Case study: Boomslang envenomation in North-Eastern South Africa.

Boomslang (Dispholidus typus) bites are rare in South Africa. This snake's venom is known to be potently haemotoxic, producing a consumptive coagulopathy through the activation of clotting factors II, X, and possibly IX. Monovalent Boomslang antivenom, produced by the South African Vaccine Producers, is highly effective in treating patients who present with haemotoxic envenomation. The majority of health care centres in South Africa do not stock this antivenom due to cost concerns and because envenomation from this snake is so infrequent; this may have lethal consequences for a patient presenting to any such a centre. The usual antivenom dose for effective treatment of a Boomslang bite is two 10 ml vials. We present a case of severe Boomslang envenomation, secondary to a man being bitten on bilateral upper limbs while inside his house, which required three vials of antivenom to treat effectively.

Indocyanine green fluorescence in robot-assisted minimally invasive esophagectomy with intrathoracic anastomosis: a prospective study.

Indocyanine green fluorescence angiography (ICG-FA) allows for real-time intraoperative assessment of the perfusion of the gastric conduit during esophagectomy. The aim of this study was to investigate the effect of the implementation of ICG-FA during robot-assisted minimally invasive esophagectomy (RAMIE) with an intrathoracic anastomosis. In this prospective cohort study, a standardized protocol for ICG-FA was implemented in a high-volume center in December 2018. All consecutive patients who underwent RAMIE with an intrathoracic anastomosis were included. The primary outcome was whether the initial chosen site for the anastomosis on the gastric conduit was changed based on ICG-FA findings. In addition, ICG-FA was quantified based on the procedural videos. Out of the 63 included patients, the planned location of the anastomosis was changed in 9 (14%) patients, based on ICG-FA. The median time to maximum intensity at the base of the gastric conduit was shorter (25 s; range 13-49) compared to tip (34 s; range 12-83). In patients with anastomotic leakage, the median time to reach the FImax at the tip was 56 s (range 30-83) compared to 34 s (range 12-66) in patients without anastomotic leakage (p = 0.320). The use of ICG-FA resulted in an adaptation of the anastomotic site in nine (14%) patients during RAMIE with intrathoracic anastomosis. The quantification of ICG-FA showed that the gastric conduit reaches it maximum intensity in a base-to-tip direction. Perfusion of the entire gastric conduit was worse for patients with anastomotic leakage, although not statistically different.

Spinal surgery for gallstones disease - Case report of a rare differential diagnosis.

INTRODUCTION AND IMPORTANCE: Abdominal pain in the right upper quadrant is very common for patients to present in the emergency department. Finding the correct diagnosis seems straightforward in most cases but can be challenging. CASE PRESENTATION: We present the case of a 75-year-old male with a rare differential diagnosis for right upper quadrant and back pain, initially diagnosed as symptomatic cholelithiasis. After referral to an abdominal surgeon, detailed history taking prior to planned cholecystectomy revealed a record of back pain due to spinal degeneration and fusion surgery, as well as a bulb of the right abdominal wall with hypesthesia in a dermatomal area in the right upper quadrant. Considering these "new" facts, a spinal surgeon was consulted and a foraminal disc hernia of the thoracic vertebrae 11/12 was identified as the cause of symptoms. Instead of the initially planned cholecystectomy, a right-sided facetectomy Th11/12, sequestrectomy and unilateral transpedicular stabilization to decompress the nerve root was successfully performed. CLINICAL DISCUSSION: Although, symptomatic cholelithiasis is one of the most common diagnoses for patients presenting with right upper quadrant pain in the presence of gallstones, other differential diagnoses have to be considered. Thoracic disc herniations can present with atypical symptoms that mimic other non-spinal causes and may pose a diagnostic challenge, sometimes even leading to unnecessary surgery. CONCLUSION: This case highlights a rare differential diagnosis for one of the most common diseases seen by emergency physicians. It emphasizes the risk of working under time pressure, especially in an emergency setting, which may lead to premature diagnostic error and treatment, endangering patient's care and safety.

The efficacy of a topically applied combination of cyphenothrin and pyriproxyfen against the southern African yellow dog tick, Haemaphysalis elliptica, and the cat flea, Ctenocephalides felis, on dogs.

