bluuebunny/crossref_metadata_2025 huggingface dataset:
Characterization of knockdown resistance in DDT‐ and pyrethroid‐resistant Culex quinquefasciatus populations from Sri Lanka
Authors: Wondji Charles S. , Priyanka De Silva W. A. P. , Hemingway Janet , Ranson Hilary , Parakrama Karunaratne S. H. P.
Published: August 2010

DDT and pyrethroid resistance in Culex quinquefasciatus have been previously reported in Sri Lanka, but the mechanisms involved have yet to be characterized. We report the presence of two mutant alleles of the sodium channel gene, the target site for both DDT and pyrethroid insecticides. Both mutations resulted in classic knockdown resistance (kdr) L1014F mutation because of either an A‐to‐T substitution or an A‐to‐C substitution. We developed two alternative assays to distinguish between the two mutations and used these to screen 214 individuals from nine geographic locations throughout Sri Lanka. Very high levels of kdr mutations were found throughout the country. A predominance of the A‐to‐C mutation was observed over the A‐to‐T with an average allele frequency of 50% and 2%, respectively. In addition to these non‐synonymous kdr substitutions, we also found an indel (TCACA) in the intron downstream of the kdr mutation. After genotyping this indel in 136 individuals, we found no evident correlation between kdr genotypes and intronic indel. The presence of two alternative kdr mutations has implications for the reliance on single molecular diagnostics for detection of resistance in field populations. Furthermore, the high levels of these kdr mutations in C. quinquefasciatus populations throughout Sri Lanka are of concern for the future of pyrethroid‐based control programmes on this island.
Could clinical audit improve the diagnosis of pulmonary tuberculosis in Cuba, Peru and Bolivia?
Authors: Siddiqi Kamran , Volz Anna , Armas L. , Otero L. , Ugaz R. , Ochoa E. , Gotuzzo E. , Torrico F. , Newell James N. , Walley J. , Robinson Mike , Dieltiens G. , Van der Stuyft P.
Published: August 2010

Objectives  To assess the effectiveness of clinical audit in improving the quality of diagnostic care provided to patients suspected of tuberculosis; and to understand the contextual factors which impede or facilitate its success.

Methods  Twenty‐six health centres in Cuba, Peru and Bolivia were recruited. Clinical audit was introduced to improve the diagnostic care for patients attending with suspected TB. Standards were based on the WHO and TB programme guidelines relating to the appropriate use of microscopy, culture and radiological investigations. At least two audit cycles were completed over 2 years. Improvement was determined by comparing the performance between two six‐month periods pre‐ and post‐intervention. Qualitative methods were used to ascertain facilitating and limiting contextual factors influencing change among healthcare professionals’ clinical behaviour after the introduction of clinical audit.

Results  We found a significant improvement in 11 of 13 criteria in Cuba, in 2 of 6 criteria in Bolivia and in 2 of 5 criteria in Peru. Twelve out of 24 of the audit criteria in all three countries reached the agreed standards. Barriers to quality improvement included conflicting objectives for clinicians and TB programmes, poor coordination within the health system and patients’ attitudes towards illness.

Conclusions  Clinical audit may drive improvements in the quality of clinical care in resource‐poor settings. It is likely to be more effective if integrated within and supported by the local TB programmes. We recommend developing and evaluating an integrated model of quality improvement including clinical audit.
Phylogeny of dengue viruses circulating in Jeddah, Saudi Arabia: 1994 to 2006
Authors: Zaki Ali , Perera David , Jahan Shahrina Shan , Cardosa Mary Jane
Published: August 2010

The nucleotide sequence of the 240 bp E/NS1 junction of 81 dengue viruses isolated from cases in Jeddah, Saudi Arabia was determined and used to serotype the viruses. The nucleotide sequences of the complete Envelope (E) genes of 19 isolates were used for a phylogenetic analysis of the dengue viruses circulating in Saudi Arabia from 1994 to 2006. Three of the four dengue serotypes (DENV‐1, DENV‐2 and DENV‐3) were found to circulate, often with more than one serotype in each outbreak. There was a major outbreak caused by DENV‐1 and DENV‐2 in 1994 while DENV‐3 emerged in 1997. In the summer of 2004, all three serotypes were isolated and this gave way to an extended outbreak of DENV‐1 that stretched from the summer of 2005 through early 2006. In the 1994 outbreak, the DENV‐1 circulating was from the America‐Africa genotype (lineage India‐2) while the most recent outbreak in 2005 and 2006 was caused by a different DENV‐1 strain from genotype Asia (lineage Asia‐2), suggesting a re‐introduction of DENV‐1 a decade after the first introduction in 1994. There has been no change in the genotypes of DENV‐2 (cosmopolitan genotype) and DENV‐3 (genotype III) circulating since introduction in 1994 and 1997, respectively.
Impact of seven rounds of mass administration of diethylcarbamazine and ivermectin on prevalence of chronic lymphatic filariasis in south India
Authors: Yuvaraj J. , Pani S. P. , Vanamail P. , Ramaiah K. D. , Das P. K.
Published: August 2010

Objective  To evaluate the impact of seven rounds of mass administration of diethylcarbamazine (DEC) and ivermectin on the prevalence of chronic lymphatic filariasis and to compare it with that observed in a placebo arm in a community‐level trial.

