Biochemical markers in emergency thoracic surgery in penetrating trauma.

BACKGROUND: Violent interpersonal acts account for a large proportion of unnatural deaths in South Africa. A significant proportion of unnatural deaths are due to penetrating thoracic trauma and preventable haemorrhage. Current indications for emergent thoracotomy are unreliable. We propose the use of lactate, shock index (SI) and base deficit (BD) as a triage tool in patients with penetrating thoracic injuries to identify those requiring surgical intervention. METHODS: A review of the trauma registry of the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) was carried out between March 2011 and March 2016. Four hundred and ninety (490) patients were collected consisting of a non-operative group of 246 patients and an operative group of 244 patients. We compared lactate, SI and BD independently and within panels to ascertain which would best predict the need for operative intervention in these patients. Abnormal was defined as lactate ≥ 4 mmol/l, SI ≥ 0.8 and BD ≤ -4 mmol/l. RESULTS: Of the 490 patients, lactate (p < 0.001), SI (p < 0.001) and BD (p < 0.001) differed significantly between operative and non-operative groups. Statistical significance was lost (p = 0.34) once BD was analysed in combination with lactate and SI. Lactate alone was a strong predictor of the need for intervention (area under the curve (AUC) = 0.814). The strongest predictor was a combined panel of lactate and SI (AUC = 0.8308, p < 0.001). CONCLUSION: Lactate and SI in combination are useful as triage tools, and could assist in decision making, by predicting which patients are more likely to require surgical intervention.

The association between cytology and histopathology in thyroid nodules over a 6-year period in an urban hospital in South Africa.

BACKGROUND: Thyroid cancer is prevalent both internationally and locally, and is the most common cause of endocrine malignancies in Africa. The prognosis of thyroid cancer in general is quite good, but to achieve good outcomes, appropriate methods for diagnosis are important. A cytology result obtained from a fine needle aspiration and biopsy (FNAB) is one such method, and is less invasive and has less risk compared with obtaining a histological result via open surgery. However, there are accuracy differences that have been reported in different literature findings. OBJECTIVES: To determine the diagnostic accuracy rate of thyroid FNAB compared with histopathological samples at an urban hospital in South Africa (SA), and compare this with international standards. METHODS: A retrospective observational study was conducted of patients who had undergone both FNAB and thyroidectomies at Helen Joseph Hospital, Gauteng Province, SA, a public tertiary hospital, between 1  January 2016 and 31  December 2021. Various analytical methods were used, including Poisson generalised linear model, binomial generalised linear model, a two-proportion z-test, McNemar's test and the F1 score. RESULTS: There were 164 participants in this study who were between the ages of 21 and 82 years old. Thirty-six records were excluded for use as a comparison between cytology and histology, as they were in Bethesda categories 1, 3 and 4. Out of the 128 records that were compared, there was statistically significant agreement v. non-agreement between cytology and histology findings for thyroid nodules (109  v. 19, p<0.001, respectively). A comparison between our sample population and internationally published standards in terms of rate of malignancy noted that our rate of malignancy was slightly higher in Bethesda 2 patients (5.88%) v. internationally published standards (0 - 3%), and slightly lower in Bethesda 4 (23.52%) and 6 (77.77%) v. internationally published standards (25 - 40% and 97 - 99%, respectively. CONCLUSION: There was good correlation between cytology and histology for thyroid nodules. Differences were noted between the percentage of malignant cases in the different Bethesda categories compared with international standards as noted above. We recommend that further studies are conducted locally to improve knowledge on this topic.

A long walk to freedom: the epidemiology of penetrating trauma in South Africa - analysis of 4 697 patients over a six-year period at Chris Hani Baragwanath Academic Hospital.

BACKGROUND: Despite the city of Johannesburg having one of the highest rates of crime in the world, no national databank for trauma exists. This study profiles the victims of penetrating trauma and identifies geographical areas in which it occurs, while describing the outcomes and patterns of injury. METHODS: A retrospective study including penetrating trauma patients triaged as Priority 1, presenting at the Chris Hani Baragwanath Academic Hospital's (CHBAH) trauma department over a six-year period (2011-2016). RESULTS: A total of 4 697 patients were included. The majority of victims were Black African males (92.1%) between the ages of 29-40 years, and stabbings were the most common mechanism of injury (71.8%), followed by gunshots. The commonest body area affected was the thorax, with a consequent haemothorax the most likely result. Weekends accounted for over 48% of all presentations - the last weekend of the month being the busiest. Region D was the area in Johannesburg with the highest trauma incidence (51.9%), with the oldest townships in Soweto found to be "hot spots". CONCLUSION: Penetrating trauma is inherently linked to alcohol abuse and interpersonal violence in South Africa,1 primarily affecting its young economic, working-class citizens. The data provided some insight into the burden, structure and challenges of our trauma system. These should be regarded as opportunities to implement change and improve our surveillance and prevention, beginning with a national trauma databank.

The epidemiology of traumatic brain injuries sustained by children under 10 years of age presenting to a tertiary hospital in Soweto, South Africa.

BACKGROUND: Traumatic brain injury (TBI) in the paediatric population is a significant contributor to death and disability worldwide. In sub-Saharan Africa, death and disability from TBI are still superseded by infectious disease. Mechanisms of injury differ by region and socioeconomics, but in general, falls, road traffic collisions (RTCs), being 'struck by/against objects' and non-accidental injuries (NAIs) are responsible for most cases. OBJECTIVES: To: (i) quantify the burden of TBI in terms of demographics, causes and severity; (ii) explore resource utilisation regarding length of stay, computed tomography (CT) brain scan use and multidisciplinary participation; (iii) interrogate possible temporal patterns of injury; and (iv) thus identify potential targets for community-based prevention strategies. METHODS: In a 5-year retrospective review of all children aged <10 years admitted with TBI between September 2013 and August 2018, demographics, date of injury, mechanism of injury, severity of TBI based on the Glasgow Coma Scale, and requirement for a CT brain scan were collected for each patient. Outcomes were reported as discharge, transfer or death. Outcomes for children sustaining isolated TBI were compared with those for children sustaining TBI with polytrauma. RESULTS: A total of 2 153 patients were included, with a mean (standard deviation) age of 4.6 (2.7) years and a male/female ratio of 1.7:1. RTCs were the most frequent cause of injury at 59% (80% of these were pedestrian-vehicle collisions), followed by falls at 24%. Mild TBIs accounted for 87% of admissions, moderate injuries for 6%, and severe injuries for 7%. Polytrauma was associated with increased severity of TBI. The cohort had a 2.3% mortality. NAIs accounted for 6% of injuries and carried a 4% mortality. The median (interquartile range) duration of hospitalisation was 1 (1 - 3) days, ranging from <24 hours to 132 days. CT scans were performed on 43% of admitted patients, and 48% of patients had consultations with another medical or allied medical discipline. Injuries were more frequent during the summer months and over weekends. Infants aged <1 year were identified as a group particularly vulnerable to injury, specifically NAI. CONCLUSIONS: Paediatric TBI was demonstrated to be a resource-intensive public health concern. From the results, we identified potential primary prevention targets that could perhaps be incorporated into broader community-based intervention programmes. We also identified a need to study long-term consequences of mild TBI further in our paediatric population.