The objective of this study was to determine the therapeutic and residual efficacy of a topically applied combination of cyphenothrin (40%) and pyriproxyfen (2%) against the tick Haemaphysalis elliptica and the flea Ctenocephalides felis on dogs. Twelve dogs were infested with 50 ticks 2 days before they were treated and with approximately 100 fleas 6 days before treatment and again 2 days before treatment and with 50 ticks and approximately 100 fleas at weekly intervals thereafter. They were ranked according to their flea counts and sex 5 days before treatment and randomly allocated to an untreated control group of 6 dogs and a treated group of 6 dogs. Ticks and fleas were collected from the dogs 48 h after treatment and 48 h after each infestation and live and dead ticks and live fleas were counted. The counts of ticks and fleas were transformed to geometric means, and efficacy was calculated by comparing these means. The product had a therapeutic efficacy of 83.1% against H. elliptica and 97.5% against C. felis 2 days after treatment. The residual period of protection during which efficacy was > or = 90% was 5 weeks for both H. elliptica and C. felis.

Single-stage nasal reconstruction with the islanded forehead flap.

BACKGROUND AND PURPOSES: Multi-staged forehead flaps are a well-recognised reconstructive workhorse for subtotal and total nasal defects. It carries the disadvantage of repeated trips to theatre for revisional surgery, which is not suited to all patient cohorts. The single-stage islanded forehead flap eliminates this need. We detail our indications and outcomes of using this flap to highlight the maintained versatility of the technique without significant compromise on reconstructive and patient outcome. SUBJECTS STUDIED AND METHODS: A prospective surgical database was collated where patients were categorised as partial or total reconstruction. We detail surgical technique and review of rationale of patient selection. Patient demographics, perioperative data and follow-up course were recorded. MAIN FINDINGS: A total of 22 patients were recorded from both the U.K. and Ethiopia via working with the charity Facing Africa. Defects occurred from a mixture of trauma, Noma and cancer resections. Thirteen were total nasal reconstructions and nine partial. The mean follow-up period was 2.25 years. We experienced two major complications which required minor revision in the theatre and two minor complications, all resolved satisfactorily. CONCLUSIONS: We demonstrate good outcomes and safety of the procedure in this first report of a varied cohort of nasal reconstructions in a heterogenous cohort of patients. We advocate the use of this flap in the multi-morbid patient where recovery can be expedited or those who have limitations from economical restraints.

Sustainability in humanitarian surgery during medical short-term trips (MSTs): feasibility of inguinal hernia repair in rural Nigeria over 6 years and 13 missions.

PURPOSE: Surgical teaching missions are known to contribute significantly in reducing the local burden of disease. However, the value of short-term medical service trips (MSTs) remains under debate. Humanitarian surgery is highly dependent on funding, and consequently, data evaluation is needed to secure funding for future projects. The aim of this trial is to evaluate the results of 6-year MSTs to rural Nigeria with a specific emphasis on hernia repairs. METHODS: Retrospective series of consecutive operations performed between 2011 and 2016 in rural Nigeria during 13 MSTs. Operations were categorized into type and number of procedures and origin of the surgeon. In terms of inguinal hernia repairs additional data was evaluated such as frequency of local anaesthesia (LA) and the type of hernia. The total amount of disability-adjusted life years (DALYs) averted during each mission are presented and discussed with regard to sustainability of these missions. RESULTS: From 2011 to 2016, a total of 1674 patients were operated. Of these, 1302 patients were operated for 1481 hernias of which 36.7% accounting as inguinoscrotal hernias. The percentage of operations performed by Nigerian staff increased from 31 to 55%. Overall, eighteen percent of the operations was solely performed by Nigerians. Totally, we averted 8092.83 DALY's accounting for 5.46 DALY's per hernia. CONCLUSION: The presented missions contribute significantly to an improvement in local healthcare and decrease the burden of disease. We were able to show the sustainable character of these surgical missions. As a next step, we will analyse the cost-effectiveness of MSTs.

Efficacy of a novel formulation of metaflumizone plus amitraz for the treatment of sarcoptic mange in dogs.

