Transforming medical education in Liberia through an international community of inquiry

A critical component of building capacity in Liberia's physician workforce involves strengthening the country's only medical school, A.M. Dogliotti School of Medicine. Beginning in 2015, senior health sector stakeholders in Liberia invited faculty and staff from U.S. academic institutions and non-governmental organizations to partner with them on improving undergraduate medical education in Liberia. Over the subsequent six years, the members of this partnership came together through an iterative, mutual-learning process and created what William Torbert et al describe as a "community of inquiry," in which practitioners and researchers pair action and inquiry toward evidence-informed practice and organizational transformation. Incorporating faculty, practitioners, and students from Liberia and the U.S., the community of inquiry consistently focused on following the vision, goals, and priorities of leadership in Liberia, irrespective of funding source or institutional affiliation. The work of the community of inquiry has incorporated multiple mixed methods assessments, stakeholder discussions, strategic planning, and collaborative self-reflection, resulting in transformation of medical education in Liberia. We suggest that the community of inquiry approach reported here can serve as a model for others seeking to form sustainable global health partnerships focused on organizational transformation.

Ondansetron/promethazine combination or promethazine alone reduces nausea and vomiting after middle ear surgery

STUDY OBJECTIVES

To determine the incidence of postoperative nausea and vomiting when a combination of ondansetron and promethazine is given prophylactically, and to ascertain the effect of postoperative nausea and vomiting on recovery room duration and patient satisfaction.

DESIGN

Prospective, randomized, placebo-controlled, double-blind study.

SETTING

University-affiliated tertiary-care hospital.

PATIENTS

87 ASA physical status I and II adult patients scheduled for middle ear surgery.

INTERVENTIONS

Patients were randomly assigned to receive one of the following interventions intravenously: ondansetron 4 mg (Group 1), promethazine 25 mg (Group 2), ondansetron 2 mg plus promethazine 12.5 mg (Group 3, combination), or placebo (Group 4).

MEASUREMENTS AND MAIN RESULTS

Independent, study blinded observers recorded complaints of nausea and number of episodes of vomiting for 24 hours following the patient's first response to commands. All patients were contacted the day after discharge to inquire about nausea and vomiting. The awakening time, postanesthesia care unit and day surgery unit durations, opioid use, and side effects were recorded. At the end of the 24-hour period, the study blinded observers asked patients for an overall assessment of their global anesthesia experience using an 11-point scale. During the 24-hour period, the incidence of postoperative nausea and vomiting was reduced from 74% (placebo) to 39% (promethazine; p = 0.03) and 29% (combination; p = 0.003). Compared with placebo, the severity of vomiting was significantly less in the combination group (p = 0.04). The number of very satisfied patients correlated negatively with the incidence of postoperative nausea and vomiting (p < 0.0001) and with the severity of vomiting (p = 0.003).

CONCLUSION

The prophylactic use of an antiemetic with middle ear surgery may reduce postoperative nausea and vomiting over 24 hours, and the ondansetron/promethazine combination or promethazine alone are cost-effective choices. Finally, the combination reduced significantly the severity of vomiting.

Sublingual midazolam premedication in children: a dose response study

The purpose of this study was to evaluate various doses of sublingual midazolam premedication in children. In our prospective, double-blind, placebo-controlled trial, children (n = 102, age range 12 to 129 months) scheduled for day surgery were randomized to receive either midazolam in one of three doses (0.25, 0.5, or 0.75 mg.kg-1) or placebo. Injectable midazolam was mixed with a thick grape syrup and placed under the tongue; the patient was asked to hold it as long as possible before swallowing. Children readily accepted the mixture. Analysing all patients randomized, none of the children receiving placebo vs 28% receiving 0.25 mg.kg-1 (P = 0.02), 52% receiving 0.5 mg.kg-1 (P < 0.001), and 64% receiving 0.75 mg.kg-1 (P < 0.001) of midazolam showed satisfactory sedation (drowsy) at 15 min after administration. Children receiving the two higher doses of midazolam (0.5 and 0.75 mg.kg-1) accepted mask induction willingly, while the group receiving 0.25 mg.kg-1 resembled the placebo group (P < 0.05).

Postoperative respiratory complications in ex-premature infants after inguinal herniorrhaphy

BACKGROUND/PURPOSE

The duration of postoperative cardiorespiratory monitoring of premature infants after inguinal herniorrhaphy is uncertain. Prolonged observation requiring hospital admission may be unnecessary and increases costs.

METHODS

This study was a retrospective review of 191 inguinal herniorrhaphies performed between 1993 and 1996 at the Hermann Children's Hospital. The authors reviewed their experience to identify factors associated with postoperative apnea and bradycardia and determine a safe period of observation.

