A Study Comparing Outcomes of Appendectomy between HIV-Infected and HIV-Negative Patients.

Background: The high prevalence of Human Immunodeficiency Virus (HIV) has added a new dimension to the management and outcomes of many general surgical conditions in South Africa. However, there is a paucity of data describing the impact of HIV status on surgical outcomes in our setting. Appendicitis is a most common gastrointestinal emergency, and its surgical outcomes in areas of high HIV prevalence are poorly described in the literature. Thus, the aim of this study is to describe and compare the outcomes of appendectomy between HIV-infected (HIV+) and HIV-negative (HIV-) patients. Methods: This is a retrospective cohort study of patients undergoing appendectomy at a large regional hospital over a 12-month period. Demographic data, duration of pre-hospital symptoms, HIV status, surgical approach, operative findings, histopathology reports, hospital stay and complications were recorded. Data for the HIV+ and HIV- patient cohorts were then described, analysed and compared. Results: The study group comprised 134 patients; 18 (13.4 %) tested positive for HIV. HIV+ patients were significantly older (mean age of 29.3 vs. 20.3 years, P= 0.002) and had longer duration of pre-hospital symptoms (mean of 3.94 vs. 2.57 days, P= 0.03). Postoperative complications (44.4 % vs. 17.2 %, P= 0.03) and lengthier hospital stays (7.28 days vs. 5.95 days, P= 0.004) were also more frequently seen in the HIV+ patients. There were no differences in appendiceal rupture rates, histopathological findings and mortality. Conclusions: Presentation in HIV+ patients was delayed and surgery was associated with significant postoperative morbidity and longer hospital stay.

HIV-positive-to-HIV-positive kidney transplantation--results at 3 to 5 years.

BACKGROUND: The outcome of kidney transplantation in human immunodeficiency virus (HIV)-positive patients who receive organs from HIV-negative donors has been reported to be similar to the outcome in HIV-negative recipients. We report the outcomes at 3 to 5 years in HIV-positive patients who received kidneys from HIV-positive deceased donors. METHODS: We conducted a prospective, nonrandomized study of kidney transplantation in HIV-infected patients who had a CD4 T-cell count of 200 per cubic millimeter or higher and an undetectable plasma HIV RNA level. All the patients were receiving antiretroviral therapy (ART). The patients received kidneys from deceased donors who tested positive for HIV with the use of fourth-generation enzyme-linked immunosorbent assay at the time of referral. All the donors either had received no ART previously or had received only first-line ART. RESULTS: From September 2008 through February 2014, a total of 27 HIV-positive patients underwent kidney transplantation. Survivors were followed for a median of 2.4 years. The rate of survival among the patients was 84% at 1 year, 84% at 3 years, and 74% at 5 years. The corresponding rates of graft survival were 93%, 84%, and 84%. (If a patient died with a functioning graft, the calculation was performed as if the graft had survived.) Rejection rates were 8% at 1 year and 22% at 3 years. HIV infection remained well controlled, with undetectable virus in blood after the transplantation. CONCLUSIONS: Kidney transplantation from an HIV-positive donor appears to be an additional treatment option for HIV-infected patients requiring renal-replacement therapy. (Funded by Sanofi South Africa and the Roche Organ Transplantation Research Foundation.).

Urological complications following unstented pediatric renal transplantation.

Urological complications which develop post-renal transplantation can be associated with significant morbidity especially in children. We evaluated the occurrence and management of all urological complications in a series of unstented pediatric renal transplants in a tertiary pediatric hospital. We reviewed the medical records of children who underwent unstented renal transplant between January 1996 and December 2014. Postoperative urological complications and the outcomes of their management were analyzed. A total of 160 unstented renal transplants were performed, and 32 urological complications were noted in 29 transplants (18%). There were 20 boys and nine girls with an age range of 2.5 years to 18.4 years. Nine (31%) of these patients had LUTD. The most common complication was VUR occurring in 17 patients (10.6%). Urine leaks occurred in six patients (3.8%) and ureteric obstruction in six patients (3.8%), and three patients (1.9%) had unexplained hydronephrosis. Loss of graft occurred in three patients (1.9%), and one patient died from sepsis post-uretero-ureterostomy. Patients with LUTD had more urological complications (P = .037). Unstenting is feasible in most pediatric renal transplants. LUTD is associated with a higher incidence of urological complications, especially VUR.

