Development and internal validation of the HIV In-hospital Mortality Prediction (HIV-IMP) risk score.

BACKGROUND: Despite advances in availability and access to antiretroviral therapy (ART), HIV still ranks as a major cause of global mortality. Hence, the aim of this study was to develop and internally validate a risk score capable of accurately predicting in-hospital mortality in HIV-positive patients requiring hospital admission. METHODS: Consecutive HIV-positive patients presenting to the Charlotte Maxeke Johannesburg Academic Hospital adult emergency department between 7 July 2017 and 18 October 2018 were prospectively enrolled. Multivariate logistic regression was used to determine parameters for inclusion in the final risk score. Discrimination and calibration were assessed by means of the area under the receiver operating curve (AUROC) and the Hosmer-Lemeshow goodness-of-fit test, respectively. Internal validation was conducted using the regular bootstrap technique. RESULTS: The overall in-hospital mortality rate was 13.6% (n = 166). Eight predictors were included in the final risk score: ART non-adherence or not yet on ART, Glasgow Coma Scale < 15, respiratory rate > 20 breaths/min, oxygen saturation < 90%, white cell count < 4 × 109 /L, creatinine > 120 µmol/L, lactate > 2 mmol/L and albumin < 35 g/L. After internal validation, the risk score maintained good discrimination [AUROC 0.83, 95% confidence interval (CI): 0.78-0.88] and calibration (Hosmer-Lemeshow χ2 = 2.26, p = 0.895). CONCLUSION: The HIV In-hospital Mortality Prediction (HIV-IMP) risk score has overall good discrimination and calibration and is relatively easy to use. Further studies should be aimed at externally validating the score in varying clinical settings.

First-presentation with psychotic behavior to the Emergency Department: Meningitis or not, that is the question.

INTRODUCTION: Meningitis is a potentially life threatening medical emergency. Psychotic behavior may be a presenting feature in patients with meningitis. We aimed to determine the value of various clinical and laboratory features at ruling-out meningitis in the patient presenting with a first-episode of psychotic behavior. METHODS: Medical records of 159 subjects presenting to a tertiary academic hospital over a 6-month period with one or more psychotic features for the first time were prospectively gathered. Pathological cerebrospinal fluid findings as well as clinical and other laboratory findings were tabulated and discussed retrospectively. RESULTS: Cerebrospinal fluid was obtained in 153/159 (96.2%) subjects. Meningitis was confirmed in twenty-eight (18.3%) subjects. Of these, a) one or more clinical feature of meningitis (headache, neck stiffness, photophobia or focal neuropathy) was present in 21 subjects (75.0%), b) visual hallucinations in 15 subjects (53.6%), c) pyrexia >37.5 °C in 7 subjects (25.0%), d) CRP >10 mg/L in 21 subjects (75.0%), e) HIV seropositive status in 19 subjects (67.9%) and f) an absence of illicit substances on urinalysis in 23 subjects (82.1%). Various combinations of these variables, where the presence of ≥1 variable was regarded as positive, were unable to rule-out meningitis in all study subjects. CONCLUSION: The absence of these six parameters; alone or in various combinations, was unable to rule-out meningitis in all patients presenting to our ED with a first-episode of psychotic behavior. When the underlying etiology of psychotic behavior is not obvious, the clinician should adopt a low threshold to perform a lumbar puncture.

First Presentation with Psychotic Symptoms to the Emergency Department.

