Search

This paper outlines a new approach to using participants' self-identified temporal triggers to center data collection around meaningful time periods as it pertains to coping with loss and trauma. We describe the utility of ecological momentary assessment and wearable technology as tools for time-informed data collection; and provide a study protocol for a recent study in which we paired these approaches to gather data from adult respondents who had lost a loved one. Data collection included two phases: a baseline phase and a target date phase. The target date phase was centered around the participant's self-identified temporal trigger. Several lmitations to this mode of data collection are disucsed. The overall approach is client centered and more accurately captures the lived experiences of individuals coping with loss and trauma. Data of this kind will begin to highlight the psychological and physiological impacts of anniversary dates among survivors of trauma and loss., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

New Orleans is no stranger to trauma. The Crescent City has a vast history of environmental calamities and oppression. Yet, New Orleans is renowned for its "joie de vivre"-or "love of life." Specifically, this community is known for its unique practice of second-line parades. Researchers have noted the healing power of second-line processions, but none have analyzed the practice and psychology of this ritual through a trauma-informed lens. The aim of this conceptual paper is to begin the conversation, rather than deliver hard fast conclusions, on the potential therapeutic function of second-line parades in response to grief. Relevant literature is presented to illustrate second-line parades, trauma theory, and to provide evidence that the therapeutic effects of second-lining may, in part, be explained by trauma theory. This paper concludes with remarks on conceptualizing the second-line funeral as a sophisticated trauma-informed approach to grief and a note for future research., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Screening echocardiography, guided by the current World Heart Federation (WHF) criteria, has important limitations that impede the establishment of large-scale rheumatic heart disease (RHD) control programmes in endemic regions. The criteria misclassify a significant number of normal cases as borderline RHD. Prior attempts to simplify them are limited by incorporation bias due to the lack of an externally validated, accurate diagnostic test for RHD. We set out to assess novel screening criteria designed to avoid incorporation bias and to compare this against the performance of the current WHF criteria., Methods: The performance of the WHF and the morpho-mechanistic (MM) RHD screening criteria (a novel set of screening criteria that evaluate leaflet morphology, motion and mechanism of regurgitation) as well as a simplified RHD MM 'rule-out' test (based on identifying a predefined sign of anterior mitral valve leaflet restriction for the mitral valve and any aortic regurgitation for the aortic valve) were assessed in two contrasting cohorts: first, a low-risk RHD cohort consisting of children with a very low-risk RHD profile. and second, a composite reference standard (CRS) RHD-positive cohort that was created using a composite of two criteria to ensure a cohort with the highest possible likelihood of RHD. Subjects included in this group required (1) proven, prior acute rheumatic fever and (2) current evidence of predefined valvular regurgitation on echocardiography., Results: In the low-risk RHD cohort (n=364), the screening specificities for detecting RHD of the MM and WHF criteria were 99.7% and 95.9%, respectively (p=0.0002). The MM rule-out test excluded 359/364 cases (98.6%). In the CRS RHD-positive cohort (n=65), the screening sensitivities for the detection of definite RHD by MM and WHF criteria were 92.4% and 89.2%, respectively (p=0.2231). The MM RHD rule-out test did not exclude any cases from the CRS RHD-positive cohort., Conclusion: Our proposed MM approach showed an equal sensitivity to the WHF criteria but with significantly improved specificity. The MM RHD rule-out test excluded RHD-negative cases while identifying all cases within the CRS RHD-positive cohort. This holds promise for the development of a two-step RHD screening algorithm to enable task shifting in RHD endemic regions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Posttraumatic stress disorder (PTSD) has been linked with cardiovascular disease (CVD), suggesting a risk for negative health outcomes among individuals with PTSD. This review synthesizes the temporal relationship between PTSD and CVD and highlights the intersection of sex and race. Methods: Covidence was used to systematically review the literature published between 1980 and 2020. Results: 176 studies were extracted. 68 (38.64%) of the studies were a predominantly male sample. 31 studies (17.61%) were a predominantly female sample. Most reported participants of both sexes ( n = 72; 40.91%) and only 5 (2.84%) did not report respondent sex. No studies reported transgender participants. 110 (62.5%) studies reported racial and ethnic diversity in their study population, 18 (10.22%) described a completely or predominantly white sample, and 48 (27.27%) did not report race or ethnicity of their study population. Conclusion: A compelling number of studies did not identify sex differences in the link between PTSD and CVD or failed to report race and ethnicity. Investigating sex, race, ethnicity, and the temporal relationship between PTSD and CVD are promising avenues for future research., Competing Interests: The authors declare that they do not have any conflicts of interest., (Copyright © 2023 Hunter, Boer and Saltzman.)

