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Background. Botswana is an economically stable middle-income country with a developing health system and a large HIV and infectious disease burden. Princess Marina Hospital (PMH) is the largest referral and teaching hospital with a mixed eight-bed intensive care unit (ICU). Objectives. To conduct an audit of PMH ICU in order to investigate major admission categories and quantify morbidity and mortality figures using a validated scoring system for quality improvement, education and planning purposes. Methods. PMH medical records and laboratory data were accessed to record demographics, referral patterns, diagnoses, HIV status, Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scores and mortality rates. Results. A total of 182 patients >14 years of age were enrolled over a 12-month period from April 2017 - March 2018. Patient’s mean age was 42.9 years, males represented 56.6% of the study population and surgical conditions accounted for 46% of diagnostic categories. Sixty percent of the patients were HIV-negative and 12% had no HIV status recorded. The mean APACHE II score was 25 and the mean length of stay in ICU was 10.3 days. Higher APACHE II scores were associated with higher mortality regardless of HIV status. The overall mortality was 42.8% and there was no difference in mortality rates in ICU or at 30 days between HIV-positive and HIV-negative ICU patient groups. Conclusions. The PMH ICU population is young with a high mean APACHE II score, significant surgical and HIV burdens and a high mortality rate. PMH ICU has significant logistical challenges making comparison with international ICUs challenging, and further research is warranted. Keywords. middle-income country, ICU, APACHE II score, clinical audit, HIV

The COVID-19 pandemic continues to test health systems resilience worldwide. Low- and middle-income country (LMIC) health care systems have considerable experience in disasters and disease outbreaks. Lessons from the preparedness and responses to COVID-19 in LMICs may be valuable to other countries.This policy paper synthesises findings from a multiphase qualitative research project, conducted during the pandemic to document experiences of Pacific Island Country and Territory (PICT) frontline clinicians and emergency care (EC) stakeholders. Thematic analysis and synthesis of enablers related to each of the Pacific EC systems building blocks identified key factors contributing to strengthened EC systems.Effective health system responses to the COVID-19 pandemic occurred when frontline clinicians and 'decision makers' collaborated with respect and open communication, overcoming healthcare workers' fear and discontent. PICT EC clinicians demonstrated natural leadership and strengthened local EC systems, supporting essential healthcare. Despite resource limitations, PICT cultural strengths of relational connection and innovation ensured health system resilience. COVID-19 significantly disrupted services, with long-tail impacts on non-communicable disease and other health burdens.Lessons learned in responding to COVID-19 can be applied to ongoing health system strengthening initiatives. Optimal systems improvement and sustainability requires EC leaders' involvement in current decision-making as well as future planning.Search strategy and selection criteria We searched PubMed, Google Scholar, Ovid, WHO resources, Pacific and grey literature using search terms 'emergency care', 'acute/critical care', 'health care workers', 'emergency care systems/health systems', 'health system building blocks', 'COVID-19', 'pandemic/surge event/disease outbreaks' 'Low- and Middle-Income Countries', 'Pacific Islands/region' and related terms. Only English-language articles were included.Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Copyright of the original work on which this publication is based belongs to WHO. The authors have been given permission to publish this manuscript. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of WHO. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant. RM is supported by a National Health and Medical Research Council (NHMRC) Postgraduate Scholarship and a Monash Graduate Excellence Scholarship. GOR is supported by a NHMRC Early Career Research Fellowship. CEB is supported by a University of Queensland Development Research Fellowship. None of these funders played any role in study design, results analysis or manuscript preparation.

Emergency care (EC) addresses the needs of patients with acute illness and injury, and has fulfilled a critical function during the COVID-19 pandemic. 'Processes' (e.g. triage) and 'data' (e.g. surveillance) have been nominated as essential building blocks for EC systems. This qualitative research sought to explore the impact of the pandemic on EC clinicians across the Pacific region, including the contribution of EC building blocks to effective responses.The study was conducted in three phases, with data obtained from online support forums, key informant interviews and focus group discussions. There were 116 participants from more than 14 Pacific Island Countries and Territories. A phenomenological approach was adopted, incorporating inductive and deductive methods. The deductive thematic analysis utilised previously identified building blocks for Pacific EC. This paper summarises findings for the building blocks of 'processes' and 'data'.Establishing triage and screening capacity, aimed at assessing urgency and transmission risk respectively, were priorities for EC clinicians. Enablers included support from senior hospital leaders, previous disaster experience and consistent guidelines. The introduction of efficient patient flow processes, such as streaming, proved valuable to emergency departments, and checklists and simulation were useful implementation strategies. Some response measures impacted negatively on non-COVID patients, and proactive approaches were required to maintain 'business as usual'. The pandemic also highlighted the value of surveillance and performance data.Developing effective processes for triage, screening and streaming, among other areas, was critical to an effective EC response. Beyond the pandemic, strengthening processes and data management capacity will build resilience in EC systems.Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant.