The International Association of Student Surgical Societies: creation and dissemination.

SUMMARY: While initiatives exist to address the worldwide need for surgeons, none involve a student-driven solution from low- and middle-income countries (LMICs). In response to falling surgical residency enrolment in South Africa, the students at the University of Cape Town (UCT) founded the UCT Surgical Society and were subsequently instrumental in creating the International Association of Student Surgical Societies (IASSS). The IASSS currently includes 25 societies in 15 countries. Its primary objectives are building sustainable networks for mutually beneficial exchanges, supporting student-driven projects, understanding issues impacting student interest in surgery, promoting global fellowship, creating an elective database and providing assistance to student surgical societies. The IASSS is a unique student-led initiative trying to improve surgical care in LMICs.

Screening for occult penetrating cardiac injuries.

OBJECTIVE: To determine the sensitivity of emergency department ultrasonography (US) in the diagnosis of occult cardiac injuries. BACKGROUND: Internationally, US has become the investigation of choice in screening patients for a possible cardiac injury after penetrating chest trauma by detecting blood in the pericardial sac. METHODS: Patients presenting with a penetrating chest wound and a possible cardiac injury to the Groote Schuur Hospital Trauma Centre between October 2001 and February 2009 were prospectively evaluated. All patients were hemodynamically stable, had no indication for emergency surgery, and had an US scan followed by subxiphoid pericardial window exploration. RESULTS: There were a total of 172 patients (median age = 26 years; range, 11-65 years). The mechanism of injury was stab wounds in 166 (96%) and gunshot wounds in 6. The sensitivity of US in detecting hemopericardium was 86.7%, with a positive predictive value of 77%. There were 18 false-negatives. Eleven of these false-negatives had an associated hemothorax and 6 had pneumopericardium. A single patient had 2 negative US examinations and returned with delayed cardiac tamponade. CONCLUSIONS: The sensitivity of US to detect hemopericardium in stable patients was only 86.7%. The 2 main factors that limit the screening are the presence of a hemothorax and air in the pericardial sac. A new regimen for screening of occult injuries to make allowance for this is proposed.

Acute appendicitis in the public and private sectors in Cape Town, South Africa.

BACKGROUND: South Africa has a low incidence of acute appendicitis, but poor outcomes. However, South African studies on appendicitis focus solely on public hospitals, neglecting those who utilize private facilities. This study aims to compare appendicitis characteristics and outcomes in public and private hospitals in South Africa. METHODS: A prospective cohort study was conducted among two public and three private hospitals in the Cape Town metropole, from September 2013 to March 2014. Hospital records, operative notes, and histology results were reviewed for patients undergoing appendectomy for acute appendicitis. Patients were interviewed during their hospitalization and followed up at monthly intervals until normal function was attained. RESULTS: A total of 134 patients were enrolled, with 73 in the public and 61 in the private sector. Education and employment were higher among private sector patients. Public sector patients had a higher rupture rate (30.6 vs 13.2 %, p = 0.023). Times to presentation were not statistically different between the two cohorts. Public sector patients had longer hospital stays (5.3 vs 2.9 days, p = 0.036) and longer return to work times (23.0 vs 12.1 days, p < 0.0001). Although complication rates were similar, complications in public hospitals were more severe. CONCLUSIONS: Public sector patients in South Africa with appendicitis have higher rupture rates, worse complications, longer hospital stays, and longer recoveries than private sector patients. Patients with perforation had longer delays in presentation than patients without perforation.

Sternotomy or drainage for a hemopericardium after penetrating trauma: a randomized controlled trial.

