was found to be linear (r=0.8650). The pressure flow correlation after grafting the skeletonised internal mammary artery to the left anterior descending coronary artery was found to be similarly linear (r=0.8766). In the sevoflurane subgroup; with the IMA still in situ; a degree of autoregulation was found to be present; but after skeletonisation this was subsequently lost (p=0.011). Conclusions: The pressure flow relationship in the internal mammary artery after skeletonising the vessel and after OPCAB anastomosis to the LAD was found to be linear. In the subgroup of pigs receiving sevoflurane; some degree of autoregulation was demonstrated in the in situ IMA. This remnant of autoregulation was lost after skeletonisation and after grafting of the vessel to the left anterior descending coronary artery

Halothane protects the isolated rat myocardium against excessive total intracellular calcium and structural damage during ischemia and reperfusion.

A recent study from our laboratory demonstrated halothane to be a powerful protectant of the isolated rat heart during reperfusion after normothermic cardioplegic arrest. It was speculated that this protective effect might be due to prevention of excessive intracellular calcium. The aim of the present study was to evaluate the effect of halothane on the total intracellular calcium (Ca2+) content and on myocardial structure both at the end of normothermic cardioplegic arrest and at the end of reperfusion. Isolated perfused rat hearts were perfused for a control period of 30 min, followed by 40 min of normothermic cardioplegic arrest with or without reperfusion for 30 min. Halothane (1.5%) was administered continuously before and after arrest. Halothane caused a significant decrease of intracellular Ca2+ at the end of normothermic cardioplegic arrest and after reperfusion. Myocardial morphology was assessed by extensive light microscopy and ultrastructure was evaluated by electron microscopy. Grading of ischemic damage showed that exposure to normothermic cardioplegia resulted in marked ischemic injury, regardless of whether the hearts were treated with halothane. Reperfusion in the presence of halothane caused a significant reversal of ischemic damage and almost complete ultrastructural repair, whereas untreated hearts still exhibited severe edema, contracture, and contracture bands. Our results indicate that the beneficial effects of halothane on myocardial structural recovery during reperfusion is associated with a reduction in excessive intracellular Ca2+. The exact mechanism of this protective action is under investigation.

Effect of compliance on a time-domain estimate of the characteristic impedance of the pulmonary artery during acute pulmonary hypertension.

In 11 pigs under general endotracheal anaesthesia, the time-domain method of determining the pulmonary arterial input impedance was compared with the frequency-domain equivalent under normal conditions as well as acute pulmonary hypertension induced by glass microspheres. The time-domain methods of determining the pulmonary arterial compliance C and pulmonary vascular bed resistance Rp compared favourably with the frequency-domain equivalents (r = 0.774, n = 60, p < 0.001 and r = 0.906, n = 60, p < 0.001, respectively), even at mean pulmonary artery pressures (MPAP) of 35 mmHg and above. A consistent and ever-increasing difference between characteristic impedance Zo(omega), estimated by averaging input impedance modulus values over a selected frequency range, and its time domain equivalent Ro with increasing MPAP was shown to be the cause of the poor fit between the measured and remodelled pulmonary blood flow. By analysing a time-domain estimate of the pulmonary characteristic impedance Ro(C, Rp, t), it was demonstrated that the characteristic impedance was dependent on C. Ro is therefore not an accurate representation of the characteristic impedance, especially under conditions of acute pulmonary hypertension. Ro(C, Rp, t) should therefore be calculated instead.

Pulmonary artery compliance: its role in right ventricular-arterial coupling.

OBJECTIVE: The aim was to investigate the ventricular/vascular coupling of the intact right heart under conditions of normal operation and acute pulmonary hypertension. METHODS: Right ventricular contractility was obtained by calculating the end systolic pressure-volume relationship (Ees) and the effective pulmonary arterial elastance (Ea), applying the Windkessel parameters of the pulmonary arterial input impedance. Coupling between the ventricle and its load could be determined in terms of Ees and Ea. Acute pulmonary hypertension was induced by injecting glass microspheres into the pulmonary vascular bed until a mean pulmonary arterial pressure of more than 35 mm Hg had been reached. Experimental subjects were Landras/Large white pigs (n = 11), studied under general anaesthesia. Ees was obtained by normalising the right ventricle pressure-diameter equivalent of Ees to stroke volume. The lumped element parameters of the Windkessel analogue were calculated from the pulmonary artery pressure and blood flow. Stroke work was calculated from the pressure-volume loop and oxygen consumption derived from the pressure-volume area. Efficiency was taken to be the ratio between stroke work and oxygen consumption. RESULTS: Ea increased significantly as mean pulmonary artery pressure rose, while Ees remained linear and constant. Stroke work, as well as efficiency, increased, with the maximum of the stroke work curve lying to the right of the efficiency maximum. At the control step (before pulmonary artery hypertension), Ees = 1.71 Ea (n = 11). CONCLUSIONS: Under control conditions, the right ventricle operates at maximum efficiency and submaximal work output. Compliance of the pulmonary artery is a significant factor in decoupling the right ventricle from its vascular load. As the compliance decreases with acute pulmonary hypertension, the maximum stroke work against load point shifted in such a manner that the right ventricle changed its operational status from a flow to a pressure pump, resulting in a decreased stroke volume.

