bluuebunny/crossref_metadata_2025 huggingface dataset:
Risk factors for active trachoma and Chlamydia trachomatis infection in rural Ethiopia after mass treatment with azithromycin
Authors: Edwards Tansy , Harding‐Esch Emma M. , Hailu Girum , Andreason Aura , Mabey David C. , Todd Jim , Cumberland Phillippa
Published: August 2010

Objectives  To investigate risk factors for ocular Chlamydia trachomatis infection and active trachoma, comparing communities receiving or not receiving an intervention programme of community‐wide azithromycin treatment and health education.

Methods  In a 3‐year post‐intervention follow‐up survey, 1722 children aged 3–9 years, from randomly selected households in 37 communities, were examined for signs of active trachoma and had samples taken to test for ocular C. trachomatis by polymerase chain reaction. Multivariate random effects logistic regression analyses considered interventions at community level, adjusting for other independent risk factors as appropriate.

Results  Younger age, ocular discharge and flies on eyes were risk factors for active trachoma in communities with and without antibiotic treatment. After azithromycin treatment, odds of active trachoma were lower in children aged 6–9 years than in children aged 3–5 years (OR 0.48, 95% CI: 0.36–0.66) and higher for children with ocular discharge (OR 4.5, 95% CI: 2.6–7.7) or flies on their eyes (OR 2.5, 95% CI: 1.6–3.7). Odds of C. trachomatis infection were lower in children aged 6–9 years than in younger children (OR 0.47, 95% CI: 0.23–0.96); and in children who received 2 or 3 doses rather than 1 (OR 0.26, 95% CI: 0.08–0.88).

Conclusions  In communities that received or did not receive the mass antibiotic treatment, the same risk factors for C. trachomatis and active trachoma were identified. Education and environmental improvements need to supplement antibiotic campaigns in order to positively impact on these remaining child level risk factors.
International open trial of uniform multi‐drug therapy regimen for 6 months for all types of leprosy patients: rationale, design and preliminary results
Authors: Kroger Axel , Pannikar V. , Htoon M. T. , Jamesh A. , Katoch K. , Krishnamurthy P. , Ramalingam K. , Jianping Shen , Jadhav Vitthal , Gupte M. D. , Manickam P.
Published: August 2010

Objective  To describe the rationale, design and preliminary results of an open trial of 6 months uniform multi‐drug therapy (U‐MDT) for all types of leprosy patients assuming a cumulative relapse rate not exceeding 5% over 5 years of follow‐up.

Methods  We intended to recruit 2500 patients each in multi‐bacillary (MB) and pauci‐bacillary (PB) groups from India (five centres) and China (two centres). Standardized clinical criteria were used to assess skin lesions in the field.

Results  A total of 2912 patients enrolled from November 2003 to May 2007 (India, 2746; China, 166). MB patients constituted 39% and 3% had grade 2 disability. During follow‐up, 27 patients (0.9%) developed new lesions. Of these, 78% were on account of reactions. Six patients had clinically confirmed relapse. Clofazimine‐related skin pigmentation was short‐lived and was acceptable to patients. We analysed data for clinical status of skin lesions. About 2.9% of patients were lost to follow‐up; 85.9% completed treatment, of whom 19% had inactive skin lesions. PB patients responded better than MB patients (27%vs. 6%; P < 0.001). At the end of the first (n = 2013) and second year (n = 807) of follow‐up post‐U‐MDT, in 49% and 46% patients, lesions were inactive, respectively (59% and 57% in PB, 37% and 28% in MB; P < 0.001).

Conclusion  U‐MDT appears to be promising with respect to clinical status of skin lesions.
The unbearable lightness of technocratic efforts at dengue control
Authors: Toledo Maria E. , Baly Alberto , Vanlerberghe Veerle , Rodríguez Maritza , Benitez Juan R. , Duvergel Jacinto , Van der Stuyft Patrick
Published: August 2010

Objective  To identify key elements that should provide an added value and assure sustainable effects of the deployment of technical tools for Aedes aegypti control.

Methods  An observational study was conducted between April 2001 and March 2002 in 30 blocks (1574 houses) in the central zone of Guantanamo city. A trial that combined two complementary technical interventions, the distribution of new ground level water tanks and the intensive use of insecticide, was nested in May 2001. Another 30 blocks (1535 houses) were selected as control area. We assessed community perceptions and household risk behaviour at baseline and after 9  months, and measured the trial’s impact through entomological indices.

Results  Perceived self efficacy to solve A. aegypti infestation and prevent dengue was not modified. We found no changes in behaviour. In the study area the container indices decreased significantly from 0.7% before to 0.1% 1 month after the intervention. Six months later, they had increased to 2.7% and uncovered new water tanks constituted 75.9% of all breeding sites. Over the 9 months after the trial the average monthly house indices were similar in the study and control areas. A technical approach and lack of community involvement in the trial’s implementation were the main causes of these short‐lived results.

Conclusions  Top–down deployment of technical tools without active involvement of the community has a temporary effect and does not lead to the behavioural changes necessary for sustainable A. aegypti control.
Laboratory reference values for healthy adults from southern Tanzania
Authors: Saathoff Elmar , Schneider Philine , Kleinfeldt Vera , Geis Steffen , Haule Dennis , Maboko Leonard , Samky Eleuter , Souza Mark de , Robb Merlin , Hoelscher Michael
Published: August 2010

Objectives  To define and discuss reference ranges for commonly determined laboratory parameters in healthy adults from southern Tanzania.