BACKGROUND: Mental health conditions account for 52.8 million (4.9-6.3%) emergency department (ED) visits in the United States. Psychotic conditions are responsible for approximately 10% of all mental health presentations. OBJECTIVE: We aimed to determine the underlying etiology and characteristics of patients presenting to the ED with a first episode of psychotic symptoms. METHODS: Medical records of 159 African, Asian, white, and mixed-race patients were prospectively reviewed. Subjects were classified into one of three groups; psychosis due to an underlying medical condition (UMC), substance-induced psychotic disorders (SIPDs), and psychosis due to other primary psychiatric disorders (OPD). Demographic details and presenting features were described and compared. RESULTS: Overall mean (standard deviation [SD]) age of all study subjects was 34.3 (13.4) years. A UMC was responsible for a first presentation with psychotic features in more than half of the study subjects (n = 87 [54.7%]), while SIPD (n = 37 [23.3%]) and OPD (n = 35 [22.0%]) were responsible for the remainder of cases. The majority of subjects were male (n = 95 [59.7%]), unemployed (n = 105 [66.0%]), and had not completed secondary school (n = 109 [68.6%]). More than one-third of subjects tested positive for human immunodeficiency virus infection (n = 63 [39.6%]). Mean (SD) duration of psychotic symptoms before ED presentation was 16.6 (26.3) days. CONCLUSIONS: UMC is a common etiology in patients presenting to the ED with a first episode of psychotic symptoms.

A review of hemodynamic monitoring techniques, methods and devices for the emergency physician.

The emergency department (ED) is frequently the doorway to the intensive care unit (ICU) for a significant number of critically ill patients presenting to the hospital. Hemodynamic monitoring (HDM) which is a key component in the effective management of the critically ill patient presenting to the ED, is primarily concerned with assessing the performance of the cardiovascular system and determining the correct therapeutic intervention to optimise end-organ oxygen delivery. The spectrum of hemodynamic monitoring ranges from simple clinical assessment and routine bedside monitoring to point of care ultrasonography and various invasive monitoring devices. The clinician must be aware of the range of available techniques, methods, interventions and technological advances as well as possess a sound approach to basic hemodynamic monitoring prior to selecting the optimal modality. This article comprises an in depth discussion of an approach to hemodynamic monitoring techniques and principles as well as methods of predicting fluid responsiveness as it applies to the ED clinician. We review the role, applicability and validity of various methods and techniques that include; clinical assessment, passive leg raising, blood pressure, finger based monitoring devices, the mini-fluid challenge, the end-expiratory occlusion test, central venous pressure monitoring, the pulmonary artery catheter, ultrasonography, bioreactance and other modern invasive hemodynamic monitoring devices.

Finding the mental foramen.

The mental foramen and mental nerve are clinically important landmarks for clinicians across various disciplines including dentists, oral maxillofacial surgeons, emergency physicians and plastic and reconstructive surgeons. To minimize complications related to procedures in the vicinity of the mental foramen and nerve, knowledge of its anatomy and anatomical variations is cardinal to concerned clinicians. In this review, basic anatomy, procedural complications, hard and soft tissue relations, variations between population groups, asymmetry, accessory mental foramina and the use of various radiological modalities to determine the position of the mental foramen are reviewed to provide a more thorough understanding of this important landmark.

Knowledge, Attitudes, and Perceptions Regarding CPR Among Non-medical Staff at a Medical School in South Africa.

Background Sudden cardiac arrest can occur unexpectedly in any person and at any place including at medical schools. Improved outcomes after cardiac arrest are dependent on the initiation of early first responder high-quality cardiopulmonary resuscitation (CPR) and rapid defibrillation. There is a lack of data pertaining to the knowledge, attitudes, and perceptions of non-medical staff at medical schools regarding CPR. The aim of this study was to determine the knowledge, attitudes, and perceptions of non-medical staff employed at a medical school in South Africa regarding CPR. Methods In this cross-sectional survey study, a paper-based questionnaire was administered to non-medical staff (i.e., all staff without a medical [MBBCh or equivalent] or nursing degree) employed at the medical school. Data were collected between August 1 and October 25, 2020. Results The final study sample comprised 150 participants. Of these, 103 (68.7%) were female, 109 (72.7%) were ≤ 40 years old, 62 (41.3%) had a postgraduate university degree, 72 (48.0%) had witnessed a medical emergency at the medical school premises and 46 (30.7%) had previously undertaken first aid or CPR training. The mean (SD) knowledge score was 4.4 ± 1.6 out of 10 with only 25 (16.7%) participants knowing what the first thing was to look out for during a medical emergency and 28 (18.7%) participants knowing the location of the automated external defibrillator. Most participants (n=136, 90.7%) indicated that CPR training should be mandatory for all employees. Conclusion Non-medical staff surveyed displayed suboptimal knowledge but positive attitudes and perceptions toward CPR. Although this was a single-center study, these results can be used to motivate CPR training of non-medical staff at all medical schools.

