Open abdominal wall defects and open spina bifida at a regional hospital in northern KwaZulu-Natal - bellwether conditions for neonatal surgery capacity.

BACKGROUND: Abdominal wall defects (AWDs), such as gastroschisis and omphalocele, and neural tube defects (NTDs) such as open spina bifida (SB) are common congenital anomalies. These anomalies are considered a leading cause of neonatal mortality and have been advocated as bellwether conditions to measure access to surgical care. METHODS: Newborns with open SB or AWD presenting to the nursery at Queen Nandi Regional Hospital over four years (2018-2021) were retrospectively identified. Clinical and electronic database records were reviewed to determine if transfers to definitive tertiary care occurred timeously. Reasons for delays and associated morbidity and/or mortality were investigated. RESULTS: Sixty-five patients were identified and two were excluded due to unavailable or incomplete records. It took a median of 8 days (IQR 2-18 days) to reach tertiary care, with SB cases waiting significantly longer (median 16 days,IQR 8-25 days) (p = 0.000). Lack of tertiary service capacity was the main reason for delays. The COVID-19 pandemic did not affect time intervals (p = 0.676). Complications were common and overall mortality at our facility was high (n = 11/63, 17.46%). CONCLUSION: Newborns with open SB or AWDs experience marked delays in reaching definitive care. This is more pronounced for cases of SB and was not influenced by the pandemic. Lack of tertiary service capacity (including bed availability, limited staff, and theatre time) is the most important limiting factor.

COVID-19 and HIV viral load suppression in children andadolescents in Durban, South Africa

Background: The coronavirus disease 2019 (COVID-19) pandemic poses challenges to paediatric and adolescent HIV treatment programme. Modelling exercises raised concerns over potential impact of disruptions. Objectives: To describe the impact of the COVID-19 pandemic on viral load (VL) testing among infants, children and adolescents on antiretroviral treatment (ART) in Durban, South Africa. Method: Routinely collected, aggregated data of monthly VL counts done on all those less than 19 years old from January 2018 to January 2022 was analysed. An interrupted time series analysis using a Prais-Winsten linear regression model, including terms for lockdowns and excess mortality determined VL trends. Results: The unadjusted mean VL was 2166 (confidence interval [CI]: 252.2) and 2016 (CI: 241.9), P = 0.039, and percentage VL suppression rates (72.9%, CI: 2.4% vs 73.6%, CI: 1.8%) across COVID and pre-COVID periods, showing no significant difference, P = 0.262. In the interrupted time series analysis, modelled monthly VL counts did not differ significantly by lockdown level (e.g., level 5 lockdown: ­210.5 VLs, 95% CI: ­483.0 to +62.1, P = 0.138) or excess mortality (­0.1, 95% CI: ­6.3 to 6.1, P = 0.969). A significant downward trend in VL testing over time, including during the pre-COVID-19 period (­6.6 VL per month, 95% CI: ­10.4 to ­2.7, P = 0.002), was identified. Conclusion: Viral load suppression for children and adolescents were not negatively affected by COVID-19. A trend of decrease in VL testing predated COVID-19. What this study adds: Evidence presented that HIV VL testing and suppression rates in children and adolescents in a high burden setting were sustained through the COVID pandemic.

Diagnostic challenges with acellular bacterial meningitis.

An immunocompetent adult presenting with acellular pneumococcal meningitis is a rare occurrence and may pose a diagnostic challenge.

The introduction of an acute physiological support service for surgical patients is an effective error reduction strategy.

INTRODUCTION: Acute surgical patients are particularly vulnerable to human error. The Acute Physiological Support Team (APST) was created with the twin objectives of identifying high-risk acute surgical patients in the general wards and reducing both the incidence of error and impact of error on these patients. A number of error taxonomies were used to understand the causes of human error and a simple risk stratification system was adopted to identify patients who are particularly at risk of error. RESULTS: During the period November 2012-January 2013 a total of 101 surgical patients were cared for by the APST at Edendale Hospital. The average age was forty years. There were 36 females and 65 males. There were 66 general surgical patients and 35 trauma patients. Fifty-six patients were referred on the day of their admission. The average length of stay in the APST was four days. Eleven patients were haemo-dynamically unstable on presentation and twelve were clinically septic. The reasons for referral were sepsis,(4) respiratory distress,(3) acute kidney injury AKI (38), post-operative monitoring (39), pancreatitis,(3) ICU down-referral,(7) hypoxia,(5) low GCS,(1) coagulopathy.(1) The mortality rate was 13%. A total of thirty-six patients experienced 56 errors. A total of 143 interventions were initiated by the APST. These included institution or adjustment of intravenous fluids (101), blood transfusion,(12) antibiotics,(9) the management of neutropenic sepsis,(1) central line insertion,(3) optimization of oxygen therapy,(7) correction of electrolyte abnormality,(8) correction of coagulopathy.(2) CONCLUSION: Our intervention combined current taxonomies of error with a simple risk stratification system and is a variant of the defence in depth strategy of error reduction. We effectively identified and corrected a significant number of human errors in high-risk acute surgical patients. This audit has helped understand the common sources of error in the general surgical wards and will inform on-going error reduction initiatives.