OBJECTIVE: To determine if stable patients with a hemopericardium detected after penetrating chest trauma can be safely managed with pericardial drainage alone. BACKGROUND: The current international practice is to perform a sternotomy and cardiac repair if a hemopericardium is detected after penetrating chest trauma. The experience in Cape Town, South Africa, on performing a mandatory sternotomy in hemodynamically stable patients was that a sternotomy was unnecessary and the cardiac injury, if present, had sealed. METHODS: A single-center parallel-group randomized controlled study was completed. All hemodynamically stable patients with a hemopericardium confirmed at subxiphoid pericardial window (SPW), and no active bleeding, were randomized. The primary outcome measure was survival to discharge from hospital. Secondary outcomes were complications and postoperative hospital stay. RESULTS: Fifty-five patients were randomized to sternotomy and 56 to pericardial drainage and wash-out only. Fifty-one of the 55 patients (93%) randomized to sternotomy had either no cardiac injury or a tangential injury. There were only 4 patients with penetrating wounds to the endocardium and all had sealed. There was 1 death postoperatively among the 111 patients (0.9%) and this was in the sternotomy group. The mean intensive care unit (ICU) stay for a sternotomy was 2.04 days (range, 0-25 days) compared with 0.25 days (range, 0-2) for the drainage (P < 0.001). The estimated mean difference highlighted a stay of 1.8 days shorter in the ICU for the drainage group (95% CI: 0.8-2.7). Total hospital stay was significantly shorter in the SPW group (P < 0.001; 95% CI: 1.4-3.3). CONCLUSIONS: SPW and drainage is effective and safe in the stable patient with a hemopericardium after penetrating chest trauma, with no increase in mortality and a shorter ICU and hospital stay. (ClinicalTrials.gov Identifier: NCT00823160).

The flaws of laser Doppler in negative-pressure wound therapy research.

Recent studies, using modalities other than laser Doppler, have indicated that perfusion during negative-pressure wound therapy (NPWT) is reduced, contrary to world literature. The aim of the present study was to evaluate whether the measuring technique of the laser Doppler could be influenced by the compressive nature of NPWT dressings and whether this could explain the conflicting findings. A hypothesis that it may be possible for laser Doppler to record similar readings to those obtained during NPWT by merely compressing tissues manually was tested on 12 NPWT dressings, with each undergoing an alternating series of manual compressive forces and NPWT (-125 mmHg). During the periods of NPWT (n = 12), the mean perfusion recording increased in five experiments, reduced in six, and remained unchanged in one. During the period when manual pressure was applied (n = 12), there was a mean increase in perfusion in six experiments and a reduction in six. The type of change in perfusion (increase or decrease) was the same for both NPWT and manual pressure in 10 of the 12 experiments. In conclusion, laser Doppler can incorrectly record increased perfusion when tissues are compressed, implying that it is flawed in the field of NPWT research as tissues are always compressed to some degree by the NPWT dressing.

A straight left heart border: a new radiological sign of a hemopericardium.

BACKGROUND: Detection of a cardiac injury in a stable patient after a penetrating chest injury can be difficult. Ultrasound of the pericardial sac may be associated with a false negative result in the presence of a hemothorax. A filling in of the left heart border inferior to the pulmonary artery, called the straight left heart border (SLHB), is a radiological sign on chest X-ray that we have found to be associated with the finding of a hemopericardium at surgery. The aim of the present study was to determine if this was a reliable and reproducible sign. METHODS: This was a prospective study of patients with a penetrating chest injury admitted between 1 October 2001 and 28 February 2009, who had no indication for immediate surgery, and were taken to the operating room for creation of a subxiphoid pericardial window (SPW). The chest X-ray was reviewed by a single trauma surgeon prior to surgery. RESULTS: A total of 162 patients with a possible occult cardiac injury underwent creation of a SPW. Fifty-five of the 162 patients (34 %) were noted to have a SLHB on chest X-ray and a hemopericardium confirmed at SPW. The sensitivity of the SLHB sign was 40 %; specificity, 84 %; and positive predictive value, 89 %. (p = 0.005, Odds ratio 3.48, lower 1.41, upper 8.62). CONCLUSIONS: The straight left heart border is a newly described radiological sign that was highly significant in predicting the presence of a hemopericardium and should alert the clinician to a possible occult cardiac injury.

Laparoscopic kidney donation - giving in the best way possible.

Laparoscopic donor nephrectomy is the preferred method of living kidney donation at most transplant centres. There are various techniques, all with their own reported benefits. This editorial gives a brief overview of the various methods in the context of ensuring maximum safety and benefit to the donor without compromising kidney transplant outcomes.

Pseudomonas aeruginosa burn wound infection in a dedicated paediatric burns unit.

