An MRI-based study of the insula in a South African population.

PURPOSE: The insula, a cortical structure buried deep within the sylvian fissure, has long posed a surgical challenge. Comprehensive knowledge of the insular anatomy is therefore integral to preoperative planning and safe interventional procedures. Since magnetic resonance imaging (MRI) is a favoured modality for the identification of cerebral structures, this study aimed to investigate the morphology and morphometry of the insula in a South African population, using MRI scans. METHODS: One-hundred MRI studies of insulae (n = 200 hemispheres) were retrospectively analysed for morphological features and morphometric parameters. RESULTS: The insulae were predominantly trapezoidal in shape (Laterality: Left: 82%; Right: 78%; Sex: Male: 84%, Female: 76%). The central insular sulcus was almost always "well seen" (Laterality: Left: 97%; Right: 99%; Sex: Male: 99%, Female: 97%). The middle short insular gyrus (MSG) was most variable in visibility, especially when compared across the sexes (p = 0.004). Insular gyri widths were comparable in both cerebral hemispheres; the posterior long gyrus (PLG) presented with the smallest mean widths. Anterior lobule (AL) widths were larger than those of the posterior lobule (PL). Widths of the insular gyri and lobules were generally larger in males than in females. The MSG and PLG widths in the left hemisphere, AL width in the right hemisphere, and the PL width in both hemispheres were significantly larger in males than in females (p = 0.001; p = 0.005; p = 0.041; p = 0.001, p = 0.015, respectively). CONCLUSION: MRI scans may be used to accurately interpret insular anatomy. The data obtained may aid neurosurgeons to perform safe insula-related surgical procedures.

Medical and Dental Students' Perceptions of the Learning Environment during Anatomic Pathology Placement at Obafemi Awolowo University, Ile-Ife, Nigeria.

BACKGROUND: The educational environment is an important factor in nurturing students' learning. Students' experiences of the climate of their learning environment positively correlate with their academic success, achievements and satisfaction. OBJECTIVES: The study aimed to determine the perceptions of medical and dental students about their learning environment during anatomical pathology clinical placement. METHODOLOGY: A prospective, cross-sectional study using a guided self-administered Dundee Ready Education Environment Measurement (DREEM) questionnaire was conducted among fourth year medical and fifth-year dental students on anatomical pathology placement at the College of Health Sciences, Obafemi Awolowo University Ile-Ife, Nigeria. One hundred and eleven of 118 students participated in the study. RESULTS: The age range was 19-35 years. The majority of the students were males ( n= 80, 72.1%). The overall mean score was 115.19 ± 25.6 (maximum obtainable total score = 200), indicating that the students perceived their learning environment as more positive than negative. The mean score for each subscale of the DREEM instrument was: 29.24/48 (60.9%) for perception of learning; 25.67/44 (58.3%) for perception of teaching; 20.89/32 (65.3%) for academic self-perception; 25.61/48(53.4%) for perception of the atmosphere of learning; and 13.52/28 (48.3%) social self-perception. No statistically significant difference was found by sex, age group, and course of study for each DREEM domain. CONCLUSION: Students' perception regarding the learning environment for anatomical pathology in the focal university shows the need for improvement across various domains. However, academic self-perception and social self-perception are the areas of greatest need.

FOND: L'environnement éducatif est un facteur important pour favoriser l'apprentissage des élèves. Les expériences des étudiants du climat de leur environnement d'apprentissage sont positivement corrélées avec leur réussite scolaire, leurs réalisations et leur satisfaction. OBJECTIFS: Le but de l'étude était de déterminer les perceptions des étudiants en médecine et en médecine dentaire sur leur environnement d'apprentissage lors d'un stage clinique en pathologie anatomique. METHODOLOGIE: Une étude prospective transversale à l'aide d'un questionnaire guidé auto-administré Dundee Ready Education Environment Measurement (DREEM) a été menée auprès d'étudiants en médecine et en médecine dentaire de quatrième année en stage de pathologie anatomique au collège des sciences de la santé, Obafemi Awolowo University Ile -Ife, Nigéria. Cent onze des 118 étudiants ont participé à l'étude. RESULTATS: La tranche d'âge était de 19 à 35 ans. La majorité des étudiants étaient des hommes ( n = 80, 72,1 %). Le score moyen global au questionnaire DREEM était de 115,19 ± 25,6 (score total = 200), indiquant que les étudiants percevaient leur environnement d'apprentissage comme plus positif que négatif. Le score moyen pour chaque sous-échelle de l'instrument DREEM était : 29,24/48 (60,9 %) pour la perception de l'apprentissage ; 25,67 /44 (58,3%) pour la perception de l'enseignement ; 20,89/32 (65,3 %) pour l'autoperception académique ; 25,61/48' (53,4 %) pour la perception de l'atmosphère d'apprentissage ; et 13,52/28 (48,3%) d'auto-perception sociale. Le domaine de l'auto-perception sociale présentait un problème nécessitant une amélioration significative. CONCLUSION: La perception des étudiants concernant l'environnement d'apprentissage de la pathologie anatomique dans l'université focale montre le besoin d'amélioration dans divers domaines. Cependant, l'auto-perception académique et l'autoperception sociale sont des domaines dont les besoins sont les plus grands. Mots clés: Milieu d'apprentissage, pathologie, perception des élèves, DREEM.

