Paediatric emergencies.

The care of sick children can be challenging for the anaesthetist who is only involved in the occasional care of paediatric patients. This paper outlines the care of medical and surgical paediatric emergencies for which an anaesthetist working at a district general hospital or equivalent may encounter. Conditions discussed include paediatric respiratory emergencies, sepsis, status epilepticus, the acute abdomen in the newborn, intussusception, the bleeding tonsil, trauma and the child with burns.

Combating junior doctors' "4am logic": a challenge for medical ethics education.

Undergraduate medical ethics education currently focuses on ethical concepts and reasoning. This paper uses an intern's story of an ethically challenging situation to argue that this emphasis is problematic in terms of ensuring students' ethical practice as junior doctors. The story suggests that it is aligning their actions with the values that they reflectively embrace that can present difficulties for junior doctors working in the pressures of the hospital environment, rather than reasoning to an ethically appropriate action. I argue that junior doctors need skills for implementing their ethical decisions and that these ought to form a central component of undergraduate medical ethics education.

A resource-based version of the argument that cloning is an affront to human dignity.

The claim that human reproductive cloning constitutes an affront to human dignity became a familiar one in 1997 as policymakers and bioethicists responded to the announcement of the birth of Dolly the sheep. Various versions of the argument that reproductive cloning is an affront to human dignity have been made, most focusing on the dignity of the child produced by cloning. However, these arguments tend to be unpersuasive and strongly criticised in the bioethical literature. In this paper I put forward a different argument that reproductive cloning is an affront to human dignity, one that looks beyond the dignity of the child produced. I suggest that allocating funds to such a pursuit can affront human dignity by diverting resources away from those existing people who lack sufficient health to enable them to exercise basic rights and liberties. This version of the argument posits cloning as an affront to human dignity in particular circumstances, rather than claiming the technology as intrinsically inconsistent with human dignity.

The junior doctor as ethically unique.

This paper argues that the professional situation of junior doctors is unique in ethically important ways and thus that ethics work focusing on junior doctors specifically is necessary. Unlike the medical student or the more senior doctor, the doctor in his or her early postgraduate years is simultaneously a responsible health professional, a subjugate learner and a human resource. These multiple roles generate the set of ethical issues faced by junior doctors, a set that has some overlaps with that faced by medical students and with that faced by more experienced doctors but is far from completely continuous with either. Further, the multiple roles that junior doctors play affect their options for negotiating the ethical challenges that they face. Their position determines not only the content of the set of ethical issues that they encounter, but also the kinds of actions they can take in the face of these challenges. Thus considering junior doctors only in combination with medical students or more senior doctors fails on two fronts. Firstly, only a very incomplete set of the ethical issues faced by junior doctors will be addressed, and, secondly, the constraints associated with the specific professional situation of junior doctors will not be adequately considered, limiting the practical applicability for these agents of any such analyses.

Primary trauma care.

The Primary Trauma Care programme is a course designed to train anaesthetists, surgeons and others in the systematic review and management of severe trauma victims at the District Hospital. Over the last 10 years, many individuals have been involved in training, empowering and supporting doctors and nurses in a number of countries. Local programmes and training courses are increasingly co-ordinated by regional offices in South America, India, China, Indonesia, the South Pacific and Africa. The Primary Trauma Care Foundation continues to support these regional offices in their need for qualified instructors, fund-raising, and for updating educational material. With anaesthetic support, the Primary Trauma Care Foundation will continue to empower anaesthetists worldwide as they work with their surgical colleagues to treat severely injured patients in areas where, previously, due to inadequate resources and training, comprehensive treatment was not available.

Global safe anaesthesia and surgery initiatives: implications for anaesthesia in the Pacific region.