Methods  Cross‐sectional clinical surveys were carried out before and after seven rounds of mass drug administration (MDA). About 54–75% of the target population were treated at each round of MDA.

Results  After seven rounds, the hydrocele prevalence had declined from the pre‐intervention level of 20.5–5.1% (P < 0.05) in the DEC arm, from 23.9% to 10.4% (P < 0.05) in the ivermectin arm and from 20.4% to 10.9% (P < 0.05) in the placebo arm, equivalent to reductions of 75.3%, 56.6% and 46.6%, respectively. The lymphoedema/elephantiasis prevalence declined only marginally and without statistical significance from 3.7% to 3.2%, 4.6% to 3.9% and 2.9% to 2.3% in the DEC, ivermectin and placebo arm. After the seventh MDA, none of the sampled people in the 0–20 age group was found with hydrocele and there was a statistically significant decline in hydrocele prevalence in all other age groups in the communities treated with DEC, the drug known to have macrofilaricidal effect. The impact was relatively less in ivermectin arm.

Conclusion  Repeated DEC administration has the potential to prevent incidence of new hydrocele cases and may resolve the manifestation at least in a proportion of affected people. Apart from reducing the microfilaraemia prevalence and transmission of infection, MDA also results in significant public health benefits by reducing the burden of hydrocele in treated communities.
C‐reactive protein and procalcitonin in the evaluation of the efficacy of a pneumococcal conjugate vaccine in Gambian children
Authors: Cheung Yin‐Bun , Zaman Syed M. A. , Ruopuro Marja‐Leena , Enwere Godwin , Adegbola Richard A. , Greenwood Brian , Cutts Felicity T.
Published: August 2010

Objective  To determine the value of C‐reactive protein (CRP) and procalcitonin in the evaluation of the efficacy of a pneumococcal conjugate vaccine in Gambian children.

Methods  The investigation was done as a substudy of a phase III pneumococcal conjugate vaccine trial. A pilot study (n = 120) to compare CRP and procalcitonin concentrations in children with pneumonia was undertaken, followed by a larger study of CRP concentrations (n = 1868) obtained from a subsample of children with clinical pneumonia seen during the trial.

Results  In the pilot study, CRP had a higher sensitivity and specificity for the detection of primary endpoint (radiographic) pneumonia than procalcitonin. In the subsequent study of 1868 episodes of clinical pneumonia, CRP showed moderate sensitivity but poor positive predictive value in identifying primary endpoint pneumonia or pneumococcal bacteraemia. Addition of CRP thresholds of 40, 60 or 120 mg/l to the diagnosis of clinical pneumonia did not give higher estimates of vaccine efficacy or vaccine attributable reduction in incidence than primary endpoint pneumonia.

Conclusion  A combination of a raised CRP concentration with a clinical diagnosis of pneumonia is a more specific endpoint than clinical pneumonia alone but less appropriate than primary endpoint pneumonia as a measure of the impact of a pneumococcal vaccine in a Gambian setting.
Insecticide‐treated net ownership and usage in Niger after a nationwide integrated campaign
Authors: Thwing Julie , Hochberg Natasha , Eng Jodi Vanden , Issifi Sanouna , James Eliades M. , Minkoulou Etienne , Wolkon Adam , Gado Habi , Ibrahim Ousmane , Newman Robert D. , Lama Marcel
Published: August 2010

Objectives  In December 2005 and March 2006, Niger conducted nationwide integrated campaigns to distribute polio vaccine and long lasting insecticide‐treated nets (LLINs) to children <5 years of age. We evaluated the campaign effectiveness, net retention, insecticide‐treated net (ITN) ownership, and usage.

Methods  Two nationwide cross‐sectional surveys in January 2006 (dry season) and September 2006 (rainy season), using a stratified two‐stage cluster sampling design. We mapped selected communities, selected households by simple random sampling, and administered questionnaires by interviewers using personal digital assistants.

Results  The first survey showed that ITN ownership in all households was 6.3% prior to the campaign, increasing to 65.1% after the campaign in the second survey. The second survey also showed that 73.4% of households with children <5 received an LLIN and that 97.7% of households that received ≥ one LLIN retained it. The wealth equity ratio for ITN ownership in households with children <5 increased from 0.17 prior to the campaign to 0.79 afterward. During the dry season, 15.4% of all children <5 and 11.3% of pregnant women slept under an ITN, while during rainy season, 55.5% of children <5 and 48.2% of pregnant women slept under an ITN.

Conclusions  Free distribution during the integrated campaign rapidly increased ITN ownership and decreased inequities between those in the highest and lowest wealth quintiles. Retention of ITNs was very high, and usage was high during malaria transmission season. However, ITN ownership and usage by vulnerable groups continues to fall short of RBM targets, and additional strategies are needed to increase ownership and usage.
High HIV risk among Uigur minority ethnic drug users in northwestern China
Authors: Zhang Li , Zhu Junling , Rui Baoling , Zhang Yuanzhi , Zhang Lijiang , Yin Lu , Ruan Yuhua , Qian Han‐Zhu , Shao Yiming
Published: August 2010

Objective  To assess differences of HIV risk between ethnicities in northwestern China.

Method  Cross‐sectional serosurvey and structured questionnaire interview of 383 injection drug users of either Han or Uigur ethnicity in Urumqi, Xinjiang.