Provision of HIV services by community health workers should be strengthened to achieve full programme potential: a cross-sectional analysis in rural South Africa.

OBJECTIVE: South Africa's community health workers (CHWs) provide a bridge between the primary healthcare (PHC) facility and its community. We conducted a cross-sectional analysis to determine the contribution of the community-based HIV programme (CBHP) to the overall HIV programme. METHODS: We collected service provision data from the daily activity register of CHWs attached to 12 PHC facilities in rural Mopani District, South Africa. Personal identifiers of individuals referred to the facility for HIV services were recorded and verified against facility routine patient registers to determine the effectiveness of referral. RESULTS: HIV services were provided on 18 927 occasions; 30% of the total activities performed by CHWs during the study period. CHWs assessed 12 159 individuals for HIV risk (13% coverage of the study population); only 290 (2%) were referred for HIV testing services. Referral was effective in 213 (73%) individuals; evidence of an HIV-positive status was found for 38 (18%) individuals. However, 30 (79%) of these individuals were referred by CHWs despite being on ART. Adherence support was provided during 5657 visits; only one individual was referred for complications. Finally, of the 864 individuals lost to the ART programme, CHWs managed to find 452 (52%) for referral back to the facility; only 241 (53%) of these were (re)initiated on ART. CONCLUSIONS: Provision of HIV services by CHWs should be strengthened to fully deliver on the programme's potential. Human resource investment, home-based HIV testing and improved tracing models constitute potential strategies to enhance CHWs impact on the HIV programme.

OBJECTIF: Les agents de santé communautaires (ASC) d'Afrique du Sud constituent un pont entre les établissements de soins de santé primaires et leur communauté. Nous avons effectué une analyse transversale pour déterminer la contribution du programme VIH basé sur la communauté (PVBC) au programme global de lutte contre le VIH. MÉTHODES: Nous avons collecté des données sur la prestation de services à partir du registre des activités quotidiennes des ASC rattachés à 12 établissements de soins de santé primaires dans le district rural de Mopani, en Afrique du Sud. Les identifiants individuels des personnes référées vers l'établissement pour des services VIH ont été enregistrés et vérifiés par rapport aux registres de routine des patients de l'établissement afin de déterminer l'efficacité de l'aiguillage. RÉSULTATS: Les services VIH ont été fournis dans 18.927 occasions; 30% du total des activités réalisées par les ASC au cours de la période d'étude. Les ASC ont évalué 12.159 personnes pour les risques du VIH (couverture de 13% de la population étudiée); seuls 290 (2%) ont été référés pour des services de dépistage du VIH. L'aiguillage a été efficace chez 213 personnes (73%). L'évidence de séropositivité a été trouvée chez 38 personnes (18%). Cependant, 30 (79%) de ces personnes ont été référées par des ASC alors qu'elles étaient sous ART. Un soutien à la compliance a été fourni au cours de 5.657 visites; un seul individu a été référé pour des complications. Enfin, sur 864 personnes perdues du programme ART, les ASC ont réussi à retrouver 452 (52%) pour les référer de nouveau à l'établissement; seuls 241 (53%) de celles-ci ont été (ré) initiées sous ART. CONCLUSIONS: La fourniture de services VIH par les ASC devrait être renforcée pour exploiter pleinement le potentiel du programme. Les investissements dans les ressources humaines, le dépistage du VIH à domicile et les modèles de traçage améliorés constituent des stratégies potentielles pour améliorer l'impact des ASC sur le programme VIH.