The need for versatility in the prosthodontic treatment of maxillofacial defects.

The main objective of this study was to survey the different maxillofacial defects of patients who presented to the Wits Dental Hospital and to review the methods that have been used to rehabilitate these patients. Forty six patient records were retrieved from patients' files and from final year reports of prosthodontic postgraduate students. The data were used to determine the type of maxillofacial defects that these patients suffered from and the treatment that had been carried out. Duration and cost of treatment was also noted. The study showed that the majority of the patients' defects were caused by cancer resections, followed by trauma, clefts, burns, and infection. Most patients received conventional 'appropriatech' treatments such as the use of adhesive-retained prostheses, whilst a small number received more sophisticated 'high tech' treatments of implant rehabilitation. The need for versatility in the prosthodontic treatment of maxillofacial defects.

The Medical Management of Opioid Dependence in South Africa

Objective : With the increase in opioid dependence in South Africa; medical practitioners are increasingly confronted with requests to treat patients with opioid use disorders. Many medical practitioners; however; do not possess the required knowledge and skills to effectively deal with these patients. An overview of the medical treatment of opioid dependence is provided. Method : A working group of key doctors working in the field of substance dependence; was elected at an Opioid Experts Meeting and compiled guidelines for the management of opioid dependence. This article provides a summery of these guidelines. Recommendations are based on current best practice as derived from scientific evidence and consensus of the working group. It should never replace individual clinical judgment

Self-actualization of youth in a summer camp.

The self-actualization scores of 57 youths who attended a summer day camp for gifted students were assessed using the Reflections Of Self by Youth (ROSY). Significant sex differences were confirmed. Contrary to Lewis's significant difference (1996) in mean self-actualization between Grades 7 and 8, self-actualization scores in this study were uncorrelated with grade.

Nifedipine-induced gingival hyperplasia: non-surgical management of a patient.

A clinical report of nifedipine-induced gingivitis in a medically compromised patient is presented. This case history also describes the challenges faced by the oral health practitioner to develop an appropriate regimen of treatment for a patient in whom neither withdrawal of the drug nor substituting for it was feasible, and periodontal surgery was contra-indicated.

Congenital ameloblastic fibroma in association with oculoauriculovertebral spectrum.

Although orodental anomalies have been reported to occur in patients with oculoauriculovertebral spectrum, no previous publications in the English literature have been located that describe an ameloblastic fibroma in a patient with this condition. This report presents a 15-month-old female monozygotic twin with concomitant oculoauriculovertebral spectrum and a congenital ameloblastic fibroma of the mandible. A theory linking the pathogenesis of the two conditions is also raised.

An evaluation of the mean cephalometric values for orthognathic surgery for black South African adults. Part 1: Hard tissue.

Maxillofacial and oral surgeons and orthodontists are currently treating an increasing number of black South African patients needing orthognathic surgical procedures. Surgical and orthodontic cephalometric analyses developed for caucasian populations has been shown to be inadequate for other racial groups (Connor and Moshiri, 1985, Briedenhann and Roos, 1988 and Flynn, Ambriogio and Zeichner, 1989). The purpose of this study was to evaluate mean measurements for black South African adults which would be comparable in diagnosis and treatment planning, to the analyses of Burstone et al., (1978) and Legan and Burstone (1980), known as Cephalometrics for Orthognathic Surgery (COGS). Lateral cephalometric radiographs of 15 male and 15 female black South African adults were evaluated for both hard and soft tissue measurements according to parameters of the COGS analyses. The results of this study showed that the cephalometric measurements established for North American caucasians by Burstone et al., (1978) and Legan and Burstone (1980) were at variance to those measurements found in a black South African population group. Thus orthodontic and orthognathic surgical treatment planning for black South Africans may be more relevant if the diagnosis is based on standard measurements specific for this particular racial group.

Morphometric analysis of the insertion of the upper head of the lateral pterygoid muscle.

OBJECTIVE: This article reports on the morphometric characteristics of the upper head of the lateral pterygoid muscle. STUDY DESIGN: Several morphologic characteristics were initially examined in 40 postmortem specimens. The length of the upper head of the lateral pterygoid muscle was determined in 34 specimens. Of the 26 specimens in which the upper head of the lateral pterygoid muscle was found to be inserted into the meniscus and condyle, 22 specimens were examined microscopically to morphometrically quantify the proportion of muscle fibers to their respective insertions. RESULTS: The upper head of the lateral pterygoid muscle was approximately 33.3 mm in length and was significantly longer in males. There were no age-related differences. Approximately 29.5% of the fibers of this muscle were inserted into the meniscus of the temporomandibular joint. CONCLUSION: This study demonstrated that the insertion of the upper head of the lateral pterygoid muscle to the meniscus ranged from a fleshy mass to a few fibers. The number of fibers entering both the meniscus and the condyle decreased correspondingly as they approached the joint and could be interpreted as this muscle having a tendon of insertion into the meniscus.