Pre-operative assessment and management of the patient with ischaemic coronary artery disease in non-cardiac surgery.

Peri-operative cardiac events are the leading cause of death following anaesthesia and surgery. We attempt to put into perspective the various methods of pre-operative assessment of patients at risk, and suggest a logical sequence for the use of potentially costly investigations such as 12-lead ECG, exercise stress ECG, ambulatory ECG monitoring, myocardial perfusion imaging, radionuclide ejection fraction, and coronary angiography. Important principles are given for the management of patients at risk of peri-operative cardiac incidents if the decision is made to proceed with non-cardiac surgery despite the potential risk or because of inoperable coronary disease.

Behavioural changes in children following minor surgery--is premedication beneficial?

One hundred and twenty-three male children, aged one to ten years, were studied to determine the influence of premedication on changes in patterns of behaviour following hospitalization for repair of inguinal hernias. Four comparable groups were selected for premedication regimen: (1) A control group without premedication; (2) oral trimeprazine tartrate 2 mg/kg, methadone 0.1 mg/kg and droperidol 0.15 mg/kg; (3) oral midazolam 0.45 mg/kg; (4) intramuscular midazolam 0.15 mg/kg. Standard inhalational anesthesia was used and caudal blocks employed for analgesia. The parents returned a questionnaire at two weeks. Changes in behaviour were reported in 78% of the children and overall, premedication showed little benefit. However, midazolam premedication was associated with a significantly lower incidence of night-time crying and awakening, compared with no premedication. Only for night-time crying and day-time toilet training did age below five years prove to be a significant contributing factor.

Heparin treatment in thrombin-induced disseminated intravascular coagulation in the baboon.

BACKGROUND AND METHODS: We postulated that low-dose heparin (10 IU/kg.hr) administered as a continuous iv infusion may prevent or ameliorate the induction of thrombin-induced disseminated intravascular coagulation in baboons under general anesthesia. In a nonrandomized experiment lasting 8 hrs, animals were divided into three groups: 11 received thrombin only (group A); ten were pretreated with heparin before thrombin administration (group B); and 15 received heparin 2 hrs after disseminated intravascular coagulation was induced with thrombin (group C). All animals were monitored hemodynamically and coagulation tests were performed hourly. Tests included the following: one-stage prothrombin ratio; activated partial thromboplastin time; fibrinogen and fibrin degradation products; thrombin time; plasma fibrinogen level; antithrombin III and activated clotting time. After the acute phase of the experiment, the animals were observed for 6 days and a postmortem examination was performed on a survivor of each group. RESULTS: Six (55%) group A animals died within 6 days, while there were no deaths in group B and one animal (7%) died in group C. In group C, the administration of heparin could not normalize the clotting profile, but the mortality rate was significantly less than in group A. The prophylactic administration of heparin in group B prevented the induction of disseminated intravascular coagulation. The postmortem findings were of interest, but no statistically valid conclusions could be made, as only one autopsy was done for each group. However, the results suggest that heparin pretreatment may protect against lung edema and liver necrosis. CONCLUSIONS: The results suggest that heparin, in a dose of 10 IU/kg.hr iv, could possibly be safely used in patients at high risk of developing disseminated intravascular coagulation and in those patients with established disseminated intravascular coagulation.

Rural anaesthetic practices in the western Cape.

The findings of specialist anaesthetists on visits to rural towns in the western Cape over 6 years are reported. The importance of academic units communicating with general practitioners, nursing staff and hospital authorities in their own working environment is emphasised. Hospital anaesthetic facilities and general practice anaesthetic methods are discussed and recommendations made and, in addition, common problems that could improve anaesthesia in general practice are summarised.

Oral midazolam in paediatric premedication.

In a premedication study involving 135 children, aged 1-10 years, four regimens were investigated: (i) no premedication; (ii) oral trimeprazine tartrate 2 mg/kg, methadone 0.1 mg/kg, droperidol 0.15 mg/kg (TMD); (iii) intramuscular midazolam (Dormicum; Roche) 0.15 mg/kg; and (iv) oral midazolam 0.45 mg/kg. All premedications were given 60 minutes before a standard halothane anaesthetic. No impairment of cardiovascular stability occurred but after premedication the mean oxygen saturation decreased by 1.6% and 1.1%, respectively, in the intramuscular midazolam and TMD groups. Overall, children under 5 years of age behaved less satisfactorily in the holding room and at induction, than those over 5 years (P less than 0.01). Midazolam, intramuscularly and orally, produced more satisfactory behaviour than the other two regimens (P less than 0.05) and, combined with a 70% more rapid recovery than the TMD regimen (P less than 0.05), suggests that oral midazolam is a more effective paediatric premedication agent than placebo or TMD.