An evaluation of mini-laparotomy cholecystectomy in the laparoscopic era: a rural experience.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the gold standard for the management of symptomatic cholelithiasis and complications of gallstone disease. Mini laparotomy cholecystectomy (MOC) may be a more appropriate option in the resource constrained rural setting due to its widespread applicability and comparable outcome with LC. The study aimed to provide an epidemiological analysis of gallstone disease in the rural population and to evaluate the outcome of MOC in a rural hospital. METHOD: A retrospective chart analysis of 248 patients undergoing cholecystectomy in a rural regional referral hospital in KwaZulu-Natal from January 2009 to December 2013 was undertaken. RESULTS: Of the 248 patients, the majority were females (n = 211, [85%]). The most frequent indications for cholecystectomy included: biliary colic (n = 115, [46.3%]); acute cholecystitis (n = 80, [32.3%]); gallstone pancreatitis (n = 27, [10.8%]). Forty cases (16.1%) were converted to open cholecystectomy (OC). The median operative time was 40 minutes (range18-57). Twenty-three morbidities (9.3%) occurred including: bile leaks (n = 6, [2.4%]); bleeding from drain site (n = 1, [0.4%]), incisional hernia (n = 8 [3.2%]) and wound sepsis (n = 8 [3.2%]). The median length of hospital stay in patients who underwent MOC was 48 hours (range: 24-72 hours) and the median time to return to work was 10 days (range: 4-14 days). There was one mortality in the entire cohort. CONCLUSION: MOC is a safe and feasible operation for symptomatic cholelithiasis when cholecystectomy is indicated. The low operative morbidity and mortality in the context of a high risk patient profile and complicated gallstone disease makes this procedure an alternative to LC where LC is inaccessible.

Associations between dietary salt, potassium and blood pressure in South African adults: WHO SAGE Wave 2 Salt & Tobacco.

BACKGROUND & AIMS: In June 2016, South Africa implemented legislation mandating maximum sodium levels in a range of processed foods with a goal of reducing population salt intake and disease burden from hypertension. Our aim was to explore the relationship between salt and blood pressure (BP) in a subsample of the World Health Organization Study on global AGEing and adult health (SAGE) Wave 2 before implementation of legislation in South Africa. METHODS & RESULTS: Blood pressure (BP) was measured in triplicate (n = 2722; median age 56 years; 33% male) and 24-h urine collected in a nested subsample (n = 526) for sodium, potassium and creatinine analysis. Hypertension prevalence was 55% in older adults (50-plus years) and 28% in younger adults (18-49 years). Median salt intake (6.8 g/day) was higher in younger than older adults (8.6 g vs 6.1 g/day; p < 0.001), and in urban compared to rural populations (7.0 g vs 6.0 g/day; p = 0.033). Overall, 69% of participants had salt intakes above 5 g/day. Potassium intakes were generally low (median 35 mmol/day) with significantly lower intakes in rural areas and older adults. Overall, 91% of adults failed to meet the daily potassium recommendation of 90 mmol/d. Salt intakes above 5 g/day, and to a greater extent, a dietary sodium-to-potassium (Na:K) ratio above 2 mmol/mmol, were associated with significantly steeper regression slopes of BP with age. CONCLUSION: These preliminary results indicate that high dietary Na:K ratio may lead to a greater increase in BP and hypertension risk with age. Interventions to increase potassium intakes alongside sodium reduction initiatives may be warranted.

Modified RS-LAMP assay and use of lateral flow devices for rapid detection of Leifsonia xyli subsp. xyli.

Ratoon stunt (RS) caused by bacterium Leifsonia xyli subsp. xyli (Lxx) results in substantial yield losses in sugarcane (Saccharum sp. L. hybrid). Since RS does not produce reliable symptoms in the field, laboratory-based techniques are necessary for detection. Loop-mediated isothermal amplification (LAMP) assay overcomes the limitations of laboratory-based techniques which are costly, time consuming and cannot be used for near-field detection. A sensitive LAMP assay was developed to detect Lxx at 65°C in 30 min. However, carry-over contamination affected the reliability of the assay. In the present study, contaminants were successfully eliminated by incorporation of uracil nucleoside glycosylase (1 U µl-1 ) into the LAMP assay and incubation for 10 min at 37°C. To avoid the use of colorimetric reagents, lateral flow devices were successfully used for the detection of LAMP products and were equally sensitive to detection by agarose gel electrophoresis. The use of exudate from leaf sheath discs as an alternate template for the LAMP assay was found to be less sensitive than xylem sap. The preprepared master mix could be stored for up to 4 months at -20°C without any reduction in performance. These changes make the assay suitable for near-field detection in laboratories with basic facilities. SIGNIFICANCE AND IMPACT OF THE STUDY: This study presents a modified loop-mediated isothermal amplification (LAMP) assay for the detection of Leifsonia xyli subsp. xyli. Modifications include incorporation of uracil nucleoside glycosylase to eliminate carry-over contamination and substitution of colorimetric detection for the use of lateral flow devices. LAMP master mix was preprepared and was stably stored up to 4 months at -20°C. Sugarcane leaf sheaths worked well as a substitute to xylem sap as template, although the sensitivity was lower. These modifications allow the assay to be conducted without contamination concerns and reduction in set up time, making it ideal for near-field diagnosis.

