Resource-poor Environment Research Articles

Peritoneal dialysis: An effective therapeutic modality in acute kidney injury

BackgroundPeritoneal dialysis (PD) as a modality of renal replacement therapy (RRT) in acute kidney injury (AKI), continues to be underused. We present our experience with PD in patients with AKI. MethodThe data of patients with AKI requiring RRT were retrospectively analyzed. The primary end point was the adequacy of dialysis, and the secondary end point included hemodynamic stability and procedure-related complications. ResultA total of 32 patients with AKI requiring RRT were included in the study. The mean age and the blood pressure at the time of hospitalization were 65.3 ± 6.73 years and 73.7 ± 8.4 mm Hg, respectively. All the patients required vasopressor support; 26 (81%) patients required ventilator support. RRT was initiated at a mean serum creatinine of 6.24 ± 1.17 mg/dL. Rigid stylet catheter was used in 9 (28.2%) and Tenckhoff catheter in 23 (71.8%) patients. The average daily ultrafiltration and weekly Kt/V achieved were 1701 ± 327 mL and 2.19, respectively; these were significantly higher in survivors. After the initiation of PD, hemodynamic instability was observed in 10 (31.2%) patients. The major therapy-related complication noted was PD peritonitis. ConclusionsIn a resource-poor environment, PD is an effective modality of RRT for AKI.

The biology and feeding ecology of Arctic charr in the Kerguelen Islands.

Subsequent to their introduction in the 1950s, Arctic charr Salvelinus alpinus have been able to establish a self-sustaining population that has adapted to the unique conditions of the sub-Antarctic Kerguelen Islands. Here, 48 individuals (198-415 mm) were caught with gillnets and their basic biology and feeding ecology were examined using stable isotope analysis. The Lac des Fougères population split use of littoral and pelagic resources evenly, although larger fish relied more heavily on littoral production and appear to follow the size-dependent life history habitat template seen in many Scandinavian lakes where smaller sized individuals occupy the pelagic zone and larger individuals dominate the littoral habitat. In Kerguelen, Arctic charr mature at the same ages (5.6 years) as Arctic charr in both sub-Arctic and Arctic lakes. Although mortality was average in comparison to comparator sub-Arctic lakes, it was high in comparison to Arctic lakes. Maximal age (>7+) was at the lower end of the range typically seen in sub-Arctic lakes. Although they inhabit a resource-poor environment, Kerguelen Arctic charr showed no evidence of cannibalism. Thus, while Arctic charr can survive and reproduce in the relatively unproductive Kerguelen lake environments, survival and growth nevertheless appear to be traded off against survival and longevity. The uniqueness of the population location and the recency of its introduction suggest that further monitoring of the population has the potential to yield valuable insights into both the adaptability of the species and its likely responses to ongoing large-scale environmental change as represented by climate change.

Environment, not phylogeny, drives herbivory and leaf attributes in trees from two contrasting forest formations of the Brazilian Atlantic Forest

ABSTRACT Background The degree of herbivory in plants can be related to leaf traits, which are, in turn, determined by phylogeny and environment. Aims The objective of our study was to determine the level of trait conservation (determined by phylogeny) vs. trait convergence (owing to overbearing effect of environmental factors) in leaf attributes and its relationship with rates of herbivory in two contrasting neotropical habitats. Methods We quantified herbivory and 12 leaf traits in 10 congeneric, co-occurring pairs of tree species of an Atlantic Rain Forest (ARF) and a coastal forest (Restinga - REST). Results Higher values of N, N:P, leaf area and water content were found for the ARF species, while REST species were characterised by higher total phenol, Ca, C:N and leaf mass per area. There was a great degree of trait convergence in leaf attributes by habitat, and a near lack of trait conservation. Rates of herbivory were related to leaf attributes and were significantly larger in ARF species compared to those in REST. Conclusions These findings indicate that leaf attributes are relatively convergent and closely related to habitat. The results also support theory in confirming greater investment in leaf defence in REST species in a more resource-poor environment than in ARF.