The COVID-19 pandemic highlighted challenges for all health systems worldwide. This research aimed to explore the impact of COVID-19 across the Pacific especially with regards to emergency care (EC) and clinicians' preparations and responses.A collaboration of Australia and Pacific researchers conducted prospective qualitative research over 18 months of the pandemic. In this three phase study data were gathered from Emergency Clinicians and stakeholders through online support forums, in-depth interviews and focus groups. A phenomenological methodological approach was employed to explore the lived experience of participants. This paper discusses the findings of the study regarding the EC building block of 'Infrastructure and Equipment.'Pre-existing infrastructure and equipment were not sufficient to help control the pandemic. Adequate space and correct equipment were essential needs for Pacific Island emergency clinicians, with donations, procurement and local ingenuity required for suitable, sustainable supplies and facilities. Adequate personal protective equipment (PPE) conferred a sense of security and increased Health Care Workers willingness to attend to patients.Investing in adequate infrastructure and appropriate equipment is crucial for an effective response to the COVID-19 pandemic. The sustainability of such investments in the Pacific context is paramount for ongoing EC and preparation for future surge responses and disasters.Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant.

This study explores emergency care (EC) and other frontline healthcare worker (HCW) experiences responding to the COVID-19 pandemic in the Pacific region. The crisis has reinforced the crucial role well-trained, resourced, and supported EC providers play in supporting vital health systems and services in all global regions not only during 'business as usual' periods, but in times of tremendous stress and surge.Qualitative data were collected from EC providers and relevant stakeholders in three research phases in 2020 and 2021. Data on the World Health Organization's (WHO) Human Resources Building Block, adapted for the Pacific EC context, was thematically analysed. Key findings were further analysed to identify enablers and barriers to effective EC pandemic management.116 participants from across the Pacific region participated in this study. Five themes emerged: (1) EC providers performed multiple pandemic roles; (2) Importance of authorities' valuing frontline HCWs; (3) HCW mental health and exhaustion; (4) HCW tension managing stigma, personal/professional expectations, and chronic health needs; and (5) Building health and human resource capacity.This study significantly contributes to the limited scientific literature on HCW experiences responding to COVID-19 across the Pacific. Recommendations arising out of this research align with consensus priorities and standards that were identified pre-pandemic by health stakeholders across the Pacific for enhancing EC system development. With limited HCWs available for many Pacific nations, it is imperative the dignity and welfare of local HCWs is genuinely prioritised.Epidemic Ethics/WHO, Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding: Australasian College for Emergency Medicine Foundation, International Development Fund Grant.

Mantle cell lymphoma (MCL) is a rare B-cell non-Hodgkin lymphoma (NHL) that is aggressive and incurable with existing therapies, presenting a significant unmet clinical need. MCL occurs mainly in elderly patients with comorbidities; thus, intense treatment options including allogeneic stem cell transplantation (Allo-SCT) are not feasible. New treatment options are emerging for this elderly/unfit treatment group, we therefore conducted a systematic review to determine whether they offered an advance on the existing recommended treatment, R-CHOP. The search strategies to identify MCL therapies were designed to capture the most relevant studies from 2013 to 2020. Following preferred reporting items for systematic reviews and meta-analyses and population,interventions, observations and study design analysis, R-CHOP, ibrutinib and bendamustine plus rituximab (BR) were taken forward for critical and statistical analysis. All three therapies were effective in increasing the overall survival (OS) and progression-free survival of elderly/unfit patients with MCL. However, none resulted in a significant increase in OS compared to R-CHOP. In addition, R-CHOP had a better toxicity profile when compared to both ibrutinib and BR. We therefore conclude that treatment of elderly/unfit patients with MCL is still a significant unmet clinical need; and suggest that outside of the clinical trial setting, R-CHOP should remain the recommended front-line treatment for this patient group.

The concepts of Native American cultural continuance and agency have become critical elements of both preserving, sharing, and extending the culture of Indigenous Americans into the future. Digital media platforms offer Native American nations a new opportunity to reach both a Native audience and society at large and contradict traditional media's cultural stereotypes and misrepresentation. Therefore, this qualitative content analysis of Cherokee Nation digital media explores what elements of cultural continuance and cultural agency are found in biographical digital storytelling. Using the key concepts extracted from the literature (visibility, envisioning a future, creative authority and autonomy, authenticity, and disrupting dominant norms) as the focus, six themes emerged from Cherokee Nation articles and documentaries.