Prevalence and presentation of neonatal sepsis at a paediatric emergency department in Johannesburg, South Africa.

Background: Despite a significant reduction in the prevalence of neonatal sepsis over the past three decades, the prevalence still remains high, especially in low- and middle-income countries. The aim of this study was to determine the prevalence and presenting features of neonatal sepsis at a paediatric emergency centre (PEC). Methods: Medical records of all neonates presenting to an academic hospital PEC over a six-month period were analysed. Data was compared between neonates with and without sepsis. The odds ratio was calculated to determine factors associated with neonatal sepsis. Results: Of the 210 neonates who were included, 43 (20.5%) were diagnosed with neonatal sepsis. Of these, 19 (44.2%) presented within the first 72 hours of life (early-onset neonatal sepsis) and 4 (9.3%) died prior to hospital discharge. A history of maternal employment (odds ratio (OR) 2.38, p=0.021), preterm birth (OR 3.24, p=0.019), low birth weight (<2.5kg) (OR 2.67, p=0.026), perinatal human immunodeficiency virus exposure (OR 3.35, p=0.002), not being breast fed (OR 4.36, p=0.001), and signs of lethargy (OR 14.01, p<0.001), dehydration (or 11.14, p<0.001), poor feeding (OR 7.20, p<0.001), irritability (OR 6.93, p<0.001), fever (OR 5.50, p<0.001), vomiting (OR 4.14, p<0.001) and respiratory distress (OR 4.12, p<0.001) were significantly associated with neonatal sepsis. Conclusion: Among neonates presenting to the PEC, various clinical features on history and examination may be useful in predicting the diagnosis of neonatal sepsis. Clinicians working in the PEC must adopt a high index of suspicion when attending to neonates presenting with these features.

Clinical Profile of Adult Patients Presenting With Renal Dysfunction to a Tertiary Hospital Emergency Department.

Background Renal dysfunction is a potentially life-threatening condition that is commonly encountered in the emergency department (ED). This study aimed to describe the clinical profile of patients presenting with renal dysfunction to a tertiary-level hospital ED. Methods Medical records of patients presenting to the ED with renal dysfunction over a six-month period (July-December 2017) were reviewed. A descriptive analysis of the data was performed. Results Serum creatinine levels were measured in 7,442 (69.9%) of the 10,642 patients that were triaged into the ED. Of these, 208 (2.8%) were identified with renal dysfunction, of which 192 consented to study participation. The median age of study subjects was 49.5 (IQR 38.8-63.0) years; 108 (56.3%) were male; proteinuria on urine dipsticks was demonstrated in 108 (56.3%); 72 (37.5%) were HIV-positive; 66 (39.6%) required dialysis; 11 (5.7%) were admitted to the ICU; and 59 (30.7%) died prior to hospital discharge. More patients presented with acute kidney injury (AKI) (46.9%) compared to chronic kidney disease (CKD) (27.6%) and acute on chronic kidney disease (AoCKD) (25.5%). Sepsis was the most common precipitant of AKI (42.2%) and AoCKD (30.6%), while chronic hypertension (35.8%) and diabetes mellitus (34.0%) were the most common comorbidities in subjects with CKD. Conclusion Patients presenting to the ED with various risk factors and comorbidities, including HIV, sepsis, hypertension, and diabetes mellitus, may have underlying renal dysfunction. ED clinicians should therefore adopt a low threshold to screen for renal dysfunction in these patients.

Clinical Profile of Acute Coronary Syndrome Presentation to the Ladysmith Provincial Hospital: High Prevalence Among the Minority Indian Population.