Aims: The World Heart Federation (WHF) criteria identify a large borderline rheumatic heart disease (RHD) category that has hampered the implementation of population-based screening. Inter-scallop separations (ISS) of the posterior mitral valve leaflet, a recently described normal variant of the mitral valve, appears to be an important cause of mild mitral regurgitation (MR) leading to misclassification of cases as WHF 'borderline RHD'. This study aims to report the findings of the Echo in Africa project, a large-scale RHD screening project in South Africa and determine what proportion of borderline cases would be re-classified as normal if there were a systematic identification of ISS-related MR., Methods and Results: A prospective cross-sectional study of underserved secondary schools in the Western Cape was conducted. Participants underwent a screening study with a handheld (HH) ultrasound device. Children with an abnormal HH study were re-evaluated with a portable laptop echocardiography machine. A mechanistic evaluation was applied in cases with isolated WHF 'pathological' MR (WHF 'borderline RHD'). A total of 5255 participants (mean age 15± years) were screened. A total of 3439 (65.8%) were female. Forty-nine cases of WHF 'definite RHD' [9.1 cases/1000 (95% confidence interval, CI, 6.8-12.1 cases/1000)] and 104 cases of WHF 'borderline RHD' [19.5 cases/1000 (95% CI, 16.0-23.7 cases/1000)] were identified. Inter-scallop separations-related MR was the underlying mechanism of MR in 48/68 cases classified as WHF 'borderline RHD' with isolated WHF 'pathological' MR (70.5%)., Conclusion: In a real-world, large-scale screening project, the adoption of a mechanistic evaluation based on the systematic identification of ISS-related MR markedly reduced the number of WHF 'screen-positive' cases misclassified as WHF 'borderline RHD'. Implementing strategies that reduce this misclassification could reduce the cost- and labour burden on large-scale RHD screening programmes., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Introduction: The World Heart Federation (WHF) screening criteria do not incorporate a strict, reproducible definition of anterior mitral valve leaflet (AMVL) restriction. Using a novel definition, we have identified two distinct AMVL restriction configurations. The first, called "distal tip" AMVL restriction is associated with additional morphological features of rheumatic heart disease (RHD), while the second, "gradual bowing" AMVL restriction is not. This "arch-like" leaflet configuration involves the base to tip of the medial MV in isolation. We hypothesize that this configuration is a normal variant., Methodology: The prevalence and associated leaflet configurations of AMVL restriction were assessed in schoolchildren with an established "very low" (VLP), "high" (HP), and "very high" prevalence (VHP) of RHD., Results: 936 studies were evaluated (HP 577 cases; VLP 359 cases). Sixty-five cases of "gradual bowing" AMVL restriction were identified in the HP cohort (11.3%, 95% CI 8.9-14.1) and 35 cases (9.7%, 95% CI 7-13.2) in the VLP cohort (P = .47). In the second analyses, an enriched cohort of 43 studies with proven definite RHD were evaluated. "Distal tip" AMVL restriction was identified in all 43 VHP cases (100%) and affected the central portion of the AMVL in all cases., Conclusion: "Gradual bowing" AMVL restriction appears to be a normal, benign variant of the MV, not associated with RHD risk nor with any other morphological features of RHD. Conversely, "Distal tip" AMVL restriction was present in all cases in the VHP cohort with no cases exhibiting a straight, nonrestricted central portion of the AMVL. This novel finding requires further investigation as a potential RHD rule-out test of the MV., (© 2021 Wiley Periodicals LLC.)