Survival and Functional Outcomes at Discharge After Traumatic Brain Injury in Children versus Adults in Resource-Poor Setting

More than 90% of trauma mortality occurs in low- and middle-income countries, especially in sub-Saharan Africa. Head injury is the primary driver of trauma mortality in the prehospital and in-hospital setting. An observational study was performed on patients presenting with traumatic brain injury (TBI) from October 2016 through May 2017 at Kamuzu Central Hospital, Malawi. Bivariate analysis and logistic regression were performed to determine the odds of favorable functional outcomes and mortality after controlling for significant covariates. Of the 356 patients with TBI, 72 (20.2%) were children <18 years of age. Males comprised 202 (87.1%) and 46 (63.9%) of the adult and pediatric cohorts, respectively. Motor vehicle crash was the leading etiology in adults and children. There was no significant difference between adult and pediatric Glasgow Coma Scale score on admission, 10.8 ± 3.9 versus 10.9 ± 3.5, respectively (P= 0.8). More adult (n= 76, 32.3%) than pediatric (n=13, 18.1%) patients died. On multivariable analysis, pediatric patients were more likely to have a favorable outcome defined by a Glasgow Outcome Scale of good recovery or moderate disability (odds ratio 3.70, 95% confidence interval 1.22-11.17, P= 0.02) and were less likely to die after TBI (odds ratio 0.29, 95% confidence interval 0.09-0.93, P= 0.04). We show a survival advantage and better functional outcomes in children following TBI. This may be attributable to increased resiliency to TBI in children or the prioritization of children in a resource-poor environment. Investments in neurosurgical care following TBI are needed to improve outcomes.

Challenges of Setting up a Lower Extremity Reconstruction Practice in a Constrained Environment.

Microsurgical lower extremity reconstruction remains challenging, especially when resources are limited such as lack of proper equipment, human resources, administrative support, and located in a remote area far from tertiary care. Nevertheless, reconstructive solutions are required, especially when in urgent trauma situations. In this article, we evaluate ways of overcoming challenges and issues that should be considered in a newly established unit by sharing our initial lower extremity reconstruction experience. We report a local hospital's initial lower extremity reconstruction experience in February 2017 to January 2018. Through a total of seven patients, we tried to enhance the environment, instruments, nurses' contribution, and perspective of the peers and community in terms of factors related to the surgeon, hardware, environment, supporting faculty, reimbursement, and patients. Four patients underwent reconstruction with a freestyle propeller flap and three with an anterolateral thigh flap; in one case, a superficial circumflex iliac artery perforator flap was chosen to salvage partial flap necrosis. Increased experience of the surgeon, new equipment, continuing nurse/patient education, and collaborating with other departments allowed us to choose more challenging flaps and be more meticulous while decreasing the operation time and hospital stay. To start a lower extremity reconstruction practice in a resource-poor environment, the surgeon needs to evaluate the relevant factors; moreover, he or she should continuously improve them until a working methodology is achieved. Despite all the challenges, the adaptations learned at this center can be applied to other local hospitals around the world to set up a lower extremity reconstruction practice and improve its outcomes.

Peri-articular infiltration in the resource-restrained environment - still a worthwhile adjunct to multimodal analgesia post total knee replacement