Methods  A population‐based sample of adult volunteers from Mbeya, Tanzania, who were not HIV positive or showing signs and symptoms of other diseases, participated in this study. We enrolled 145 women and 156 men between 19 and 48 years of age to determine clinical chemistry (CC), haematology and lymphocyte immunophenotyping (LIP) parameters using standard laboratory methods. Medians and nonparametric 95% reference ranges for each parameter were determined and compared with reference ranges from the USA, Europe and from other African countries.

Results  Agreement with ranges from developed countries was poor: for CC values the average concordance was 80.9% and 86.7% with values from two developed countries. Haematology ranges from the USA classified 86.3% of values correctly, whereas ranges from three different sub‐Saharan Africa (SSA) sites classified between 82.5% and 94.5% of values correctly. The agreement of LIP reference ranges was 87.5% with values determined in Germany but between 91.7% and 95.8% compared with values determined at other sites in SSA.

Conclusion  Clinical reference ranges determined in developed countries are inadequate for use in SSA. Laboratories in this region should either define their own or use values determined under similar conditions. The ranges reported here are more appropriate for use in SSA than ranges determined in developed countries.
Is HIV infection associated with an increased risk for cholera? Findings from a case–control study in Mozambique
Authors: Von Seidlein Lorenz , Wang Xuan‐Yi , Macuamule Arminda , Mondlane Catarina , Puri Mahesh , Hendriksen Ilse , Deen Jacqueline L. , Chaignat Claire‐Lise , Clemens John D. , Ansaruzzaman M. , Barreto Avertino , Songane Francisco F. , Lucas Marcelino
Published: August 2010

Objective  As residents of sub‐Saharan Africa are at high risk for HIV and cholera, it is biologically plausible that immune suppression caused by HIV infection predisposes to cholera. Our aim was to assess the potential association between both diseases.

Methods  We conducted a case–control study in Beira, Mozambique, a high‐risk area for HIV and cholera. Between 1 January 2005 and 30 June 2006, experienced counsellors invited 132 suspected cholera cases and 528 age‐ and sex‐matched controls to an HIV counselling and testing centre.

Results  Forty (30%) of the invited cases and 127 (24%) of the invited controls came for HIV testing. No significant differences in demographic and socio‐economic baseline characteristics were detected between participants and non‐participants. Twentyfive of 167 (15%) individuals who underwent testing were found HIV‐positive. The probability of a positive HIV‐test was highest in participants between 40 and 49 years; 6 of 14 (43%) tested HIV‐positive. Nine of 40 (23%) cholera cases were found to be HIV‐infected compared with 16 of 127 (13%) controls (adjusted odds ratio 2.6; 95% CI 0.9–7.5; P = 0.08).

Discussion  The findings suggest that in a cholera‐endemic area, HIV infection is associated with an increased risk for cholera. More research in HIV endemic settings is needed to confirm the findings and to explore the effect of HIV‐related immunosuppression on the transmission of cholera.
Uptake of HIV and syphilis testing of pregnant women and their male partners in a programme for prevention of mother‐to‐child HIV transmission in Uganda
Authors: Kizito Dennison , Woodburn Patrick W. , Kesande Beleth , Ameke Christine , Nabulime Juliet , Muwanga Moses , Grosskurth Heiner , Elliott Alison M.
Published: August 2010

Objective  To describe uptake of HIV and syphilis testing in a prevention of mother‐to‐child HIV transmission programme in Uganda.

Methods  Analysis of data from routine HIV and syphilis testing at Entebbe Hospital antenatal services.

Results  A total of 20 738 women attended antenatal services. Exactly 62.8% of women, but only 1.8% of their male partners, accepted testing for HIV; 82.2% of women, but only 1.1% of their male partners accepted syphilis testing. Partners of women with positive HIV results were more likely to come for subsequent testing. Of 200 couples whose partners accepted HIV‐testing within 30 days of one another, 19 (9.5%) were HIV‐discordant, representing 65.5% of couples with at least one partner HIV‐positive. HIV prevalence was 12.6% for women and 10.8% for men; syphilis prevalence was 4.0% for women and 6.2% for men.

Conclusion  Uptake of HIV and syphilis testing was fairly good among pregnant women attending antenatal clinics at Entebbe Hospital, but very low among their male partners. The level of HIV‐discordant couples was high. These clinics should be made more couples‐friendly to identify both HIV‐positive men for treatment and discordant couples for HIV prevention.
Interpretation of mycobacterial antibodies in the cerebrospinal fluid of adults with tuberculous meningitis
Authors: Restrepo Blanca I. , Pino Paula A. , Volcy Michel , Franco Andrés F. , Kanaujia Ganga V. , Robledo Jaime
Published: August 2010

Objective  Microbiological identification of Mycobacterium tuberculosis is insensitive and slow, and clinical distinction of tuberculous meningitis (TBM) from other subacute or chronic meningoenchephalitides (SACM) is difficult. Successful use of highly specific M. tuberculosis serological assays on cerebrospinal fluid has been reported, but their performance for diagnosis in a tuberculosis endemic country where they would be of most value is unclear. We sought to determine the biological basis for the uncertainty in interpretation of antibody detection in the CSF of TBM patients.