Results  Both Uigur minority ethnicity and residence in a Uigur or mixed Uigur/Han community were independently associated with higher HIV risk.

Conclusion  HIV prevention programs should give special focus on minority ethnic drug users and their communities.
Effects of revised diagnostic recommendations on malaria treatment practices across age groups in Kenya*
Authors: Zurovac D. , Njogu J. , Akhwale W. , Hamer D. H. , Larson B. A. , Snow R. W.
Published: August 2010

Objective  The recent change of treatment policy for uncomplicated malaria from sulfadoxine‐pyrime‐thamine to artemether‐lumefantrine (AL) in Kenya was accompanied by revised malaria diagnosis recommendations promoting presumptive antimalarial treatment in young children and parasitological diagnosis in patients 5 years and older. We evaluated the impact of these age‐specific recommendations on routine malaria treatment practices 4–6 months after AL treatment was implemented.

Methods  Cross‐sectional, cluster sample survey using quality‐of‐care assessment methods in all government facilities in four Kenyan districts. Analysis was restricted to the 64 facilities with malaria diagnostics and AL available on the survey day. Main outcome measures were antimalarial treatment practices for febrile patients stratified by age, use of malaria diagnostic tests, and test result.

Results  Treatment practices for 706 febrile patients (401 young children and 305 patients ≥5 years) were evaluated. 43.0% of patients ≥5 years and 25.9% of children underwent parasitological malaria testing (87% by microscopy). AL was prescribed for 79.7% of patients ≥5 years with positive test results, for 9.7% with negative results and for 10.9% without a test. 84.6% of children with positive tests, 19.2% with negative tests, and 21.6% without tests were treated with AL. At least one antimalarial drug was prescribed for 75.0% of children and for 61.3% of patients ≥5 years with a negative test result.

Conclusions  Despite different recommendations for patients below and above 5 years of age, malaria diagnosis and treatment practices were similar in the two age groups. Parasitological diagnosis was under‐used in older children and adults, and young children were still tested. Use of AL was low overall and alternative antimalarials were commonly prescribed; but AL prescribing largely followed the results of malaria tests. Malaria diagnosis recommendations differing between age groups appear complex to implement; further strengthening of diagnosis and treatment practices under AL policy is required.
Optimizing antibiotic usage in adults admitted with fever by a multifaceted intervention in an Indonesian governmental hospital
Authors: Hadi Usman , Keuter Monique , Van Asten Henri , Van Den Broek Peterhans ,   on behalf of the study group ‘Antimicrobial resistance in Indonesia: Prevalence and Prevention’ (AMRIN)
Published: August 2010

Objective  To optimize antimicrobial treatment of patients with fever upon admission to the department of internal medicine of Dr Soetomo Hospital in Surabaya, Indonesia.

Method  Prospective intervention study. The intervention comprised development of a consensus guideline, an official declaration of the guideline by the head of department, distributing a guideline pocketbook, carrying out blood cultures free of charge, teaching sessions and refresher courses. The outcome was measured with reference to (i) percentage of patients with fever started on antibiotic therapy, (ii) amount of antibiotics used expressed as defined daily doses (DDD)/100 patient‐days, (iii) percentage of appropriate prescriptions and of prescriptions without indication as assessed by independent reviewers, (iv) percentage of treatments in accordance with guidelines, (v) percentage of patients in whom blood cultures were taken before starting antimicrobial therapy, (vi) percentage of treatments appropriately stopped on re‐evaluation of the patients at 72 h and (vii) mortality.

Results  The study involved 501 patients, 95 residents and 60 specialists. After the intervention 17% patients less were treated with antibiotics upon admission and antibiotic use fell from 99.8 to 73 DDD/100 patient‐days. The percentage of patients with sepsis and dengue treated in accordance with the guideline increased by 23% and 30%. The percentage of appropriate therapies, therapies without indication and mortality did not change significantly. The percentage of patients for whom a blood culture was taken upon admission increased from 3% to 81%; however, almost all were taken after they commenced antibiotic therapy. Therapy was not adjusted after 72 h in any case. Interrupted time series analysis showed that the start of development of the guideline and the declaration of the guideline were the interventions with the greatest impact.

Conclusion  The multifaceted intervention had limited success. A very important drawback to the prudent use of antibiotics was the absence of adequate microbiological diagnostics.
Accessibility and utilisation of delivery care within a Skilled Care Initiative in rural Burkina Faso
Authors: Hounton Sennen , Chapman Glyn , Menten Joris , De Brouwere Vincent , Ensor Tim , Sombié Issiaka , Meda Nicolas , Ronsmans Carine
Published: August 2010

Objectives  The Skilled Care Initiative (SCI) was a comprehensive skilled attendance at delivery strategy implemented by the Ministry of Health and Family Care International in Ouargaye district (Burkina Faso) from 2002 to 2005. We aimed to evaluate the relationships between accessibility, functioning of health centres and utilisation of delivery care in the SCI intervention district (Ouargaye) and compare this with another district (Diapaga).

Methods  Data were collected on staffing, equipment, water and energy supply for all health centres and a functionality index for health centres were constructed. A household census was carried out in 2006 to assess assets of all household members, and document pregnancies lasting more than 6 months between 2001 and 2005, with place of delivery and delivery attendant. Utilisation of delivery care was defined as birth in a health institution or birth by Caesarean section. Analyses included univariate and multivariate logistic regression.

