A review of the anatomy and a step-by-step visual guide to performing an ultrasound-guided supraclavicular brachial plexus block

Background: The aim of this description is to provide step-by-step guidelines for performing an ultrasound-guided supraclavicularbrachial plexus nerve block. Methods: The brachial plexus in the supraclavicular fossa of sixty healthy volunteers was scanned in the horizontal/transverse plane. The relevant regional anatomy was studied to identify the muscular and vascular structures seen on the ultrasound screen. Results: The entire process was documented and a standard, step-by-step guide to performing ultrasound-guided supraclavicular brachial plexus blocks was developed. Conclusion: This description serves as a comprehensive guide to a technique for performing ultrasound-guided supraclavicular brachial plexus blocks safely and successfully. It also aims to provide the reader with the background knowledge of the technique and the surrounding regional anatomy

Post-mortem brain weight reference range for a select South African population / Rango de referencia del peso cerebral post-mortem para una población sudafricana seleccionada

Human brain weight plays a significant role in clinical and forensic settings, as cause of death may affect brain weight; and may be used in the detection of abnormalities associated with neurological disorders. Brain weights are geography specific and incorrect reference ranges may hinder interpretation during clinical and autopsy settings. This study assessed the influence of age, sex and race on post-mortem brain weights of a select medico-legal population; to create a geographically relevant reference range of brain weights for the eThekwini region. Standard autopsy protocol and procedures, using the Ghon method of dissection were implemented on four hundred and eighty-one decedents. Decedents were obtained from a medico-legal state mortuary in the eThekwini region, KwaZulu-Natal, South Africa from June 2015 to March 2016. Black South African decedents comprised 83.6 % (402/481) of the sample population and whom reference ranges were formulated. Male decedents attained peak weight significantly earlier in the 11-20 year age interval, whereas female decedents in the 41-50 year age interval. However, no significance was observed between brain weight and age (p=0.799). Significant differences between sexes was noted, with mean male brains weighing significantly more (137.69 g, p<0.001). The mean brain weights were 1404.82±145.07 g and 1267.13±163.96 g in Black males and females, respectively. Post-mortem brain weights were predominantly of Black South Africans, with brain weights of both sexes comparably like those reported in the Northern hemisphere. However, brain weights attained peak weight at different age intervals, with variant brain weights between different racial groups within South Africa. Therefore, brain weight reference ranges may not be applicable to another geographic locality.

El peso del cerebro humano tiene un rol importante en los entornos clínicos y forenses, ya que la causa de la muerte puede afectar el peso del éste; además puede se puede usar en la detección de anomalías asociadas con trastornos neurológicos. Los pesos cerebrales son específicos de la geografía y rangos de referencia incorrectos pueden dificultar la interpretación en la clínica y la autopsia. Este estudio evaluó la influencia de la edad, el sexo y la raza en el peso cerebral post-mortem de una población médico-legal seleccionada; para crear un rango de referencia geográficamente relevante de pesos cerebrales para la región eThekwini. El protocolo y los procedimientos estándar de autopsia, utilizando el método de disección de Ghon, se implementaron en 481 cadáveres. Los cadáveres se obtuvieron de un depósito de cadáveres médico-legal en la región de eThekwini, KwaZulu-Natal, Sudáfrica, entre junio de 2015 a marzo de 2016. Los cadáveres, afro descendientes de Sudáfrica, comprendían el 83,6 % (402/ 481) de la población de la muestra y se formularon los rangos de referencia. Los fallecidos masculinos alcanzaron el peso máximo significativamente más temprano en el intervalo de edad de 11-20 años, mientras que las mujeres fallecidas, correspondió al intervalo de edad de 41 años. Sin embargo, no se observó significación entre el peso del cerebro y la edad (p = 0,799). Se observaron diferencias significativas entre sexos, con cerebros masculinos medios que pesaban significativamente más (137,69 g, p<0,001). Los pesos cerebrales medios fueron 1404,82±145,07 g y 1267,13±163,96 g en hombres y mujeres negros, respectivamente. Los pesos cerebrales post-mortem fueron predominantemente de sudafricanos negros, con pesos cerebrales de ambos sexos comparables a los reportados en el hemisferio norte. Sin embargo, los pesos cerebrales alcanzaron el peso máximo a diferentes intervalos de edad, con pesos cerebrales variables entre diferentes grupos raciales dentro de Sudáfrica. Por lo tanto, los rangos de referencia de peso del cerebro pueden no ser aplicables a otra localidad geográfica.

