The mortality rate of patients with open abdomen and contributing factors - a three-year audit in a major academic trauma unit.

BACKGROUND: Damage control surgery (DCS) is a widely used approach in trauma. An open abdomen carries complications, increased morbidity and mortality. This study aims to quantify the mortality rate, determine contributory factors and factors influencing the decision to perform DCS and assess morbidity in patients undergoing open abdomen. METHODS: A retrospective review was conducted on 205 patients in Charlotte Maxeke Johannesburg Academic Hospital Trauma Unit. The mortality rate was evaluated over a 24-hour, 7-day and 28-day period. Data were collected by a data collection sheet from 1 January 2016 to 31 December 2018. RESULTS: Of the 205 patients, 193 were male and the median age was 34.34 years. Penetrating trauma was the most predominant mechanism of injury in 162 (79%), with gunshot injuries seen in the majority (130/162). The mortality rate was 55/205 (26.8%) for open abdomen patients, 19/55 (34.5%) within the first 24 hours, 22/55 (40%) in the 24-hours to 7-days period, and 14/55 (25.4%) in the 8-day to 28-day period. Statistically significant factors contributing to mortality were haemodynamic instability, hypothermia, coagulopathy, massive transfusion, vasopressors, and significant associated injuries. Morbidities were entero-atmospheric fistula (EAF) in 7.3% (Clavien-Dindo grade IIIa), surgical site infection in 45.3% (Clavien-Dindo grade I) and ventral hernia in 10.24% (Clavien-Dindo grade IIIb). CONCLUSION: Most open abdomens were performed in males, with gunshot injuries being the most common mechanism. The majority of mortalities were within the 24-hours to 7-days period. The most common morbidity associated with an open abdomen was surgical site infection.

Baseline characteristics of 32 patients with Gaucher disease who were treated with imiglucerase: South African data from the International Collaborative Gaucher Group (ICGG) Gaucher Registry.

BACKGROUND: Gaucher disease (GD) is a rare inherited autosomal recessive metabolic disorder with a prevalence in the general population of ~1 per 100 000. To optimise the recognition, diagnosis and management of patients with GD in South Africa (SA), it is important to have an understanding of local patterns of presentation of the disease. OBJECTIVES: To describe the baseline pretreatment characteristics of the SA cohort of patients enrolled into the International Collaborative Gaucher Group (ICGG) Gaucher Registry whowere treated with imiglucerase (Cerezyme; Sanofi Genzyme). METHODS: The ICGG Gaucher Registry is an observational, longitudinal, international database that tracks the clinical, demographic, genetic, biochemical and therapeutic characteristics of patients with GD globally, irrespective of disease severity, treatment status or treatment choice. The study population included all SA patients reported in the ICGG Gaucher Registry as of 1 May 2020. RESULTS: The registry included 49 SA GD patients, of whom 32 received imiglucerase as first primary GD therapy. All the patients had GD type 1, 59.4% were female, and mean and median ages at diagnosis were 14.7 and 9.8 years, respectively. The most common genotype was N370S/N370S (37.5%). At treatment initiation, 30.0% of patients had been splenectomised. Among patients for whom data were available, anaemia was present in one-third of non-splenectomised patients and 12.5% of those with splenectomy, and moderate or severe thrombocytopenia was reported in two-thirds of non-splenectomised patients. Bone pain was present in 30.8% and 57.1% of non- splenectomised and splenectomised patients, respectively. No bone crises were reported, and data relating to other bone complications were available for only ≤3 patients. CONCLUSIONS: Haematological findings and bone pain in this group are similar to those in the global ICGG Gaucher Registry cohort. Lack of baseline data for other bone complications limits interpretation in that regard. Clinicians who treat patients with GD are encouraged to submit accurate, complete and up-to-date information so that comprehensive data for the subset of SA GD patients can be maintained to improve recognition and diagnosis, and guide appropriate and effective use of treatment for SA patients.

Severe gestational gigantomastia: management challenges.

