The Influence of HIV Status on Acute Appendicitis: A Retrospective Study from South Africa.

BACKGROUND: Despite the human immunodeficiency virus (HIV) being the most common comorbidity in South African surgical patients, its impact on appendicitis has not been well-described. We aimed to determine HIV status' influence on patients' presentation, assessment, management and outcomes with acute appendicitis. METHODS: The retrospective chart review included all patients aged 12 years and older who were HIV-positive or HIV-negative and presented with acute appendicitis between 1 January 2013 and 31 December 2019. The primary outcome measure was survival to discharge. Secondary outcomes included analysis of the presentation (vital signs), assessment (biochemical, inflammatory markers) and management (intraoperative anatomical severity grading, length of hospital stay). RESULTS: Of the 1096 patients with appendicitis, 196 (17.9%) were HIV-positive, and CD4 counts were available for 159. The median age was 23 years, with the HIV-positive patients being older and HIV-negative group having more males (58.7%). While the HIV-positive patients had a longer median length of hospital stay, there was no statistically significant difference in the two groups' incidence of high-grade appendicitis (p = 0.670). The HIV-positive patients had a higher median shock index (OR 7.65; 95% [CI 2.042-28.64]) than their HIV-negative counterparts. HIV-positivity had a significant association with mortality (OR 9.56; 95% CI [1.68-179.39]), and of the seven HIV-positive patients who died, 66.7% (n = 4) had a CD4 < 200 cells/mm3 (OR 8.6; 95% CI [1.6-63.9]). CONCLUSION: HIV-positive patients, those with CD4 < 200 cells/mm3 or not on ART, have increased mortality risk and may benefit from increased perioperative surveillance. Patients with an unknown HIV status in a high-prevalence population should be offered HIV testing to risk stratify more accurately.

A profile of traumatic brain injuries and associated cervical spine injuries at a regional hospital in the KwaZulu-Natal Province.

BACKGROUND: Clearing the cervical spine in an unconscious blunt trauma patient is an elusive concept. The aim of this study was to describe the incidence of cervical spine injury (CSI) in patients with a traumatic brain injury (TBI). The study was conducted on patients who underwent imaging of both the cervical spine and the brain in one sitting at a busy government healthcare facility in Pietermaritzburg. METHODS: This was a retrospective, cross sectional study of all the trauma patients presenting to a regional hospital emergency department (ED) in the KwaZulu-Natal (KZN) Province, who underwent computed tomography (CT) imaging of the brain and the cervical spine in one sitting during the period January 2016 to June 2016. RESULTS: Adult males formed the majority (78.9%) of the study population and had the highest incidence of TBI, the most common identified pathology in CT being parenchymal injuries (41%). The mechanisms that resulted in the majority of injuries sustained were assault (38.7%) and motor vehicle collisions (MVCs) (25%), while seven patients (4.76%) had a combined diagnosis of TBI and CSI. The average Glasgow Coma Scale (GCS) was 12. CONCLUSION: Young adult males are at the greatest risk of sustaining TBI, with assault being the most common mechanism of injury. Combined diagnoses of TBI and CSI are rare and were mostly noted in patients involved in MVCs and pedestrian vehicle collisions. While the chance of an abnormal CT scan increased with a decreasing GCS score, 33% of patients with a mild TBI did not have abnormal CT findings, and 25% patients with severe TBI had no abnormal CT findings.

Impact of lockdown measures implemented during the Covid-19 pandemic on the burden of trauma presentations to a regional emergency department in Kwa-Zulu Natal, South Africa.

INTRODUCTION: The Covid-19 pandemic triggered unprecedented nationwide regulations aimed primarily at slowing the spread of the virus. The objective of this study was to describe the effect of these regulations on the number and severity of trauma presentations to a regional emergency department in Kwa-Zulu Natal. METHODS: A retrospective cohort study of the triage register at Edendale Hospital Emergency Department was conducted, comparing all trauma presentations in the month of April 2020 with those from the preceding two years. The number of patients, mechanism of trauma and severity of illness were recorded and compared. RESULTS: A 47% reduction in the number of trauma cases was recorded for April 2020. The proportion of severe cases did not change. The categories showing a major decrease were motor vehicle accidents, pedestrian vehicle accidents, assault and gunshot wounds. The incidence of dog bite wounds and burns remained unchanged. CONCLUSION: This study shows that the burden of trauma presenting to the emergency department was decreased in the month of April 2020 by the regulations implemented in response to the Covid-19 pandemic.