Background Cardiovascular diseases were responsible for 17% of the 460236 natural deaths in South Africa in 2015. Previous studies have reported a disproportionately higher incidence of ischemic heart disease (IHD) and its risk factors among individuals of Indian descent residing in South Africa. The aim of this study was to explore the clinical profile of patients presenting with a diagnosis of acute coronary syndrome (ACS) and to compare the characteristics of patients of Indian descent to those of non-Indian descent. Methods Retrospective data were derived from the medical charts of 160 consecutive patients presenting to the Ladysmith Provincial Hospital over a 44-month period with a diagnosis of ACS. Findings were described and compared. Results The mean (SD) age of study patients was 55.8 (±12.8) years. The majority of subjects were male (n=90, 56.3%) and unemployed (n=98, 62.3%). The racial distribution of the study sample comprised 103 (64.4%) Indian, 36 (22.5%) Black, and 21 (13.1%) White subjects. Compared to non-Indian subjects, a significantly higher proportion (p<0.05) of Indian subjects were male (64.7% vs 41.4%), cigarette smokers (52.0% vs 32.8%), had a previous history of ACS (37.3% vs 10.3%), were diabetic (33.3% vs 17.2%), and were hypertensive (58.8% vs 29.3%). Conclusion The disproportionately high frequency of ACS among the minority Indian population of Ladysmith is concerning. There is a need for rigorous public health interventions to create local awareness, encourage lifestyle modification, and thereby improve control of cardiovascular risk factors, especially among high-risk population groups.

A Comparative Assessment of the Nova Stat Profile Prime Plus® Critical Care Analyzer.

BACKGROUND: Point-of-care testing (POCT) plays an integral role in the management of acutely ill patients presenting to the emergency department (ED). Due to its rapid turnaround time, POCT has been shown to improve ED workflow, reduce unnecessary admissions and lessen the burden on ED staff. The aim of the study was to compare the accuracy, precision and linearity of the Nova Stat Profile Prime Plus® (Nova Biomedical, Waltham, MA, USA) to the Radiometer ABL800 FLEX® (Radiometer South Africa Pty Ltd, Gauteng) and the Abbott i-stat Chem8+® (Abbott, Princeton, NJ, USA) POCT analyzers. METHODS: A convenience sample of 150 discarded whole blood specimens was obtained and analyzed. Paired test measurements were conducted for method comparison. Accuracy was measured by pairing individual results from the Nova Stat Profile Prime Plus® with either the Radiometer ABL800 FLEX® or the Abbot i-stat Chem8+® analyzers by calculating the differences. RESULTS: The with-in run percentage coefficient of variation (%CV) was below 2.4% for pH, carboxyhemoglobin (COHb), deoxyhemoglobin (HHb), total hemoglobin (tHb), total bilirubin (tBil), sodium (Na), potassium (K), chloride (Cl), ionized calcium (iCa), urea, glucose and lactate, and was below 5.1% for all other analytes. The day-to-day %CV was below 1.6% for pH, COHb, HHb, tHb, tBil, Na, K, Cl, iCa, urea, glucose and lactate, and below 6.10% for all other analytes. The correlation coefficient (r) was 0.351 and ranged from 0.897 to 0.998 for all analytes. The mean bias was minimal for all analytes. CONCLUSION: There was a good correlation between the Nova Stat Profile Prime Plus® and the Radiometer ABL800 FLEX®/Abbott i-STAT Chem8+® POCT analyzers. The Stat Profile Prime Plus® exhibited good precision both within-run and day-to-day.

The "Intubox": Enhancing Frontline Healthcare Worker Safety During Coronavirus Disease 2019 (COVID-19).

There has been a substantial burden of healthcare worker infection during the current coronavirus (COVID-19) pandemic, likely due to a lack of adequate preparedness, suboptimal institutional infection control measures, atypical patient presentation, poor compliance with personal protective equipment (PPE) and exposure to high-risk aerosol generating procedures, such as endotracheal intubation. There is significant concern that developing countries will face heightened levels of staff exposure during the COVID-19 pandemic. To mitigate this exposure risk during procedures, such as endotracheal intubation, various "aerosol boxes" have been designed by frontline healthcare workers. However, in practice these boxes were found to hamper endotracheal intubation and other procedures due to the limited space and manoeuvrability they allow. To further reduce particle dispersion and to improve on the practicality and ergonomic design of the prototype "aerosol box", the Intubox was developed by staff at the Charlotte Maxeke Johannesburg Academic Hospital after instituting several changes to the prototype design.