SUMMARY: Gestational gigantomastia is rare and characterised by rapid and disproportionate enlargement of the breast during pregnancy. It often requires surgical removal of more than 1500 g of breast tissue. Of the 50 case reports published worldwide, not one was in South African literature. This unusual case report is of a female presenting with gigantomastia at five weeks gestational age. The patient was multiparous and decided to terminate the pregnancy due to the physical and emotional effects of the large, pendulous breasts. Management included breast reduction and free nipple grafting in a staged approach. The complications are briefly outlined. Despite rare presentation, patient satisfaction was achieved.

The functionality of African-specific variants in the TGFB1 regulatory region and their potential role in HIVAN.

BACKGROUND: Transcription of transforming growth factor beta-1 (TGF-ß1) is regulated by a polymorphic promoter region containing African-specific single nucleotide polymorphisms (SNPs). Some of these SNPs have higher frequencies among Southern Africans compared to other African populations and their functionality has only been partially studied. Due to the high prevalence of HIV-associated nephropathy (HIVAN) in Africans we hypothesized that functional African TGFB1-promoter SNPs may contribute to HIVAN pathogenesis. METHODS: The functionality of the TGFB1 -1347 C>T variant and African-specific variants (-1287 G>A, -1154 C>T, -387 C>T and -14 G>A) were examined by measuring reporter gene expression in kidney and fibroblast cell lines co-transfected with TGFB1-promoter constructs and an HIV-Tat expression vector. TGF-ß1 immunohistochemical staining was performed on kidney biopsies with HIVAN (n = 18) and compared to control biopsies without HIVAN or tubulointerstitial disease (n = 12) using semi-quantitative and digital image analysis. HIVAN cases were genotyped for TGFB1 -1347 and -387 SNP variants. RESULTS: TGFB1-promoter haplotypes containing the African -387 T-allele resulted in ~ five-fold repression of TGFB1-promoter activity compared to -387 C haplotypes (p ≤ 0.024). HIV-Tat upregulated TGFB1-promoter activity for haplotypes containing -1347 T and -387 T in transfected renal cells (≈ 1.6-fold; p ≤ 0.030) and fibroblasts (≈ 1.3-fold; p ≤ 0.016). The renal interstitium from HIVAN biopsies, compared to HIV-positive and -negative controls, differed in the semi-quantitative TGF-ß1 staining and digital optical density analyses. The TGFB1 -1347 and -387 genotypes in HIVAN cases were similar to population controls. CONCLUSION: African-specific haplotypes lower TGFB1-promoter activity and expression levels and HIV-Tat upregulates TGFB1 promoter activity irrespective of the haplotype.

The role of carbetocin in the prevention and management of postpartum haemorrhage.

Carbetocin is a new synthetic analogue of oxytocin. It has a longer half life than oxytocin. This review examines the current evidence for the use of carbetocin as an alternative to oxytocin, as a first-line agent in the pharmacological management of the third stage of labour.

Iron status determination in pregnancy using the Thomas plot.

INTRODUCTION: Physiological changes during pregnancy affect routine tests for iron deficiency. The reticulocyte haemoglobin equivalent (RET-He) and serum-soluble transferrin receptor (sTfR) assay are newer diagnostic parameters for the detection of iron deficiency, combined in the Thomas diagnostic plot. We used this plot to determine the iron status of pregnant women presenting for their first visit to an antenatal clinic in Bloemfontein, South Africa. METHODS: Routine laboratory tests (serum ferritin, full blood count and C-reactive protein) and RET-He and sTfR were performed. The iron status was determined using the Thomas plot. RESULTS: For this study, 103 pregnant women were recruited. According to the Thomas plot, 72.8% of the participants had normal iron stores and erythropoiesis. Iron-deficient erythropoiesis was detected in 12.6%. A third of participants were anaemic. Serum ferritin showed excellent sensitivity but poor specificity for detecting depleted iron stores. HIV status had no influence on the iron status of the participants. CONCLUSION: Our findings reiterate that causes other than iron deficiency should be considered in anaemic individuals. When compared with the Thomas plot, a low serum ferritin is a sensitive but nonspecific indicator of iron deficiency. The Thomas plot may provide useful information to identify pregnant individuals in whom haematologic parameters indicate limited iron availability for erythropoiesis.

Sepsis in obstetrics and the role of the anaesthetist.

