The International Study of Asthma and Allergies in Childhood (ISAAC) Phase Three: a global synthesis

This ISAAC Phase Three synthesis provides summarised information on the main findings of the study, regional tables and figures related to the prevalence and severity of current symptoms of asthma, rhinoconjunctivitis and eczema in the main regions of the world. The large number of surveyed children (≈1,200,000), the large number of centres (233) and countries (98) that participated in ISAAC Phase Three makes this study the most comprehensive survey of these diseases ever undertaken. Globally, the prevalence for current asthma, rhinoconjunctivitis and eczema in the 13-14-year age group was 14.1%, 14.6% and 7.3%, respectively. In the 6-7-year age group the prevalence for current asthma, rhinoconjunctivitis and eczema was 11.7%, 8.5% and 7.9%, respectively. The study shows a wide variability in the prevalence and severity of asthma, rhinoconjunctivitis and eczema which occurs not just between regions and countries but between centres in the same country and centres in the same city. This study definitively establishes that the prevalence of those diseases can be very high in non-affluent centres with low socioeconomic conditions. The large variability also suggests a crucial role of local environment characteristics to determine the differences in prevalence between one place and another. Thus, ISAAC Phase Three has provided a large body of epidemiological information on asthma, rhinoconjunctivitis and eczema in childhood from contrasting environments which is expected to yield new clues about the aetiology of those conditions and reasons for their marked global variability.

The impact of lower limb amputation on community reintegration of a population in Johannesburg: A Qualitative perspective

Aim: To explore the experiences and perceptions of people with lower limb amputations from the Johannesburg metropolitan area on the impact that their amputations had on their lives and their return to their communities. Methods: Semi-structured audio-taped in-depth interviews were used to collect data on 12 purposively selected participants. Ethical clearance was obtained. A General Inductive Approach was used to generate or discover themes within the data using a process of systematic coding. Results: Emerging from the qualitative data were psychological, social and religious themes. Suicidal thoughts, dependence, poor acceptance, public perception about body image, phantom limb related falls and hopes of obtaining prostheses were reported. Some reported poor social involvement due to mobility problems and employment concerns, while families and friends were found to be supportive. Participants had faith in God. Conclusion: Generally, most participants had come to terms with the amputation and were managing well while some expressed that they were struggling with reintegration to their communities of origin three months postoperatively with both functional and psychosocial challenges.

Inter-examiner reliability when using the Objective Structured Practical Examination (OSPE) mark sheet for physiotherapy practical

The Objective Structured Practical Examination (OSPE) format is used during practical examinations as part of the physiotherapy undergraduate curriculum at the University of the Witwatersrand. Various factors influence inter-examiner reliability and investigating the inter-examiner reliability when using the OSPE can lead to improvement of the examination process. The aim of this study was to establish inter-examiner reliability when using the OSPE mark sheet. Methods: Twelve examiners participated in this study. Thirty-three second year PT students were examined at six stations and by two examiners at each station. The Spearman’s correlation test was used to establish inter-examiner reliability. Results: The general inter-examiner reliability of the OSPE mark sheet was high. There was a high correlation between examiners who had the same level of experience (r=0.79 to r=0.93; p<0.001). The background knowledge section of the OSPE mark sheet showed the greatest inter-examiner reliability (r=0.75 to r=0.91; p<0.001). Discussion: In general, a high inter-examiner reliability was found. Examiners with the same level of experience seemed to generally have better inter-examiner reliability when using the OSPE mark sheet. Furthermore, a well-described, operationalised list of micro-skills also improved inter-examiner reliability. Conclusion: The OSPE mark sheet aids inter-examiner reliability. The use of this method of examination should be encouraged.