In 2015 three major events occurred for global anaesthesia and surgery. In January, the World Bank published Disease Control Priorities 3rd edition (DCP 3rd edition). This volume, Essential Surgery, highlighted the cost effective role of anaesthesia and surgery in global health. In April, the Lancet Commission on Global Surgery released its report "Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development". The report focuses on five key areas to promote change including: access to timely surgery, surgical workforce and procedural capability, surgical volume, data collection such as perioperative mortality rate, and financial protection. In May, the 68th World Health Assembly (WHA) voted in favour of Resolution A68/31: Strengthening emergency and essential surgical and anaesthesia care as a component of universal health coverage. The resolution was passed unanimously and it is the first time that surgery and anaesthesia have received such prominence at WHA level. These three events all have profound implications for the provision and access of safe anaesthesia and surgery in the Pacific region in the next 15 years. This article considers some of the regional factors that affect these five key areas, especially with regard to anaesthetic specialist workforce density in different parts of the region. There are many challenges to improve anaesthesia access, safety, and workforce density in the Pacific region. Future efforts, initiatives and support will help address these problems.

Cardiovascular physiology in a case of heterotopic cardiac transplantation.

Successful heterotopic cardiac transplantation in a 24 year old man with end stage cardiomyopathy provided an opportunity to study cardiovascular physiology. The donor and native hearts, functioning independently in parallel, were studied by serial physical examination, electrocardiography, echocardiography, nuclear angiography and cardiac catheterization. Results indicated that the donor left heart assumed the predominant role in supplying systemic output, possibly contributing to decreasing function of the patient's own (native) heart. Analysis of serial nuclear angiograms revealed an initial postoperative ejection fraction of 52 and 21 percent in the donor and the native left ventricle, respectively; repeat studies 3 months postoperatively showed values of 50 and 9 percent, respectively, indicating significant deterioration in native left ventricular cardiac function. Observation of valve motion of the native heart showed major irregularities of the aortic valve in contrast to seemingly normal, regular mitral valve motion. These data rise interesting questions regarding interpretation of valve motion as an indicator of ventricular function.

Ultrastructure of Blastocystis hominis in human stool samples.

A study of the ultrastructure of Blastocystis hominis in human stools found morphological differences between the organisms seen and those present in laboratory cultures. B. hominis found in stool samples showed little morphological variation with storage time before fixation, but were consistently smaller (approximately 5 microns in diameter), with a thicker surface coat than the cultured organisms. The large central vacuole, characteristic of the cultured organisms, and accepted as standard morphology of B. hominis, was rarely observed in organisms present in stool samples. Instead, a number of small vacuoles, or possibly a network of interconnected vacuoles, were noted. After short-term culture, organisms from these samples appeared with the typical vacuolated morphology. No large vacuoles were present in organisms obtained at colonoscopy. These results suggest that the vacuolated form as previously described may be an artefact of culture conditions, and that the form of B. hominis present in the gastrointestinal tract is avacuolar.

Coccidian/cyanobacterium-like bodies as a cause of diarrhea in Australia.

Coccidian/cyanobacterium-like bodies (CLBs) were detected in the stool specimens of 5 Australian patients over a 6 mth period from July to December, 1992. Four of the 5 patients had recent travel history to a neighbouring overseas destination, including Papua New Guinea and Bali, Indonesia. These 4 patients had clinical presentations of acute onset, recurrent diarrhea which was prolonged and accompanied by weight loss, anorexia and lethargy. These symptoms are consistent with reports from other countries as being associated with CLBs. Large numbers of CLBs were detected by microscopic examination of direct and stained preparations of the stool specimens from these patients during the course of illness. In contrast, the one patient without any foreign travel history exhibited only mild diarrhea of short duration with only small numbers of CLBs detected in the stool specimen. Fecal examinations for bacterial and viral enteric pathogens were negative. Fecal reducing substances were not detected in the one child patient. Examinations for other parasitic enteric pathogens were all negative except for the detection of low numbers of Blastocystis hominis in one patient. CLBs should be considered as a possible etiology of unexplained diarrhea in patients who have returned to Australia from neighbouring tropical countries. Variation from the well documented clinical syndrome which has been attributed to infection with this organism may occur. CLBs may be endemic to Australia and neighbouring countries. If so, many more cases of CLB associated illness will be encountered.

Erysipelothrix rhusiopathiae: an uncommon but ever present zoonosis.