Objective: The World Heart Federation (WHF) criteria incorporate a Doppler-based system to differentiate between 'physiological' and 'pathological' mitral regurgitation (MR)-a sole criterion sufficient for the diagnosis of WHF 'borderline' rheumatic heart disease (RHD). We have identified that interscallop separations (ISS) of the posterior mitral valve (MV) leaflet, can give rise to pathological MR in an otherwise-normal MV. We aimed to establish and compare the prevalence of ISS-related MR among South African children at high and low risk for RHD., Methods: A prospective cross-sectional echocardiographic study of 759 school children (aged 13-18) was performed. Cases with MR≥1.5 cm underwent a second comprehensive study to determine the prevalence of RHD according to the WHF guideline and establish the underlying mechanism of MR., Results: Of 400 high-risk children, two met criteria for 'definite RHD' (5 per 1000 (95% CI 1.4 to 18.0); p=0.5) and 11 for 'borderline RHD' (27.5 per 1000 (95% CI 15.4 to 48.6)). Of 359 low-risk children, 14 met criteria for borderline RHD (39 per 1000 (95% CI 23.4 to 64.4)). Comprehensive echocardiography identified an underlying ISS as the mechanism of isolated pathological MR in 10 (83.3%) high-risk children and 11 low-risk children (78.5%; p>0.99)., Conclusions: ISS are a ubiquitous finding among South African schoolchildren from all risk profiles and are regularly identified as the underlying mechanism of WHF pathological MR in borderline RHD cases. A detailed MV assessment with an emphasis on ascertaining the underlying mechanism of dysfunction could reduce the reported numbers of screened cases misclassified as borderline RHD., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Progressive curricular changes in medical education over the past two decades have resulted in the diaspora of gross anatomy content into integrated curricula while significantly reducing total contact hours. Despite the development of a wide range of alternative teaching modalities, gross dissection remains a critical component of medical education. The challenge posed to modern anatomists is how to maximize and integrate the time spent dissecting under the current curricular changes. In this study, an alternative approach to the dissection of the pelvis and perineum is presented in an effort to improve content delivery and student satisfaction. The approach involves removal of the perineum en bloc from the cadaver followed by excision of the pubic symphysis, removal and examination of the bladder and associated structures, examination and bisection of the midline pelvic organs in situ, and midsagittal hemisection of the pelvis for identification of the neurovasculature. Results indicate that this novel dissecting approach increases the number of structures identified by 46% ± 14% over current dissecting methods. Survey results indicate that students were better able to integrate lecture and laboratory concepts, understand the concepts, and successfully identify more structures using the new approach (P < 0.05). The concept of anatomic efficiency is introduced and proposed as a standard quantitative measure of gross dissection proficiency across programs and institutions. These findings provide evidence that innovative solutions to anatomy education can be found that help to maintain critical content and student satisfaction in a modern medical curriculum., (© 2019 American Association of Anatomists.)

Background: Studies determining the reliability of the World Heart Federation (WHF) anterior mitral valve leaflet (AMVL) measurement are limited by the introduction of bias in their test-retest analyses. This study sought to determine the reliability of the current AMVL measurement while controlling for systematic bias., Methods: Retrospective analysis of echocardiographic data from 16 patients with previous acute rheumatic fever was performed. Included in this study was an optimized cine loop of the mitral valve (MV) [reader-optimized measurement (ROM]) in the parasternal long-axis view and an optimized still image of the MV obtained from the same cine loop [specialist-optimized image (SOI)]. Each still image and associated cine loop was quadruplicated and randomized to determine intra- and inter-rater agreement and quantify the impact of zoom on AMVL measurement., Results: Specialist-optimized image without zoom reflected the highest degree of agreement in both cohorts with an ICC of 0.29 and 0.46. The agreement in ROM images without zoom was ICC of 0.23 and 0.45. The addition of zoom to SOI decreased agreement further to an ICC of 0.20 and 0.36. The setting associated with the poorest agreement profile was ROI with zoom with an ICC of 0.13 and 0.34, respectively. The intra-rater agreement between readers in both cohorts was moderate across all settings with an ICC ranging between 0.64 and 0.86., Conclusions: The WHF AMVL measurement is only moderately repeatable within readers and demonstrates poor reproducibility that was not improved by the addition of a zoom-optimized protocol. Given our study findings, we cannot advocate the current WHF AMVL measurement as a reliable assessment for RHD., (© 2020 Wiley Periodicals LLC.)