BACKGROUND: Pseudomonas aeruginosa infection is a major cause of morbidity in burns patients. There is a paucity of publications dealing with this infection in the paediatric population. We describe the incidence, microbiology and impact of P. aeruginosa infection in a dedicated paediatric burns unit. METHODS: A retrospective review of patients with clinically significant P. aeruginosa infection between April 2007 and January 2010 in the burns unit at Red Cross War Memorial Children's Hospital in Cape Town, South Africa, was performed. RESULTS: During the 36-month study period, 2 632 patients were admitted. Of 2 791 bacteriology samples sent for microscopy, culture and sensitivity, 406 (14.5%) were positive for P. aeruginosa. Thirty-four patients had clinically significant P. aeruginosa wound infection, giving an incidence of 1.3%. Three patients had loss of Biobrane or allografts, and 23 cases of skin graft loss occurred in 18 patients. An average of 12 dressing days was needed to obtain negative swabs. All isolates were sensitive to chlorhexidine, whereas 92.5% were resistant to povidone-iodine. Piperacillin-tazobactam was the systemic antimicrobial to which there was most resistance (36.1%), and tobramycin had least resistance (3.3%). CONCLUSIONS: The incidence of clinically significant burn wound infection is low in our unit, yet the morbidity due to debridement and re-grafting is significant. We observed very high resistance to topical povidone-iodine. Resistance to systemic antimicrobials is lower than that reported from other burns units.

Attitudes and beliefs of South African medical students toward organ transplantation.

The aim of this study was to assess and analyse the attitudes and beliefs of medical students regarding organ donation, procurement, and transplantation. Medical students at the University of Cape Town were prospectively surveyed using a self-administered questionnaire. There were 346 study participants; the mean age was 21 (range 18-33) yr, 38% were male and 62% was female. Only 8% of respondents were registered donors; clinical and white students constituted the majority of this group. Of the 315 "non-donors," the main reason for not donating was "I have not really thought about organ donation" (59%). Most students (91%) would accept an artificial organ; and 87% and 52% of students would accept human and animal organs respectively. Muslim students (11%, p<0.05) and those who believe in an after-life or reincarnation (18%, p=0.00) were less willing to accept human or animal organs. About 95% of respondents stated that they would like to learn more about transplantation and would keep information about it in their practice but only 18% of respondents knew where to find information for potential donors and recipients. Most students have a favorable attitude toward organ transplantation; religion and belief systems impact on willingness to receive organs.

Penetrating cardiac injury following sewing needle ingestion.

Penetrating cardiac injuries are common in South Africa. Reports describing traumatic lesions to the heart caused by caudo-cranial migration of ingested foreign bodies are however extremely rare. Delayed presentation and intervention are associated with poor outcome in these patients; cardiac tamponade remains the most serious complication. We present the case of a 19 year-old man who sustained a left ventricular injury after intentionally swallowing eight sewing needles. The impacted needle was removed through a median sternotomy and the patient recovered uneventfully.

Management of the retained knife blade.

BACKGROUND: The retained knife blade is an unusual and spectacular injury. The aim of this study was to review our experience with the management of such injuries. METHODS: A retrospective chart review of patients with retained knife blades treated at Groote Schuur Hospital Trauma Centre from January 1996 to December 2007 was undertaken. RESULTS: Thirty-three patients with retained knife blades were identified. Site of wound entry was the thorax in 13 patients (40%), the neck and back in 7 patients (21%) each, upper and lower extremities in 4 (12%), and the face and abdomen in 1 patient (3%) each. Thirty patients (91%) were hemodynamically stable on admission; two (6%) presented with wound abscesses, and one patient (3%) with active bleeding required emergency surgery. All 33 blades were extracted after clinical and radiological assessment. Simple withdrawal of the blade was possible in 19 cases (58%) and the likelihood of post-extraction bleeding was only 5%. Thirteen patients (40%) required an open surgical approach through dissection of the entry wound, laparotomy, or thoracotomy. Video-assisted thoracoscopic removal was used in one case. Retained thoracic blades were significantly associated with postoperative sepsis (P = 0.0054). There were no deaths. CONCLUSIONS: All impacted knife injuries require careful clinical and radiological assessment. Simple withdrawal can be performed safely in the emergency room provided potential life-threatening vascular and solid organ injuries have been excluded. There should be a low threshold for investigating and treating patients with retained intrathoracic blades for postoperative sepsis.

The inhibition of the Human Immunodeficiency Virus type 1 activity by crude and purified human pregnancy plug mucus and mucins in an inhibition assay.