RESULTS

Among 191 elective inguinal herniorrhaphies performed, 57 (29.8%) were in expremature infants (< or =60 weeks postconception). Five (8.8%) infants either failed extubation or were unable to extubate (group 1). The average age for this group was 41.0 +/- 1.2 weeks compared with 47.2 +/- 1.0 (P = .06) for those who were successfully extubated (group II). Preoperative apnea-bradycardia was found in four (80%) infants in group I compared with 32 (61.5%) in group II (P = 0.67). All group I and 21 (40.4%, P = .09) group II infants with a history of preoperative apnea required intubation for an average of 24.4 +/- 7.8 days and 8.2 +/- 2.4 days, respectively (P = .04). American Society of Anesthesia (ASA) scores were 2.6 +/- 0.4 for group I compared with 1.8 +/- 0.1 for group 11 (P = .01). The use of both intraoperative narcotics (three [60%] in group I v six [12%] in group II, P = .01]) and vecuronium (four [80%] in group I v 16 [31%] in group II, P = .03) were significantly more common in group I infants. Operating room time was 46.4 +/- 4.1 minutes for group I compared with 60.6 +/- 3.9 minutes for group II (P = .27). Postoperative apnea-bradycardia occurred in all five group I infants and two (3.8%, P = .001) group II infants. Group II infants were treated successfully with supplemental oxygen.

CONCLUSIONS

All instances of postoperative apnea-bradycardia and laryngospasm occurred within 4 hours after operation without significant differences between groups. The risk of postoperative cardiorespiratory distress requiring reintubation in premature infants who undergo inguinal herniorrhaphy is not insignificant (8.8%). The judicious use of narcotics and vecuronium, and limiting patient selection to those with ASA score of less than 3 may lessen the need for reintubation. When present cardiorespiratory distress occurs early; therefore we recommend outpatient inguinal herniorrhaphy as a safe and cost-effective choice.

The expanding clinical spectrum of idiopathic polypoidal choroidal vasculopathy

OBJECTIVE

To expand the clinical spectrum of idiopathic polypoidal choroidal vasculopathy based on historical cases and newly recognized observations.

METHODS

A review of the previously reported 45 cases was carried out. An additional 20 cases were retrospectively reviewed to examine the clinical nature and course of idiopathic polypoidal choroidal vasculopathy.

RESULTS

New observations on the clinical spectrum of idiopathic polypoidal choroidal vasculopathy were noted for demographic features, the nature and course of the vascular lesion, the possible association with intraocular inflammation, and the indocyanine green angiographic characteristics.

CONCLUSIONS

Idiopathic polypoidal choroidal vasculopathy seems to be a distinct clinical entity that has a predilection for individuals of pigmented races. The disorder should be differentiated from typical choroidal neovascularization and other known choroidal degenerative, inflammatory, and ischemic disorders because of differences in clinical course and treatment.

Induction, recovery, and safety characteristics of sevoflurane in children undergoing ambulatory surgery. A comparison with halothane

BACKGROUND

Sevoflurane is an inhalational anesthetic with characteristics suited for use in children. To determine whether the induction, recovery, and safety characteristics of sevoflurane differ from those of halothane, the following open-labeled, multicenter, randomized, controlled, phase III study in children undergoing ambulatory surgery was designed.

METHODS

Three hundred seventy-five children, ASA physical status 1 or 2, were randomly assigned in a 2:1 ratio to receive either sevoflurance or halothane, both in 60% N2O and 40% O2. Anesthesia was induced using a mask with an Ayre's t piece or Bain circuit in four of the centers and a mask with a circle circuit in the fifth center. Maximum inspired concentrations during induction of anesthesia were 7% sevoflurane and 4.3% halothane. Anesthesia was maintained by spontaneous ventilation, without tracheal intubation. End-tidal concentrations of both inhalational anesthetics were adjusted to 1.0 MAC for at least 10 min before the end of surgery. Induction and recovery characteristics and all side effects were recorded. The plasma concentration of inorganic fluoride was measured at induction of and 1 h after anesthesia.

RESULTS

During induction of anesthesia, the time to loss of the eyelash reflex with sevoflurane was 0.3 min faster than with halothane (P < 0.001). The incidence of airway reflex responses was similar, albeit infrequent with both anesthetics. The total MAC.h exposure to sevoflurane was 11% less than the exposure to halothane (P < 0.013), although the end-tidal MAC multiple during the final 10 min of anesthesia was similar for both groups. Early recovery as evidenced by the time to response to commands after sevoflurane was 33% more rapid than it was after halothane (P < 0.001), although the time to discharge from hospital was similar for both anesthetics. The mean ( +/- SD) plasma concentration of inorganic fluoride 1 h after discontinuation of sevoflurane was 10.3 +/- 3.5 microM. The overall incidence of adverse events attributable to sevoflurane was similar to that of halothane, although the incidence of agitation attributable to sevoflurane was almost threefold greater than that attributable to halothane (P < 0.004).

