Complications of high volume circumcision: glans amputation in adolescents; a case report

Background

The past four years has seen a rapid roll-out of male medical circumcision services in South Africa in response to clinical trials showing circumcision prevents HIV acquisition in heterosexual men. Clinics conduct substantial numbers of circumcisions per day. We report three cases of glans amputation in adolescents attending high volume clinics where modified Models of Optimising Volume and Efficiency (MOVE) are implemented.

Case presentations

Three cases of glans amputation in young healthy men that presented for voluntary medical male circumcision. The procedures were performed by highly experienced medical officers in two cases. All these cases shared characteristics: younger males with immature genitalia, forceps guided circumcision, and likely operator fatigue. Voluntary male medical circumcision programs should include regular monitoring and evaluation and training of operators to ensure high quality surgical techniques such as working in clean areas and taking frequent breaks.

Conclusion

Circumcision is a relatively simple medical procedure, however regular training and quality control in high volume Male Medical Circumcision sites is essential to prevent rare catastrophic adverse events.

Nutrient load concept-reservoir vs. bay impacts: a case study from a semi-arid watershed

Large flow-through reservoirs and lakes possess environmental gradients and monitoring programs are mostly adapted for cost and time effectiveness. Bay areas are often more isolated from the main water body and are likely to have unobserved different environmental processes and impacts. This study was performed at the Itaparica Reservoir, São Francisco River, located in semi-arid Northeast Brazil, with dendritic form. Water residence time in the Icó-Mandantes Bay was estimated by hydrodynamic flow and transport simulations. The P-chlorophyll a relationship was used to develop the P use efficiency coefficient for critical P load estimation of 25 μg P L^-1. Phosphorus sources and input rates into a bay and the respective reservoir were calculated and compared regarding their different origins for the period after flooding (1988) and for 2013. After impoundment, the P load highly exceeded the carrying capacity because of leaching and mineralization processes. In 2013, P inputs were still above this threshold, whereas inflow and sub-basin P export during the rainy season were crucial. But eutrophication processes have increased in the bay relative to the main water body. Hence, water in hydraulic isolated parts is prone to eutrophication processes, thus, bays have to be specially considered in water resource management.

Simulations of nutrient emissions from a net cage aquaculture system in a Brazilian bay

Hydrodynamics and transport simulations were conducted with the modeling software TELEMAC-2D on Icó-Mandantes bay, a branch of the Itaparica reservoir. The bay has a maximal operational water level amplitude of 5 m and is suffering from eutrophication and algae bloom. Therefore, we investigated low and high water level scenarios with two different high resolution meshes, with the purpose to deeper understand their impact on transport of substances and to improve the watershed management. In particular, nutrient emissions from a hypothetical net cage aquaculture system located in the bay were investigated on half-year cycles. We observed a relevant impact on water quality for a tilapia production of 130 t y(-1); i.e. after 6 months' simulation we obtained around 8 μgP L(-1) and 6 μgP L(-1) at the source of emissions, for low and high water scenarios, respectively.

Mivacurium after atracurium in children

The effect of mivacurium after atracurium was evaluated in 36 children anesthetized with halothane-nitrous oxide-oxygen by measuring the force of contraction of the adductor pollicis during train-of-four stimulation at 0.1 Hz. The children were evaluated in two main groups. In Group 1 the effect of bolus doses of mivacurium after equipotent repeat doses of atracurium were evaluated. When the first twitch of the train-of-four response (T1) had recovered to 25% of control after a tracheally intubating dose of atracurium, a repeat dose of atracurium was given, on subsequent recovery to 25%, an equipotent dose of mivacurium was administered. In Group 2 when T1 had recovered to > 10% from 0.5 mg/kg atracurium, a mivacurium infusion was started; the initial infusion rate was 4 micrograms.kg-1.min-1 with adjustments made to maintain 90%-99% depression of T1. Patients were allowed to recover spontaneously from the effect of the relaxants. In Group 1 prolongation of the effect of mivacurium was noted after atracurium; the recovery indices (25%-75% and 5%-95%) of mivacurium were longer than those seen when mivacurium is the sole relaxant but shorter than atracurium. In Group 2, 15 min after the start of the mivacurium infusion, the dose requirement was 3.7 +/- 0.3 micrograms.kg-1.min-1 (approximately about one-third that required after a tracheally intubating dose of mivacurium). The infusion requirement increased gradually (P < 0.0001) until, at 90 min of infusion, it was 7.4 +/- 0.8 micrograms.kg-1.min-1. In Group 2 the recovery indices were similar to those seen when mivacurium is the sole relaxant given. When mivacurium is given after atracurium, evidence of the residual neuromuscular effects of the atracurium are detected beyond the usual recovery range.