ABSTRACT BACKGROUND: Peri-articular infiltrations (PAI) in total knee arthroplasty (TKA) offer effective analgesia, and are cost effective, safe and easy to perform. Currently there is no gold standard technique based on evidence-based medicine; described methods are based on consensus recommendations. The latest literature supports PAI including complex and multiple drug combinations, such as liposomal bupivacaine, ropivacaine and ketorolac, which are not available in all settings. This study aims to prove that a basic PAI technique using widely available and inexpensive agents offers good and effective outcomes in a resource-poor environment METHODS: A double-blind randomised control trial compared the effectiveness of PAI with a simple, widely available anaesthetic solution (bupivacaine and adrenalin) to a normal saline control group. Infiltration volumes were calculated at 1 ml/kg and the infiltration technique followed a specific protocol. Post-operative outcomes included visual analogue scores (VAS), ambulation scores, morphine use, knee range of motion (ROM) and time to discharge RESULTS: Two comparable groups of 26 patients each were included (intervention: 81% female, mean age 64.8±8.8 years vs control: 65% female, mean age 67.0±7.6 years). All pain-related measures favoured the intervention group but failed to reach statistical significance at 24 and 72 hours. Mean VAS scores at 48 hours were significantly lower in the intervention group. (VAS score 3.0±1.6 vs 4.1±1.2, p=0.013). The other parameters measured strongly favoured the intervention group but did not prove to be significant CONCLUSIONS: A volume per kilogram PAI technique making use of widely available, cost-effective agents provides a statistical reduction in VAS scores at 48 hours post TKA. This suggests that in a resource-poor environment PAI is still a valuable addition to the multimodal analgesia pathway in the post-operative management of TKA. Maximum drug doses may show even more promising results, specifically in the first 24 hours post-operatively. Further studies investigating PAI for TKA in resource-restrained environments are indicated Level of evidence: Level 2 Keywords: standardisation peri-articular infiltration, multimodal analgesia, pre-emptive analgesia

Acute inferior mesenteric venous thrombosis in a child

Inferior mesenteric venous thrombosis is a very rare condition with serious management challenge, especially in a resource-poor environment. The acute variety is associated with high morbidity and mortality, especially if there are accompanying bowel infarction and peritonitis. The case of a 12-year-old boy was referred from a private hospital after a failed attempt at appendicectomy. The patient presented with features of generalized peritonitis and severe sepsis. Exploratory laparotomy after optimization showed massive hemorrhagic ascetic fluid, extensive left colonic gangrene extending from distal transverse colon to the sigmoid colon, and thrombosis in the branches of the inferior mesenteric vessel. The patient died 36 h postoperatively at the intensive care unit. A high index of suspicion and early bowel resection in cases of associated bowel infarction will improve outcome.

Power harvesting from physiological serum in microfluidic enzymatic biofuel cell

The microfluidic biofuel cells have the potential to be improved for officially using in biomedical devices as a power source. It is noted that the basic design criterion of the power generating device such as glucose biofuel cell is a challenging task, especially in the presence of body fluids. In this study, a new glucose/O2 microfluidic biofuel cell based on printed circuit board and double-sided pressure sensitive adhesive tape was demonstrated. The electrodes of microfluidic biofuel cell were reduced graphene oxide‑gold nanoparticles-poly neutral red composite linked to Aspergillus niger glucose oxidase as a bioanode and Mytheliophthora thermophile laccase for biocathode. The open circuit voltage (OCV) and maximum power density of the microfluidic biofuel cell operating in physiological serum (pH 5.5) have obtained 0.2 V and 3.6 μW cm−2 at a flow rate of 50 μL min−1, respectively. The features of this rapid prototyping fabrication method, such as need not access to expensive clean room facility and affordability make it highly suitable for utilizing in resource poor environment.

Management of Sickle Cell Intrahepatic Cholestasis: An Argument in Favor of Automated Exchange Transfusion

Sickle cell disease patients are commonly treated at transfusion medicine services, and understanding of the hepatic manifestations of the disease is key for optimal management, specifically, in individuals presenting with sickle cell intrahepatic cholestasis (SCIC). SCIC represents a rare, severe hepatic crisis wherein sinusoidal red cell sickling leads to massive hepatocyte dysfunction and cholestatic laboratory findings. Acute SCIC is defined by abdominal pain with progressive hepatic injury associated with hyperbilirubinemia, renal failure, encephalopathy, and coagulopathy. Patients are generally managed with red blood cell exchange transfusion (RBCEx), when available, as this is a potentially fatal condition. Simple transfusion may be utilized in resource-poor environment or when patients refuse RBCEx. As less than 50 adult cases have been described in the literature, many of them with limited follow-up, randomized clinical trials comparing RBCEx with other treatments are currently unfeasible. Likewise, a chronic form exists, but is less well characterized, and is associated with persistent bilirubinemia and a variable course in terms of progressive hepatic disease. We undertake a brief review of the literature and discuss two cases of SCIC managed with RBCEx at our institution.