CONCLUSIONS

Sevoflurane compared favorably with halothane. Early recovery after sevoflurane was predictably more rapid than after halothane, although this was not reflected in a more rapid discharge from the hospital. The incidence of adverse events was similar for both anesthetics. Clinically, the induction, recovery, and safety characteristics of sevoflurane and halothane are similar. Sevoflurane is a suitable alternative to halothane for use in children undergoing minor ambulatory surgery.

Unusual variant of familial aniridia

A woman and her two children had apparent dominantly inherited ocular abnormalities including aniridia, ptosis, nystagmus, corneal pannus, persistent pupillary membrane, lenticular opacities, and foveal hypoplasia. A broad spectrum of iris abnormalities was observed: the daughter had aniridia with persistent pupillary membrane strands traversing the anterior lens capsule; the iris of the mother and son had a velvety surface with no detailed crypts, but did have some persistent pupillary membrane tags extending from the collarette. All three family members had moderately severe bilateral ptosis, pendular nystagmus, corneal pannus, and visual acuity of 20/200. Several systemic abnormalities also were noted, including obesity and mental retardation in the two children, and alopecia, cardiac abnormalities, and frequent spontaneous abortion in the mother. Family history indicated that the children's maternal grandmother also had similar ocular findings. We believe that this constellation of findings represents a rare, apparently dominant, variant of aniridia.

A randomized clinical trial of feeder vessel photocoagulation of proliferative sickle cell retinopathy. II. Update and analysis of risk factors

Follow-up of patients enrolled in a randomized prospective trial of feeder vessel photocoagulation for proliferative sickle cell retinopathy has shown that photocoagulation is effective in preventing vitreous hemorrhage and visual loss from vitreous hemorrhage. In addition, a reduction of visual loss from all causes in photocoagulated eyes approaches statistical significance. Analysis of control eyes shows that there are three independent risk factors for the occurrence of vitreous hemorrhage: (1) the presence of the SC genotype, (2) the presence of vitreous blood at the initial evaluation and, (3) the presence of greater than 60 degrees of perfused neovascularization.

A randomized clinical trial of feeder vessel photocoagulation of proliferative sickle cell retinopathy. I. Preliminary results

A randomized prospective clinical trial of feeder vessel photocoagulation for proliferative sickle cell retinopathy was performed. In Chicago there were 34 argon laser-treated eyes and 30 control eyes. In Kingston there were 53 xenon arc treated eyes and 50 control eyes. Prolonged loss of visual acuity was rare in both photocoagulated and control eyes. Argon laser and xenon arc feeder vessel photocoagulation reduced the incidence of vitreous hemorrhage and visual loss from vitreous hemorrhage. However, photocoagulation was associated with an increased risk of choroidal neovascularization (xenon arc greater than argon laser) and retinal detachment (argon laser), although visual loss from these complications has not been seen in these patients so far.

Retinal macroaneurysms

Five patients had macroaneurysms of the retinal arterioles. These macroaneurysms may be observed without pathologic sequelae or may be associated with circinate retinopathy, intraretinal hemorrhage, subretinal hemorrhage, or intravitreal hemorrhage. They may also evolve into more widespread vascular anomalies resembling adult Coats disease in some respects. Photocoagulation therapy is occasionally indicated.

Mooren's ulcer: two cases occurring after cataract extraction and treated with hydrophilic lens

Two patients developed Mooren's ulcer following cataract extraction. The first case was complicated by ocular trauma 8 years prior to surgery and by vitreous loss at the time of surgery. The second patient underwent cataract extraction without complication. Surgical trauma may have been the inciting factor in the development of these ulcers. Both patients experienced dramatic relief of ocular pain following the application of hydrophilic lenses. There was no apparent alteration in the course of the disease in either case. The use of hydrophilic soft lenses is suggested for symptomatic relief of the severe ocular pain experienced by patients with Mooren's ulcer.

Evolution of the retinal black sunburst in sickling haemoglobinopathies

In a prospective study of 38 patients, who were initially selected as being at an early stage of sickling retinopathy, three developed circular black chorio-retinal scars (black sunbursts) during a period of 6 to 24 months. These lesions appear to be the sequelae of intraretinal and subretinal haemorrhage. They occur in the fundus periphery and do not interfere with vision.

Spontaneous regression (autoinfarction) of proliferative sickle retinopathy

Of 45 patients with proliferative sickle retinopathy in stages III, IV, and V, nine patients (eight with hemoglobin SC disease, one with sickle cell thalassemia) showed spontaneous regression (autoinfarction) of retinal sea fans. One mechanism involved in autoinfarction of neovascular tissue is progressive, centripetal retraction of the anterior vascular arcade of the peripheral retina. In addition, vitreous traction on feeder vessels may result in sluggish blood flow and occlusion of these vessels, or may tear the sea fan completely away from its feeder vessels. In view of the many incidences of vitreous hemorrhages that occur in patients with proliferative retinopathy, however, we recommend treatment of neovascularization rather than prolonged observation.