Prevalence of arthritis according to age, sex and socioeconomic status in six low and middle income countries: analysis of data from the World Health Organization study on global AGEing and adult health (SAGE) Wave 1.

BACKGROUND: In higher income countries, social disadvantage is associated with higher arthritis prevalence; however, less is known about arthritis prevalence or determinants in low to middle income countries (LMICs). We assessed arthritis prevalence by age and sex, and marital status and occupation, as two key parameters of socioeconomic position (SEP), using data from the World Health Organization Study on global AGEing and adult health (SAGE). METHODS: SAGE Wave 1 (2007-10) includes nationally-representative samples of older adults (≥50 yrs), plus smaller samples of adults aged 18-49 yrs., from China, Ghana, India, Mexico, Russia and South Africa (n = 44,747). Arthritis was defined by self-reported healthcare professional diagnosis, and a symptom-based algorithm. Marital status and education were self-reported. Arthritis prevalence data were extracted for each country by 10-year age strata, sex and SEP. Country-specific survey weightings were applied and weighted prevalences calculated. RESULTS: Self-reported (lifetime) diagnosed arthritis was reported by 5003 women and 2664 men (19.9% and 14.1%, respectively), whilst 1220 women and 594 men had current symptom-based arthritis (4.8% and 3.1%, respectively). For men, standardised arthritis rates were approximately two- to three-fold greater than for women. The highest rates were observed in Russia: 38% (95% CI 36%-39%) for men, and 17% (95% CI 14%-20%) for women. For both sexes and in all LMICs, arthritis was more prevalent among those with least education, and in separated/divorced/widowed women. CONCLUSIONS: High arthritis prevalence in LMICs is concerning and may worsen poverty by impacting the ability to work and fulfil community roles. These findings have implications for national efforts to prioritise arthritis prevention and management, and improve healthcare access in LMICs.

Enthesopathic patterns of two South African female cadavers.

Enthesopathy is considered to be an osseous phenomenon, either disease-specific or bone-site specific, which occurs at the enthesis of bone. Upon routine cadaveric dissection of the glenohumeral region in two Caucasian females, enthesopathy of the right proximal humerus was observed unilaterally in both cases. Case 1 exhibited an inconsistent pattern of bony protuberances and crests dispersed across the lesser and greater tuberosities of the right humeral head. Varying degrees of ossification of the distal subscapularis muscle was also observed. Case 2 presented with a distinctively large enthesophyte that protruded supero-medially from the proximal right humerus. In addition, ossification of the distal-most aspect of the supraspinatus muscle was identified. Cases 1 and 2 were both reflective of osteophytic enthesopathy as proliferative change was clearly visible on the proximal aspect of each humerus. Whilst the presence of enthesopathies may be indicative of underlying pathology, it may prove beneficial to the field of bioarchaeology for the remodelling of lifestyles of ancient civilizations through the provision of current day variations as seen in these two case studies.

Pattern and distribution of peripheral arterial disease in diabetic patients with critical limb ischemia (rutherford clinical category 4-6).