Prevalence, pattern and determinants of urine abnormalities among school pupils in a semi-urban community

Background: Dipstick urinalysis is a semi-quantitative examination of the urine, which can be utilized as a screening and diagnostic tool in children. It is rapid, sensitive, easy to perform and affordable for the resource-poor environment. Objectives: To describe the pattern of urinalysis findings using urinary dipsticks and the determinants of urine abnormality among pupils in primary schools in a semi-urban area. Methods: Apparently healthy 387 pupils were recruited from 10 public and 5 private primary schools in Ikenne Local Government Area of Ogun State, Nigeria using multi-stage and proportionate sampling techniques. Data on demography, nutritional status and urinary examination were obtained using Interviewer-administered questionnaires, clinical examination and dipstick urinalysis respectively. Results: Dipstick urinalysis revealed the following; urine pH and specific gravity were normal in 98.2% and 100.0% of the pupils respectively. Protein, leukocyte esterase, nitrite, bilirubin, urobilinogen, blood and ketones were detected in 18.1%, 15.8%, 14.2%, 3.3%, 2.1%, 0.8%, and 0.5% respectively. Glucose and ascorbic acid were generally absent in the urine samples. Female gender significantly contributed to the pattern of urinalysis (leukocyte esterase and nitrites). Proteinuria was most frequent among the underweight (38/70; 54.3%). Urine abnormalities were more prevalent among pupils in public schools compared with private schools though not statistically significant, and not influenced by gender. Conclusion: Asymptomatic proteinuria and urinary tract infection are not uncommon among children. Female gender and socio-economic status play a role in the incidence of the conditions.

Utilizing a wearable smartphone-based EEG for pediatric epilepsy patients in the resource poor environment of Guinea: A prospective study. (N5.001)

Utilizing a wearable smartphone-based EEG for pediatric epilepsy patients in the resource poor environment of Guinea: A prospective study. (N5.001)

Disaster relief trials: perceptions of a disaster-themed bicycling event

PurposeBicycling enthusiasts have been organizing community events in US cities to demonstrate how bicycles may be of use in the aftermath of a disaster event. The purpose of this paper is to examine the perceived value of these events and levels of engagement in the same amongst emergency managers, community organizers and bicycling advocates.Design/methodology/approachData were collected through 21 in-depth, telephone interviews with emergency management officials and bicycling advocates in bicycle-friendly jurisdictions in the USA and analyzed using initial and focused coding, analytic memos and theoretical sorting.FindingsThe study found that event organizers and other bicycle advocates widely embraced the concept as a means to change societal perceptions of bicycles as viable modes of transportation, indicating at least some level of interest in taking an active role in its pursuit. Emergency managers were generally receptive to the idea, but they largely saw the value as restricted to raising public awareness about hazards and individual preparedness measures; and they mostly envisioned for themselves a minimal role in event planning and execution.Practical implicationsThe findings suggest that when operating in a resource-poor environment with limited public and political support, there are innovative partnerships and ideas that can be successfully leveraged to advance multiple purposes.Originality/valueAlmost no empirical research has looked at the disaster relief trial concept, given the relative newness and novelty of the idea. An examination of perceived value of disaster-oriented community bicycling events seems warranted as such events continue to grow in existing locations and emerge in new locales each year.

Palliative external beam radiotherapy for advanced breast cancer patients with brain metastasis in the university college hospital Ibadan.