Paediatric HIV - Looking beyond CD4 Counts

Paediatric HIV remains a significant health and social challenge in sub-Saharan Africa despite many countries gaining improved access to antiretroviral treatment. Paediatric HIV affects multiple body systems and has the potential to cause wide ranging impairments as well as activity and participation limitations. The aim of this paper is to highlight some of the impairments that remain, despite the children having access to better medical care, in order to establish a possible role for physiotherapists. Nine studies conducted through the department of physiotherapy at the University of the Witwatersrand, South Africa are presented. The results of these studies demonstrate the neurodevelopmental, musculoskeletal, respiratory and quality of life challenges which children infected with HIV as well as their caregivers continue to face. The need for long term, multidisciplinary follow up of children infected with HIV is emphasized.

Quality of life following a major lower limb ampu tation in Johann esburg, South Africa

To determine the impact of lower limb amputation on qualityof life in people in the Johannesburg metropolitan area of South Africa, duringtheir reintegration to their society/community of origin.A longitudinal pre- test- post test design was utilized. Consecutive samplingwas used to recruit and interview participants (n=73) who met the inclusioncriteria. Ethical clearance was obtained. The hospitals and participants gaveinformed consent.The EQ-5D, Barthel Index, and Modified Household Economic andSocial Status Index were used to collect data. Participants were interviewed preoperatively and then followed upthree months post-operatively. Data were analysed using STATA version 10. Categorical data were analysedusing Chi-square/Fischer’s exact test and continuous data were analysed using Wilcoxon signed rank and medianregression.Most (n=21, 52.5 %) participants had no income. One participant was homeless, 17.5% (n=7) lived in shacks.The preoperative and postoperative median VAS of the EQ-5D was 60 and 70 respectively showing no significantimprovement in QOL (median EQ-5D VAS). The preoperative and postoperative median total BI score was 20 and 19respectively, showing a significant reduction in function (median total BI) three months postoperatively (p<0.001).Preoperative mobility was a predictor of postoperative quality of life. Being female was a predictor of higher qualityof life.The average EQ-5D VAS score and overall function (total BI) were generally scored high both preoperativelyand postoperatively but there was no significant improvement in EQ-5D VAS score and there was a significant reductionin function after three months. Higher scores in mobility preoperatively is a predictor of higher quality of lifepostoperatively.

HIV/AIDS in Physiotherapy Education – Mainstreaming Using UN Principles

HIV /AID S remains at epidemic levels in South Africa with onein ten people affected by the HI virus. The United Nations program for AID S(UNAID S) has defined five principles that can be used to mainstream HIV .The five key principles are: the development of a clearly defined entry point;use of existing policies, structures and frameworks; advocacy sensitizationand capacity building; distinguishing between the external (institutionalinterventions) and internal (staff risks and vulnerability) domain; and developingstrategic partnerships. A proposed HIV curriculum for physiotherapists wasbeen developed from a series of studies undertaken to understand the issues related to HIV using the principles ofmainstreaming.The purpose of this paper is to explore how each principle of mainstreaming can be applied in physiotherapyeducation and curricula.Each mainstreaming principle was considered and ways in which it could be mainstreamed into physiotherapytraining and practice, using data from the patients’, academics’ and clinicians’ experience were proposed.The five principles can be used in South African settings. In principle one the aetiology, approaches to treatment,management of conditions and symptoms are used to identify entry points for introducing HIV teaching. Relevantexamples of conditions associated with HIV include pain, stroke, specific muscle weakness patterns, fatigue andcardiopulmonary system problems (e.g. breathlessness). The role of physiotherapy in HIV management is also a goodentry point.For principle two, policies were considered. Pertinent areas such as antiretroviral use, frameworks such as theInternational Classification of Function (ICF), Worthington’s rehabilitation framework and CBR can also be integratedwith HIV physiotherapy curriculum and practice. Sensitised and aware staff as promoted in principle three,can advocate for affected patients and role model appropriate practice and attitudes in HIV management thuscontributing to reducing stigma and burnout. Integrating policies with the need to avoid risks and correct inappropriateattitudes of staff is promoted and promoting strategic partnerships and collaborative work will help provideappropriate services.Using the mainstreaming principles allows for the inclusion of HIV content in physiotherapy education and practice.Both physiotherapy curriculum and continuous professional development may use this information to respondappropriately.