Results  Distance to health facility, education and asset ownership were major determinants of delivery care utilisation, but no association was found between the functioning of health centres (as measured by infrastructure, energy supply and equipment) and institutional birth rates or births by Caesarean section. The proportion of births in an institution increased more substantially in the SCI district over time but no changes were seen in Caesarean section rates.

Conclusion  The SCI has increased uptake of institutional deliveries but there is little evidence that it has increased access to emergency obstetric care, at least in terms of uptake of Caesarean sections. Its success is contingent on large‐scale coverage and 24‐h availability of referral for life saving drugs, skilled personnel and surgery for pregnant women.
Assessing the costs and cost‐effectiveness of a Skilled Care Initiative in rural Burkina Faso
Authors: Newlands David , Yugbare‐Belemsaga Danielle , Ternent Laura , Hounton Sennen , Chapman Glyn
Published: August 2010

Objectives The objectives of this study were to assess the cost‐effectiveness of a skilled attendance strategy (the Skilled Care Initiative, SCI) in enhancing maternal health care in a remote, rural district of Burkina Faso and to analyse more broadly the costs and cost patterns of maternal health provision in the intervention and comparison districts.

Methods The approach used was to cost the standard provision of maternal care, to analyse the main cost structures, and to derive cost estimates per facility. The additional costs attributable to SCI were identified. Several measures of cost‐effectiveness or performance were calculated, including cost per delivery and utilisation.

Results If the increase in deliveries in Ouargaye between 2004 and 2005 is attributed solely to the stimulus of demand for skilled care by the SCI community mobilisation and behavioural communication change activities, the incremental cost per delivery was $164 international dollars. This compares with an average cost per delivery in Health Centres across the two districts of $214 international dollars. However, if a broader measure of SCI costs is used, the incremental cost per delivery increases markedly, to $1306 international dollars. At the level of individual Health Centres, utilisation is a better measure of performance than cost per delivery and Health Centres in Ouargaye are utilised more than in Diapaga.

Conclusions Demand side actions, such as community mobilisation and behavioural communication change activities, can be as important in improving skilled care at delivery as investment in health facilities, assuming there is some spare capacity, as has been the case in Burkina Faso. These conclusions have important potential implications for planning and resource allocation to achieve safer delivery for all women in Burkina Faso.
Treatment seeking for symptoms suggestive of TB: comparison between migrants and permanent urban residents in Chongqing, China
Authors: Wang Yang , Long Qian , Liu Qin , Tolhurst Rachel , Tang Shenglan
Published: August 2010

objectives To understand the health‐seeking behaviour of rural‐to‐urban migrants with chronic cough in Chongqing city, and compare this with the permanent urban population taking into account the socioeconomic factors influencing delays in access to healthcare in urban China.

methods Patient survey in 23 health facilities from different levels of two urban districts in Chongqing: 1005 tuberculosis (TB) suspects (229 rural‐to‐urban migrants and 776 permanent urban residents) were interviewed about socioeconomic status and service‐seeking behaviours.

results Migrants (67.7%) delayed treatment by more than 2 weeks, as did 54.0% of urban residents (P < 0.01). The reasons given by migrants for the delay in seeking care were lack of money and lack of perceived need for care. Female TB suspects, people without health insurance, those without sufficient knowledge of TB, without full‐time employment and people with low incomes also experienced longer patient delay (P < 0.01).

conclusions To be more effective, TB control efforts need to be better accessible to the economically and socially vulnerable.
Predictive indicators for Ross River virus infection in the Darwin area of tropical northern Australia, using long‐term mosquito trapping data
Authors: Jacups Susan P. , Whelan Peter I. , Markey Peter G. , Cleland Sam J. , Williamson Grant J. , Currie Bart J.
Published: August 2010

Objectives  To describe the epidemiology of Ross River virus (RRV) infection in the endemic Darwin region of tropical northern Australia and to develop a predictive model for RRV infections.

Methods  Analysis of laboratory confirmed cases of RRV infection between 01 January 1991 and 30 June 2006, together with climate, tidal and mosquito data collected weekly over the study period from 11 trap sites around Darwin. The epidemiology was described, correlations with various lag times were performed, followed by Poisson modelling to determine the best main effects model to predict RRV infection.

Results  Ross River virus infection was reported equally in males and females in 1256 people over the 15.5 years. Average annual incidence was 113/100 000 people. Infections peaked in the 30–34 age‐group for both sexes. Correlations revealed strong associations between monthly RRV infections and climatic variables and also each of the four implicated mosquito species populations. Three models were created to identify the best predictors of RRV infections for the Darwin area. The climate‐only model included total rainfall, average daily minimum temperature and maximum tide. This model explained 44.3% deviance. Using vector‐only variables, the best fit was obtained with average monthly trap numbers of Culex annulirostris, Aedes phaecasiatus, Aedes notoscriptus and Aedes vigilax. This model explained 59.5% deviance. The best global model included rainfall, minimum temperature and three mosquito species. This model explained 63.5% deviance, and predicted disease accurately.