Competence in performing emergency skills: How good do doctors really think they are?

INTRODUCTION: Despite the differences in exposure and experience in dealing with medical emergencies, all doctors should nevertheless be competent to assist a patient in need of resuscitation. The objective of this study was to describe the level of self-assessed emergency skill competence that specialist trainees in various disciplines possessed as well as to identify factors that may have contributed to their level of self-perceived competence. METHODS: A prospective, cross-sectional, questionnaire study of various specialist trainees' self-perceived levels of competence in emergency skills was conducted across three academic hospitals in Johannesburg, South Africa. Trainees from General Surgery and Internal Medicine (Clinical) and Psychiatry and Radiology (Non-Clinical) rated their self-perceived level of competence in a list of basic, intermediate and advanced emergency skills according to a five-point Likert ranking scale. RESULTS: Ninety-four specialist trainees participated in the study - a response rate of 36%. The overall median competence rating for cardiac arrest resuscitation was 3.0 [IQR 3.0, 4.0] (i.e. intermediate). The median competence rating for cardiac arrest resuscitation in the clinical group (4.0) [IQR 3.0, 4.0] was higher than in the non-clinical group (3.0) [IQR 2.0, 3.0] (p < 0.001). Current or expired certification in Paediatric Advanced Life Support (PALS) or Advanced Paediatric Life Support (APLS) courses increased perceived competence and delays in starting specialisation resulted in a decrease in overall competence composite scores for each year of delay after internship. DISCUSSION: General Surgery and Internal Medicine trainees had a higher level of self-perceived competence in various emergency skills than their non- clinical counterparts. Current certification in advanced life support courses had a positive impact on trainees' self- perceived levels of competence in emergency skills. Specialist trainees who had less delay before starting their specialist training also demonstrated higher levels of perceived competence.

Competence in performing emergency skills: how good do doctors really think they are?

Introduction.Despite the differences in exposure and experience in dealing with medical emergencies, all doctors should nevertheless be competent to assist a patient in need of resuscitation. The objective of this study was to describe the level of self-assessed emergency skill competence that specialist trainees in various disciplines possessed as well as to identify factors that may have contributed to their level of self-perceived competence. Methods.A prospective, cross-sectional, questionnaire study of various specialist trainees' self-perceived levels of competence in emergency skills was conducted across three academic hospitals in Johannesburg, South Africa. Trainees from General Surgery and Internal Medicine (Clinical) and Psychiatry and Radiology (Non-Clinical) rated their self-perceived level of competence in a list of basic, intermediate and advanced emergency skills according to a five-point Likert ranking scale. Results.Ninety-four specialist trainees participated in the study ­ a response rate of 36%. The overall median competence rating for cardiac arrest resuscitation was 3.0 [IQR 3.0, 4.0] (i.e. intermediate). The median competence rating for cardiac arrest resuscitation in the clinical group (4.0) [IQR 3.0, 4.0] was higher than in the non-clinical group (3.0) [IQR 2.0, 3.0] (p < 0.001). Current or expired certification in Paediatric Advanced Life Support (PALS) or Advanced Paediatric Life Support (APLS) courses increased perceived competence and delays in starting specialisation resulted in a decrease in overall competence composite scores for each year of delay after internship. Discussion. General Surgery and Internal Medicine trainees had a higher level of self-perceived competence in various emergency skills than their non- clinical counterparts. Current certification in advanced life support courses had a positive impact on trainees' self- perceived levels of competence in emergency skills. Specialist trainees who had less delay before starting their specialist training also demonstrated higher levels of perceived competence