Parenting stress of caregivers of young children who are HIV Positive

OBJECTIVE

Paediatric HIV remains a major challenge in Sub-Saharan Africa. Paediatric HIV is a multi-generational disorder with far-reaching implications for the whole family. Parenting stress in caregivers of HIV infected children has been studied in developed countries but never in South Africa. The aim of this study was to determine the extent of parenting stress in caregivers of children infected with HIV in South Africa. Further objectives were to monitor the levels of stress over one year after caregivers started attending a paediatric HIV clinic and to ascertain what factors were predictive of a decrease in parenting stress over that time.

METHOD

One hundred and twenty two caregiver and children dyads were recruited into this study. Caregivers completed the Parenting Stress Index/ Short form at baseline and after six and 12 months. Demographic information was collected and the children's heights, weights and CD4 counts were recorded at each visit.

RESULTS

The families that participated in this study came from very poor socio-economic backgrounds. Eighty five percent of the children were still being cared for by their biological mothers. The parenting stress levels of the caregivers in this study were extremely high at baseline. Although the parenting stress levels did come down significantly over the study period (p< 0.001) they remained high and warrant further investigation and management. A better level of education, better housing facilities and fewer adults living in the household were the three most important factors predicting a decrease in parenting stress over a one year period.

CONCLUSION

Parenting stress of caregivers of young children infected with HIV is extremely high and warrants further investigation and long term management.

An ongoing large outbreak of measles in Merseyside, England, January to June 2012

From 1 January to 30 June 2012, 359 confirmed and 157 probable cases of measles were reported in Merseyside, England. The most affected age groups were children under five years and young adults from 15 years of age. Most cases have been sporadic. There have been few outbreaks in nurseries; however, no outbreaks have been reported in schools. Of the cases eligible for vaccination, only 3% of the confirmed cases were fully immunised.

An ongoing large outbreak of measles in Merseyside, England, January to June 2012

From 1 January to 30 June 2012, 359 confirmed and 157 probable cases of measles were reported in Merseyside, England. The most affected age groups were children under five years and young adults from 15 years of age. Most cases have been sporadic. There have been few outbreaks in nurseries; however, no outbreaks have been reported in schools. Of the cases eligible for vaccination, only 3% of the confirmed cases were fully immunised.

Methods of weaning preterm babies <30 weeks gestation off CPAP: a multicentre randomised controlled trial

BACKGROUND

Controversy exists whether different continuous positive airway pressure (CPAP) weaning methods influence time to wean off CPAP, CPAP duration, oxygen duration, Bronchopulmonary Dysplasia (BPD) or length of admission.

AIMS

In a multicentre randomised controlled trial, the authors have primarily compared CPAP weaning methods impact on time to wean off CPAP and CPAP duration and secondarily their effect on oxygen duration, BPD and time of admission.

METHODS

Between April 2006 and October 2009, 177 infants <30 weeks gestational age (GA) who fulfilled stability criteria on CPAP were randomised to one of the three CPAP weaning methods (M). M1: Taken 'OFF' CPAP with the view to stay 'OFF'. M2: Cycled on and off CPAP with incremental time 'OFF'. M3: As with m(2), cycled on and off CPAP but during 'OFF' periods were supported by 2 mm nasal cannula at a flow of 0.5 l/min.

RESULTS

Based on intention to treat analysis, there was no significant difference in mean GA or birthweight between the groups (27.1 ± 1.4, 26.9 ± 1.6 and 27.3 ± 1.5 (weeks ± 1SD) and 988 ± 247, 987 ± 249 and 1015 ± 257 (grams ± 1SD), respectively). Primary outcomes showed M1 produced a significantly shorter time to wean from CPAP (11.3 ± 0.8, 16.8 ± 1.0, 19.4 ± 1.3 (days ± 1SE) p<0.0001, respectively) and CPAP duration (24.4 ± 0.1, 38.6 ± 0.1, 30.5 ± 0.1 (days ± 1SE) p<0.0001, respectively). All the secondary outcomes were significantly shorter with M1, (oxygen duration: 24.1 ± 1.5, 45.8 ± 2.2, 34.1 ± 2.0 (days ± 1SE) p<0.0001, BPD: 7/56 (12.5%), 29/69 (42%), 10/52 (19%) p=0.011 and length of admission: 58.5 ± 0.1, 73.8 ± 0.1 69.5 ± 0.1 (days ± 1SE) p<0.0001, respectively).