Conclusions  We have produced a model that accurately predicts RRV infections throughout the year, in the Darwin region. Our model also indicates that predicted anthropogenic global climatic changes may result in an increase in RRV infections. Further research needs to target other high‐risk areas elsewhere in tropical Australia to ascertain the best local climatic and vector predictive RRV infection models for each region. This methodology can also be tested for assessing utility of predictive models for other mosquito‐borne diseases endemic to locations outside Australia.
Mixed Singing in European Songbirds — a Review
Authors: Helb Hans‐Wolfgang , Dowsett‐Lemaire Françoise , Bergmann Hans‐Heiner , Conrads Klaus
Published: August 2010

Abstract and Summary

The phenomenon of mixed singing in songbirds has recently been interpreted as one of vocal convergence facilitating interspecific competition. This paper examines the welldocumented cases of mixed singing in European songbirds with regard to the relationships between mixed singers and their models, and the frequency of occurrence of such behaviour.

Mixed singers are individual members of songbird species which in their full song extensively copy vocal patterns of an alien species and reproduce them next to their own. Models are, in most cases, taken from congeneric species, usually sibling species (Table 2). A few species, however, copy totally unrelated songbirds but some structural resemblance is often found between the vocalizations of model and imitator.

Mixed songs are usually rare, found in isolated individuals. Mixed songs can be adopted in some populations by a large proportion of the birds in situations of isolation or in small areas of overlap between largely allopatric species.

Some mixed singers of several species remain unmated or hybridize with the model species. Discounting a small number of possible exceptions, e. g. blackcap Sylvia atricapilla and garden warbler S. borin, mixed songs are best regarded as the result of misdirected song learning. There is no justification for categorizing mixed singing as an example of vocal convergence, as has been done by Dobkin (1979).

Als Mischsänger werden Singvogelindividuen definiert, die in ihrem Vollgesang regelmäßig Lautmuster einer anderen Art imitieren. Das artfremde Muster wird entweder wechselnd mit dem eigenen vorgebracht, oder beide werden zu einem einheitlichen Gebilde kombiniert.

In den meisten Fällen gehören die gewählten Vorbilder nächstverwandten Arten an, normalerweise Schwesternarten (Tab. 2). Nur selten werden nicht verwandte Vorbilder imitiert, die aber strukturelle Übereinstimmungen mit dem Gesang des Nachahmers aufweisen.

In der Mehrzahl der Fälle werden nur einzelne Individuen einer Population zu Mischsängern. Ausnahmsweise gibt es mischsingende Populationen oder Teilpopulationen, so bei Isolation oder in schmalen Überlappungszonen allo‐patrischer Arten.

Mischsänger verschiedener Arten blieben unverpaart oder gingen eine Bindung mit der Vorbildart ein. Mit wenigen möglichen Ausnahmen (z. B. Sylvia atricapilla — S. borin) muß man annehmen, daß Mischgesang auf Tradierungsfehler beim Gesangslernen zurückgeht. Es gibt bislang keinerlei Berechtigung, Mischsingen im Sinne von Dobkin(1979) als ein Beispiel akustischer Konvergenz einzustufen.
Outcomes of Day Care: A Pilot Study on Changes in Cognitive Function and Agitated Behaviors of Demented Elderly in Korea
Authors: Kim Nam‐Cho , Kim Hee‐Seung , Yoo Yang‐Sook , Hahn Suk‐Won , Yeom Hye‐A.
Published: August 2010

This study was conducted to examine outcomes of day care for the demented elderly in Korea by assessing changes in their cognitive function and agitated behaviors over time. In one group the repeated measures design was used. The data were collected from March 1999 to August 1999, with an initial sample size of 22 at the baseline time point. The demented elderly cognitive function was maintained as stable during the 10‐week study period, while their agitated behaviors increased over time. These results indicated the further need to examine the factors affecting the problematic behaviors. This pilot study showed that day‐care programs may be effective in maintaining the stability of cognitive function in the mildly to moderately demented elderly in Korea. Further investigation of effective behavioral modification within the day‐care setting might encourage positive governmental support for day‐care programs for the demented population in Korea.
The laryngeal mask airway in emergency medicine
Authors: KENNEDY MARCUS P , HIGGINS DAVID
Published: August 2010

The Laryngeal Mask Airway (LMA) is an upper airway adjunct lying intermediate in function between the endotracheal tube and the oropharyngeal airway. It has gained wide acceptance since its introduction into United Kingdom anaesthetic practice in 1988.

We review the principles of advanced airway management in the emergency department and examine the application of the LMA to this area. We conclude that the LMA may have a small role in pre‐hospital and CPR airway management, and a very significant role in the management of difficult or failed endotracheal intubation.
Intravenous magnesium in hyperacute fulminating asthma
Authors: WEBB MARK
Published: August 2010

Intravenous magnesium is an effective bronchodilator. Its efficacy in the treatment of clinical asthma however is unproven.

In this case, a 19 year old man presented with hyperacute fulminating asthma. Intubation was avoided after intravenous magnesium sulphate 20 mmol.

This case provides further evidence that intravenous magnesium may have a role in acute severe asthma.
Blunt carotid trauma following a rugby match
Authors: CLEARY MICHAEL I , ASHBY RICHARD H , PILLAY ROOKMANGITHAN
Published: August 2010

Objective: To describe an association between rugby and blunt trauma to the carotid artery.