Methods  We identified prospectively 46 adults with SACM and explored the concordance between TBM diagnosis and detection of highly specific M. tuberculosis antibodies in CSF. The source of antibodies in CSF was explored by evaluating the correlation between antibody titres in CSF with those in serum, or with the albumin quotient. Intrathecal IgG synthesis was assessed by the IgG index.

Results  Positive antibody titres were more frequent among TBM patients (76%), but were also present in individuals with other SACM (59%). A positive correlation between antibody titres in CSF with those in serum, or with the albumin quotient, supported the leakage of antibodies from plasma to CSF through an increased blood–brain barrier permeability. Intrathecal IgG synthesis was only detected in 35% of the TBM cases.

Conclusion  Plasma antibodies likely synthesized in response to previous tuberculosis infections were a major source of mycobacterial antibodies in CSF due to leakage through an impaired blood–brain barrier. Interpretation of mycobacterial antibodies in CSF of adults for TBM, however specific, must take into account the contribution of antibodies from plasma, and hence, has questionable use for diagnosis.
ST2859 serogroup A meningococcal meningitis outbreak in Nouna Health District, Burkina Faso: a prospective study
Authors: Sié A. , Pflüger V. , Coulibaly B. , Dangy J. P. , Kapaun A. , Junghanss T. , Pluschke G. , Leimkugel J.
Published: August 2010

We analysed cerebrospinal fluid samples from suspected meningitis cases in Nouna Health District, Burkina Faso, during the meningitis seasons of 2004–2006. Serogroup A ST2859 meningococci belonging to the ST5 clonal complex of subgroup III meningococci were the predominant causative agent. ST2859 bacteria were associated with focal outbreaks in the north of the district. While >10% of the population of an outbreak village carried ST2859, the population in the south of the district was predominantly colonised by serogroup Y ST4375 meningococci, which were associated with only sporadic cases of meningitis. Colonisation with the less virulent Y meningococci may interfere with the spread of the ST2859 to the south of the district, but there are concerns that this serogroup A clone may cause a third wave of subgroup III meningococcal disease in the African Meningitis Belt.
Experimental hut evaluation of the pyrrole insecticide chlorfenapyr on bed nets for the control of Anopheles arabiensis and Culex quinquefasciatus
Authors: Mosha F. W. , Lyimo I. N. , Oxborough R. M. , Malima R. , Tenu F. , Matowo J. , Feston E. , Mndeme R. , Magesa S. M. , Rowland M.
Published: August 2010

Objective  To determine the efficacy of chlorfenapyr against Anopheles arabiensis and Culex quinquefasciatus in East Africa and to identify effective dosages for net treatment in comparison with the commonly used pyrethroid deltamethrin.

Methods  Chlorfenapyr was evaluated on bed nets in experimental huts against A. arabiensis and C. quinquefasciatus in Northern Tanzania, at application rates of 100–500 mg/m2.

Results  In experimental huts, mortality rates in A. arabiensis were high (46.0–63.9%) for all dosages of chlorfenapyr and were similar to that of deltamethrin‐treated nets. Mortality rates in C. quinquefasciatus were higher for chlorfenapyr than for deltamethrin. Despite a reputation for being slow acting, >90% of insecticide‐induced mortality in laboratory tunnel tests and experimental huts occurred within 24 h, and the speed of killing was no slower than for deltamethrin‐treated nets.

Conclusions  Chlorfenapyr induced low irritability and knockdown, which explains the relatively small reduction in blood‐feeding rate. Combining chlorfenapyr with a more excito‐repellent pyrethroid on bed nets for improved personal protection, control of pyrethroid‐resistant mosquitoes and pyrethroid resistance management would be advantageous.
Very young children with uncomplicated falciparum malaria have higher risk of hypoglycaemia: a study from Suriname
Authors: Zijlmans Wilco C. W. R. , Van Kempen Anne A. M. W. , Ackermans Mariëtte T. , De Metz Jesse , Kager Piet A. , Sauerwein Hans P.
Published: August 2010

Objective  To measure glucose kinetics and the influence of age, nutritional status and fasting duration in children with uncomplicated falciparum malaria (UFM) under the age of 5 years.

Methods  Plasma glucose concentration, endogenous glucose production (EGP) and gluconeogenesis (GNG) were measured using [6,6‐2H2]glucose and 2H2O in 17 very young (<3 years) and 7 older (3–5 years) Surinamese children with UFM admitted to the Distrikt Hospital Stoelmanseiland and Diakonessen Hospital Paramaribo over 17 months.

Results  Plasma glucose concentration was lower in the group of very young children than in the older children (P = 0.028). There were no differences in EGP and GNG between the groups. Overall GNG contributed 56% (median, range 17–87%) to EGP, with no differences between the groups (P = 0.240). Glucose clearance was lower in the older children (P = 0.026). Glucose concentration did not differ between children with weight for length/height less than −1.3 SD and children with weight for length/height greater than −1.3 SD (P = 0.266). Plasma glucose concentration was not predicted by fasting duration (P = 0.762).