CONCLUSION

Method 1 significantly shortens CPAP weaning time, CPAP duration, oxygen duration, BPD and admission time.

Monitoring indicates greater resilience for birds than for mammals in Kakadu National Park, northern Australia

Context A previous study reported major declines for native mammal species from Kakadu National Park, over the period 2001–09. The extent to which this result may be symptomatic of more pervasive biodiversity decline was unknown. Aims Our primary aim was to describe trends in the abundance of birds in Kakadu over the period 2001–09. We assessed whether any change in bird abundance was related to the arrival of invading cane toads (Rhinella marina), and to fire regimes. Methods Birds were monitored at 136 1-ha plots in Kakadu, during the period 2001–04 and again in 2007–09. This program complemented sampling of the same plots over the same period for native mammals. Key results In contrast to the decline reported for native mammals, the richness and total abundance of birds increased over this period, and far more individual bird species increased than decreased. Fire history in the between-sampling period had little influence on trends for individual species. Interpretation of the overall positive trends for bird species in Kakadu over this period should be tempered by recognition that most of the threatened bird species present in Kakadu were unrecorded in this monitoring program, and the two threatened species for which there were sufficient records to assess trends – partridge pigeon (Geophaps smithii) and white-throated grass-wren (Amytornis woodwardi) – both declined significantly. Conclusions The current decline of the mammal fauna in this region is not reflected in trends for the region’s bird fauna. Some of the observed changes (mostly increases) in the abundance of bird species may be due to the arrival of cane toads, and some may be due to local or regional-scale climatic variation or variation in the amount of flowering. The present study provides no assurance about threatened bird species, given that most were inadequately recorded in the study (perhaps because their decline pre-dated the present study). Implications These contrasting trends between mammals and birds demonstrate the need for biodiversity monitoring programs to be broadly based. The declines of two threatened bird species over this period indicate the need for more management focus for these species.

Changes in cerebral oximetry during peritoneal insufflation for laparoscopic procedures

Background:

Changes in cardiac output may occur during insufflation for laparoscopic procedures. However, there are limited data regarding its potential effects on cerebral oxygenation.

Materials and Methods:

Cerebral oxygenation (ScO₂), end tidal CO₂, heart rate, blood pressure and oxygen saturation by pulse oximetry were recorded every 5 minutes prior to insufflation, during insufflation and after desufflation. Minute ventilation was increased to maintain normocapnia and the depth of anesthesia was adjusted or fluids/phenylephrine administered to maintain the blood pressure within 20% of the baseline.

Results:

The cohort for the study included 70 adults for laparoscopic herniorrhaphy, gastric bypass or cholecystectomy. A total of 1004 ScO₂ values were obtained during laparoscopy. The ScO₂ decreased from the baseline in 758 of the 1004 data points. The ScO₂ was 0–9 less than the baseline in 47.8% of the values, 10–19 less than the baseline in 24.9% of the values and 20–29 less than the baseline in 26 values (2.6%). Eighty-two (8.2%) of the values were less than 80% of the baseline value, while 25 values (2.5%) were less than 75% of the baseline value. Twelve patients had at least one ScO₂ value that was less than 80% of the baseline and 6 had at least one ScO₂ value that was less than 75% of the baseline. Four patients of the cohort had ScO₂ values less than 80% of the baseline for more than 50% of the laparoscopic procedure.

Conclusions:

Although relatively uncommon, significant changes in cerebral oxygenation do occur in some patients during insufflation for laparoscopic surgery.