Introduction: Intentional self-poisoning is a significant part of the toxicological burden experienced by emergency centres. The aim of this study was to describe all adults presenting with intentional self-poisoning over a six-month period to the resuscitation unit of Khayelitsha Hospital, Cape Town., Methods: Adult patients with a diagnosis of intentional self-poisoning between 1 November 2014 and 30 April 2015 were retrospectively analysed after eligible patients were obtained from the Khayelitsha Hospital Emergency Centre database. Missing data and variables not initially captured in the database were retrospectively collected by means of a chart review. Summary statistics were used to describe all variables., Results: A total of 192 patients were included in the analysis. The mean age was 27.3 years with the majority being female (n = 132, 68.8%). HIV-infection was a comorbidity in 39 (20.3%) patients, while 13 (6.8%) previously attempted suicide. Presentations per day of the week were almost equally distributed while most patients presented after conventional office hours (n = 152, 79.2%), were transported from home (n = 124, 64.6%) and arrived by ambulance (n = 126, 65.6%). Patients spend a median time of 3h37m in the resuscitation unit (interquartile range 1 h 45 m-7 h 00 m; maximum 65 h 49 m). Patient acuity on admission was mostly low according to both the Triage Early Warning Score (non-urgent n = 100, 52.1%) and the Poison Severity Score (minor severity n = 107, 55.7%). Pharmaceuticals were the most common type of toxin ingested (261/343, 76.1%), with paracetamol the most frequently ingested toxin (n = 48, 25.0%). Eleven patients (5.7%) were intubated, 27 (14.1%) received N-acetylcysteine, and 18 (9.4%) received benzodiazepines. Fourteen (7.3%) patients were transferred to a higher level of care and four deaths (2%) were reported., Discussion: Intentional self-poisoning patients place a significant burden on emergency centres. The high percentage of low-grade acuity patients managed in a high-acuity area is of concern and should be investigated further.

Introduction: International guidance suggests that injury-associated haemorrhagic shock should be resuscitated using blood products. However, in low- and middle-income countries resuscitation emphasises the use of crystalloids - mainly due to poor access to blood products. This study aimed to estimate the amount of blood loss from serious injury in relation to available emergency blood products at a secondary-level, public Cape Town hospital., Methods: This retrospective, cross-sectional study included all injured patients cared for in the resuscitation area of Khayelitsha Hospital's emergency centre over a fourteen-week period. Injuries were coded using the Abbreviated Injury Scale, which was then used to estimate blood loss for each patient using an algorithm from the Trauma Audit Research Network. Descriptive statistics were used to describe blood volume lost and blood units required to replace losses greater than 15% circulating blood volume. Four units of emergency blood are stored in a dedicated blood fridge in the emergency centre. Platelets and fresh plasma are not available., Results: A total of 389 injury events were enrolled of which 93 were excluded due to absent clinic data. The mean age was 29 (±10) years. We estimated a median of one unit of blood requirement per week or weekend, up to a maximum of eight or six units, respectively. Most patients (n = 275, 94%) did not have sufficient injury to warrant transfusion. Overall, one person would require a transfusion for every 15 persons with a moderate to serious injury., Conclusion: The volume of available emergency blood appears inadequate for injury care, and doesn't consider the need for other causes of acute haemorrhage (e.g. gastric, gynaecological, etc.). Furthermore, lack of other blood components (i.e. plasma and platelets) presents a challenge in this low-resourced setting. Further research is required to determine the appropriate management of injury-associated haemorrhage from a resource and budget perspective.

This focused review presents a critical appraisal of the World Heart Federation criteria for the echocardiographic diagnosis of rheumatic heart disease (RHD) and its performance in African RHD screening programmes. It identifies various logistical and methodological problems that negatively influence the current guideline's performance. The authors explore novel RHD screening methodology that could address some of these shortcomings and if proven to be of merit, would require a paradigm shift in the approach to the echocardiographic diagnosis of subclinical RHD., (© 2017 The authors.)

Introduction: At the core of the district health system is the emergency centre, for many the entry point into the healthcare system. Limited data is available on the patient population served by district-level emergency centres in South Africa. The objective of this study is to describe the case mix of adult patients managed in the resuscitation unit of a district-level hospital in the Western Cape., Methods: A six-month prospective observational study was conducted in the resuscitation unit of Khayelitsha Hospital. Data were collected by clinicians in the unit by means of a Smartphone application on their own devices. Variables collected included patient demographics, patient acuity, patient comorbidities, diagnosis made in the unit, interventions received, length of stay, and disposition. Summary statistics were used to describe all variables., Results: A total of 2324 patient admissions were analysed. The mean age was 36.9 years with a male predominance (n = 1367, 58.8%). Most patients were triaged into high-acuity categories (n = 1626, 70%). HIV infection was the most common comorbidity (n = 530, 22.8%). Acute medical (n = 1181, 50.8%) and trauma-related patients (n = 928, 39.9%) dominated the cohort. The median length of stay was 195 min and 502 (21.6%) patients were transferred to higher levels of care. There were 74 (3.2%) deaths., Conclusion: This study yields novel epidemiological data of emergency care in a district-level emergency centre. It highlights the burden of trauma and acute medical emergencies at the district level and can be used as a foundation for further research to provide targeted and effective healthcare to all citizens.