Low- and middle-income countries (LMICs) across the Pacific region have been severely impacted by the COVID-19 pandemic, and emergency care (EC) clinicians have been on the frontline of response efforts. Their responsibilities have extended from triage and clinical management of patients with COVID-19 to health system leadership and coordination. This has exposed EC clinicians to a range of ethical and operational challenges.This paper describes the context and methodology of a rapid, collaborative, qualitative research project that explored the experiences of EC clinicians in Pacific LMICs during the COVID-19 pandemic. The study was conducted in three phases, with data obtained from online regional EC support forums, key informant interviews and focus group discussions. A phenomenological approach was adopted, incorporating a hybrid inductive and deductive thematic analysis. Research findings, reported in other manuscripts in this collection, will inform multi-sectoral efforts to improve health system preparedness for future public health emergencies.Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z (Phases 1 and 2A) and an Australasian College for Emergency Medicine Foundation International Development Fund Grant.

Universal access to safe, effective emergency care (EC) during the COVID-19 pandemic has illustrated its centrality to healthcare systems. The 'Leadership and Governance' building block provides policy, accountability and stewardship to health systems, and is essential to determining effectiveness of pandemic response. This study aimed to explore the experience of leadership and governance during the COVID-19 pandemic from frontline clinicians and stakeholders across the Pacific region.Australian and Pacific researchers collaborated to conduct this large, qualitative research project in three phases between March 2020 and July 2021. Data was gathered from 116 Pacific regional participants through online support forums, in-depth interviews and focus groups. A phenomenological approach shaped inductive and deductive data analysis, within a previously identified Pacific EC systems building block framework.Politics profoundly influenced pandemic response effectiveness, even at the clinical coalface. Experienced clinicians spoke authoritatively to decision-makers; focusing on safety, quality and service duty. Rapid adaptability, past surge event experience, team-focus and systems-thinking enabled EC leadership. Transparent communication, collaboration, mutual respect and trust created unity between frontline clinicians and 'top-level' administrators. Pacific cultural assets of relationship-building and community cohesion strengthened responses.Effective governance occurs when political, administrative and clinical actors work collaboratively in relationships characterised by trust, transparency, altruism and evidence. Trained, supported EC leadership will enhance frontline service provision, health security preparedness and future Universal Health Coverage goals.Epidemic Ethics/World Health Organization (WHO), Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding: Australasian College for Emergency Medicine Foundation, International Development Fund Grant.

The rate of suicide among people in the United States is high among those ages 15 through 34. People in this age range are active online, and therefore, social media platforms give health communicators a method for reaching them with messages intended for suicide intervention. This paper proposes a framework for the construction of social media messages designed to influence behavioral intention and motivate action by suicide gatekeepers (those aware of a peer’s suicide ideation). The framework is conceptualized through the lens of the theory of planned behavior and its determinants of behavioral intention—attitudes, subjective norms, and perceived behavioral control. Three concepts are provided that may influence each of the determinants: framing with interdependence, emphasizing reciprocal relationships, and using empowering language.

Introduction This study describes the demographics, aetiology, emergency centre diagnosis and severity indicators of patients with head injuries presenting to the largest referral hospital emergency centre in Botswana. Methods Cross-sectional retrospective data was collected from July 2015 to September 2015 for all emergency centre head injury presentations at Princess Marina Hospital. Information was extracted from emergency centre records regarding patient demographics, mechanism of injury, clinical observations, diagnosis, and treatment. Results Three-hundred and sixty head injury patients presented to the emergency centre in the three months, averaging four per day. 80% were less than 40 years of age and males accounted for 69% of all presentations. 58% of injuries were listed as being accidental, 39% recorded from assaults and 38% from road traffic accidents. The most common emergency centre clinical diagnosis was concussion and the most common radiological diagnosis skull fracture. The median Glasgow Coma Scale was 15 with a range from 3 to 15; and, among patients for whom Revised Trauma Score could be calculated, 79% scored the lowest probability of death in the Revised Trauma Score. Discussion Head injury disproportionately overburdened males in this study, and head injury aetiology and demographic picture was similar to regional data. Severity scoring using the Glasgow Coma Scale was only available among 66% of patients and Revised Trauma Score calculable in half of presentations. Only 55% of head injury patients were discharged from the emergency centre, despite the preponderance of low severity scores. Head CTs appear to have been over-utilised and implementation of a Traumatic Head CT guideline for our setting is proposed. This study improves understanding of the burden of head injury in Botswana and advocates for national referral guidelines for patients with head injury in Botswana.