BACKGROUND: This study investigated the pattern and distribution of peripheral arterial disease in diabetic patients with critical limb ischaemia (CLI) and to stratify the findings according to the patients' risk factor profile, gender and age group. METHOD: We conducted a one-year prospective descriptive study (January 2014 to December 2014) at Groote Schuur Hospital, University of Cape Town. The research protocol and the informed consent were approved by the Institutional Review Board, and all subjects included in this study gave an informed consent. We included all diabetic patients over the age of 18 years with critical limb ischemia who had pre and post-intervention vascular imaging. The calculated minimum sample size was 63 limbs. We hypothesize that the proportions of arterial segment patency categories and the arterial foot arch status varies according to gender, age group and risk factor combinations in diabetic patients. The Null hypothesis (N0) assumes that the proportions of arterial segment patency categories and arch status are the same in diabetic patients irrespective of gender, age group and risk factor combination. The equality of distribution was analysed using the One Sample Chi-square test. Three risk factor combination groups were analysed: Group 1 (diabetes mellitus, hypertension, dyslipidemia), Group 2 (diabetes mellitus, hypertension, dyslipidemia, ex-smoker) and Group 3 (diabetes mellitus, hypertension, dyslipidemia, smoker). RESULTS: Seventy-one patients were analysed (38 females and 33 males). We recorded the patency grades (ranging from normal to occlusion) of arteries in all 3 lower extremity arterial segments (aortoiliac; femoropopliteal and tibioperoneal segments). Altogether the patency grades of 820 lower extremity arteries were recorded. Diabetics, collectively, were found to have more severe occlusive disease in the tibioperoneal segment (P < .001). Group 3 patients however, had more severe occlusive disease in the femoropopliteal segment compared to the other subgroups (P < .001). Group 1 and Group 2 patients had more severe occlusive disease in the tibioperoneal segment (P < .001). Females were more likely to have complete foot arches (22/37; P = .004) while males tended to have more incomplete foot arches (17/32; P = .048). CONCLUSION: Diabetic patients collectively have severe tibioperoneal occlusive disease. However, Group 3 patients tend to have disproportionately more occlusive disease in the femoropopliteal segment (P < .001). Diabetic female patients with CLI are more likely to have a complete arterial foot arch than males (P = .004).

An arthroscopic evaluation of the anatomical "critical zone".

BACKGROUND: The "critical zone", a region of speculated vascularity, is situated approximately 10 mm proximal to the insertion of the supraspinatus tendon. Despite its obvious role as an anatomical landmark demarcator, its patho-anatomic nature has been identified as the source of rotator cuff pathology. Although many studies have attempted to evaluate the vascularity of this region, the architecture regarding the exact length, width and shape of the critical zone, remains unreported. This study aimed to determine the shape and morphometry of the "critical zone" arthroscopically. MATERIALS AND METHODS: The sample series, which was comprised of 38 cases (n = 38) specific to pathological types, employed an anatomical investigation of the critical zone during routine real-time arthroscopy. Demographic representation: i) sex: 19 males, 19 females; ii) age range: 18-76 years; iii) race: white (n = 29), Indian (n = 7) and coloured (n = 2). RESULTS: The incidence of shape and the mean lengths and widths of the critical zone were determined in accordance with the relevant demographic factors and patient history. Although the cresenteric shape was predominant, hemispheric and sail-shaped critical zones were also identified. The lengths and widths of the critical zone appeared markedly increased in male individuals. While the increase in age may account for the increased incidence of rotator cuff degeneration due to poor end-vascular supply, the additional factors of height and weight presented as major determinants of the increase in size of the critical zone. CONCLUSIONS: In addition, the comparisons of length and width with each other and shape yielded levels of significant difference, therefore indicating a directly proportional relationship between the length and width of the critical zone. This detailed understanding of the critical zone may prove beneficial for the success of post-operative rotator cuff healing.

An anatomical investigation of the carotid canal.

BACKGROUND: The carotid canal (CC) located in the petrous temporal bone transmits the internal carotid artery, internal carotid venous plexus and sympathetic nerve plexus from the neck into the cranial cavity. It is an accessible passage into the cranial cavity and is considered an important anatomical landmark for neurosurgeons. The aim of this study was to investigate the topographical, morphometric and morphological parameters of the CC. MATERIALS AND METHODS: An examination of the CC and related adjacent structures in 81 dry skull specimens was performed. Distribution of sample by sex was 34 females and 47 males, and by race 77 African and 4 Caucasian. The mean age was 50 years (range: 14-100 years). RESULTS: The external opening of the CC was found to be round-shaped, oval-shaped and tear-drop-shaped in 28.4%, 49.4% and 22.2% of the specimens, respectively. (1) Mean diameters [mm]: (a) medio-lateral 7.52 mm and (b) antero-posterior 5.41mm. Statistically significant difference in the vertical diameter was recorded in the race groups and laterality of the samples. (2) Mean distances [mm] between: (a) medial margins of external opening of CC was 50.03 mm, (b) lateral margins of external opening of CC was 62.73 mm and (c) external openings of CC and foramen lacerum was 15.6 mm. There was a statistically significant correlation between race and location of the opening of external CC in relation to foramen lacerum (viz. postero-lateral, lateral and diagonal, and lateral). CONCLUSIONS: The present study corroborated previous reports on the CC; however, the tear-drop shaped external CC opening was a unique finding. The knowledge of the reference measurements pertaining to the CC and its relationship to adjacent structures may postulate a suitable surgical "safe-zone" range within the CC area.