BACKGROUND: The female reproductive tract is amongst the main routes for Human Immunodeficiency Virus (HIV) transmission. Cervical mucus however is known to protect the female reproductive tract from bacterial invasion and fluid loss and regulates and facilitates sperm transport to the upper reproductive tract. The purpose of this study was to purify and characterize pregnancy plug mucins and determine their anti-HIV-1 activity in an HIV inhibition assay. METHODS: Pregnancy plug mucins were purified by caesium chloride density-gradient ultra-centrifugation and characterized by Western blotting analysis. The anti-HIV-1 activities of the crude pregnancy plug mucus and purified pregnancy plug mucins was determined by incubating them with HIV-1 prior to infection of the human T lymphoblastoid cell line (CEM SS cells). RESULTS: The pregnancy plug mucus had MUC1, MUC2, MUC5AC and MUC5B. The HIV inhibition assay revealed that while the purified pregnancy plug mucins inhibit HIV-1 activity by approximately 97.5%, the crude pregnancy plug mucus failed to inhibit HIV-1 activity. CONCLUSION: Although it is not clear why the crude sample did not inhibit HIV-1 activity, it may be that the amount of mucins in the crude pregnancy plug mucus (which contains water, mucins, lipids, nucleic acids, lactoferrin, lysozyme, immunoglobulins and ions), is insufficient to cause viral inhibition or aggregation.

The characterisation of mucin in a mature ovarian teratoma occurring in an eight year old patient.

INTRODUCTION: The presence of MUC5AC (M1 antigen) and MUC6 have previously been found in ovarian mucinous cyst. We characterized the mucins in the crude mucus and tissue of a mature ovarian teratoma in an 8 year old girl. MATERIALS AND METHODS: Mucins were purified from crude mucus by density gradient ultra-centrifugation in CsCl and analysed by gel-filtration and SDS-PAGE analysis. Mucin identification and expression was by western blotting and immunohistochemistry. RESULTS: Histology showed a tumour with solid and cystic areas, with the cysts lined by colonic and respiratory mucosae. Equal volumes of 'sol' and 'gel' phases of approximately 10.0 ml of crude mucus were obtained. Gel filtration and SDS-PAGE analyses suggested that the mucin was mainly of the large polymeric type which dissociated upon reduction of disulphide bonds with DTT. The colonic and respiratory epithelia predominantly expressed acidic mucin of the sialated and sulphated types respectively. MUC1 and MUC1c were expressed exclusively in respiratory epithelium, MUC2 and some MUC6 (focal) in the colonic tissue and MUC5AC in both tissues. Western blotting confirmed the presence of MUC2, MUC5AC and MUC5B in the secreted gel. Serine, threonine and proline made up the bulk of the amino acids in the sample. DISCUSSION: Ovarian teratoma produced a highly viscous mucus secretion in which the mucin was largely polymeric and of the MUC2, MUC5AC and MUC5B type. The respiratory component of the teratoma expressed MUC1 and MUC1c and the colonic components of the teratoma expressed MUC2 and some MUC6. MUC5AC was expressed in both components.

A clinical-scale BioArtificial Liver, developed for GMP, improved clinical parameters of liver function in porcine liver failure.

Liver failure, whether arising directly from acute liver failure or from decompensated chronic liver disease is an increasing problem worldwide and results in many deaths. In the UK only 10% of individuals requiring a liver transplant receive one. Thus the need for alternative treatments is paramount. A BioArtificial Liver machine could temporarily replace the functions of the liver, buying time for the patient's liver to repair and regenerate. We have designed, implemented and tested a clinical-scale BioArtificial Liver machine containing a biomass derived from a hepatoblastoma cell-line cultured as three dimensional organoids, using a fluidised bed bioreactor, together with single-use bioprocessing equipment, with complete control of nutrient provision with feedback BioXpert recipe processes, and yielding good phenotypic liver functions. The methodology has been designed to meet specifications for GMP production, required for manufacture of advanced therapy medicinal products (ATMPs). In a porcine model of severe liver failure, damage was assured in all animals by surgical ischaemia in pigs with human sized livers (1.2-1.6 kg liver weights). The BioArtificial liver (UCLBAL) improved important prognostic clinical liver-related parameters, eg, a significant improvement in coagulation, reduction in vasopressor requirements, improvement in blood pH and in parameters of intracranial pressure (ICP) and oxygenation.