Midazolam and amnesia in pediatric premedication.

One hundred and twenty-eight children aged three to ten years, were studied to determine the effect of premedication on amnesia for the preanesthetic period. Four comparable groups were used: A control group, no premedication; oral trimeprazine tartrate 2 mg/kg, methadone 0.1 mg/kg plus droperidol 0.15 mg/kg (T.M.D.); oral midazolam 0.45 mg/kg; intramuscular midazolam 0.15 mg/kg. Amnesia was tested for four pictorial facts, and for induction of anesthesia. For pictorial facts, both routes of midazolam administration gave a sixty percent incidence of amnesia compared with sixteen percent in the control group (p less than 0.001). The T.M.D. premedication provided a forty-three percent incidence, also better than the control group (p less than 0.05). Induction was remembered by fifty percent of the midazolam children compared with sixty-six percent of the T.M.D. group (p greater than 0.05) and eight-one percent of the control group (p less than 0.05). The potential advantages of amnesia in pediatric premedication are discussed.

The effect of halothane, enflurane and isoflurane on the circulation.

This study, in open-chested dogs, sought to explore the relationship between whole-body oxygen delivery and oxygen consumption during anaesthesia, using increasing concentrations of halothane, enflurane and isoflurane. Results indicate that the cardiac index and oxygen delivery became critical at less than 1 MAC (minimal alveolar concentration of anaesthetic) for the three commonly used vapours. Halothane caused the least depression of contractility, but the stroke volume was reduced by the well-maintained afterload at 1 MAC. Enflurane and isoflurane were associated with more depression of contractility, but the cardiac output was maintained by an increase in heart rate in the case of isoflurane and reduced mean arterial pressure during the use of enflurane.

The load independence of the end-systolic pressure-length relationship of the heart.

The end-systolic pressure-volume relationship is the state of the art in the measurement of myocardial contractility. This index is load-independent and relatively independent of heart rate. In this study the load-independent character of the end-systolic pressure-length (ESPL) relationship was evaluated in dogs under general anaesthesia. The results indicated that the ESPL is pre- and afterload-independent, since the comparative values of ESPL from afterloaded and reduced preload contractions did not differ significantly (N = 75; P = 0.5993). The application of the ESPL relationship as a means of describing the function of the heart as a muscle as well as a pump is discussed.

Pancreatic transplantation in a patient with severe insulin resistance. A case report.

A 22-year-old white woman with insulin-dependent diabetes mellitus of 20 years' duration and advanced secondary complications underwent pancreatic transplantation for severe insulin resistance and rapidly progressive nephropathy. Resistance to all forms and strengths of subcutaneously administered insulin had necessitated almost permanent hospitalisation for the previous 10 years. Short-term improvement of the endocrine and metabolic status was achieved by initial segmental and subsequent whole pancreatic transplantation.

[Oxygen balance in the normal dog myocardium with increased concentrations of inhaled anesthetics]. / Die suurstofbalans in die normale hondmiokardium gedurende toenemende konsentrasies van inhalasienarkosemiddels.

Myocardial oxygen supply and demand in the normal dog were evaluated as the concentration of halothane, enflurane or isoflurane was increased. Although coronary blood flow decreased as the anaesthetic gas concentration increased, the O2 supply-to-demand ratio remained stable owing to a decrease in the myocardial O2 consumption.

Community-acquired pneumonia--factors influencing intensive care admission.

The mortality rate in critically ill patients with pneumonia who require invasive vital organ support, including mechanical ventilation, in an intensive care unit (ICU) remains above 50%. The contribution of these costly life support systems to the survival of patients with extensive pneumonia is a matter for debate. The high mortality rate in this group of patients can be attributed in part to the fact that they are frequently referred for ICU care when their condition has already deteriorated to the point of no return. A retrospective study over 18 months of 34 cases of community-acquired pneumonia (17 patients required ventilatory support in the respiratory ICU) was undertaken to identify criteria which would justify early admission to an ICU. These were first-line clinical and biochemical factors, three of which were present in all patients on admission to hospital: (i) bronchopneumonia or lobar pneumonia involving more than two lobes (P less than 0.001); (ii) respiratory rate greater than 30/min (P less than 0.001); and (iii) partial arterial oxygen pressure less than 8 kPa (P less than 0.001). Other systemic factors associated with a poor prognosis and admission to the ICU were clinical signs of septicaemia, abnormal liver function and low serum albumin value. A scoring system for severity of pneumonia based on these factors is proposed. The possibility of an improved prognosis in a potentially reversible disease can become a reality if this approach is employed prospectively.