Perforated caecal duplication cyst presenting as an appendicular abscess.

A duplication cyst of the caecum is a very rare congenital malformation, representing 0.4% of all gastrointestinal duplications. We present a case of cystic duplication of the caecum in a 12-year-old child who presented with a right iliac fossa mass and peritonitis. An ischaemic, perforated caecal duplication cyst was found on emergency laparotomy, mandating a right hemicolectomy.

An urban trauma centre experience with abdominal vena cava injuries.

BACKGROUND: The aim of the study was to present the surgical management of injuries to the abdominal vena cava (AVC) and to identify clinical and physiological factors and management strategies which affect the outcome. METHOD: A retrospective review was conducted of AVC injuries in patients attending the trauma centre at Groote Schuur Hospital, Cape Town, from January 2003 to December 2011. Demographic data, mechanism and agent of injury, level of injury, physiological parameters, associated injuries, trauma scores, management strategy, morbidity and mortality, and length of hospital stay were taken from the trauma centre's operative databank at Groote Schuur Hospital. RESULTS: Thirty-fi ve patients with AVC injuries were identifi ed. There were 33 penetrating injuries (94%). Gunshot wounds accounted for 28 of them (85%). There were 19 (54%) infrarenal, 9 (26%) juxtarenal, 3 (7%) suprarenal and 4 (11%) retrohepatic AVC injuries. Most patients were treated with ligation (66%). There were 17 (49%) deaths. There were signifi cant differences in the preoperative systolic blood pressure (p = 0.044), number of red cell units transfused (p = 0.001), serum lactate (p = 0.007), arterial pH (p = 0.002) and preoperative temperature (p = 0.000) between the survivors and non-survivors. There was also a signifi cant difference in ligation versus repair between the two groups (p = ≤ 0.000). There was no difference in the injury severity, level of injury and the number of associated injuries between survivors and non-survivors. CONCLUSION: AVC injuries are associated with high mortality. Patients presenting with clinical and physiological evidence of shock and who require "damage control" surgery are more likely to suffer a worse outcome, particularly when multiple physiological deragements are present. Patients who died often have severe associated injuries.

Severe post-pancreatoduodenectomy haemorrhage: An analytical review based on 118 consecutive pancreatoduodenectomy patients in a South African Academic Hospital.

BACKGROUND: Bleeding after a major pancreatic resection, although uncommon, has serious implications and substantial mortality rates. AIM: To analyse our experience with severe post-pancreatoduodenectomy haemorrhage (PPH) over the last 7 years to establish the incidence, causes, intervention required and outcome. METHOD: All patients who underwent a pancreatoduodenectomy (PD) between January 2008 and December 2015 were identified from a prospectively maintained database. Data analysed included demographic information, operative details, anastomotic technique, histology, postoperative complications including pancreatic fistula and PPH, length of hospital stay, need for blood products and special investigations. Pancreatic fistula was classified according to the International Study Group of Pancreatic Surgery (ISGPS) classification. A modified ISGPS classification was used for PPH. RESULTS: One hundred and eighteen patients underwent PD during the study period of whom 6 (5.0%) died perioperatively. Twenty patients (16.9%) developed a pancreatic fistula and 11 patients (9.3%) had a severe PPH of whom one (9.1%) died. No patients had a severe bleed during the first 24 hours postoperatively. Four patients bled within the first 5 days and the remaining 7 after five days. Six patients bled from the gastroduodenal artery and were all preceded by a pancreatic fistula. Three of the 7 patients who bled late presented with extraluminal bleeding, 3 presented with intraluminal bleeding and 1 with a combination of both. Patients presenting in the first 5 days were all successfully managed either endoscopically or surgically. Five patients who presented beyond 5 days postoperatively were managed primarily with interventional angiography, either with coiling or deployment of a covered stent. Three patients who had radiological intervention developed a liver abscess or necrosis. CONCLUSION: Severe PPH is associated with substantial morbidity. Clinical factors including the onset of the bleeding, presentation with either extra and/or intraluminal haemorrhage, and the presence of a pancreatic fistula give an indication of the likely aetiology of the bleeding. A management algorithm based on these factors is presented.

Stent graft repair of subclavian and axillary vascular injuries: The Groote Schuur experience.