Background:Brain metastasis is a dreaded complication that significantly reduces the quality of life in breast cancer patients. The treatment options are limited by the inability of many chemotherapeutic agents to cross the blood–brain barrier. Surgery also has a limited role, except in few selected patients with oligometastasis. Therefore, whole-brain radiotherapy (WBRT) remains the available option that gives a gratifying result. However, the benefit of this treatment modality in our resource-poor environment needs to be investigated.Materials and Methods:The data of breast cancer patients with brain metastasis who were treated with WBRT using cobalt-60 equipment between 2005 and 2009 were retrospectively collected from the departmental medical record unit. The information extracted included biodata, presenting symptoms, imaging modality for confirmation of brain metastasis, treatment records, performance status pre-WBRT and 4 weeks post-WBRT, and other supportive treatments.Results:A total of 52 female patients were reviewed between 2005 and 2009. The mean age of patients was 44.7 years. The common clinical features on presentation were headache, nausea, and visual impairment in 30.8% of patients with the WHO performance status score ranging between 2 and 4. Patients with more than three brain deposits accounted for 71.2% of all the brain metastases. The mean radiation dose used for WBRT was 30 Gy in 10 fractions, and total responses recorded were 86.5% with 53.8% complete improvement in patients' performance status 4 weeks after WBRT treatment.Conclusion:WBRT is an effective treatment modality for patients with brain metastasis in our resource-poor environment. However, improvement of patients' performance status declined with advancing age.

Measuring public hospitals performance in health resource poor environment: a data envelopment analysis approach

Measuring public hospitals performance in health resource poor environment: a data envelopment analysis approach

Measuring Public Hospitals Performance in Health Resource Poor Environment: A Data Envelopment Analysis Approach

Performance metrics of public hospitals in health resource poor environment should be considered crucial in the process of functional evaluation of the health sector. These metrics assume important dimensions in term of implication for service extension, stewardship and justifications of public resource expenditure. The present study utilised data envelopment analysis (DEA) methodology to shed light on the operational data of 32 government-owned hospitals in order to identify the magnitude of (in)efficiency in the hospital system. Results of DEA models indicate that 66.7% of these public hospitals are technically inefficient with overall average efficiency score of 0.73. In addition, 22 hospitals were found to be scale inefficient; 57.6% of these facilities being under increasing returns to scale regime. The study suggests a resource re-allocation strategy as well as managerial and policy initiatives focused on reducing costs of care.

Risk pump in Gerbillus pyramidum: quality of poor habitats increases with more conspecifics

Reducing predation risk is fundamental to many animals. Among those, social animals are studied for one type of anti-predator defense. They aggregate in certain habitats to dilute risk, share vigilance, defend each other, and reduce their chances of being attacked. However, this tendency is not necessarily unique: solitary animals may also benefit from the presence of conspecifics. Thus, we hypothesize that even solitary animals should aggregate whenever there is safety in numbers. Additionally, this tendency to aggregate should create a “risk pump”, a positive feedback in aggregation because more individuals bring more safety, which brings more individuals. We also analyzed if they will aggregate in resource-rich or resource-poor environment. Aggregation in a richer and thus crowded environment implies risk pump is a stronger mechanism than competition. Aggregation in a resource-poor environment indicates the presence of risk pump, but one weaker than competition. To test the existence and direction of a “risk pump” in non-social animals, we compared quality between patches at different distances and population densities in three experiments. We used the most abundant gerbils of the Negev Desert: Gerbillus andersoni and G. pyramidum. Results supported the hypothesis of aggregation in the resource-poor patch for both species.