Post-mortem organ weights at a medico-legal state facility in the eThekwini region / Peso de órganos post-mortem en un servicio médico legal en la región eThekwini

SUMMARY: Organ weights may be influenced by various demographic parameters and environmental conditions, and they differ among populations. Numerous studies have been conducted in the Northern hemisphere, with paucity of literature regarding organ weights of many Southern hemispheric populations. This study aimed to document post-mortem organ weights of decedents in the eThekwini region, and to determine the influence of age, sex, population grouping and body length on the weight of these organs. The study utilised 500 decedent organs (n=500), obtained from a medico-legal state mortuary in the eThekwini region, KwaZuluNatal, South Africa. It entailed gross examination and weighing of the thoracic viz. heart, right and left lungs, and abdominal organs viz. liver, spleen as well as the right and left kidneys. All organs attained maximum or peak weights at various age intervals, with the heart continuing to increase in weight until 80 years of age. Organ weights illustrated statistical significance with age. The heart, lungs and liver were the only organs that showed statistical significance with sex. However, mean spleen weights were higher in females than in males, while the weights of both kidneys were higher in males. Organ weights of White decedents were higher than those of other population groups. There was a positive correlation between body length and all organ weights. Post-mortem organ weights of the present study are comparably higher than those reported in the Northern hemisphere. Therefore, organ weights reported from one geographic location may not be applicable to another and may lead to erroneous references ranges and possibly hinder interpretation during autopsy settings.

RESUMEN: El peso de los órganos puede estar influenciado por diversos parámetros demográficos y condiciones ambientales; además estos difieren entre las poblaciones. Se han realizado numerosos estudios en el hemisferio norte, con escasa información en la literatura sobre el peso de órganos en poblaciones del hemisferio sur. Este estudio tuvo como objetivo documentar el peso de órganos post mortem en la región eThekwini y determinar la influencia de la edad, sexo, agrupación de la población y longitud corporal sobre el peso de los órganos. Para el estudio se utilizaron 500 órganos (n = 500), obtenidos del Servicio Médico Legal de la Región eThekwini de KwaZulu-Natal, Sudáfrica. Se estudiaron el peso y tamaño de las vértebras torácicas, el corazón, pulmones derecho e izquierdo, órganos abdominales, como el hígado, bazo, además del peso de los riñones derecho e izquierdo. Los pesos medios de órganos registrados para la población de la muestra fueron: corazón (328,93 g), pulmón derecho (581,73 g), pulmón izquierdo (485,92 g), hígado (1376,62 g), bazo (153,50 g), riñón derecho (146,67 g) y riñón izquierdo (154,32 g). Los órganos alcanzaron pesos máximos a diferentes intervalos de edad: el corazón continuó aumentando de peso hasta los 80 años de edad (438.00 g), mientras que los pulmones alcanzaron un peso maximo a los 61-70 años (720.70 g / 573.11 g). Los órganos abdominales, como el hígado (1550,67 g), el bazo (196,87 g) y los riñones (146,67 g / 154,32 g), alcanzaron todos el peso máximo entre los 41-50 años de edad. Todos los pesos de los órganos mostraron diferencias estadísticamente significativas de acuerdo a la edad. En el corazón, los pulmones y el hígado se observó una diferencia estadísticamente significativa de acuerdo al sexo. Sin embargo, los pesos medios del bazo fueron mayores en las mujeres que en los hombres, mientras que el peso de ambos riñones fueron mayores en los hombres. El peso de los órganos de los cadáveres de la muestra fue mayor al peso que en otros grupos de población. Al comparar los diferentes grupos de población, el riñón derecho fue el único órgano en el que no se observó una diferencia estadísticamente significativa. Hubo una correlación positiva entre la longitud corporal y los pesos de los órganos. Los pesos de los órganos post-mortem, del presente estudio, son comparativamente mayores a los reportados en el hemisferio norte. Por lo tanto, información sobre el peso de órganos de una ubicación geográfica determinada puede no ser aplicable a otra y puede conducir a una interpretación errónea durante la autopsia.