Clinical features: A 15 year old male presented with neurological signs following a rugby match. Blunt dissection of the carotid artery was confirmed by angiography.

Intervention and outcomes: Vigorous non‐operative management including anticoagulation was undertaken. A good clinical outcome was obtained.

Conclusion: Blunt trauma to the carotid artery should be suspected in patients who develop neurological symptoms and signs in association with rugby.
Reduction of acute patellar dislocation under femoral nerve blockade
Authors: HOY GREGORY , WALPOLE BRYAN
Published: August 2010

Complications of traumatic reduction of the acutely dislocated patella may be significant, including osteochondral and chondral defects of either patella or lateral femoral condyle. The true incidence of chondral damage due to traumatic reduction both before presentation and in emergency departments is unknown. Femoral nerve block can produce good analgesia and excellent muscle relaxation with an effective block, allowing early atraumatic reduction if spontaneous reduction has not already occurred. This method was employed in three cases, using prilocaine 1.5% solution with adrenaline 1:200,000 via the single injection technique, with good results. Femoral nerve block is a feasible and well tolerated procedure in our experience, and may help reduce complication rates in patellar dislocations.
Chemically induced or inherited myotonia?
Authors: COYNE BEVERLEY A
Published: August 2010

Objective: To present a case of chemically induced myotonia occuring as a result of intentional ingestion of trifluoperazine and Defender Australia Bindi plus Clover Lawn WeederR (chlorophenoxy compounds present as 4‐chloro‐2‐methylphenoxyacetic acid (MCPA) as a dimethylamine salt 15% W/V and 3,6‐dichloro‐2‐methoxybenzoic acid (dicamba) 2.5% W/V). To discuss myotonia.

Clinical features: A 38 year old man with features suggestive of dystrophia myotonica presented with severe myotonia, urinary retention and dry lips. There was no personal or known family history of this muscular disorder.

Intervention: He was treated with 2mgs of intravenous benztropine mesylate, and 50 grams of activated charcoal and 150 mls of 70% sorbitol orally. An indwelling catheter was inserted. Laryngoscopy and upper gastrointestinal tract endoscopy were performed. The myotonia was managed conservatively and complete recovery occurred as evidenced by normal electromyography on day six of his admission.

Conclusion: Myotonia is a rare complication of toxin ingestion. In this case, the toxins may have unmasked subclinical dystrophia myotonica or induced myotonia de novo.
Investigation of patients with haematuria following trauma
Authors: SAMMUT J F C , GAUDRY P L
Published: August 2010

Study objective: To evaluate the effect of applying a protocol for radiological investigation of patients with traumatic haematuria.

Design: Retrospective review of admitted patients in a two year period who had traumatic haematuria. Clinical findings, radiological investigation and outcome were evaluated.

Setting: Westmead Hospital, an urban Australian teaching hospital.

Results: Among 186 patients with traumatic haematuria, a total of 13 renal injuries were diagnosed (eight minor contusions, five major injuries). Of 133 patients who had radiological investigations, 58 satisfied the protocol and these included all the five major injuries. There were 75 patients who had radiological investigation outside the protocol and no significant injuries were detected.

Conclusion: Patients with blunt trauma, microscopic haematuria without shock and no suspicion of intra‐abdominal injury do not warrant further investigation to elucidate the cause of their haematuria.
Use of the oesophageal Doppler to facilitate resuscitation
Authors: ADDY E V , HIGGINS D J , SINGER M
Published: August 2010

Two cases are presented where a transoesophageal Doppler probe was used to measure aortic blood flow during resuscitation. This technique allowed rapid and continuous assessment of cardiac output, myocardial contractility and volume status. Using this information, therapy during resuscitation was optimised for these patients in whom insertion of a pulmonary artery catheter was considered hazardous.
Dangerous interaction between amitriptyline and pimozide in the presence of hypokalaemia
Authors: Leach Deborah S , Levinson Michele
Published: August 2010

A 23 year old woman on pimozide 4mg mane and amitriptyline 50mg mane and 100mg nocte developed ventricular tachycardia following ingestion of twice her usual evening dose of amitriptyline. Serum K+ was 3.0mmol/L. There were no other obvious contributory factors. Pimozide has previously been linked with sudden death and a variety of ECG changes. This report raises the possibility that interaction between pimozide and amitriptyline may cause ventricular tachycardia, particularly in the presence of hypokalaemia.
Two cases of acute renal failure after brown snake bite
Authors: KRUK CHRISTOPHER , SPRIVULIS PETER , JELINEK GEORGE A
Published: August 2010

Two patients from southern metropolitan Perth presented to Fremantle Hospital within a three week period with brown snake (genus Pseudonaja) envenomation, resulting in coagulopathy, thrombocytopaenia, anaemia and acute renal failure. Coagulopathy and thrombocytopaenia are well recognised complications of brown snake bite. However acute renal failure from brown snake bite has been described on only six previous occasions in the Australian literature, three from Western Australia in 1976. In these three cases, the genus of snake was not confirmed and the atypical envenomation syndromes suggested that other genera may have been responsible.