Paediatric Emergency Department preparedness in Nigeria: A prospective cross-sectional study.

INTRODUCTION: Paediatric emergency medicine (PEM) is poorly developed in low and middle-income countries. The magnitude of challenges facing Paediatric Emergency Departments (PEDs) in Nigeria has not been well described. This study aimed to assess paediatric emergency care preparedness across PEDs in Nigeria. METHODS: This was a prospective cross-sectional study that utilized a self-administered questionnaire and a check list to assess three key domains (managerial, medication and equipment) in tertiary care PED facilities that were recruited across Nigeria. Preparedness scores and other institutional attributes were compared between zones and regions. RESULTS: Thirty-four tertiary-level PEDs across Nigeria were included. The mean number of patient visits over the 30-day period prior to data collection was 253.2 (±261.2). The mean (SD) managerial, medication and equipment performance scores of the included PEDs were 42.9% (±14.3%), 50.7% (±22.3%) and 43.9% (±11.8%) respectively. The mean (SD) total performance score was 46.9% (±15.3%). Only 13 PEDs had a total performance score of >50%. There was a statistically significant higher mean equipment score (p = 0.029) in the Southern region (47.6 ± 3.1) compared to the Northern region (38.9 ± 2.3) of the country. CONCLUSIONS: This study reports a global but remediable deficiency in emergency care preparedness amongst PEDs in tertiary care facilities in Nigeria. This study highlights the need for training of PED managers in basic and advanced life support and for the improvement in medication and equipment procurement across Nigeria.

Knowledge, Attitudes and Perceptions Regarding Basic Life Support Among Teachers in Training.

Background Cardiac arrests may occur anytime, anywhere and to anyone including learners at schools. Teachers have a moral obligation to care for learners while on the school premises. Outcomes after cardiac arrest are better when the first-responder possesses adequate knowledge and skill in basic life support (BLS) and cardiopulmonary resuscitation (CPR). The aim of this study was to assess the knowledge, attitudes and perceptions of student-teachers pertaining to BLS. Methods This was a self-administered, questionnaire based, prospective and cross-sectional study of senior undergraduate student-teachers enrolled at a South African university. The study was conducted between 04 November 2017 and 18 February 2018. Results A total of 316 student-teachers, with a mean age of 21.8 ± 2.6 years completed the survey. Trauma-related emergencies, allergic reactions and breathing difficulties were witnessed during practice teaching sessions at various schools by 52.5% (n = 166), 36.4% (n = 115) and 32.9% (n = 104) of participants, respectively. The mean knowledge score pertaining to BLS was 4.0 ± 1.7 out of 12 points. Previous CPR training was associated with a good knowledge score (p = 0.005) and confidence in responding to an emergency (p = 0.005). Most of the participants (N = 288, 91.1%) had no formal training in CPR with more than three-quarters (76.4%) of them not knowing where to acquire training. Barriers to initiating CPR included fear of litigation (n = 264, 83.5%), injury to the victim (n = 238, 75.3%), presence of blood, vomitus or secretions (n = 206, 65.2%) and fear of contracting a disease (n = 186, 58.8%). Most (n = 255, 80.7%) respondents reported that they would perform CPR on a learner at school. Conclusion Student-teachers surveyed in this study displayed poor knowledge and perceptions but positive attitudes with regards to the practice of CPR and BLS. Consideration should be given to including formal CPR training as part of the curriculum for teachers in training.

Occupational blood and body fluid exposures and human immunodeficiency virus post-exposure prophylaxis amongst intern doctors.