Conclusions  Our data suggest a higher risk of hypoglycaemia in very young children with uncomplicated malaria as plasma glucose concentration was lower in this study group. Since this could not be attributed to an impaired EGP, and because glucose clearance was lower in the older children, we presume that older children were better capable of reducing glucose utilization during fasting. Studies on glucose kinetics are feasible in very young children with malaria and give more insight in the pathophysiology of hypoglycaemia.
Anaemia in a rural Ugandan HIV cohort: prevalence at enrolment, incidence, diagnosis and associated factors
Authors: Mugisha Joseph O. , Shafer Leigh Anne , Der Paal Lieve Van , Mayanja Billy N. , Eotu Henry , Hughes Peter , Whitworth Jimmy A. G. , Grosskurth Heiner
Published: August 2010

Objectives  To determine the prevalence and incidence of anaemia in HIV‐positive and negative individuals; to identify risk factors for anaemia, prior to the introduction of HAART; and to determine the validity of the clinical diagnosis of anaemia.

Methods  Between 1990 and 2003, we followed a rural population based cohort of HIV‐infected and uninfected participants. Prevalence and incidence of anaemia were determined clinically and by laboratory measurements. The sensitivity, specificity and predictive values of clinical diagnosis were calculated.

Results  The prevalence of anaemia at enrolment was 18.9% among HIV‐positive and 12.9% among HIV‐negative participants (P = 0.065). Incidence of anaemia increased with HIV disease progression, from 103 per 1000 person‐years of observation among those with CD4 counts >500 to 289 per 1000 person‐years of observation among those with CD4 counts <200. Compared to laboratory diagnosis, the clinical diagnosis of anaemia had a sensitivity of 17.8%, specificity of 96.8%, a positive predictive value of 50.6% and a negative predictive value of 86.4%. Being female, low CD4 cell counts, HIV‐positive, wasting syndrome, WHO stage 3 or 4, malaria, fever, pneumonia and oral candidiasis were associated with prevalent anaemia.

Conclusions  Anaemia prevalence and incidence were higher among HIV‐positive than negative participants. Compared to laboratory diagnosis, clinical detection of anaemia had a low sensitivity. Clinicians working in settings with limited laboratory support must be conscious of the risk of anaemia when managing HIV/AIDS patients, particularly when using antiretroviral drugs which by themselves may cause anaemia as a side effect. We recommend that haemoglobin should be measured before starting ART and monthly for the first three months.
Estimates of the burden of malaria morbidity in Africa in children under the age of 5 years
Authors: Roca‐Feltrer Arantxa , Carneiro Ilona , Armstrong Schellenberg Joanna R. M.
Published: August 2010

Objective  To estimate the direct burden of malaria among children younger than 5 years in sub‐Saharan Africa (SSA) for the year 2000, as part of a wider initiative on burden estimates.

Methods  A systematic literature review was undertaken in June 2003. Severe malaria outcomes (cerebral malaria, severe malarial anaemia and respiratory distress) and non‐severe malaria data were abstracted separately, together with information on the characteristics of each study and its population. Population characteristics were also collated at a national level. A meta‐regression model was used to predict the incidence of malaria fevers at a national level. For severe outcomes, results were presented as median rates as data were too sparse for modelling.

Results  For the year 2000, an estimated 545 000 (uncertainty interval: 105 000–1 750 000) children under the age of 5 in SSA experienced an episode of severe malaria for which they were admitted to hospital. A total of 24 000 (interquartile range: 12 000–37 000) suffered from persistent neurological deficits as a result of cerebral malaria. The number of malaria fevers associated with high parasite density in under‐5s in SSA in 2000 was estimated as 115 750 000 (uncertainty interval: 91 243 000–257 957 000).

Conclusion  Our study predicts a lower burden than previous estimates of under‐5 malaria morbidity in SSA. As there is a lack of suitable data to enable comprehensive estimates of annual malaria incidence, we describe the information needed to improve the validity of future estimates.
Antiretroviral therapy in resource‐limited settings 1996 to 2006: patient characteristics, treatment regimens and monitoring in sub‐Saharan Africa, Asia and Latin America
Authors:   The ART‐LINC Collaboration of the International Databases to Evaluate AIDS (IeDEA)
Published: August 2010

Objectives  To describe temporal trends in baseline clinical characteristics, initial treatment regimens and monitoring of patients starting antiretroviral therapy (ART) in resource‐limited settings.

Methods  We analysed data from 17 ART programmes in 12 countries in sub‐Saharan Africa, South America and Asia. Patients aged 16 years or older with documented date of start of highly active ART (HAART) were included. Data were analysed by calculating medians, interquartile ranges (IQR) and percentages by regions and time periods. Not all centres provided data for 2006 and 2005 and 2006 were therefore combined.

Results  A total of 36 715 patients who started ART 1996–2006 were included in the analysis. Patient numbers increased substantially in sub‐Saharan Africa and Asia, and the number of initial regimens declined, to four and five, respectively, in 2005–2006. In South America 20 regimes were used in 2005–2006. A combination of 3TC/D4T/NVP was used for 56% of African patients and 42% of Asian patients; AZT/3TC/EFV was used in 33% of patients in South America. The median baseline CD4 count increased in recent years, to 122 cells/μl (IQR 53–194) in 2005–2006 in Africa, 134 cells/μl (IQR 72–191) in Asia, and 197 cells/μl (IQR 61–277) in South America, but 77%, 78% and 51%, respectively, started with <200 cells/μl in 2005–2006. In all regions baseline CD4 cell counts were higher in women than men: differences were 22cells/μl in Africa, 65 cells/μl in Asia and 10 cells/μl in South America. In 2005–2006 a viral load at 6 months was available in 21% of patients Africa, 8% of Asian patients and 73% of patients in South America. Corresponding figures for 6‐month CD4 cell counts were 74%, 77% and 81%.