In our patients, brown snake envenomation was confirmed with the Commonwealth Serum Laboratories Venom Detection Kit. The renal failure was self‐limiting in both cases though one patient required dialysis for 12 days. Neither patient developed rhabdomyolysis or myoglobinuria. These are the first cases of acute renal failure complicating definite brown snake envenomation reported from Western Australia. The most likely snake in both cases was the dugite (P affinis), however gwardar (P nuchalis) envenomation could not be excluded. Renal failure after brown snake bite is a rare but important complication.
Publications by Fellows of the Australasian College for Emergency Medicine in the Medline®‐indexed medical literature, 1984–1993
Authors: Jelinek George A , Sprivulis Peter C
Published: August 2010

All articles published from 1984 to 1993 by Fellows of the Australasian College for Emergency Medicine in journals indexed by Medline® were analysed according to journal, type of article, methodology, topic, and authors.

One hundred and sixty four articles were published overall, increasing from nine in 1984 to a peak of 33 in 1991. The topics were injury in 44 papers (27%), illnesses 34 (21%), poisoning 21 (13%), administration 20 (12%), envenomation 16 (10%), technology 14 (9%), disaster/prehospital six (4%), CPR five (3%) and other subjects in four (2%). The number of authors per paper averaged 2.6 and did not increase significantly over the ten years, in contrast to international trends.

There were 68 original research articles, 36 review articles, 29 case reports, 28 letters and three editorials. Original articles were principally descriptive with 31 retrospective and 19 prospective surveys; there were nine controlled and eight uncontrolled clinical trials, and one laboratory research project. The majority of papers (71%) were published in journals based in Australasia, with the remainder (29%) in international journals.

Australasian emergency physicians are making an increasing contribution to the wider medical literature.
The medico‐legal report in emergency medicine
Authors: Young Simon , Wells David
Published: August 2010

The preparation of a medico‐legal report is an exercise in communication between the emergency physician and the legal system. A proper request and informed consent are essential prior to commencing report preparation. A structured format incorporating elements of background information, medical history, physical examination, specimens obtained, treatment provided and opinion is suggested.
Blood conservation in elective surgery
Authors: Davies Michael
Published: August 2010

The primary aim of blood conservation is to reduce blood loss during major surgery. Some surgery however inevitably involves blood loss and in this situation blood conservation techniques are indicated. These techniques include preoperative donation, simple haemodilution, combined haemodilution and intraoperative autologous blood transfusion and blood scavenging during and after surgery.

Simple haemodilution

Simple haemodilution involves the use of a suitable colloid for blood replacement during surgery until the patient's haemoglobin falls below 8–10g/dl. This technique is widely practised and can only be safe if repeated haemoglobin measurements are made throughout the operation and postoperative course.

Combined intraoperative haemodilution and autotranfusion

In this process two units of blood are taken from the patient after induction of anaesthesia and are replaced with a suitable colloid. Our preference is to use polygeline because it is relatively cheap, has a low reaction rate and its short half‐life is an advantage. The two units of blood collected are retransfused at the end of surgery, thus boosting the patient's haemoglobin and supplying a significant amount of platelets and coagulation factors. Blood that is lost during surgery has a lower haemoglobin and therefore the net loss in red cells is less with the process than if the patient's haemoglobin was left at a normal level.

Intraoperative scavenging

This involves the collection of blood from the operative site during surgery in a sterile fashion. The blood can then either be retransfused as whole blood or processed using a cell processor, washing the red cells and supplying washed packed red cells. These techniques have become more practical with the advent of cheaper disposable equipment and have some place in major surgery.

Conclusion

Blood conservation techniques involve a number of different approaches, each of which can be applied in a specific situation provided one has sufficient experience in their application.
A new clinical sign to aid the diagnosis of locked posterior dislocation of the shoulder
Authors: Mah Edward T , Wang Allan W , Atkinson Robert N
Published: August 2010

We have observed a new clinical sign in three cases of locked posterior dislocation of the shoulder. The diagnosis was missed initially in all three cases with the standard clinical and radiographic examinations. This sign, a prominent superior angle of the scapula in the posterior triangle of the neck raises the possibility of a locked posterior shoulder dislocation. The diagnosis can then be confirmed by selective radiological investigations, thus avoiding the common occurrence of a missed or late diagnosis.
Protecting privacy during video recording resuscitations
Authors: Gaudry Paul L , Ryan John M , Aders Hugh P
Published: August 2010

The practice of video recording resuscitations is reviewed with respect to the following issues:

the protection of patients' rights to privacy during and after recordings

the non status of recordings as a medical record

the need for staff acceptance and institutional approval prior to beginning recordings

the use of recordings for quality improvement audit, critical incident monitoring, instructional feedback and resuscitation review conferences

the recommendation that recordings are then erased, and

the utility of legislative protection to facilitate the process of quality improvement.
Is the adult emergency department really adults only?
Authors: Levick Nadine , Lorchirachoonkul Thanaporn
Published: August 2010

Objectives

To quantify the use of an adult emergency department (ED) by paediatric patients and identify the acuity and spectrum of these presentations.

To determine the seniority and paediatric experience of emergency department staff involved with these patients.

To address the appropriateness of the paediatric guidelines in an ‘adult only’ emergency department.

Setting

The Royal Melbourne Hospital, an ‘adult only’ metropolitan tertiary hospital with 40,000 ED presentations annually and an admission rate of 30%.

Methods

Paediatric (18 years and under) ED attendances were recorded retrospectively over 12 months. Prospective data were then gathered for two weeks on acuity, clinical data and disposition for each patient as well as seniority and extent of paediatric training of medical staff involved.