MetaPink Program: Simplifying the Breast Cancer Journey for Patients With Advanced Stage Breast Cancer in Nigeria

Background and context: Breast cancer is the number one diagnosed cancer in Nigeria. 75% of these breast cancer diagnosis are at stage 3 and 4. This is due in part to lack of awareness of the signs and symptoms, inadequate screening and diagnostic facilities, insufficient policies and guidelines, and fear. Metastatic breast cancer patients do not have the time nor the strength to deal with the stress, delay, and confusion of trying to find adequate care. Run For a Cure Africa (RFCA) wishes to establish a program that helps navigate metastatic breast cancer patients in Lagos state, and surrounding states in Nigeria toward breast cancer care and resources. Aim: The MetaPink program empowers and educates patients with advanced stage breast cancer by providing them with timely and relevant information and resources on their disease and how they, the patient, can improve their quality of life and overall prognosis. Additionally, RFCA creates greater awareness of metastatic breast cancer in the community and the necessity for regular screenings. Strategy/Tactics: This project is being implemented by RFCA. RFCA is working work with the health care professionals (HCP) in the oncology and community health department at the Lagos University Teaching Hospital (LUTH) in addition to their organization mentors, The Rose Foundation in Houston, Texas. RFCA is also working with community associations, drama troupes, and groups to create sensitization in hard to access areas. Patients and participants of the MetaPink program have a support team, through the monthly support group, with whom they fellowship, ask advice, gain insight, and just off load any looming concerns. Program/Policy process: RFCA enrolls metastatic patients through our supported clinics, call ins, and our screening outreaches. Each patient enrolled in the program gets a starter pack. RFCA hosts monthly support groups and Q&amp;A sessions anchored by medical professionals, RFCA also hosts community outreach events via the radio, market drama skits, and musical awareness presentations. Periodically we follow-up and communicate with MetaPink program participants via MetaPink WhatsApp, telephone, in-person meetings/visits, and support group meetings. Outcomes: The objective of the MetaPink program is to simplify the breast cancer journey for metastatic breast cancer patients in Nigeria and give them the emotional support and confidence to understand and navigate through their personal breast cancer journey. RFCA also creates larger community awareness of advanced stage breast cancer in a method that is culturally appealing and resonates with the environment. What was learned: As the program progresses, RFCA will learn how to effectively navigate patients in this resource-poor environment. This will contribute to their quality of life and improved breast cancer management in Nigeria. [Figure: see text]

Exploring Antipsychotic Prescribing Behaviors for Nursing Home Residents With Dementia: A Qualitative Study

ObjectivesCaution is advised when prescribing antipsychotics to people with dementia. This study explored the determinants of appropriate, evidence-based antipsychotic prescribing behaviors for nursing home residents with dementia, with a view to informing future quality improvement efforts and behavior change interventions. DesignSemistructured qualitative interviews based on the Theoretical Domains Framework (TDF). Setting and ParticipantsA purposive sample of 27 participants from 4 nursing homes, involved in the care of nursing home residents with dementia (8 nurses, 5 general practitioners, 5 healthcare assistants, 3 family members, 2 pharmacists, 2 consultant geriatricians, and 2 consultant psychiatrists of old age) in a Southern region of Ireland. MeasuresUsing framework analysis, the predominant TDF domains and determinants influencing these behaviors were identified, and explanatory themes developed. ResultsNine predominant TDF domains were identified as influencing appropriate antipsychotic prescribing behaviors. Participants’ effort to achieve “a fine balance” between the risks and benefits of antipsychotics was identified as the cross-cutting theme that underpinned many of the behavioral determinants. On one hand, neither healthcare workers nor family members wanted to see residents over-sedated and without a quality of life. Conversely, the reality of needing to protect staff, family members, and residents from potentially dangerous behavioral symptoms, in a resource-poor environment, was emphasized. The implementation of best-practice guidelines was illustrated through 3 explanatory themes (“human suffering”; “the interface between resident and nursing home”; and “power and knowledge: complex stakeholder dynamics”), which conceptualize how different nursing homes strike this “fine balance.” ConclusionsImplementing evidence-based antipsychotic prescribing practices for nursing home residents with dementia remains a significant challenge. Greater policy and institutional support is required to help stakeholders strike that “fine balance” and ultimately make better prescribing decisions. This study has generated a deeper understanding of this complex issue and will inform the development of an evidence-based intervention.