BACKGROUND: Healthcare workers (HCWs) are constantly vulnerable to occupational blood and body fluid exposures (OBBFEs). Exposed HCWs experience emotional, physical and psychological trauma. Less experienced HCWs, such as intern doctors, are more prone to OBBFEs. OBJECTIVES: The aim of this study was to investigate the prevalence and practices pertaining to OBBFEs amongst a select group of intern doctors in the Gauteng province of South Africa. METHODS: A quantitative cross-sectional descriptive study using a questionnaire based on a practical model was used. Intern doctors were recruited from four major hospitals in Gauteng. RESULTS: A total of 175 intern doctors participated in the study. There was a total of 182 (mean = 1.04, standard deviation [s.d] 0.88) reported OBBFEs amongst 136 (77.7%) subjects. The exposures occurred predominantly whilst subjects were working in surgery (n = 50, 27.5%), obstetrics and gynaecology (n = 49, 26.9%) and internal medicine (n = 48, 26.4%) departments; were superficial wounds (n = 69, 37.9%); were acquired during vascular puncture or intravenous line insertion (n = 69, 37.9%); and occurred when subjects were working >12 h shifts (n = 101, 55.5%). Human immunodeficiency virus (HIV) post-exposure prophylaxis (PEP) was initiated in 141 (77.5%) out of the 182 exposures. Only 90 (63.8%) subjects completed the recommended 28-day course of PEP. Two (1.1%) subjects reported that they had acquired HIV infection as a consequence of the OBBFE. CONCLUSION: Occupational blood and body fluid exposures are common amongst intern doctors. It is recommended that regular training, health education and monitoring compliance should be incorporated during the induction of medical intern doctors in hospitals. The availability of PEP regimens with better tolerability will encourage compliance.

Locating the mental foramen at the bedside with point of care ultrasound imaging.

INTRODUCTION: Ultrasound guided neuro-anaesthesia is a developing field of interest to clinicians from various disciplines. The objective of this proof of concept study was to explore the ability, ease and rapidity of ultrasonography in locating the mental foramen. METHODS: A convenience sample of 100 patients aged 18 years or older, with no known pathology to the mandibular region, that presented to a single urban ED were enrolled. All patients underwent an ultrasound examination on both sides of the face to locate the mental foramina. RESULTS: A total of 100 patients' mental foramina were studied. Mean age was 35.7 years (SD 9.1 years), 50% were black and 25% each were asian and white. The mental foramina were ultrasonographically identified in all (100%) of the subjects in the study group. Although requiring a larger quantity of ultrasound gel, the mental foramina were also visualized in all twelve subjects with facial hair. Three out of the 100 subjects were noted to have accessory mental foramina. The overall mean time taken to locate the first mental foramen in each patient was 16.1 seconds (SD 12.9 seconds). For the first 25 subjects studied, the mean time taken was 34.7 seconds (SD 13.4 seconds), whereas for the next 75 subjects studied, the mean time taken was 9.9 seconds (SD 3.0 seconds). CONCLUSION: Bedside ultrasound imaging is a potentially reliable method to identify and locate the mental foramen. With practice and experience, the mental foramen can be more easily identified.

HTLV-1, ATLL, refractory hypercalcaemia and HIV-1 co-infection.

Adult T-cell lymphoma/leukemia (ATLL) is a rare tumour of T-lymphocytes that is associated with human T-lymphotrophic virus type 1 (HTLV-1) infection as well as severe/refractory hypercalcaemia. Human immunodefficiency virus type 1 (HIV-1) infected individuals are at increased risk of acquiring co-infection with HTLV-1. We present the case of a 37 -year -old HIV-1 positive and antiretroviral therapy naive woman who was admitted to the ICU with delirium, a generalised maculopapular rash, severe hypercalcaemia of 4.48 mmol/L (normal < 2.7 mmol/L) and a positive HTLV-1 serology. The diagnosis of ATLL was confirmed on biopsy. Her hypercalcaemic state proved refractory to conventional therapy, but was rapidly corrected with a modified haemodialysis technique using a dialysate with a low low-calcium concentration.

Audit of defibrillators at an urban public sector hospital.