Erysipelothrix rhusiopathiae is an important animal pathogen with a worldwide distribution, yet this zoonotic infection is rarely reported in humans. Three cases of E. rhusiopathiae infection, which illustrate the varied clinical presentations of this pathogen in humans, are presented together with the pathological findings and treatment regimens.

Use of the interview in admissions.

A description of one method of dealing with nonacademic information from applicants seeking acceptance into a physical therapy curriculum is presented. The strengths of this admission process are interviewer training sessions, use of simulated interviews presented by videotape, subsequent discussion of ratings, specific criteria to support interview ratings, and an arbitration procedure. Attempts were made to increase the objectivity of the interview through frequent meetings of the admission committee to decide on the areas of the interview and specific criteria on which to rate each area. In the areas of weighting factors, training of interviewers, development of specific interview criteria, arbitration procedure, and the use of the computer printout, this admission process could be easily adapted to other allied health programs. Details of the interview are discussed.

Effect of magnetic resonance imaging on core body temperature in anaesthetised children.

Children undergoing magnetic resonance imaging (MRI) often require general anaesthesia (GA). Children under GA are at risk of decreases in body temperature. This risk may be greater during MRI due to MRI scanners requiring cool ambient temperatures. Conversely, radiofrequency radiation emitted by MRI scanners is absorbed by the patient as heat energy, creating a risk of an increase in body temperature. The aim of this study was to determine the proportion of anaesthetised children undergoing an MRI scan who develop hyperthermia or hypothermia, and the risk factors associated with temperature changes in these children. Pre-scan and post-scan tympanic temperatures were obtained from 193 children (aged three months to six years) undergoing an MRI procedure under GA. No active warming or cooling devices were used during the MRI scans. The median duration for anaesthesia was 42 minutes (35 to 57 minutes). Fifty-two percent of children were hypothermic after their scan, while no subjects were hyperthermic after their scan. The mean (± standard deviation) pre-scan temperature was 36.2°C±0.5°C, and the mean (± standard deviation) post-scan temperature was 35.9°C±0.6°C (an overall mean temperature decrease of 0.28°C was observed [95% confidence interval, -0.36°C to -0.19°C], P <0.001). In conclusion, core body temperature was found to decrease slightly during an MRI scan under GA. These results suggest that more focus is needed regarding the cooling effects of GA agents during MRI, as opposed to the heating effects of the MRI scanner.

Acting parentally: an argument against sex selection.

The Human Fertilisation and Embryology Authority's (HFEA) recent restrictive recommendations on sex selection have highlighted the need for consideration of the plausibility of ethical arguments against sex selection. In this paper, the author suggests a parental virtues approach to some questions of reproductive ethics (including sex selection) as a superior alternative to an exclusively harm focused approach such as the procreative liberty framework. The author formulates a virtue ethics argument against sex selection based on the idea that acceptance is a character trait of the good parent. It is concluded that, because the argument presented posits a wrong in the sex selecting agent's action that is not a harm, the argument could not function as a justification of the HFEA's restrictive position in light of their explicit commitment to procreative liberty; it does, however, suggest that ethical approaches focused exclusively on harm fail to capture all the relevant moral considerations and thus that we should look beyond such approaches.

Macrophages related to leptomeninges and ventral nerve roots. An ultrastructural study.

In immature rats active macrophages were frequently seen projecting into the subarachnoid space from the surface of the leptomeninges. They also occurred between the layers of the pia and within the nerve roots. They were most frequent during the first two weeks after birth, which is a period of rapid neural growth and myelination in ventral roots. In contrast, they were much fewer at later stages. The ultrastructural characteristics of these cells are described. It is suggested that these cells take part in tissue growth and remodelling by the removal of material which degenerates or becomes redundant during development. For example, they may ingest effete leptomeningeal cells or fragments of them. Those within the ventral roots may phagocytose abnormal Schwann cells, or the myelin of sheaths which have failed to develop normally. It is also suggested that macrophages may be involved in the excavation of the subarachnoid space. Another possible function in which they may be involved is the ingestion of material, possibly of a protein nature, from the cerebrospinal fluid.