Sepsis in pregnancy and the puerperium remains a significant cause of maternal mortality and morbidity worldwide. Major morbidity arising as a result of obstetric sepsis includes fetal demise, organ failure, chronic pelvic inflammatory disease, chronic pelvic pain, bilateral tubal occlusion and infertility. Early recognition and timely response are key to ensuring good outcome. This review examines the clinical problem of sepsis in obstetrics and the role of the anaesthetist in the management of this condition.

Dysphagia lusoria: a case of an aberrant right subclavian artery and a bicarotid trunk.

Dysphagia Lusoria is dysphagia secondary to an aberrant right subclavian artery that has a retroesophageal course. Adachi and Williams categorized aortic arch anomalies, showing that the right subclavian artery arising in this fashion (as the final branch of the descending aortic arch) is one of the more common. However, this very rarely coexists with a bicarotid trunk. We present such a case as it is manifested in a 36-year-old lady complaining of marked weight loss and dysphagia. The diagnosis remained elusive until a CT scan of the chest was performed; angiography further delineated the pathology. It is believed that the combination of the common carotid origins with the retroesophageal course of the aberrant vessel more frequently accounts for symptoms in the absence of an aneurysm of the origin of the aberrant vessel. Several techniques to manage the aberrant vessel have been described in the literature, but we favoured open ligation and transposition to the right carotid artery.

Improving tracheostomy care: a prospective study of the multidisciplinary approach.

OBJECTIVES: Suboptimal standards in tracheostomy care have been highlighted as a growing concern in view of the increasing demands for intensive care services. Our objective is to assess the impact of our model for tracheostomy care on patients with short-term tracheostomies (<4 months in situ) following their discharge from the intensive care unit. The model has three components: The St Mary's tracheostomy care bundle checklist, a dedicated tracheostomy multidisciplinary team and an educational programme. DESIGN: A 38-month prospective cohort study. SETTING: A London Teaching Hospital. PARTICIPANTS: A total of 102 patients with tracheostomy within the 19-month pre-intervention cohort and 95 patients in the 19-month post-intervention cohort. MAIN OUTCOME MEASURES: The number of clinical incidents, mean time taken for decannulation, mean total tracheostomy time and total number of days spent in the intensive care unit were assessed before and after the intervention. RESULTS: Time to decannulation following intensive care unit discharge decreased from 21 to 11 days, as did the mean total tracheostomy time, from 34 to 25 days (both statistically significant with a P < 0.0001 Mann-Whitney U-test). The number of critical incidents, which included all patients prior to exclusion, substantially declined following the introduction of intervention from 58 to 7 in the second year after intervention. CONCLUSIONS: A multidisciplinary care model significantly expedited the decannulation process and reduced the overall time that a tracheostomy was in situ. The intervention was associated with a reduction in clinical incidents and shorter intensive care unit admissions, which can be associated with significant monetary savings.

Low dose radiotherapy for adenotonsillar lymphoid hyperplasia in HIV-positive patients.

Lymphoid hyperplasia is common in HIV positive patients. The aim of this study was to determine the response to radiotherapy. Thirty-three adult patients with recurrent tonsillitis or upper airway obstruction due to tonsillar hyperplasia and conformed histology of follicular hyperplasia were included. Thirteen underwent a 24 Gy course of radiotherapy and were followed up for a minimum of 16 weeks post-radiotherapy. There was a statistically significant decrease in the median tonsillar size (95% confidence interval [-3;-2]) and in the median CD4 count (95% CI [3;152]) after 16 weeks. None of the patients had acute tonsillitis or airway obstruction after radiotherapy. Low dose radiotherapy is effective in the management of adenotonsillar hyperplasia in HIV positive patients.

Beliefs of grade six learners' regarding adolescent pregnancy and sex.