What are the Reasons for Patients not Adhering to their Anti-TB Treatment in a South African District Hospital?

Introduction :TB is a major health problem in South Africa; with increasing numbers of patients notified; inadequate successful treatment rates and an emerging problem with resistant strains. This study was conducted at a District Hospital in KwaZulu-Natal where the successful treatment rate was as low as 23. The aim of this study was to identify key factors at the hospital that may affect adherence to TB treatment and to recommend interventions that could improve adherence. Methods:The study design was a case control study using prospectively collected data. Information was collected over an 8-month period; when the patients started their anti-TB treatment; according to the known factors that influence TB adherence. The patients were then followed up to determine those who did not adhere to their treatment; and those who successfully completed treatment. The two groups involved; therefore; were the controls (those who did adhere) and the cases (those who did not adhere). The data previously collected were then compared for significant associations with the controls and cases. Results :Data were obtained from 159 TB patients; 105 (66) were adherent and 54 (34) non-adherent. The following variables showed a significant association (p 0.05) with non-adherence: higher level of education; distance from the hospital; time taken to travel; the method of transport; satisfaction with the hospital; food security; income; the smoking of tobacco and/or marijuana; the patients' perspective and beliefs; HIV testing and status; functional status; social support; the relationship with the TB nurse; depression score; and self-rating of confidence. A stepwise logistic regression was performed; and only two variables remained significantly associated: travel time (OR7.9; 95CI 1.4-44.1) and the relationship with the TB nurse (OR2.6; 95CI 1.3-5.1). Conclusions: The most important recommendation is to improve the relationship between patients and TB nurses through training in communication skills. A more holistic assessment of patients would help identify issues such as depression; and a more patient-centred approach would help to understand and address patient's concerns; beliefs and expectations. It may also be important to ensure that management and administrative systems support a more patient-centred approach. It may be important to encourage the recruitment of family physicians who are trained in communication skills and a patient-centred approach; to work in the rural areas; where they can mentor and teach other colleagues and staff. More needs to be done in terms of helping patients to access facilities through transport; or in making services more available at the community level through DOTS (Directly Observed Treatment) supporters and adequate home-based carer support

Prevalence of Pneumocystis jirovecii and Mycoplasma pneumoniae in Patients Presenting with Pneumonia at Hospitals in Port Elizabeth

The study was conducted to determine the prevalence of Pneumocystis jirovecii and Mycoplasma pneumoniae in patients presenting with community-acquired pneumonia; in order to improve treatment management programmes. Sputum specimens from 45 patients presenting with pneumonia/symptoms of pneumonia admitted to hospitals in the Port Elizabeth region were assessed. Details of patient's gender; age; HIV and Mycobacterium tuberculosis status were provided by the hospitals. PCRs were performed employing primers directed at the following genes: P. jirovecii for detection of mitochondrial large subunit ribosomal RNA (mtLSUrRNA) and for cotrimoxazole resistance mutation analysis dihrdropteroate synthase (DHPS) and dihydrofolate reductase (DHFR); M. pneumoniae for detection of P1 adhesin and 16SrRNA. Women were seen to be at high risk for community-acquired P. jirovecii colonisation. Overall; prevalence of P. jirovecii was 73(33/45 patients). P. jirovecii was mainly associated with HIV (28/30 P. jirovecii-positive patients for which clinical data were available) and co-colonisation with M. tuberculosis was observed in 10 HIV cases and one HIV-negative patient. DHPS and DHFR primers seriously lacked sensitivity and on six and four PCR products obtained; respectively; no resistanceassociated mutations were found. M. pneumoniae was detected in one patient. The high prevalence of P. jirovecii and presence of M. pneumoniae in cases of pneumonia investigated emphasises that in the absence of definitive diagnoses; it is crucial to monitor treatment responses carefully; especially when first line antibiotic preferences are a-lactams or cephalosporins