BACKGROUND: Trauma-related subclavian and axillary vascular injuries (SAVIs) are generally associated with high morbidity and mortality rates in the surgical literature. There is an emerging trend towards increasing use of stent grafts (covered stents) for repair, with evidence limited to small case series and case reports. OBJECTIVES: To report on the clinical and device-related outcomes of stent graft repair of trauma-related SAVIs at a single institution. METHODS: A retrospective chart review of all patients with trauma-related SAVIs requiring stent graft repair was performed. Outcome measures included technical success, mortality, amputation rate, device-related complications (early and late), and reintervention rates (early and late). RESULTS: A total of 31 patients was identified between June 2008 and October 2013 (30 males, 1 female). Mean age was 27.9 years (range 19-51). All 31 patients sustained a penetrating injury (93.5% stab, 6.5% gunshot injuries). There were 21 subclavian and 10 axillary artery injuries. Five patients (16%) were HIV-positive. Nine patients (29%) were shocked on presentation. Early results (30 days): There were no periprocedural deaths. Primary technical success was 83.9% (26/31). Five patients required adjunctive interventional or operative procedures. There were no early procedure-related complications, reinterventions or open conversions in this study. Overall, suboptimal results were seen in five patients (one type I endoleak and four type II endoleaks). Follow-up results (>30 days): Nineteen patients (61.3%) were available for follow-up. Mean duration of follow-up was 55.7 weeks (range 4 - 240). Overall stent graft patency was 89.5% (17/19). Four patients (21.1%) had an occluded stent graft. Stent graft salvage was possible in two patients. Three type II endoleaks were seen on follow-up. Late reinterventions were performed in five patients (26.3%). Conversion to an open procedure was not required in any patient. There was one late death and one major amputation of a stented limb in a patient who had sustained severe soft-tissue injuries during the follow-up period. CONCLUSION: Perioperative, early and intermediate results suggest that stent graft repair of select trauma-related SAVIs is relatively safe and effective. Axillary arteriovenous fistulas remain a particular challenge using this treatment modality. Larger prospective studies are required to define the utility of stent grafts for select trauma-related SAVIs better.

A new paradigm emerges from the study of de novo mutations in the context of neurodevelopmental disease.

The study of de novo point mutations (new germline mutations arising from the gametes of the parents) remained largely static until the arrival of next-generation sequencing technologies, which made both whole-exome sequencing (WES) and whole-genome sequencing (WGS) feasible in practical terms. Single nucleotide polymorphism genotyping arrays have been used to identify de novo copy-number variants in a number of common neurodevelopmental conditions such as schizophrenia and autism. By contrast, as point mutations and microlesions occurring de novo are refractory to analysis by these microarray-based methods, little was known about either their frequency or impact upon neurodevelopmental disease, until the advent of WES. De novo point mutations have recently been implicated in schizophrenia, autism and mental retardation through the WES of case-parent trios. Taken together, these findings strengthen the hypothesis that the occurrence of de novo mutations could account for the high prevalence of such diseases that are associated with a marked reduction in fecundity. De novo point mutations are also known to be responsible for many sporadic cases of rare dominant mendelian disorders such as Kabuki syndrome, Schinzel-Giedion syndrome and Bohring-Opitz syndrome. These disorders share a common feature in that they are all characterized by intellectual disability. In summary, recent WES studies of neurodevelopmental and neuropsychiatric disease have provided new insights into the role of de novo mutations in these disorders. Our knowledge of de novo mutations is likely to be further accelerated by WGS. However, the collection of case-parent trios will be a prerequisite for such studies. This review aims to discuss recent developments in the study of de novo mutations made possible by technological advances in DNA sequencing.

Isolated gallbladder perforation following blunt abdominal trauma.

A 32-year-old man sustained an isolated perforation of the gallbladder following blunt abdominal trauma. A preoperative diagnosis was made on an ultrasound scan, which showed a pericholecystic fluid collection only. At laparotomy, a gallbladder perforation at the infundibulum was identified with a localised bile collection, warranting a cholecystectomy. Isolated gallbladder injury from blunt abdominal trauma is rare, and a high index of suspicion is required to establish the diagnosis. Cholecystectomy is the treatment of choice.

Determination of the median nerve safe-zone in the carpal tunnel using the distal forearm bony prominences.