Conclusions  The public health approach to providing ART proposed by the World Health Organization has been implemented in sub‐Saharan Africa and Asia. Although CD4 cell counts at the start of ART have increased in recent years, most patients continue to start with counts well below the recommended threshold. Particular attention should be paid to more timely initiation of ART in HIV‐infected men.
Paediatric HIV and neurodevelopment in sub‐Saharan Africa: a systematic review
Authors: Abubakar Amina , Van Baar Anneloes , Van de Vijver Fons J. R. , Holding Penny , Newton Charles R. J. C.
Published: August 2010

Objective  To determine the degree of motor, cognitive, language and social‐emotional impairment related to HIV infection in children living in sub‐Saharan Africa (SSA).

Methods  Literature searches using MEDLINE and PsycINFO. Additionally, the reference lists of previous reviews were checked to ensure that all eligible studies were identified. Cohen’s d, a measure of effect size, was computed to estimate the level of impairment.

Results  Six reports met the inclusion criteria. In infancy a consistent delay in motor development was observed with a median value of Cohen’s d = 0.97 at 18 months, indicating a severe degree of impairment. Mental development showed a moderate delay at 18 months, with a median value d = 0.67. Language delay did not appear until 24 months of age, d = 0.91. Less clear findings occurred in older subjects.

Conclusion  Although HIV has been shown to affect all domains of child functioning, motor development is the most apparent in terms of severity, early onset, and persistence across age groups. However, motor development has been the most widely assessed domain while language development has been less vigorously evaluated in SSA, hence an accurate quantitative estimate of the effect cannot yet be made.
Evaluating skilled care at delivery in Burkina Faso: principles and practice
Authors: Graham Wendy , Themmen Ellen , Bassane Brahima , Meda Nicolas , De Brouwere Vincent
Published: August 2010

There are strong expectations of what could be achieved by skilled care at delivery for maternal and newborn survival and health. Meeting these expectations involves the translation of the concepts and principles of skilled attendance into the reality of routine programmes. This process of translation brings to light some of the tensions which lie behind the consensus on the ideal package and particularly the alternative configurations of provider and place necessary in the immediate term. Lessons learnt from the implementation of specific projects and initiatives have a crucial role to play in informing scaling‐up and the achievement of universal coverage.

The Skilled Care Initiative implemented in Burkina Faso by Family Care International, evaluated and reported here, provides many lessons for moving from concepts to practice. Firstly, there is the crucial issue of local contextual adaptation, as no one‐size‐fits‐all for skilled attendance. Secondly, interventions to achieve skilled care require and imply different levels of intensity of implementation, depending on the functionality of the wider health system in the intervention area. Thirdly, there is the crucial issue of the balance and sequencing of supply‐ and demand‐side interventions. Finally, the concept of skilled attendance at delivery does not exist in a vacuum in space or time, and concurrent health initiatives and cross‐sectoral developments, such as transport and road improvements, can strongly influence outcomes. This not only presents challenges for the implementation of specific interventions within health institutions and communities, but also for the evaluation of their effects.
Effects of a Skilled Care Initiative on pregnancy‐related mortality in rural Burkina Faso
Authors: Hounton Sennen , Menten Joris , Ouédraogo Moctar , Dubourg Dominique , Meda Nicolas , Ronsmans Carine , Byass Peter , De Brouwere Vincent
Published: August 2010

Objective  The aim of this paper is to assess to what extent a Skilled Care Initiative (SCI) was associated with pregnancy‐related mortality in Ouargaye district, Burkina Faso.

Methods  We used a quasi‐experimental design to compare pregnancy‐related mortality within the intervention district (health facility areas covered by the SCI vs. areas not covered) and between the intervention district (Ouargaye) and a comparison district (Diapaga). Population‐based data were used to examine differences in pregnancy‐related mortality levels, their determinants and how they related to uptake of care, as well as examining contexts and mechanisms of pregnancy‐related deaths that occurred. Data analyses included descriptive statistics, univariate and multivariate regression analyses.

Results  The main risk factors for pregnancy‐related mortality in rural Burkina Faso were age (extreme ages of reproductive period), low coverage of antenatal care and low institutional delivery. The introduction of the SCI, as implemented within the study reference period, had no appreciable effect on pregnancy‐related mortality.

Conclusion  Although the SCI was conceptually well designed and implemented, structural constraints may have limited its effectiveness for reducing pregnancy‐related mortality within its period of implementation. Lessons have been identified which might enable similar skilled attendance strategies to make their full potential impact on pregnancy‐related mortality in remote and rural settings.
Disappearance of phantom limb pain following hyperbaric oxygen therapy
Authors: BANHAM NEIL D G , KEETLEY SHARON
Published: August 2010

A 67 year old man with severe peripheral vascular disease and subsequent bilateral below knee amputations was treated with hyperbaric oxygen therapy for non‐healing ulcers on his right leg stump.

After one treatment on a 10 metre table (105 minutes) his previously severe phantom limb pain resolved and has since not returned. This has not previously been described and warrants further study.
The increasing impact of asthma on a metropolitan emergency department
Authors: MEEK R
Published: August 2010

Statistics relating to asthma were collected at Ryde Hospital from 1983 and 1988. Particular attention was paid to the amount of time emergency department staff devoted to the assessment and treatment of patients with asthma.