Results

Paediatric patients accounted for 3.9% of presentations in the retrospective study and 2.8% in the prospective study. In the younger age groups, paediatric patients were of higher acuity, with greater admission rates and less trauma than average, with opposite trends in adolescents. Amongst the adolescent group the rate of patients ‘who did not wait’ was double that of the general ED population. Most patients (74%) were managed by staff with no paediatric training. Australasian College for Emergency Medicine (ACEM) advanced trainees were the most confident in managing children.

Conclusions

Paediatric patients do present to this ‘adult only’ ED. In this setting medical staff experience and training in paediatric management is variable. Suitable training and guidelines should be considered to address this issue. This study supports the ACEM requirement for paediatric training and has implications for emergency medicine paediatric training and Continuing Medical Education programs in the future. Multicentre studies, incorporating patient outcome data, would further clarify these issues.
The role of the emergency department in the management of patients with atypical chest pain
Authors: Bryant Michael
Published: August 2010

There is often an inconsistent approach to the management of patients with chest pain which is not due to myocardial infarction. The stratification of risk groups, utility of diagnostic tests and current practice in the USA are discussed. Recommendations for a change in our current practice are:

Patients with unstable angina, acute myocardial infarction and those with a high suspicion of acute myocardial infarction should be admitted to hospital.

Those patients with atypical chest pain should be considered for early exercise testing in or from the emergency department.

In the absence of the facility for exercise testing in or from the emergency department, patients with atypical chest pain should be admitted to hospital.
The impact of violence on emergency department staff
Authors: Brookes Jennifer G
Published: August 2010

The impact of violence on the carers has yet to be clearly defined and explored. Research has shown that there is significant under‐reporting of violence against emergency department personnel.

There exist published reports of serious injury or death to staff due to violence occurring in the emergency department. Physical violence occurs in about 50% of violent incidents. The occurrence of threats, assault not resulting in injury, and the psychological impact of such violence need further examination. The part workplace violence has to play in occupational stress and ‘burnout’ are all issues yet to be comprehensively studied and reported.

One study has shown a significant reduction in assault and injury in staff trained in aggression control techniques. Further evaluation of aggression control training and psychological debriefing are needed to determine the effect of such measures on the incidence of violence and its sequelae on care givers.

Only when there is further research to determine the physical, emotional and financial impact on the carer can the cost of violent events be defined and give financial justification to employers for investing in measures aimed at reducing the impact of these events on the carer.
Cardiac tamponade
Authors: Hayes James E
Published: August 2010

Cardiac tamponade is a life threatening condition that results from accumulation of intrapericardial fluid or air, leading to impaired cardiac filling and consequent reduction of cardiac output. There are many causes, best categorised as non‐traumatic and traumatic.

The diagnosis is most commonly made on echocardiographic evidence of effusion together with the clinical findings. Clinical findings, however, are non‐specific and often unreliable especially early in the process of cardiac tamponade. A high index of suspicion must therefore be maintained.

Definitive treatment consists of pericardiocentesis or surgical drainage, the choice of which will depend upon the urgency of the situation, the aetiology and the available facilities and personnel.
Computerising emergency department guidelines with an Intranet
Authors: Waller Richard H
Published: August 2010

An emergency department's guidelines/protocols can be transferred simply and cheaply to a secure ‘intranet’ using readily available software and hardware. This format facilitates revision and distribution of the protocols and provides access at the clinical workstation. The use of hypertext links facilitates access and allows incorporation of video, graphic and audio files to the protocols.
A triage observation scale improves the reliability of the National Triage Scale in children
Authors: Browne Gary J , Gaudry Paul L , Lam Lawrence
Published: August 2010

Aim

To test the reliability of the National Triage Scale in children.

Setting

An emergency department in a metropolitan university hospital.

Methods

Prospective study of 13,923 emergency department presentations. During phase one standard triage was performed using the National Triage Scale. During phase two triage was performed utilising a triage observation tool. Critical incidents and complaint reports were monitored during both phases.

Results

During phase one, correlation between triage category and admission rate was weak but statistically significant (r = ‐ 0.47; p = 0.04). During phase two, triage category had a far stronger correlation with admission rate (r = ‐ 0.99; p < 0.0001). Critical incidents and complaint reports decreased significantly in phase two compared with phase one by 95% and 94% respectively.

Conclusion

A triage observation tool (TOT) gives more reliable assignment of triage category, in particular more reliable recognition of children at high risk of serious illness.
Trial participation leads to a delay in thrombolysis for acute myocardial infarction
Authors: Aitken Peter , Green David
Published: August 2010

Objective

To determine if there is a significant delay in time to thrombolytic administration for patients participating in clinical trials.

Methods

A retrospective audit of all patients given a thrombolytic agent for acute myocardial infarction in the Emergency Department of the Gold Coast Hospital in 1995.

Results

Trial participants (n=17) had a mean door to needle time of 61.9 minutes compared with non trial participants (n=66) whose mean door to needle time was 43.2 minutes. This was found to be statistically significant (p<0.05) and equated to a 43% increase in time to thrombolysis for trial participants.

Conclusion

Participation in clinical trials leads to a delay in time to thrombolysis for the individual patient which must be weighed against the potential benefit of research trials to the community.