BACKGROUND: The compression of the median nerve (MN) in the carpal tunnel (CT) is one of the most common aetiologies of entrapment neuropathy syndromes in clinical practice. The aim of this study was to investigate the relationship of the palpable bony prominences of the distal forearm (radial styloid process [RSP] and ulnar styloid process [USP]) with MN in the CT, in order to determine a safe-zone of the MN during carpal tunnel procedures. MATERIALS AND METHODS: This study involved the bilateral dissection of the CT region of 30 adult cadaveric specimens (n = 60). RESULTS: The mean distance between the RSP and USP was 49.34 mm. The mean distance of the MN from the RSP and the USP were 22.44 mm and 26.66 mm, respectively. The mean diameter of the MN within the CT deep to the flexor retinaculum was 5.93 mm. In addition, the MN was located postero-lateral and postero-medial to palmaris longus tendon (PLT) in 78.33% and 21.67% of specimens, respectively. CONCLUSIONS: This study found that the MN was located less than 60% of the RSP-USP distance from the RSP. Furthermore, the MN was mostly located postero-lateral to the PLT. Therefore, injection or surgical incision made at/medial to a point 60% of the RSP-USP distance from the RSP will be outside the safe-zone of the MN. The knowledge of this surface anatomical relationship of the MN may be useful during decompression for CT syndrome.

The variant course of the suprascapular artery.

The suprascapular artery (SSA) has been identified to be of clinical relevance in surgical intervention and fracture healing of the shoulder. Despite the classic description of its course and relation to the superior transverse scapular ligament, it is subject to much variation. The aims of this study were: (i) to describe the course of the SSA in relation to the superior transverse scapular ligament, (ii) tob determine the prevalence of the course of the SSA in relation to the superior transverse scapular ligament, (iii) to determine the prevalence of the variant origin of the SSA in cases presenting with variant course of the latter, and (iv) to establish a difference in laterality and that between adults and foetuses. The course of the SSA was investigated through the macro- and micro dissection of the antero-andpostero-superior shoulder regions of 31 adult and 19 foetal cadaveric specimens (n = 100). The SSA was observed to pass inferior to the superior transverse scapular ligament accompanied by the suprascapular nerve (20%), which corroborated the findings of previous studies. Subsequently, this variant course of the SSA also appeared to present with the variant origin of it in many instances (13%): from the 3rd part of the subclavian artery (4%), 1st part of the axillary artery (2%), 2nd part of the axillary artery (5%) and SSA (2%). Injury to the SSA may cause more serious trauma than that of arteries which are isolated from the great vessels, therefore the recognition and knowledge of variation in the origin and course of the SSA is significant in the treatment of diseases in the shoulder and cervical regions. Furthermore, the accompaniment of the suprascapular nerve with the SSA at the suprascapular notch inferior to the superior transverse scapular ligament may lead to neuropathy syndromes due to the pulsation of the artery against the nerve within the confined notch.

Longitudinal data resource from the Wellbeing of Older People cohort of people aged >50 years in Uganda and South Africa from 2009 to 2019.

BACKGROUND: The population of people aged ≥60 years continues to increase globally, and has been projected by the United Nations Population Division to increase to 21% of the total population by 2050. In addition, the number of older people living with HIV has continued to increase owing to the introduction of antiretroviral therapy as a treatment for HIV-infected people. Most of the older people living with HIV are in sub-Saharan Africa, an area that faces the biggest burden of HIV globally. Despite the high burden, there are limited reliable data on how HIV directly and indirectly affects the health and wellbeing of older people within this region. OBJECTIVE: To showcase the availability of data on how HIV directly and indirectly affects the health and wellbeing of older people in Uganda and South Africa (SA). METHODS: The World Health Organization Study on global AGEing and adult health (SAGE), in collaboration with Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI and LSHTM) Uganda Research Unit and the Africa Health Research Institute (AHRI) in SA, started the SAGE Wellbeing of Older People Study (WOPS) in Uganda and SA in 2009. Since initiation, respondents have been surveyed every 2 years, with four waves of surveys conducted in Uganda and three waves in South Africa. RESULTS: The available datasets consist of two cohorts of people, aged >50 years, who were surveyed every 2 years between 2009 and 2018. The prevalence of HIV positivity over this period increased from 39% to 54% in Uganda and 48% to 62% in SA. The datasets provide comparisons of variables at a household level and at an individual level. At the individual level, the following measures can be compared longitudinally for a 10-year period for the following variables: sociodemographic characteristics; work history and benefits; health states and descriptions; anthropometrics performance tests and biomarkers; risk factors and preventive health behaviours; chronic conditions and health services coverage; healthcare utilisation; social cohesion; subjective wellbeing and quality of life; and impact of caregiving. CONCLUSION: This article describes the WOPS in Uganda and SA, the population coverage of this study, and the survey frequency of WOPS, survey measures, data resources available, the data resource access and the strengths and weaknesses of the study. The article invites interested researchers to further analyse the data and answer research questions of interest to enhance the impact of these data.