Asthma attendances increased by 52% over the five years with the proportion of patients admitted increasing from 24% to 32%. The peak times of presentation were the evenings; April, May and June were the busiest months. The time taken in the emergency department for assessment and treatment increased over the five years from 2.3 to 4,2 hours per day, an 83% increase.

While the factors behind this rising incidence are debatable and require attention in their own right, it is clear that the work load from asthma is increasing for emergency departments. Important issues raised include emergency department staffing and outpatient asthma education.
Oxygen therapy in emergency medicine Part 1. Physiology and oxygen delivery systems
Authors: SMART DAVID R , MARK PAUL D
Published: August 2010

Oxygen is essential to life, and supplemental oxygen is the most frequently used drug in the treatment of acutely ill and injured patients. There are sound physiological reasons for the use of supplemental oxygen in emergency medicine, however the rationale for oxygen therapy is poorly understood by junior staff and the prescription of oxygen dosage often haphazard. An understanding of oxygen, its side effects, systems of delivery and reasons for precise dosage is essential in the management of very ill patients.

Oxygen should be regarded as a drug and careful titration of its dosage against clinical response is necessary for maximum benefit. This article reviews the physiology of oxygen, systems of delivery and the rationale for their use.
Headache in the emergency department
Authors: FISCHER DAVID
Published: August 2010

Non‐traumatic headache is an unusual presenting complaint in emergency medicine, representing only 1.4% of all patients seen over 45 consecutive days at the Royal Hobart Hospital Department of Emergency Medicine.

Computerised tomographic (CT) scanning was used to assist diagnosis in 28% of cases, with nearly half (47%) of CT scans positive. Twenty three percent of patients were admitted to hospital.

Emergency physicians are reminded that patients with headache commonly have serious underlying pathology.
Computerisation of emergency department clinical attendance records
Authors: CAMERON PETER A , COLERIDGE JOHN , EPSTEIN JOSEPH
Published: August 2010

A relatively simple computerised emergency department (ED) attendance record was installed at the Western Hospital with no increase in staffing. The system allows for the entry of patient information and file creation, triage classification, diagnosis and disposition details. A McDonnell Douglas ED module (1988 version), upgraded at Western Hospital, was installed one year prior to the study period. Such systems have the potential to allow data from the 4,000,000 ED annual attendances in Australia to be analysed productively. The recent interest in workload indices and casemix funding formulae has added impetus to the need to computerise ED attendance records.

Data entry was performed by clerical staff at the time of registration and following discharge. Diagnostic coding was performed by hospital medical officers. The introduction of the computerised attendance records was associated with no increase in staffing and was accepted by the staff with minimum difficulty.
Intravenous regional calcium gluconate for hydrofluoric acid burns of the digits
Authors: WILKES GARRY J
Published: August 2010

Objective:To describe an alternative, simple and effective treatment of digital burns from hydrofluoric acid.

Clinical features:Two patients are described with typical presentations from digital exposure to hydrofluoric acid. In both cases topical treatment with calcium gluconate gel was unsuccessful in relieving symptoms.

Intervention and outcome:Both patients were successfully treated with intravenous regional calcium gluconate based on a Bier's block technique.

Conclusion:Digital burns from hydrofluoric acid resistant to treatment with calcium gluconate gel may be successfully treated with this technique, without the need for removal of finger nails or the complicated, protracted technique of intra‐arterial calcium infusions.
Repeat cylindrical battery ingestion
Authors: KAPLAN GARY , TOTTEN VICKEN Y
Published: August 2010

Cylindrical batteries are not commonly ingested. Their size and shape may pose problems different from those seen with disk battery ingestion. We present a case of repeat cylindrical battery ingestion in a schizophrenic woman. The presentation and course, potential treatment modalities and complications of cylindrical battery ingestion are discussed.
Hypomagnesaemic hypocalcaemia and status epilepticus
Authors: HITCHCOCK TOM , MARINOVICH NORM
Published: August 2010

Objective: To describe and discuss a case of status epilepticus as a result of hypomagnesaemic hypocalcaemia and the implications for the investigation of the fitting patient.

Clinical features: A 69 year old man with a recent illness characterised by weight loss and diarrhoea presented in status epilepticus. Tetany was absent in the post‐ictal period. Investigation revealed hypomagnesaemic hypocalcaemia, macrocytic anaemia and hypoalbuminaemia.

Intervention: After initial resuscitation with oxygen and anticonvulsants, magnesium replacement alone corrected the biochemical abnormality.

Conclusion: Both hypocalcaemia and hypomagnesaemia can cause seizure activity. Calcium and magnesium levels are useful investigations in the fitting patient even without signs of tetany. When hypomagnesaemic hypocalcaemia occurs, the likely cause is magnesium deficiency and magnesium replacement alone is indicated.
Diabetic ketoacidosis
Authors: PREISZ PAUL , HAMER WAYNE , FULDE GORDIAN
Published: August 2010

Diabetic ketoacidosis is a common medical emergency and may represent up to 14% of all diabetic admissions with an annual incidence of about 4.6 cases per 1,000 diabetics per year.