OBJECTIVES To describe provider characteristics, knowledge acquisition, perceived relevance, and instruction quality of the Society of Critical Care Medicine's Pediatric Fundamentals of Critical Care Support course pilot implementation in Botswana. DESIGN Observational, single center. SETTING Academic, upper middle-income country. SUBJECTS Healthcare providers in Botswana. INTERVENTIONS A cohort of healthcare providers completed the standard 2-day Pediatric Fundamentals of Critical Care Support course and qualitative survey during the course. Cognitive knowledge was assessed prior to and immediately following training using standard Pediatric Fundamentals of Critical Care Support multiple choice questionnaires. Data analysis used Fisher exact, chi-square, paired t test, and Wilcoxon rank-sum where appropriate. MAIN RESULTS There was a significant increase in overall multiple choice questionnaires scores after training (mean 67% vs 77%; p < 0.001). Early career providers had significantly lower mean baseline scores (56% vs 71%; p < 0.01), greater knowledge acquisition (17% vs 7%; p < 0.02), but no difference in posttraining scores (73% vs 78%; p = 0.13) compared with more senior providers. Recent pediatric resuscitation or emergency training did not significantly impact baseline scores, posttraining scores, or decrease knowledge acquisition. Eighty-eight percent of providers perceived the course was highly relevant to their clinical practice, but only 71% reported the course equipment was similar to their current workplace. CONCLUSIONS Pediatric Fundamentals of Critical Care Support training significantly increased provider knowledge to care for hospitalized seriously ill or injured children in Botswana. Knowledge accrual is most significant among early career providers and is not limited by previous pediatric resuscitation or emergency training. Further contextualization of the course to use equipment relevant to providers work environment may increase the value of training.

Introduction: Successful cardiopulmonary resuscitation (CPR) relies, in part, on the availability and the correct functioning of resuscitation equipment. These data are often lacking in resource-constrained African settings. Aim: To assess the availability and the functional status of CPR equipment in resuscitation trolleys at district hospitals in Botswana. Setting: The study was conducted across four district hospitals in Botswana. Methods: A cross-sectional study was conducted using a checklist adopted following the Emergency Medical Services of South Africa (EMSSA) guidelines, modified and contextualised to Botswana. Results: All the four district hospitals had inadequate number of CPR equipment available in the resuscitation trolleys. The overall availability of drugs and equipment ranged from 19% to 31.1%. Availability of equipment needed for maintaining circulation and fluids ranged from 27% to 49%, while availability of items for airway and breathing ranged from 9.2% to 24.1%. The overall availability of essential drugs for resuscitation was only 20.4%, and in some wards expired drugs were kept in the trolley. Out of 40 wards that participated in the study, only 10 kept CPR algorithms in the resuscitation trolley. The resuscitation trolley was checked on a daily basis only in the critical care units. Conclusion: The resuscitation trolleys were not maintained as per standards. Failure to improve the existing situation could negatively impact the outcome of CPR. Evidence-based standard checklists for resuscitation trolleys need to be enforced to improve the quality of CPR provision in district hospitals in Botswana.

This study aims to present and discuss acute Head Injury (HI) presentations including etiology, referral patterns and disposition in patients presenting to a major referral hospital in Gaborone, Botswana. Cross-sectional, retrospective data collection from July 2015 through September 2015 extracted descriptions of patient demographics, mechanism of injury, comorbidities, diagnosis and disposition from Emergency Centre (EC) records. 360 HI patients presented in three months, averaging four per day and increasing on weekends and end of the month. HI disproportionately impacted young adult males, with motor vehicle accidents accounting for 38%, violence implicated in 39% and 80% recorded as blunt trauma. HIV status was unknown for 84% of patients at the time of presentation and 10% of patients were recorded as HIV positive. Patients referred from external hospitals had a higher admission rate. HI in young males is a significant trauma burden in this hospital, similar to the known regional trauma patterns. More studies regarding trauma, alcohol, and violence related to paydays should be considered to investigate and reduce the burden of HI in Botswana.