Escalating adolescent pregnancy and risky sexual behaviour is becoming more common amongst young adolescents and especially amongst black adolescents in South Africa. Statistics confirm that South African adolescents as young as fourteen are already sexually active and become pregnant. The decision to become sexually active with resulting adolescent pregnancy whether planned or not, are directly influenced by the teenager's beliefs. A person's beliefs consist of a person' own individual beliefs or attitude as well as what the individual subjective norm which the individual perceive as other people's beliefs regarding the same object of reason. The aim of the study was to describe the attitude of black grade six learners under the age of fourteen, towards adolescent pregnancy and sex. A quantitative descriptive research design was used. Results were clustered according to demographic variables as well as beliefs that consist of attitude and subjective norm. Findings provided insight into the beliefs of grade six learners regarding sex and adulthood, the roll of peer pressure, relationships of adolescent parents, social interaction of teenage parents, ability of adolescent parent's ability to provide in the needs of the baby, the adequacy of a child support grant to raise a baby as well as the levels of education of adolescent parents. This article provide a detailed reflection on these results and propose off a doll parenting intervention strategy as means of modification of attitude and subjective norms of grade six learners in order to alter sexual behaviour.

Occupational Exposure to Bloodborne Viruses amongst Medical Practitioners in Bloemfontein; South Africa

Background : The possibility of occupational exposure to bloodborne viruses such as HIV; hepatitis B virus (HBV) and hepatitis C virus (HCV) is an everyday reality to health care workers. This study reports on doctors' extent and outcome of exposure to bloodborne viruses in Bloemfontein. Methods : descriptive study was done. Doctors (n=441) actively involved in public and/or private medical practice were requested to anonymously complete a questionnaire regarding occupational exposure to bloodborne viruses (HIV; HBV; and HCV). Results : A response rate of 51.7 was obtained. More than half (54.2; 95 CI [ 47.7 ; 60.5 ]) of respondents were exposed to bloodborne viruses; 48.3 occurring with HIV positive patients and 4.3with known HBV positive patients; and no positive HCV patients. After exposure occurred; 68.9 of patients were tested for HIV; 10.9 for HBV and only 4.2 for HCV infection. The frequency of serological testing for doctors immediately after exposure was 65.3 for HIV; 21.7 for HBV and 8.2 for HCV. No seroconversion to HIV or HCV was reported; while two seroconversions to HBV were reported. Most exposures occurred as a result of needle stick injury (85) and occurred in the operating theatre during . The majority (59.8procedures 59.3)of exposed doctors did not take any prophylactic treatment and those who did; did not always complete the treatmentConclusion : The risk of seroconversion to HIV after occupational exposure was as expected; while seroconversion to HBV was less than expected. The lack of adequate follow up serological testing after occupational exposure is alarming. It is the responsibility of the occupationally exposed doctor to adequately comply with prophylactic measures and undergo serological testing to ensure the least possible risk of contracting infection from a bloodborne virus

Knowledge of and Attitude towards Pain Relief during Labour of Women Attending

Objective: This study determined women's knowledge of and attitudes to pain relief during labour. Methods : This descriptive study included 151 women; 18 years or older; attending the antenatal clinic of Cecilia Makiwane Hospital. Women were interviewed using a questionnaire that determined their knowledge of and attitudes regarding pain relief. Results : The median age of the women was 29 years and most was pregnant for a second or third time. More than half the women (56.3) indicated that they knew about pain relief and most had received their information from a previous labour experience (56.5) or from friends and relatives (55.3). Of the women who had knowledge of pain relief (n=85); 65.9 had experienced severe pain during previous labour and 65.3 indicated injections. Half the women (51.7) believed that they should experience mild pain; however; while 55.7 of these had found the experience to be unacceptable. Most women (59.8) who had been pregnant were not told what to expect when in labour. Of those who had been told (n=41); 75.6) and good (31.2 found the information useful. The women who had previously delivered in a health facility rated the service received in relieving labour pain as fair (47.3)). Most of the women (99.3) believed that the staff had an important role to play in helping to relieve labour pain. Most of the women (78) expressed no concern about problems associated with pain relief methods; while a large number (83.4)expressed little or no confidence in labour pain relief.Conclusion : Most of the women gained knowledge regarding pain relief from past experiences or from friends and relatives. Even though the few women who received information about what to expect during labour found the information useful; most expressed little confidence in labour pain relief

Good Short-Term Outcome of Kangaroo Mother care in Low Birth Weight Infants in a Rural South African Hospital