Third molar surgery in general dental practice.

A survey to determine the treatment procedures adopted by general dental practitioners for the removal of impacted third molar teeth was undertaken. Questionnaires were mailed to a sample of 100 practising dentists. Of the 67 per cent that responded, 41.8 per cent (28) indicated that they would attempt the procedure while the remaining 51.2 per cent (39) would not do so. Neither the length of professional experience nor whether they practised in metropolitan or country areas had a bearing on whether the impacted tooth would be removed or not. In general, South African general dental practitioners routinely removed overlying bone by means of a bur, sutured the mucosal incision wound, prescribed antibiotics, analgesics and a mouthwash, and recalled their patients for a post-operative review. Steroids were not prescribed.

Congenital dermoid cyst of the tongue.

True dermoid cysts of the oral cavity are rare, usually presenting as midline swellings in the floor of the mouth and occasionally elsewhere in the oral cavity. This report describes the diagnosis and management of a congenital dermoid cyst of the lateral aspect of the body of the tongue in a 10-year-old girl. The theories of the pathogenesis of this cyst during embryogenesis of the tongue are also reviewed.

An evaluation of the mean cephalometric values for orthognathic surgery for black South African adults. Part II: Soft tissue.

In Part I of a two-part study, the mean measurements of hard tissue cephalometric values for orthognathic surgery for a selected sample of black South African adults were compared to the values recorded Burstone et al (1978) for caucasian North Americans and the values reported by Flynn, Ambrogio and Zeichner (1989) for African-Americans. Part II of this study compares the mean soft tissue cephalometric values for orthognathic surgery in black South African adults with the population groups studied by Legan and Burstone (1980) and Flynn et al (1989). Significant variations were found mainly in and around the mouth, the naso-labial angle and the angle of the throat of black South Africans when compared to caucasian North Americans (Legan and Burstone, 1980) and African-Americans (Flynn et al, 1989). The findings of this study may be useful in providing racially specific mean cephalometric values in the planning and treatment of dento-skeletal surgery in black South African adults.

Oral health finance and expenditure in South Africa.

The objective of this paper was to examine the cost of oral health in South Africa over the past decade Particular emphasis was placed on the contribution made by medical schemes which is the main source of private health care funding. Some of the problems facing this huge industry were also briefly explored. Primary aggregate data on oral health expenditure were obtained from the Department of Health, Pretoria and from the offices of the Registrar of Medical Schemes, Pretoria. The results show that in 1994, 4.7 per cent of the total health care budget was allocated to oral health. Of this amount, 14.2 per cent came from the state, 71.9 per cent from medical schemes and the remainder calculated to be from direct out-of-pocket payments. Furthermore, real expenditure for oral health by medical schemes grew robustly and almost continuously from 1984 through to 1994, generally outstripping medical inflation.

Lateral pterygoid muscle and its relationship to the meniscus of the temporomandibular joint.

OBJECTIVE: The theory of internal derangement of the temporomandibular joint involves the anterior displacement of the meniscus, which is thought to be the result of hyperactivity of the lateral pterygoid muscle. There is, however, a great deal of confusion with respect to the attachment of this muscle to the meniscus. This anatomic study reexamines the meniscal attachment of the lateral pterygoid muscle, in particular, the upper head of this muscle. STUDY DESIGN: The anatomic relationship between the lateral pterygoid muscle and the meniscus was examined in the postmortem specimens of 25 males and 15 females between the ages of 7 to 85 years. RESULTS: In 65% of specimens, the upper head of the lateral pterygoid muscle was attached to the medial aspect of the capsule, meniscus, and to the pterygoid fovea of the condyle. In 27.5% of specimens, the upper head was attached solely to the condyle; in the remaining 7.5% of cases, there were other types of attachments of the lateral pterygoid muscle to the meniscus. CONCLUSION: This study confirms that the lateral pterygoid muscle has a variable attachment to the meniscus. The role of this muscle in the displacement of the meniscus is still unknown and further research into temporomandibular disorders should involve the investigation of other structures in the craniomandibular complex.

Third molar surgical procedures: practices by maxillofacial and oral surgeons in South Africa.

An audit of the treatment procedures routinely adopted by maxillofacial and oral surgeons for the removal of impacted third molars under general anaesthesia was undertaken in South Africa. Most maxillofacial and oral surgeons agree on the method of bone removal, the prescribing of antibiotics, analgesic agents and mouthwashes, the suturing of the incision wound and the post-operative review of patients. The results were compared to a similar study undertaken by Falcon and Roberts (1992) in the UK. With the exception of the method of bone removal, maxillofacial and oral surgeons in both groups share a similar approach to the treatment procedures adopted in the removal of impacted third molars. Some variability, however, existed in both studies with regard to the use of intra-operative local anaesthetic agents, the administration of peri-operative steroids and the use of non-steroidal anti-inflammatory agents.