Introduction Free Open Access Medical Education encompasses a broad array of free online resources and discussion fora. The aim of this paper was to describe whether Emergency Medicine trainees in different contexts know about Free Open Access Medical Education, whether or not they know about its different platforms, which ones they use, and what the major barriers to regular usage are. Methods A convenience sample was surveyed on awareness and use of Free Open Access Medical Education blogs, podcasts, websites and Twitter at three institutions (in Australia, Botswana and Papua New Guinea) and one deanery (United Kingdom) between June 2013 and June 2014 using an online survey tool or via hand-distributed survey. Results 44 trainees responded: four from Botswana, seven from Papua New Guinea, ten from the United Kingdom and 23 from Australia. 82% were aware of blogs, 80% of websites, 75% of podcasts and 61% of Twitter as resources in Emergency Medicine. Awareness and use of specific resources were lower in Botswana and Papua New Guinea. For blogs, podcasts and websites, trainees who had looked at a resource at least once were neutral or agreed that it was relevant. For Twitter, some trainees found it difficult to navigate or not relevant. Lack of awareness of resources rather than lack of internet access was the main barrier to use. Conclusion The Emergency Medicine trainees in both developed and low resource settings studied were aware that Free Open Access Medical Education resources exist, but trainees in lower income settings were generally less aware of specific resources. Lack of internet and device access was not a barrier to use in this group.L’enseignement médical gratuit en accès libre englobe un large éventail de ressources et forums de discussion gratuits en ligne. Les objectifs de cette étude sont de décrire si les stagiaires en médecine d’urgence dans différents contextes ont connaissance de l’enseignement médical gratuit en accès libre, s’ils ont ou non ils ont connaissance de ses différentes plateformes, quelles sont celles qu’ils utilisent et quels sont les principaux obstacles à leur utilisation régulière.Une enquête a été menée sur un échantillon de commodité sur la sensibilisation aux blogs, podcasts, sites Internet et comptes Twitter sur l’enseignement médical gratuit en accès libre et leur utilisation, dans trois établissements (en Australie, au Botswana et en Papouasie-Nouvelle-Guinée) et un doyenné (Royaume-Uni) entre juin 2013 et juin 2014, en utilisant un outil d’enquête en ligne ou par le biais d’un questionnaire distribué en personne.44 stagiaires ont répondu: quatre provenant du Botswana, sept de Papouasie-Nouvelle-Guinée, dix du Royaume-Uni et 23 d’Australie. 82% connaissaient les blogs, 80% les sites, 75% les podcasts et 61% les comptes Twitter en tant que ressources en médecine d’urgence. La sensibilisation et l’utilisation de ressources spécifiques étaient plus faibles au Botswana et en Papouasie-Nouvelle-Guinée. Concernant les blogs, les podcasts et les sites Web, les stagiaires qui avaient consulté une ressource au moins une fois en avaient une opinion neutre ou convenaient qu’elle était pertinente. Concernant Twitter, certains stagiaires ont trouvé qu’il était difficile d’y naviguer ou estimaient le service non pertinent. Le principal obstacle à l’utilisation était le manque de sensibilisation aux ressources plutôt que le manque d’accès à Internet.Les stagiaires en médecine d’urgence interrogés dans les pays développés comme dans les contextes à faibles ressources étaient conscients de l’existence de ressources en enseignement médical gratuit en accès libre, mais les stagiaires dans les contextes à faible revenu étaient généralement moins conscients des ressources spécifiques. Le manque d’accès à Internet ou à des appareils n’était pas un obstacle à l’utilisation au sein de ce groupe.

Background. Sub-Saharan Africa has a significant shortage of healthcare providers, and educational collaborations are recommended as one of the crucial steps to increase the medical workforce. Objectives. To describe a successful innovative postgraduate medical specialisation programme involving two neighbouring African countries, Botswana and South Africa (SA). Methods. After lengthy consultative processes, a postgraduate training programme was approved between the University of Botswana and the Colleges of Medicine of SA (CMSA). This programme utilised a 4-year Master of Medicine (MMed) curriculum for consecutive training and examinations in both countries. Extensive collaborations with government and regulatory bodies in both countries were required to facilitate the programme. Results. Despite initial diverse challenges, the two countries continue to support the partnership, with 40 local doctors having graduated as medical specialists since 2014, and additional MMed programmes in development for Botswana. Conclusions. The University of Botswana and CMSA partnership model is a novel and sustainable cross-border collaboration with significant benefits for both health systems and individual trainees. It is possible to have a successful and high-quality specialisation programme without all the resources in place by being innovative and leveraging external partnerships and collaborations. This partnership hopes to encourage other developing countries to explore similar associations.

In the past 5 years Botswana graduated its first home-grown doctors and emergency medicine specialists for the country. The postgraduate emergency medicine specialist training arrangement between Botswana and South Africa was challenging in development, implementation and maintenance. Numerous varied supports from ACEM and its International Emergency Medicine Network were integral to these successes. This article encourages further investment of ACEM grants and scholarships in Africa by describing how ACEM supported significant advances in Botswana emergency medicine.