A spectrum of disease is encountered and mortality rates vary in different series from 1.9% to 15%. The pathogenesis of diabetic ketoacidosis is discussed in detail with particular emphasis on interpretation of biochemistry results and on fluid and electrolyte resuscitation.

A flexible approach to fluid resuscitation, careful interpretation of biochemistry results, and close monitoring should be combined with other standard aspects of management such as titratable insulin infusions and early treatment of identifiable precipitants in order to minimise morbidity and mortality.
Premature labor precipitated by red‐back spider envenomation
Authors: KNOX IAN , CAVE DON
Published: August 2010

Objective: To present the first reported case of premature labor complicating severe red‐back spider envenomation and the use of antivenom in its treatment.

Clinical features: A 33 year old multiparous woman, 30 weeks pregnant, arrived at hospital almost a day after being bitten. She displayed classical features of red‐back spider envenomation and was having regular, moderately strong, uterine contractions. She had a history of premature labor with previous pregnancies.

Intervention: She was treated initially with red‐back spider antivenom followed shortly afterwards by an indomethacin suppository. This markedly improved her symptoms of envenomation and significantly reduced the strength and frequency of uterine contractions. A second ampoule of antivenom with another indomethacin suppository all but resolved the patient's clinical problems. She was discharged without sequelae.

Data synthesis: Medline search was undertaken for reports of the complications of Latrodectus envenomation in pregnancy.

Conclusion: Premature labor is a rare complication of red‐back spider envenomation. Antivenom is a safe and essential part of its management.
Axillary vein thrombosis and compartment syndrome in upper limb trauma
Authors: Cullen Paul
Published: August 2010

Axillary thrombophlebitis and compartment syndrome are potential complications of upper limb trauma with significant morbidity and mortality. A 25 year old man presented 24 hours following an isolated limb injury with these synchronous complications. Early systemic anticoagulation and fasciotomy resulted in significant bleeding and anaemia. Renal function remained normal despite evidence of significant rhabdomyolysis (CK>16 000U/L). Several attempts at closure of fasciotomies were frustrated by major swelling and finally, devitalised biceps brachii was debrided in toto. He was discharged with residual sensory and motor deficits. Three months later, he had marked disability from weakness, sensory disturbance and post‐phlebitic swelling.
Pharmacokinetics of prilocaine in intravenous regional anaesthesia
Authors: SMYTH JAMES , HENDRIE JAMIE , BERLINSKI NEIL , O'CALLAGHAN CHRIS , LOUIS WJ
Published: August 2010

To determine the acute pharma‐cokinetics of prilocaine in intravenous regional anaesthesia (IVRA), plasma prilocaine levels before and after tourniquet release were measured for sixteen patients (including six children) with forearm fractures. A dose of 2.5mg/kg was used with a minimum cuff occlusion time of 20 minutes. No patients had detectable drug levels prior to tourniquet release. Peak drug concentrations were reached within 10 minutes of tourniquet release in all patients. Average peak drug concentration was 1.23mcg/ml. By 30 minutes, drug levels had reached an average of 0.34mcg/ml (range <0.3–0.6mcg/ml). The pharmacokinetic curves of the children were similar in profile to the adults, with analysis of variance failing to demonstrate a significant difference between curves. In no patients did prilocaine reach toxic levels. These results show that prilocaine used at a dose of 2.5 mg/kg is safe and that an observation period of 30 minutes following IVRA is adequate. IVRA does not appear to be contraindicated in children.
The emergency department management of torsades de pointes
Authors: Carey Martin J
Published: August 2010

This case report describes the features of polymorphic ventricular tachycardia known as torsades de pointes. The arrhythmia was probably triggered as a result of the patient taking a small dose of sotalol, in conjunction with other risk factors. The treatment of torsades de pointes is discussed, including the role of transcutaneous cardiac pacing in the emergency management of this arrhythmia.
Hypobaric decompression sickness
Authors: Whitfield Ann , Scheinkestel Carlos D , Miller Ian L , Cooper D Jamie , Tuxen David V
Published: August 2010

The Royal Australian Air Force (RAAF) mimics emergency aircraft decompression and hypoxia in a chamber decompressed over two to six minutes to a simulated altitude of 25,000 feet (7500m). Air crews in the chamber are trained to use oxygen apparatus including positive pressure breathing systems under these conditions. Over a seven year period, the RAAF has performed approximately 2500 subject decompressions and the Alfred Hospital Hyperbaric Service has treated 11 patients suffering decompression sickness (DCS) following this hypobaric exposure.

The 11 patients (eight males, three females, mean age 26±4 years) presented with typical DCS, with joint pains (9), paraesthesiae (7) and concentration and memory deficits (6). One had major neurological deficits including ataxia and dysarthria. Patients required a mean of seven treatments (range 2–25) to a depth of 18m on 100% oxygen. Two patients with refractory symptoms were recompressed with a 50: 50 mix of helium and oxygen and the patient with severe neurological deficit required recompression to 30m.

Nine patients had complete resolution of DCS with treatment, one patient resolved fully by one month after treatment, the patient with more severe neurologic deficit recovered completely by 12 months and one patient with persistent mild sensory deficits was lost to follow‐up by the Alfred Hospital. There were no major differences in presenting symptoms, number of treatments, or outcome between these patients and 422 treated patients suffering DCS following diving over the same time period.