A novel spot-on formulation containing metaflumizone plus amitraz (ProMeris/ProMeris Duo for Dogs, Fort Dodge Animal Health, Overland Park, KS) was evaluated for efficacy against sarcoptic mange mites in naturally infested dogs. Sixteen dogs were allocated to two equal groups and were housed individually. Eight of the dogs were treated topically with metaflumizone plus amitraz at the proposed minimum dose rate (20mg/kg of each of metaflumizone and amitraz, at a dose volume of 0.133ml/kg) on Days 0 and 28. The other eight were treated with metaflumizone plus amitraz at the proposed minimum dose rate on Days 0, 14, 28 and 42. To enumerate Sarcoptes scabiei mites, skin scrapings were taken on each of Days 2, 14, 28, 42 and 56. Clinical signs of mange and the extent of sarcoptic lesions were evaluated on each dog when scrapings were made. Evaluation of the efficacy of the treatment was based on the absence of mites supported by the absence of clinical signs associated with canine sarcoptic mange. Treatment with metaflumizone plus amitraz at the minimum proposed dose rate at monthly (two treatments) or two-weekly (four treatments) intervals resulted in a rapid reduction of mites and improved clinical signs. The overall cure rates at Day 56, based on zero mite counts and/or resolution of clinical signs were 75% and 83% of dogs for the monthly and two-weekly regimens, respectively.

Efficacy of a novel formulation of metaflumizone plus amitraz for the treatment of demodectic mange in dogs.

A novel spot-on formulation containing metaflumizone plus amitraz (ProMeris/ProMeris Duo for Dogs, Fort Dodge Animal Health, Overland Park, KS) was evaluated for efficacy against demodectic mange mites in naturally infested dogs. Sixteen dogs were allocated to two equal groups and individually housed. Eight of the dogs were treated topically with metaflumizone plus amitraz at the proposed minimum dose rate (20mg/kg of each of metaflumizone and amitraz, 0.133ml/kg) on Days 0, 28, and 56. The other eight were treated with metaflumizone plus amitraz at the proposed minimum dose rate on Days 0, 14, 28, 42, 56, and 70. Mite numbers were estimated from skin scrapings taken on Days -3 to -1, 28, 56, and 84. Clinical signs of mange and the extent of demodectic lesions on each dog were evaluated when skin scrapings were conducted. Efficacy of the treatment was based on a reduction in mite numbers and an assessment of the clinical signs associated with canine demodectic mange. Treatment at monthly or two-weekly intervals for 3 months resulted in a rapid reduction in mite numbers (>94 and >99% for the monthly and two-weekly treatments, respectively) and an improvement in clinical signs. Success rates, based on zero mite counts in skin scrapings at Day 84 were 42.9 and 62.5% of dogs for the monthly and two-weekly regimens, respectively.

Birds as hosts of immature ixodid ticks in Free State Province, South Africa.

The objective of this study was to determine the species spectrum of ixodid ticks infesting birds in Free State Province, South Africa. To this end a large number of birds belonging to several species were examined for ticks and a total of 180 birds belonging to 39 species at 17 localities were infested, and ticks belonging to eight species were recovered. The immature stages of only two, namely Amblyomma marmoreum and Hyalomma marginatum rufipes, were sufficiently prevalent and numerous to safely assume that they regularly use birds as hosts. Helmeted guineafowls, Numida meleagris, were the most heavily infested and one harboured a total of 319 larvae and four nymphs. Amongst the other species an eastern clapper lark, Mirafra fasciolata, was infested with 69 larvae and a nymph, but no other bird harboured more than 40 ticks. The larvae and nymphs of H. m. rufipes were most numerous on birds from April to August.

The efficacy of an imidacloprid/moxidectin combination against naturally acquired Sarcoptes scabiei infestations on dogs.

The study was undertaken to evaluate and compare the efficacy of an imidacloprid (10% w/v)/moxidectin (2.5% w/v) combination (Advocate Bayer HealthCare, Animal Health) with that of selamectin for the treatment of Sarcoptes scabiei on dogs. Thirty naturally infested dogs, of which one was later withdrawn because of distemper, were allocated to two equal groups and individually housed. The dogs in each group were treated twice, four weeks apart, with either the combination product (0.1 mL/kg body weight) or with selamectin (0.05 mL/kg body weight) administered topically. Skin scrapings were made every 14 days over a period of 50 to 64 days after the first treatment to quantify mite numbers. Clinical signs and the extent of sarcoptic lesions were assessed on each dog when skin scrapings were made. Efficacy was based on the presence or absence of mites, supported by clinical signs associated with canine sarcoptic mange. From Day 22 and onwards no Sarcoptes mites were found in the skin scrapings of any of the treated dogs. Treatment with the imidacloprid/moxidectin formulation or with selamectin was highly effective against Sarcoptes scabiei and resulted in an almost complete resolution of clinical signs within 50 to 64 days after the initial treatment.