Background: Nurses are usually the first to identify the need for and initiate cardiopulmonary resuscitation (CPR) on patients with cardiopulmonary arrest in the hospital setting. Cardiopulmonary resuscitation has been shown to reduce in-hospital deaths when received from adequately trained health care professionals.Aim: We aimed to investigate nurses’ retention of CPR knowledge and skills at district hospitals in Botswana.Methods: A quantitative, quasi-experimental study was conducted at three hospitals in Botswana. A pre-test, intervention, post-test, and a re-test after 6 months were utilised to determine the retention of CPR knowledge and skills. Non-probability, convenience sampling technique was used to select 154 nurses.The sequences of the test were consistent with the American Heart Association’s 2010 basic life support (BLS) guidelines for health care providers. Data were analysed to compare performance over time.Results: This study showed markedly deficient CPR knowledge and skills among registered nurses in the three district hospitals. The pre-test knowledge average score (48%) indicated that the nurses did not know the majority of the BLS steps. Only 85 nurses participated in the re-evaluation test at 6 months. While a 26.4% increase was observed in the immediate post-test score compared with the pre-test, the performance of the available participants dropped by 14.5% in the re-test 6 months after the post-test.Conclusion: Poor CPR knowledge and skills among registered nurses may impede the survival and management of cardiac arrest victims. Employers and nursing professional bodies in Botswana should encourage and monitor regular CPR refresher courses.

Fax: +03 89472775 A 45-year-old male patient with an inoperable cardiac paraganglioma (PGL) and history of resected bilateral carotid paragangliomas was referred for 18F -FDG PET/CT study to exclude recurrent tumour. The patient was hypertensive with elevated urine catecholamine on a routine annual follow-up. Family history was positive for PGL [1,2]. 18F -FDG PET/CT revealed an avid 18F -FDG left supracardiac PGL with multiple new avid FDGfoci adjacent to the right internal carotid artery and in the aortocaval region denoting recurrent metachronous tumours (Figure 1). These lesions exhibited high maximum standard uptake values (SUVmax) ranging from 10 to 40. Our case highlights the importance of 18F –FDG PET/CT as a superior armamentarium in localizing recurrent PGLs in patient with mediastinal PGLs with the associated familial PGL syndrome [3,4]. They have tendency to develop metastatic disease indicating that these tumours are often aggressive and should be carefully followed.

Healthcare facilities in low-income and middle-income countries lack an objective measurement tool to assess emergency care capacity. The African Federation for Emergency Medicine developed the Emergency Care Assessment Tool (ECAT) to fulfil this function. The ECAT assesses the provision of key medical interventions (signal functions) that emergency units (EUs) should be able to perform to adequately treat six common, life-threatening conditions (sentinel conditions). We describe the piloting and refinement of the ECAT, to improve usability and context-appropriateness. We undertook iterative, multisite refinement of the ECAT. After pilot testing at a South African referral hospital, subsequent studies occurred at district, regional and central facilities across four countries representing the major regions of Africa: Cameroon, Uganda, Egypt and Botswana. At each site, the tool was administered to three participants: one senior physician, one senior nurse and one other clinical provider. Feedback informed refinements of the ECAT, and an updated tool was used in the next-studied country. Iteratively implementing refined versions of the tool in various contexts across Africa resulted in a final ECAT that uses signal functions, categorised by sentinel conditions and evaluated against discrete barriers to emergency care service delivery, to assess EUs. It also allowed for refinement of administration and data analysis processes. The ECAT has a total of 71 items. Advanced facilities are expected to perform all 71 signal functions, while intermediate facilities should be able to perform 53. The ECAT is the first tool to provide a standardised method for assessing facility-based emergency care in the African context. It identifies where in the maturation process a hospital or system is and what gaps exist in delivery of care, so that a comprehensive roadmap for development can be established. Although validity and feasibility testing have now occurred, reliability studies must be conducted prior to amplification across the region.

Phlegmasia cerulea dolens (PCDs) is a rare and serious complication of massive deep venous thrombosis of the lower extremities, which has a high mortality rate. It is characterized by the sudden onset of severe leg pain, massive edema, cyanosis, venous gangrene, compartment syndrome and arterial compromise, often followed by pulmonary embolism and death. We report one case of a long distance driver who presented with PCDs, complicated by fatal pulmonary embolism.Key words: Compartment syndrome, deep vein thrombosis, phlegmasia cerulea dolens

Research Findings: Federal, state, and local agencies legislate and support inclusive settings for the education of young children with disabilities. Recommended practices outline critical elements for meeting the educational and developmental needs of children with and without disabilities in inclusive settings, and minimal and essential quality characteristics have been articulated. Research has suggested that inclusive and non-inclusive settings may offer different levels of care as measured against best practices and essential quality characteristics. Therefore, the purpose of the current study was to examine program quality in inclusive and non-inclusive preschool classrooms using observational, interview, and survey data. Results showed that inclusive classrooms earned higher scores on an observational measure of global quality and higher scores on an observational measure of language and literacy. Results also suggested that teachers with higher levels of education tend to have classrooms of higher...