How Air Ambulance Services Can Improve Care Delivered to Remote Indigenous Communities

Introduction Approximately fifty percent of Canada's Indigenous population resides in remote and rural communities, where life expectancy is five to seven years shorter than in the rest of Canada. Barriers to health care include, but are not limited to: low population density, long transportation and wait times, high rates of staff turnover, harsh weather climates, and inadequate human resources. Ornge is the air ambulance and critical care transport provider for the province of Ontario. Ontario is Canada's second largest province, with a landmass of more than 1 million km2, and a population of about 13 million people. Northern Ontario constitutes 87% of the land area of the province, but has less than 7% of the population. Ornge operates 12 bases across the province, and employs a fleet of 8 Pilatus PC-12 fixed wing aircraft and 11 AW 139 rotor wing aircraft to support the air ambulance transport needs of the province. As well, Ornge utilizes contract air carriers to provide transport for predominantly low acuity patients. We hypothesized that air ambulance services have the medical, logistical, educational, and technological and data capabilities to improve access to care for remote Indigenous communities. Increasing involvement of air ambulance services in delivering health care to remote Indigenous communities will improve patient outcomes and represent an opportunity for air ambulance services to expand their scope of work. Methods Ornge has developed a five-part strategy to help improve access to care for Indigenous communities. Results 1. Telemedicine: Over the past year, Ornge has conducted approximately 75 telemedicine consultations with the nurses servicing four remote indigenous communities. Survey data from the nurses has uniformly been extremely positive of the value of the telemedicine support. 2. Point of Care Lab Tests: Over the past six months, 58 patients within two communities have benefitted from point of care lab tests supplied by Ornge. Patient care has been improved dramatically and unnecessary transports have been prevented. 3. Education: Ornge has delivered educational sessions to nurses and doctors servicing these remote communities. This has improved the working relationships between all parties. As well, Ornge has helped develop a proposal to train indigenous members as first responders within seven remote communities. 4. Outreach: Ornge has delivered three sessions of first aid/cpr and "Stop the Bleed" training to Indigenous youth. As well, Ornge is now delivering Primary and Secondary Injury and Opioid prevention sessions to Indigenous Youth. 5. Data: Stakeholders are now using Ornge data to help identify strategies to improve access to care for Indigenous communities. Conclusion Air ambulance services have the expertise and capabilities to help improve access to care for remote Indigenous communities. This represents an area of potential opportunity for air ambulance services. Expanding the mandate of air ambulance services to improving access to care to these remote communities can help improve patient outcomes, allow for care closer to home, and allows for accurate triaging of air ambulance assets in a relative resource-poor environment.

Conventional galactography in the management of suspicious nipple discharge :A forgotten art?

Background: Conventional Galactography is a simple procedure and a cheap tool in evaluating suspicious nipple discharge(SND). It accurately demonstrates the intraductal lesion for confident diagnosis and timely intervention. SND, a common symptom, occurs spontaneously and unilaterally from a single duct. Cancer has been found in some patients with SND. Objective: To examine radiologists' knowledge and practice of galactography in the evaluation of SND and determine if training in performing galactography existed. Methods: A Standardized structured questionnaire with 16 questions was served to radiologists in centres around Nigeria. Descriptive and inferential statistics were done where indicated with SPSS Version 20 (IBM Corp., Armonk NY, USA) and significance levels were set at p<0.05. Results: 58 (64.4%) out of 90 questionnaires were returned. 58% had been in practice for between 11-20 years. 98% worked in departments where breast imaging was available. 26.8% of radiologists reported handling over 10 breast cases/week and SND was reported as a common complaint. Only 8% listed galactography among their department's protocol for managing SND and just 10.5% of respondents had received training to perform it. Only 31% had ever done the procedure. Of those who had performed it, 83% attested that it helped in resolving the cause of the SND. Conclusion: In a resource-poor environment like ours where breast cancer is common and late presentation is the rule, galactography being a cheap tool, it stands to reason that radiologists should widely recommend and use it for early diagnosis. This however does not appear to be the case.