Microvascular reconstruction of facial defects in settings where resources are limited.

The surgical treatment of defects caused by noma is challenging for the surgeon and the patient. Local flaps are preferred, but sometimes, because of the nature of the disease, there is not enough local tissue available. We describe our experience of free tissue transfer in Ethiopia. Between 2008 and 2014, 34 microsurgical procedures were done over 11 missions with the charity Facing Africa, predominantly for the treatment of defects caused by noma (n=32). The mean duration of operation was 442 minutes (range 200 - 720). Six minor wound infections were treated conservatively and did not affect outcome, a return to theatre was required in 4 patients with wound infections and one with a haemorrhage; 2 flaps failed and 2 partially failed, one patient developed an oronasal fistula, and one had an infection at the donor site that required a repeat graft. In settings where resources are limited, free flaps can be used when local tissue is not available and they cause less morbidity than pedicled tissue transfer.

Small mammals as hosts of immature ixodid ticks.

Two hundred and twenty-five small mammals belonging to 16 species were examined for ticks in Free State, Mpumalanga and Limpopo Provinces, South Africa, and 18 ixodid tick species, of which two could only be identified to genus level, were recovered. Scrub hares, Lepus saxatilis, and Cape hares, Lepus capensis, harboured the largest number of tick species. In Free State Province Namaqua rock mice, Aethomys namaquensis, and four-striped grass mice, Rhabdomys pumilio, were good hosts of the immature stages of Haemaphysalis leachi and Rhipicephalus gertrudae, while in Mpumalanga and Limpopo Provinces red veld rats, Aethomys chrysophilus, Namaqua rock mice and Natal multimammate mice, Mastomys natalensis were good hosts of H. leachi and Rhipicephalus simus. Haemaphysalis leachi was the only tick recovered from animals in all three provinces.

Elephant shrews as hosts of immature ixodid ticks.

Two hundred and seventy-three elephant shrews, consisting of 193 Elephantulus myurus, 67 Elephantulus edwardii and 13 animals belonging to other species, were examined for ixodid ticks at 18 localities in South Africa and Namibia. The immature stages of Ixodes rubicundus, Rhipicentor nuttalli, Rhipicephalus warburtoni and a Rhipicephalus pravus-like tick were the most numerous of the 18 tick species recovered. Substantial numbers of immature Rhipicephalus arnoldi, Rhipicephalus distinctus and Rhipicephalus exophthalmos were also collected from elephant shrews at particular localities. Larvae of I. rubicundus were most numerous on E. myurus in Free State Province from April to July and nymphs from June to October. Larvae of R. nuttalli were most numerous on these animals during April, May, August and September, and nymphs in February and from April to August. The immature stages of R. warburtoni were collected from E. myurus only in Free State Province, and larvae were generally most numerous from December to August and nymphs from April to October.

Katkor cat litter, a non-invasive method of collecting cat urine for phosphate determination.

This study was done to compare the collection of cat urine, for phosphate concentration determination, by catheterisation with that via a proprietary cat litter (Katkor). The passage of urine through the litter or its retention in the litter for a period of 2 hours did not affect the concentration of phosphates compared with that of the original sample. Apart from a small volume of urine trapped in the litter by capillary action, and some urine adhering to the funnel in which the litter was placed, the litter proved to be an excellent medium for routine urine collection from cats, and more especially as an alternative to catheterisation when regular collection from a particular cat is required.

Efficacy of orally administered powdered aloe juice (Aloe ferox) against ticks on cattle and ticks and fleas on dogs.

The efficacy of orally administered powdered aloe juice (Aloe ferox) was evaluated against ticks on cattle and against ticks and fleas on dogs. Twelve calves were each infested over a 25-day period with approximately 4000 larvae of Rhipicephalus (Boophilus) decoloratus and allocated to 3 groups of 4 calves each. Three days after the last larval infestation and daily for 22 days thereafter, the calves in 1 group were fed 5 mg/kg body weight and those in another 25 mg/kg body weight of powdered aloe juice incorporated in game maintenance pellets, while the animals in the 3rd group received only pellets. Detached female ticks were collected daily and counted and the weights and the fertility of groups of 50 engorged female ticks collected from the animals were ascertained. The powdered aloe juice in the game maintenance pellets had no effect on the tick burdens of the calves or on the fertility of the ticks. Six dogs, in each of 2 groups, were treated daily for 15 consecutive days, commencing on Day -5 before the 1st tick infestation, with either 0.39 g or 0.74 g of powdered aloe juice, administered orally in gelatin capsules, while a 3rd group of 6 dogs served as untreated controls. All the dogs were challenged with Haemaphysalis leachi on Days 0 and + 7, and with Ctenocephalides felis on Days + 1 and + 8, and efficacy assessments were made 1 day after flea and 2 days after tick challenge, respectively. Treatment was not effective against ticks or fleas on the dogs.