The number of children participating in public school preschool programs has steadily increased over the last two decades. While the use of specific practices to support the transition to kindergarten has received a great deal of attention, there are little data on the use of transition practices by public school preschool teachers to support children's entry into the public school preschool setting. This article presents findings from a national sample of 2434 public school preschool teachers on the use of 25 transition practices to support the transition of young children into public school preschool programs. The study represents a collaborative extension of the National Center for Early Development and Learning (NCEDL) Kindergarten Transition Survey [Pianta, R. C., Cox, M. J., Taylor, L., & Early, D. (1999). Kindergarten teachers’ practices related to the transition to school: Results of a national survey. Elementary School Journal, 100 (1), 71–86]. Public school preschool teachers reported using an average of 12.81 of the 25 transition practices included in the survey, with a total of 12 of the 25 transition practices reportedly in use by 70% or more of teachers responding to the survey. Findings from this study indicate that three variables – training on the use of specific transition practices, classroom composition, and school context – were related to the use of transition practices by public school preschool teachers.

Research Findings: Previous research has documented conflicting results on the relationship between program quality and the percentage of children receiving subsidized child care (subsidy density) in early childhood centers. This research examined the relationship between subsidy density and the quality of infant and preschool classrooms in child care centers, taking into consideration teacher education and salary as well as other structural variables associated with quality. A multimethod evaluation was conducted with 110 child care centers utilizing an interview of center directors as well as classroom observations using standardized measures of quality and language/literacy in the classroom. Regression analyses indicate that subsidy density does not predict the quality of infant classrooms. However, subsidy density is a significant predictor of the quality of preschool classrooms. Teacher education is predictive of some quality indicators, but teacher salary is not. Practice or Policy: Practice and pol...

Tanzania in East Africa has a population of over 36 million and is one of the poorest countries in the world. Life expectancy has declined and infant mortality rates are increasing. Four consultant specialist hospitals and 17 regional hospitals service the mainland. Kilimanjaro Christian Medical Centre is a major specialist teaching hospital with 500 beds, serving the entire north-west of the country. There is a small 'casualty' ward with three cubicles and one resuscitation room. Malaria, HIV, respiratory infections and gastroenteritis are the chief causes of death in children. Changing lifestyle and Western influences have increased diabetes and vascular disease in adults, and large numbers of trauma deaths are increasingly encountered. Kilimanjaro Christian Medical Centre 'Casualty' admission data are presented, as well as an insight into the challenges of emergency medicine in this country.

Introduction Death as a result of body packing syndrome is not well described within Africa (including Botswana) and therefore not commonly considered in a differential diagnosis. We describe a fatal presentation of a toxicological emergency related to body packing that was initially mistaken for an infective cause. Case report A 43-year-old Tanzanian male presented to the Princess Marina Hospital Emergency Centre with acute vomiting and bloody diarrhoea. He started with massive haematemesis and deteriorated quickly into cardiac arrest with attempts to resuscitate him proving futile. The main concern was for haemorrhagic fever but this was disproven on post mortem when 66 wrapped packages were found in his intestines. Discussion Patients involved in drug trafficking can present to any emergency centre. The acute presentation may mimic other, more prevalent conditions. In the event of death, an understanding of local legal and public health procedures is necessary to ensure a structured investigation.