INTRODUCTION: Life-threatening emergencies are not limited to the emergency department. Any delay in intervention during an emergency often culminates into a poor outcome. Early electrical defibrillation is one of the most important interventions in patients with cardiac arrest. This study aimed to conduct a clinical audit of defibrillator devices at an urban public sector hospital in Johannesburg. METHODS: All defibrillator devices within various areas of the hospital were assessed. Device characteristics were recorded into a data collection sheet and subjected to further analysis. RESULTS: This study assessed 112 out of 123 areas in the hospital with a total of 143 defibrillators comprising 139(97.2%) manual external defibrillators (MED) and four(2.8%) automated external defibrillators (AED). MEDs were located in the general wards (n=52, 37.4%), theatre complex (n=25, 17.9%), high dependency areas (n=27, 19.4%) and non-sleepover areas (n=35, 25.2%). Daily checklist books were available for 101 (72.7%) MEDs, 26 (18.7%) had at least once daily documented checks over a 5-day period while 57 (41.0%) had been serviced in the last 12 months. Seven MEDs (4.9%) and one AED (0.7%) had critical problems. CONCLUSION: Compliance with regard to the availability of defibrillator checklist books, conducting and recording of daily defibrillator checks, timely service maintenance of defibrillators and identification of critical device problems was suboptimal in this study. There is a need for ongoing training of hospital staff as well as the establishment of systems to prevent potential adverse consequences due to device failure.

Survival after Cardiac Arrest Secondary to Massive Pulmonary Embolism.

INTRODUCTION: It is estimated that the diagnosis of pulmonary embolism (PE) is missed in as many as 84% of all cases of PE. Cardiac arrest following PE is generally associated with poor outcomes. CASE REPORT: A 43-year-old man presented to the Emergency Department (ED) in cardiac arrest. Swelling of his right lower limb was noted on arrival. Point of care ultrasound was performed during ongoing cardiopulmonary resuscitation (CPR) and showed a thrombus in the right iliofemoral vein as well as dilatation of the right ventricle. Fibrinolytic therapy was initiated immediately and a return of spontaneous circulation (ROSC) was achieved 30 minutes later. The diagnosis of PE was finally confirmed on computed tomography pulmonary angiography once haemodynamic stability was achieved. The patient was thereafter transferred to the intensive care unit for postresuscitation care and further management. Several days later, he was discharged home neurologically intact and fully recovered. DISCUSSION: Since outcomes after cardiac arrest following PE are generally dismal, available and potentially life-saving interventions to restore pulmonary circulation should be rapidly implemented when PE is the likely cause of cardiac arrest.

A Case of Female Acute Urinary Retention Presenting to the ED.

INTRODUCTION: Acute urinary retention is a rare occurrence in women necessitating further investigation. Potential underlying causes may be broadly classified into obstructive, neurological, pharmacological, and psychogenic categories. CASE: A 36-year-old nulliparous female presented to the Emergency Department with a two-day history of acute urinary retention. Point-of-care ultrasonography and CT scan imaging confirmed the presence of a large uterine mass causing compression of the bladder. The acute retention was relieved with urethral catheterization. A Uterine leiomyoma was confirmed on histology after hysterectomy. DISCUSSION: Once the acute urinary retention has been relieved by insertion of a urethral catheter, the underlying cause of the obstruction must be determined. Although uterine leiomyoma is a fairly common finding in the general population, it is an extremely rare cause of acute urinary retention in women with just a handful of reported cases in the literature.

Humanitarian Medical Response to the Syrian Arab Republic (April 7, 2013 to April 23, 2013).

The Syrian Arab Republic is entrenched in a deadly civil war, plunging the country into a state of chaos. With 3.2 million refugees abroad, 7.6 million internally displaced persons, and more than 200,000 killed, humanitarian assistance and international intervention are in dire need. This report outlines the response to the Syrian humanitarian crisis by a South African-based nongovernmental organization (NGO). It describes the experiences of a health care worker, the patient profiles, and the lessons learned in a war zone. Responding to a nation in need is of paramount importance. In order to maximize the benefit conferred, the team should always attempt to implement measures that leave a lasting legacy.