Seasonal occurrence and production effects of the biting louse Damalinia limbata on Angora goats and 2 treatment options.

Adult biting lice Damalinia limbata (Gervais 1844) were most numerous on Angora goats in southwestern Free State Province from November to May with the smallest numbers present during August. Nymphs were most numerous from January to March with the smallest numbers present during July. The largest proportion of adult lice was present on the ventral surface of goats during winter, when population numbers were lowest, and the largest proportion of nymphs during summer, when population numbers were highest. Infestation did not affect the body weight of goats, but adversely affected both the quantity and quality of mohair produced. A single treatment with deltamethrin, applied as a pour-on along the mid-line of the backs of the goats, effectively controlled infestation and resulted in a significant increase in mohair production compared with untreated goats. Deltamethrin sprayed along the sides of the animals was equally effective in controlling infestation.

Total reconstruction of the nose in settings where resources are limited.

We describe a series of 8 patients who had total reconstruction of the nose during 4 separate missions to Ethiopia. The aetiology was noma (n=3), assault (n=2), acid burn (n=1), squamous cell carcinoma (n=1), and a sequela of meningococcal septicaemia (n=1). Reconstruction was with forehead flaps when adequate tissue was available (n=6) and with radial forearm flaps when it was not (n=2). Some reconstructive approaches require procedures to be done in stages, and in settings where resources are limited, difficulties with the continuity of care and provision for the management of complications, must be overcome.

Effect of moderate dietary protein restriction on the progression of overt diabetic nephropathy: a 6-mo prospective study.

To assess whether moderate dietary protein restriction can delay the progression of overt diabetic nephropathy, 22 subjects with insulin-dependent diabetes mellitus were randomly assigned to an unrestricted protein diet (> 1.6 g.kg body wt-1.d-1) or a moderately protein-restricted diet (0.8 g.kg body wt-1.d-1) and followed prospectively for six mo. Direct isotope methods were used to assess renal function. Protein intake was assessed by measurement of urinary urea nitrogen. The two groups were well-matched for age, sex, duration of diabetes, glycemic control, blood pressure, and degree of renal insufficiency. Patients consuming the unrestricted protein diet (n = 11) showed a progressive decline in glomerular filtration rate of 1.3 mL.min-1.mo-1 with no change in proteinuria. Patients consuming the moderately protein-restricted diet showed a marked decrease in the degree of proteinuria (2.15-1.13 g/d, P = 0.036) and a stabilization of glomerular filtration rate. This occurred independently of changes in blood pressure or glycemic control. Moderate dietary protein restriction can ameliorate progression of overt diabetic nephropathy.

Percutaneous delivery of carbamazepine and selected N-alkyl and N-hydroxyalkyl analogues.

Advantages associated with the transdermal delivery route are well documented, but in the past scientists have concentrated primarily on means of decreasing the barrier function of the skin for improved permeability. Pro-drugs, which possess more favourable physicochemical properties for improved transdermal permeability may have considerable potential. These have been considered in the past but recent information concerning structure activity relationships in dermal penetration has prompted increased interest. During this study, N-methyl (2), N-ethyl (3) and N-(2-hydroxyethyl) carbamazepine (4) analogues were synthesised for transdermal evaluation.

The dispersion of the Karoo paralysis tick, Ixodes rubicundus, within a naturally infested population of sheep in South Africa.

The ratio of variance to mean (s2/means) of numbers of Ixodes rubicundus (males and females) per sheep was used as a measure of the dispersion pattern of this tick within a naturally infested population of sheep. Sheep were divided into two groups, one with previous contact with I. rubicundus and the other with no previous contact. Samples of 10 sheep from each group were searched for ticks on a weekly basis for 19 weeks during the winter of 1986. In each group, both male and female ticks had an s2/means ratio greater than 1 for the majority of observation periods indicating an aggregated dispersion pattern. The degree of aggregation was greater with increasing density of the ticks. The implications of these results are discussed both in relation to sampling procedures and potential control strategies.