Importance The Pioneer Accountable Care Organization (ACO) Model aims to drive health care organizations to reduce expenditures while improving quality for fee-for-service (FFS) Medicare beneficiaries. Objective To determine whether FFS beneficiaries aligned with Pioneer ACOs had smaller increases in spending and utilization than other FFS beneficiaries while retaining similar levels of care satisfaction in the first 2 years of the Pioneer ACO Model. Design, Setting, and Participants Participants were FFS Medicare beneficiaries aligned with 32 ACOs (n = 675 712 in 2012; n = 806 258 in 2013) and a comparison group of alignment-eligible beneficiaries in the same markets (n = 13 203 694 in 2012; n = 12 134 154 in 2013). Analyses comprised difference-in-differences multivariable regression with Oaxaca-Blinder reweighting to model expenditure and utilization outcomes over a 2-year performance period (2012-2013) and 2-year baseline period (2010-2011) as well as adjusted analyses of Consumer Assessment of Healthcare Providers & Systems (CAHPS) survey responses among random samples of beneficiaries in Pioneer ACOs (n = 13 097), FFS (n = 116 255), or Medicare Advantage (n = 203 736) for 2012 care. Exposures Beneficiary alignment with a Pioneer ACO in 2012 or 2013. Main Outcomes and Measures Medicare spending, utilization, and CAHPS domain scores. Results Total spending for beneficiaries aligned with Pioneer ACOs in 2012 or 2013 increased from baseline to a lesser degree relative to comparison populations. Differential changes in spending were approximately −$35.62 (95% CI, −$40.12 to −$31.12) per-beneficiary-per-month (PBPM) in 2012 and -$11.18 (95% CI, −$15.84 to −$6.51) PBPM in 2013, which amounted to aggregate reductions in increases of approximately −$280 (95% CI, −$315 to −$244) million in 2012 and −$105 (95% CI, −$148 to −$61) million in 2013. Inpatient spending showed the largest differential change of any spending category (−$14.40 [95% CI, −$17.31 to −$11.49] PBPM in 2012; −$6.46 [95% CI, −$9.26 to −$3.66] PBPM in 2013). Changes in utilization of physician services, emergency department, and postacute care followed a similar pattern. Compared with other Medicare beneficiaries, ACO-aligned beneficiaries reported higher mean scores for timely care (77.2 [ACO] vs 71.2 [FFS] vs 72.7 [MA]) and for clinician communication (91.9 [ACO] vs 88.3 [FFS] vs 88.7 [MA]). Conclusions and Relevance In the first 2 years of the Pioneer ACO Model, beneficiaries aligned with Pioneer ACOs, as compared with general Medicare FFS beneficiaries, exhibited smaller increases in total Medicare expenditures and differential reductions in utilization of different health services, with little difference in patient experience.

The purpose of this study was to examine maternal and adolescent depression, maternal and teen sensation seeking, and maternal smoking, and their associations with adolescent smoking. Data were collected from a sample of 47 male and 66 female adolescents (ages 11—18 years) and their mothers from three different health clinics. The findings indicated that maternal sensation seeking was linked indirectly with adolescent smoking through teen sensation seeking, both of which were significantly associated with teen smoking (β = 0.29,p< 0.001 and β = 0.32,p< 0.001, respectively). Teen depression was associated positively with teen smoking (β = 0.24,p< 0.01) when controlling for sensation seeking behaviors. Maternal smoking was also directly linked to adolescent smoking (β = 0.20,p< 0.05). These findings underscore a potentially important role of sensation seeking in the origins of adolescent smoking, and clarify pathways of influence with regard to maternal attitudes and behaviors in subsequent teenage nicotine use.

Background. Burnout during registrar training is high, especially in resource-limited settings where stressors are intensified. Burnout leads to decreased quality of life for doctors, poor job and patient satisfaction, and difficulty retaining doctors. Objectives. Primary: to measure burnout among registrars working at Princess Marina Hospital in Gaborone, Botswana. Secondary: to determine factors contributing to burnout and identify potential wellness interventions. Methods. The validated Maslach Burnout Inventory was used to measure the degree of emotional exhaustion, depersonalisation and personal accomplishment. Work-related difficulties and potential wellness interventions were explored through multiple-choice and open-ended questions. Results. Of 40 eligible registrars, 20 (50%) completed the survey. High levels of burnout were reported for emotional exhaustion in 65% (13/20), depersonalisation in 45% (9/20), and personal accomplishment in 35% (7/20) of registrars. A high degree of burnout was reported by 75% (15/20) of registrars in one or more domains. In the previous 7 days, registrars worked an average of 77 hours, took 1.5 overnight calls, slept 5.7 hours per night, and 53% (10/19) had ≥1 of their patients die. Five (25%) registrars considered leaving Botswana to work in another country, which correlated with those with the highest degree of burnout. The most common frustrations included insufficient salary and limited medical resources. Suggested interventions included improved mentorship and wellness lectures. Conclusions. There is a high degree of burnout, especially emotional exhaustion, among registrars. Encouragingly, most registrars have a desire to work in Botswana after training. Future research on improving registrar wellness in low-resource settings is urgently needed.

This chapter charts the recent evolution of research focused on reflective supervision provided to practitioners delivering services to young children and their families through early intervention programs. The authors explore research focused on defining reflective supervision, identifying five essential elements or “active ingredients” of reflective supervision as a professional development model and demonstrating the impact on practitioners. The impact studies described in this chapter have produced empirical data demonstrating an increase in reflective supervision behaviors as a result of participation. In addition, the studies provide qualitative accounts of practitioners’ experiences, conveying positive effects on intervention practice and reduction of practitioner job stress.