DCS may occur with exposure to high altitude. The severity and treatment is similar to that occurring following diving. Resolution of symptoms and signs may be achieved by recompression therapy.
Depressed myocardial contractility following massive envenomation by an unknown snake
Authors: Wilson Glenda M
Published: August 2010

Objective

To describe a case of severe envenomation following snake‐bite requiring multiple doses of polyvalent antivenom, and associated with marked hypotension and left ventricular failure.

Clinical features

A 24 year old man developed signs and symptoms of severe envenomation following a definite bite from an unidentified snake. There was a delay in seeking treatment, during which time he ingested a quantity of alcohol. He developed a profound coagulopathy, and refractory hypotension following the commencement of antivenom, the cause and management of which constituted a difficult clinical problem in his initial management in a small country hospital. He later developed left ventricular failure.

Outcome

He required a brief period of intensive care management, including continuous positive airway pressure (CPAP) ventilation, despite having received four ampoules of polyvalent antivenom, the initial three ampoules prior to arrival at a tertiary hospital. He recovered fully and was discharged five days after the bite.

Conclusion

This case supports the animal and limited clinical data which suggest that snake venoms may depress myocardial contractility. It highlights the need for more antivenom in this clinical situation.
From whom do students learn in emergency departments?
Authors: Kelly Anne‐Maree
Published: August 2010

This prospective survey of medical students was conducted to identify the occupational groups within the emergency department from whom students felt they were learning and to estimate the relative contribution to learning of each occupational group. The results suggest that major contributions to learning are made by a variety of occupational groups including registrars, consultants, resident medical officers and nursing staff.
Central cord syndrome
Authors: Kennedy Marcus P
Published: August 2010

Central cord syndrome is a relatively common partial cord syndrome occurring in all age groups and often manifest by a confounding neurological presentation. A level of awareness is necessary to diagnose and manage this syndrome optimally.
Sudden death following butane inhalation
Authors: May Christopher R
Published: August 2010

Despite vigorous resuscitation, two young males died shortly after recreational inhalation of butane gas from cigarette lighter refilling cylinders. Inhaled hydrocarbons may predispose to lethal myocardial arrhythmias. The use of adrenaline in resuscitating such patients should be reconsidered.
Emergency department recognition and management of dissecting thoracic aneurysm
Authors: Richards Karen A
Published: August 2010

Dissecting thoracic aneurysm is a rapidly fatal disease if left untreated. A high clinical suspicion is essential in making the diagnosis. Treatment with β blockade and vasodilation is begun before definitive diagnostic investigations are performed. In Australia, contrast CT scanning and increasingly transoesophageal echocardiography are readily available tests and may be preferred to angiography in many centres. However, cases of dissecting thoracic aneurysm are still missed as they may present in a variety of subtle ways. Dissecting thoracic aneurysm should always be considered in the differential diagnosis of patients in the emergency department with unexplained symptoms or signs, particularly the combination of chest pain, pulse deficits and neurological dysfunction.
Light‐guided tracheal intubation as an alternative for difficult intubation
Authors: Burne Scott G , Navaratnam Siva , Bishai Maher Nassis
Published: August 2010

Airway management is an important skill in resuscitation. Failure to ensure adequate ventilation may have disastrous consequences. Anatomical and pathological causes may preclude tracheal intubation by direct laryngoscopy. A case is described of successful tracheal intubation with laryngoscopic grades III and IV, by two separate light‐guided intubations. The device used was the Trachlight® which has the advantages of being safe and inexpensive, and can enable rapid intubation without manipulation of the head and neck. The technique has been shown to be easily learnt. The authors recommend its use in emergency departments where it has applications in patients with cervical spine injuries and in cases of difficult or failed intubations.
Priapism
Authors: Garrett Peter
Published: August 2010

Priapism is a prolonged painful erection unaccompanied by sexual desire. Two cases of priapism are described with different aetiologies, management and outcome. Early and appropriate intervention is vital to minimise the likelihood of subsequent impotence. Techniques available include aspiration, intracavernosaladrenergic therapy and surgical shunting procedures.
Upper airway trauma
Authors: Little Roderick W
Published: August 2010

Twelve cases of injury to the upper airway due to external trauma seen over a seven year period in the emergency department are presented. Four injuries resulted from penetrating trauma and eight from blunt trauma.

Active airway management was initially required in seven patients. Two patients died of severe neurological injury despite appropriate airway management. Surgical intervention was undertaken in five of the ten survivors, with good results. One patient was discharged with a tracheostomy.

All patients presented with symptoms or signs of airway injury. However, airway injuries are uncommon, patients may present without signs or symptoms and these injuries may be overlooked, with potentially disastrous consequences. Airway trauma should be suspected in all cases of blunt or penetrating trauma to the head, neck or chest. Emphasis should be placed on control of the airway and judicious performance of diagnostic procedures, followed by surgical repair where indicated.
Splenic complications of pancreatitis: A case report and review of the literature
Authors: Raftos John R , Ethell Anthony T , Freiman John S
Published: August 2010

A 44 year old male with pancreatitis developed the complications of splenic artery and vein thrombosis, resulting in splenic necrosis, an infected perisplenic haematoma and bleeding gastric varices. He was successfully treated with antibiotics, surgical debridement and splenectomy. The aetiological mechanisms of the involvement of the spleen and the importance of splenic complications in pancreatitis are discussed.