Comparative outcome analysis of trauma and non-trauma emergency laparotomy using a modified NELA tool format.

BACKGROUND: Emergency laparotomy (EL) encompasses a diverse range of procedures that general surgeons commonly perform for both trauma and non-trauma related conditions in South Africa (SA). Despite differences in the underlying pathology and influence of the surgical procedure, these patients share one care pathway for preoperative, operative and postoperative care. This study reviewed patients undergoing trauma EL and non-trauma EL in a general surgery setting at a rural KwaZulu-Natal tertiary hospital to compare results between the groups using a modified National Emergency Laparotomy Audit (NELA) tool format. METHODS: Consecutive adult patients undergoing midline EL at Ngwelezana Hospital between 1 March and 31 May 2018 were included. Patient factors analysed were demographic data (age, gender) and risk factors: National Confidential Enquiry into Perioperative Deaths (NCEPOD) grade, American Society of Anesthesiologists (ASA) grade, and comorbidity. Process of care factors included grade of the physician, time to surgery, time of surgery and duration of surgery. The primary outcome measure was mortality. Secondary outcome measures were intensive care unit (ICU) admissions, complications, and length of stay (LOS) > 14 days. RESULTS: The study included 110 participants who met the inclusion criteria representing a total of 174 laparotomies. The trauma EL group had lower ASA grades (p = 0.003), less comorbidities (p = 0.002), more often went to theatre within six hours (42/56; 75.0%) (p < 0.001), more admissions to ICU (23/56; 41.1%) (p < 0.001), more complications (29/56; 51.8%) (p = 0.039), and higher length of stay > 14 days (16/56; 28.6%) (p = 0.037). CONCLUSION: The trauma EL group represents a high-risk group for morbidity and mortality at Ngwelezana Hospital.

Renal replacement therapy in intensive care units in KwaZulu-Natal Province, South Africa.

Background: Renal replacement therapy (RRT) is a scarce resource in southern Africa. Critically ill patients are at risk of developing acute kidney injury (AKI), which may require RRT. There are few data on the utilisation of RRT in southern African intensive care units (ICUs). Objectives: To determine the indications for initiating RRT in critically ill patients in ICUs in KwaZulu-Natal, South Africa (SA) and to describe the methods and dosing of RRT. Methods: A prospective observational study was performed to investigate the indications for initiating, methods and dosing of RRT among patients admitted to four ICUs in KwaZulu-Natal Province, SA. All adult patients were eligible for inclusion. Results: A total of 108 patients who received RRT were included in the study. The most common reasons for initiation of RRT were a high/rising creatinine, high/rising urea, acidosis and fluid balance. The majority of the patients (79.6%; n=86) had three or more indications for RRT. A total of 353 intermittent haemodialysis/slow low-efficiency dialysis (IHD/SLED) sessions and 84 continuous renal replacement therapy (CRRT) sessions were recorded. The median (interquartile range (IQR)) CRRT dose was 25.8 (19.1 - 28.8) mL/kg/h. The median (IQR) urea reduction ratio for IHD/SLED was 32.4% (15.0 - 49.8). Conclusion: Patients in this study had multiple indications for initiating RRT. The dosing of RRT was not optimal, with a wide range shown in CRRT, and the majority of patients did not achieve a urea reduction ratio (URR) >65%. Contributions of the study: Renal replacement therapy is a scarce resource in Africa. Little is known about the current types and dosing of RRT in critical care units in South Africa. We showed that critically ill patients had multiple indications for RRT and the dosing was not optimal.

A closer look at burn injuries and epilepsy in a developing world burn service.

BACKGROUND: Burn injuries in South Africa result in significant morbidity and mortality, and specific vulnerable groups of patients are at increased risk of sustaining a burn injury. Epileptic patients are one such vulnerable group. The spectrum of burn injuries sustained by epileptic patients in a South African township and the pattern of injury, mechanism and outcome were reviewed in this study. METHOD: A retrospective review of all epileptic patients admitted to the burn service of Edendale Hospital was undertaken for the period July 2011 to June 2013. RESULTS: One hundred and ninety-seven adult patients were admitted with burns over this period. There were 39 epileptic patients in this cohort, of whom 26 were female. The average age of the patients was 36 years (a range of 21-40 years). The majority of patients sustained a small total body surface area burn. The most common mechanism of burn was from a fire or flames, followed by hot water scalding. Coal or wood fires were the predominant energy source used for heating and cooking at home. CONCLUSION: Epileptics comprise a significant proportion of patients who sustain a burn injury. Typically, they sustain burns during a seizure. These are mostly caused by open flames in the South African environment, and are deep. They tend to be confined to the upper torso, upper limbs and hands. Injury prevention programmes should target epileptics as a vulnerable group.