Objective: The aim of the study was to determine the outcome of kangaroo mother care (KMC) in low birth weight infants at a community hospital. Methods : This descriptive study included 87 mothers and their low birth weight infants who were in a stable condition and eligible for KMC at Dr JS Moroka Hospital; Thaba Nchu. The infants were assessed four times: at birth; twice during hospitalisation; and a week after discharge. Infants received breast milk exclusively.Results : Regarding the mothers' obstetric history (n=87); gravidity ranged from 1 to 7 (median 3); with a 43 incidence of miscarriage. The median birth weight of the infants (n=87) was 1.5 kg (first assessment); the discharge weight (third assessment) was 1.8 kg; and a week after discharge (fourth assessment) it was 2.2 kg. Initially the infants lost weight significantly from birth to the second assessment (95 CI for median decrease [-0.02; -0.01]); but significantly gained weight from the second to the third (95 CI for median decrease [0.27; 0.33]) and from the third to the fourth assessment (95 CI for median decrease [0.32; 0.45]). Approximately half (49) of the infants had developed jaundice by the time of second assessment. These babies had a significantly lower birth weight [0.12;0.30]. Conclusion : Our findings confirm that infants with a low birth weight treated with KMC can have a good growth pattern; and exclusive breast milk is sufficient to guarantee such growth. Kangaroo mother care is a safe method for stable infants with a low birth weight in a community hospital

Nutritional Status of Disabled Schoolchildren in Bloemfontein (2002 - 2003)

Objectives. To assess the nutritional status of disabled schoolchildren using anthropometric measures and dietary intake; and to compare estimated energy expenditure with energy intake and body weight.Design. A descriptive; cross-sectional survey was undertaken.Setting. The study was conducted at three Bloemfontein schools for disabled children (Tswellang: physically disabled; Pholoho: mentally disabled; Martie du Plessis: both mentally and physically disabled).Subjects. Subjects included a random selection of 145 boys and girls aged 8 - 15 years.Outcome measures. Standard methods were used to determine height; demi-span; knee-height; weight; midupper arm circumference and triceps skinfolds. A 24-hour recall combined with a food frequency questionnaire and 7-day weighed food record were used to determine usual dietary intake of day scholars and hostel scholars respectively. Resting energy expenditure (REE) was calculated for each child using Shofield equations. Total energy expenditure (TEE) was calculated by multiplying the appropriate physical activity level (PAL) factor by REE. Results. The high prevalence of stunting (weight-for-height -2 standard deviations (SD)) (Tswellang 47.7; Pholoho 37.3); and underweight (weight-for-age -2 SD) (Tswellang 29.8; Pholoho 18.7) was a matter of concern. Although median energy intake was slightly lower than the recommended intakes; median protein intake tended to be adequate; while micronutrient intake was low. Median energy intake determined by the 24-hour recall tended to be lower (Pholoho -769 kJ) or nearly the same (Tswellang 327 kJ) as the calculated TEE (PAL1.2 - 1.8).Conclusion. Nutrient density and texture of the children's diet should be monitored to improve nutritional status. In future studies more accurate methods should be used to determine energy intake and expenditure

Patients' satisfaction with government health care and services in the Taung district, North West Province.

This was a descriptive study that determined patients' satisfaction with health care in the Taung district state health institutions, North West Province. One hospital, three health centres and five clinics were randomly selected, and consecutive patients were recruited at outpatients during 17 May 2000 - 17 June 2000. The patients completed a questionnaire regarding the service or care provided. Five hundred and sixty seven patients participated in the study. The median age was 30 years, and most patients were female (76.7%). More than half of patients (56.8%) were not satisfied with the availability of medicines and other supplies. Approximately two thirds of patients (65.2%) did not know about the quality of telephone services rendered. There was a high level of dissatisfaction (63.1%) among patients regarding accessing doctors after hours. Most patients were satisfied with the general attitude of health workers (62.1%) but 21.2% were dissatisfied. Few (11.7%) patients felt rushed during consultation. Most patients felt they received good health education when their illness was discussed (74.6%). Words and explanations used were easy to understand (76.7%); and they were not discouraged from asking questions (69.9%, n=539). Generally the level of satisfaction among the patients was high except for difficulty in accessing doctors after hours and lack of medicines.