The reliability of physical examination in diagnosing arterial injury in penetrating trauma to extremities: A first look at different anatomical regions and injury mechanisms.

BACKGROUND: The accuracy of physical examination to exclude arterial injury in penetrating trauma to extremities has been well established. OBJECTIVES: To determine whether the accuracy of physical examination to exclude arterial injury is similar to that of a computed tomography arteriogram (CTA) for different anatomical regions and mechanisms of injury, and in patients with concomitant fractures compared with those without. METHODS: A retrospective review was conducted on all patients who underwent CTA for penetrating injuries to an extremity between 1 June 2016 and 30 June 2017. The presence of arterial injuries was noted, and these were grouped into anatomical areas. Clinical notes were reviewed for the presence of hard signs of arterial injury at initial examination. RESULTS: A total of 220 lower limb and 133 upper limb CTAs were included. The mean patient age was 28.9 years (range 11 - 68). The overall sensitivity of physical examination in detecting a CTA-confirmed arterial injury was 95.3% (95% confidence interval (CI) 88.4 - 98.7), with a specificity of 93.9% (95% CI 90.2 - 96.4). Physical examination of the thigh had the highest specificity of 96.4% (95% CI 91.8 - 98.8), followed by the lower leg at 94.4% (95% CI 81.3 - 99.3), the upper arm at 89.6% (95% CI 79.7 - 95.7) and the forearm at 77.8% (95% CI 40.0 - 97.2). For gunshot wounds the specificity was 96.1% (95% CI 92.4 - 98.3), while for stab wounds it was 86.8% (95% CI 74.7 - 94.5). CONCLUSIONS: This study agrees with current literature indicating that physical examination has high specificity in detecting arterial injury in the setting of penetrating trauma to an extremity. However, it shows that the specificity is not equal for all anatomical regions or mechanisms of injury.

Orthopaedic referrals using a smartphone app: uptake, response times and outcome

Background. It is well established that South Africa (SA) suffers an immense burden of violence and injuries. The responsibility of providing care for these injuries falls mainly on public health services, resulting in overloading of the health system. Prior to a recent intervention, the large burden had been exacerbated by limitations in the traditional referral system that highlighted the need for a better referral system. Vula's smartphone app was introduced at Tygerberg Hospital in August 2016. This study evaluated the uptake, response times and outcomes using this app.Objectives. The main objectives of the study were to describe: (i) the number of referrals; (ii) referral response times; (iii) referring facilities; and (iv) referral outcomes. Secondary objectives were to: (i) evaluate whether the referral outcome pathway was appropriate; and (ii) assess professional conduct and evidence of upskilling.Methods. This retrospective, descriptive study investigated Vula app referrals to the Division of Orthopaedic Surgery at Tygerberg Hospital between 1 August 2016 and 31 March 2017. Vula was advertised to key facilities in the hospital's referral network. All referrals to the division during the study period were systematically included in the analysis of operational outcomes, although some were excluded from the subsequent referral outcome analysis. Operational outcomes included the number of referrals, referring facilities and referral response times. Referral outcome analysis included the clinical diagnosis, referral pathway, whether the referral was used for upskilling and whether it was conducted in a professional manner.Results. A total of 2 275 referrals from 39 different facilities were received during the study period from 238 individual users; 50% of referrals received a response within 11 minutes, while a small percentage received no response. Clinical and demographic characteristics of 1 985 patients included in the referral outcome analysis indicated that the majority of trauma and emergency referrals involved males, with closed fractures being the most frequent clinical presentation. Although the most common referral outcome was immediate transfer, one-third of the patients were treated at the referring hospital with advice only.Conclusions. The large volume of orthopaedic referrals received through the Vula app suggests that Vula represents a successful alternative to traditional referral methods. Referrals managed by advice only could suggest that Vula facilitates some relief for the overburdened trauma services. Future research could further explore Vula's role in strengthening the public health system, including interventions for high-volume referral areas and upskilling of referring health workers

Irrigation water quality and the threat it poses to crop production: evaluating the status of the Crocodile (West) and Marico catchments, South Africa.

Ensuring food security is becoming increasingly difficult due to limited freshwater resources. Low-quality irrigation water also poses a severe threat to crop yield and quality. The aim of this study was to evaluate the water quality associated with the Crocodile (West) and Marico catchments, which represent one of South Africa's most developed regions. Sources of irrigation water include the hypertrophic Hartbeespoort Dam, as well as the heavily impacted Crocodile (West) River. Analysis of historical irrigation water quality data (from January 2005 to December 2015) revealed that the Hartbeespoort and Crocodile (West) irrigation schemes were exposed to calcium sulfate enrichment, likely as a result of extensive mining activities in the Bushveld Igneous Complex. Also, significant differences in water quality parameters occurred between these irrigation schemes and the reference system (Marico-Bosveld Irrigation Scheme), while important salt (chloride and sodium) and nutrient (inorganic nitrogen and orthophosphate (as phosphorus)) concentrations exceeded threshold values provided by irrigation water quality guidelines. The Hartbeespoort and Crocodile (West) irrigation schemes also presented distinctive temporal (long-term and seasonal) patterns in water quality. Seasonal variation in pH levels at the Hartbeespoort Irrigation Scheme is likely caused by excessive algae growth and cyanobacteria blooms (Mycrocystis sp.), which also pose an important threat to human and animal health. Despite mitigation efforts by government and other stakeholders, some of South Africa's major irrigation schemes remain highly impacted as a result of water quality deterioration.