Biodistribution and metabolism in rats and mice of bucromarone.

The metabolism and disposition of bucromarone, labeled with 14C on the chromone group, has been investigated in C3H mice and Wistar rats. In separate experiments, animals received 4.4 mmol/kg, iv or po, [14C]bucromarone hydrochloride or succinate. More than 90% of the administered radioactivity was excreted in bile, after iv and po administration. Less than 5 min after iv injection, radioactivity concentrated in all tissues, and blood concentration became very low as compared with its initial level. After po administration, no more than 10% of the dose was incorporated in the tissues. The discrepancy between the high biliary excretion and the low tissue and blood concentration after po administration suggested that bucromarone was well absorbed through the gastrointestinal tract; but after liver uptake, drug and its metabolites were excreted in the bile, less than 10% being distributed into the extrahepatic blood. Comparison of the iv and po areas under the plasma 14C-radioactivity concentration-time curves indicated a poor bioavailability of the molecule after po administration. Analysis of the radioactivity content of bile showed that bucromarone was extensively metabolized after both administration routes. Unchanged bucromarone and three main metabolites, monodesbutylbucromarone, didesbutyl bucromarone, and 2-(3-5-dimethyl-4-hydroxybenzoyl) chromone, amounting to 85% of the bile radioactivity, were identified by HPLC and mass spectrometry. These findings are consistent with a dealkylation of the N-dibutyl group, yielding potential pharmacologically active metabolites monodesbutyl and didesbutyl bucromarone.

Disposition and metabolism of letosteine in rats.

The metabolism and disposition of letosteine, labeled either with 14C or 35S, has been investigated in Sprague-Dawley rats. In separate experiments, rats received 20 mg/kg, iv or orally, [14C]letosteine or [35S]letosteine. Radioactivity was rapidly excreted, mainly in urine, after iv and oral administration. Recovery of radioactivity from 0-72-hr excreta averaged 95% after both routes of [14C]letosteine administration, whereas only 50% was recovered when [35S]letosteine was administered. 14CO2 accounted for about 7.3% (iv) and 5.1% (po) of the dose of [14C]letosteine. Comparison of the iv and oral areas under the plasma 14C radioactivity concentration-time curves suggested that oral absorption of letosteine was complete. Analysis of the radioactivity content of urine showed that letosteine undergoes rapid and extensive metabolism. Several metabolites were identified by TLC, HPLC, and MS. The findings are consistent with a splitting of the ester group of letosteine and subsequent cleavage of the thiazolidinyl ring, yielding cysteine, hypotaurine, taurine, and inorganic sulfate. The metabolite derived from the side chain was identified in the urine as 3-(hydroxycarbonylmethylthio)propanoic acid. It undergoes further oxidation into sulfoxide and sulfone derivatives, which are also present in the urine.

The effect of food and time of administration on the absorption of diethylamine chromocarbe.

In order to evaluate the influence of food and time of administration on the absorption of diethylamine chromocarbe, a bioavailability study was performed in 8 volunteers by using a new method of plasmatic drug evaluation. The results obtained indicate that lunch has little effect on diethylamine chromocarbe absorption in comparison with the administration 0.5 h before breakfast. The bioavailability parameters Cmax, tmax, and AUC are not statistically different and the two methods of administration can be considered as bioequivalent. The absorption of diethylamine chromocarbe seems to be reduced when the drug is administered before dinner. This delay on absorption may be due to circadian rhythm of tractus gastrointestinal absorption or to the reduction of physiological activity of volunteers.

Role of alpha-fetoprotein (AFP) in the regulation of ovarian activity during hepatocarcinogenesis and post-natal development.

N-fluorenylacetamide produces an augmentation of serum AFP which is accompanied by a drastic decrease of ovarian activity. A passive augmentation of the AFP level of adult rats, produced by injection of this protein provokes the same phenomenon: i.e. a decrease of follicular maturation, a decrease number of corpora lutea and finally a drop in the plasma progesterone level. The study of ovarian post-natal development shows that ovarian maturity occurs on the 35th day of life when AFP level reaches its adult serum concentration. These facts support the hypothesis that AFP plays a role in the regulation of ovaries during the sexual maturation of the female rat.