The profile of orthopaedic sports medicine publishing in South Africa.

Background: The South African Journal of Sports Medicine (SAJSM) and the South African Orthopaedic Journal (SAOJ) are two open access, peer-reviewed journals which provide ongoing education to the sports medicine community. Objectives: The purpose of this review was to appraise articles with a sports orthopaedic focus published in SAJSM and SAOJ. A secondary aim was to evaluate trends regarding the focus of the articles, levels of evidence, authors' affiliations, and country of origin. Methods: An electronic search of the SAJSM from 1982 to 2021 and SAOJ from 2008 to 2021 was conducted to identify relevant articles. The eligibility of the articles was determined according to the following inclusion criteria: SAJSM articles with reference to musculoskeletal anatomy and/or an injury in any sport, and SAOJ articles focusing specifically on sports, sports teams and low-velocity traumatic injuries in sports people. Results: This study included specific sports orthopaedic articles in SAJSM (n=161) and SAOJ (n=41). The articles originated from 67 institutions in 19 countries. In SAJSM, the majority of articles were published by local authors (n=44, 61%). There was a non-significant difference in the proportion of articles from local and international institutions in SAOJ. In SAJSM, the sports covered most frequently included rugby, cricket, running and soccer, whereas in SAOJ most articles referred to low-velocity injuries. With regard to trend analysis, a significant decline in articles with Level V evidence published by SAJSM was observed (p<0.001). Similarly, articles with Level V evidence published by SAOJ showed a decline, although it was non-significant. Conclusion: The focus of SAJSM in particular is relevant to sports played, injury patterns and the healthcare resources for sports people in South Africa. The level of evidence published by SAJSM has improved significantly over time.

'Make exercise the elixir across an economic divide': A message to COVID-19 decision makers.

South Africa, like other countries around the world, has used a lockdown strategy to address the initial phases of the COVID-19 epidemic. The significant restrictions on population movement have included initially limiting exercise to the home. There is substantial evidence for the many benefits of exercise. This study specifically emphasises the benefits of exercise to the immune system, particularly for those most vulnerable to the effects of the SARS-CoV-2 virus and proposes measures to improve access to exercise in a demographically diverse and economically disparate society.

Coming full circle: thirty years of paediatric fluid resuscitation.

Fluid bolus therapy (FBT) is a cornerstone of the management of the septic child, but clinical research in this field is challenging to perform, and hard to interpret. The evidence base for independent benefit from liberal FBT in the developed world is limited, and the Fluid Expansion as Supportive Therapy (FEAST) trial has led to conservative changes in the World Health Organization-recommended approach to FBT in resource-poor settings. Trials in the intensive care unit (ICU) and emergency department settings post-FEAST have continued to explore liberal FBT strategies as the norm, despite a strong signal associating fluid accumulation with pulmonary pathology in the paediatric population. Modern clinical trial methodology may ameliorate the traditional challenges of performing randomised interventional trials in critically ill children. Such trials could examine differing strategies of fluid resuscitation, or compare early FBT to early vasoactive agent use. Given the ubiquity of FBT and the potential for harm, appropriately powered examinations of the efficacy of FBT compared to alternative interventions in the paediatric emergency and ICU settings in the developed world appear justified and warranted.

The utility of procalcitonin in the prediction of serious bacterial infection in a tertiary paediatric intensive care unit.

To determine utility of procalcitonin (PCT) for the prediction of bacterial infection in critically ill children, we analysed the relationship between serum PCT, cultures and other laboratory markers of bacterial sepsis or viral infection in a tertiary paediatric intensive care unit (PICU). The outcome measures were levels of PCT in proven bacteraemia, pneumonia and viral respiratory infection; and comparison of PCT to immature to total neutrophil ratio (ITR) in prediction of bacteraemia. In 420 children with suspected sepsis, 1,226 serum PCT levels were analysed. Children with bacteraemia had a higher median PCT (2.03 ng/ml, interquartile range [IQR] 0.67-42.4) than those who did not have bacteraemia (0.82 ng/ml, IQR 0.295-2.87) (P=0.033). PCT was a significant but only moderate predictor of bacteraemia (AUC 0.65). In 866 episodes of suspected sepsis where paired PCT and ITR were performed, the median ITR in children with bacteraemia was 0.19 ng/ml (IQR 0.04-0.35), and the median PCT was 6.5 ng/ml (IQR 0.71-61.8). PCT was a marginally better predictor of bacteraemia (AUC 0.69) than the ITR (AUC 0.66). In children with viral respiratory tract infection only, the median PCT was 1.26 ng/ml (0.35-5.5), and in those with likely bacterial pneumonia the median PCT was 0.80 ng/ml (IQR 0.28-1.70). In a heterogeneous population of children in a tertiary PICU, PCT measured at a single timepoint was a moderate predictor of proven bacteraemia. In our population PCT did not reliably identify localised bacterial infection or distinguish bacterial from viral respiratory infection.

Intensive care management of children intubated for croup: a retrospective analysis.

Croup remains the commonest reason for acute upper airway obstruction in children, yet there are scarce contemporary data of airway management in those requiring intubation. We performed a retrospective analysis of the intensive care management of children intubated for croup in two quaternary Paediatric Intensive Care Units: Royal Children's Hospital Melbourne, Australia and Alberta Children's Hospital Calgary, Canada. Patients intubated for less than three days were compared with those intubated for greater than three days. Patients less than 10 kg body weight were compared to those greater than 10 kg. Demographic, clinical and microbiological data were recorded. Seventy-seven cases of croup requiring intubation were identified. The median duration of intubation was 60 hours. Parainfluenza was the most common viral aetiology, detected in 30% of cases. Antibiotics were prescribed in 51% of patients. Corticosteroids were prescribed pre intubation in two-thirds of patients and all post intubation, with the median dose being prednisolone 3 mg/kg/day. Primary extubation failure occurred in 6.5% of patients. Neither the duration of intubation nor patient size were associated with extubation failure. An air leak test was performed in 69% of patients and poorly predicted extubation success. One non-urgent tracheostomy was performed and there was one death from hypoxic ischaemic encephalopathy. Endotracheal tube leak is poorly recorded and may not predict successful extubation.

Ethical and legal considerations in video recording neonatal resuscitations.

As guidelines for neonatal resuscitation evolve from a growing evidence base, clinicians must ensure that practice is closely aligned with the available evidence, based on methodologically sound and ethically conducted research. This paper reviews ethical, legal and risk-management issues arising during the design of a quality-assurance project to make video recordings of neonatal resuscitations after high-risk deliveries. The issues, which affect patients, researchers, staff and the hospital at large, include the following: 1) Informed consent for research involving emergency procedures is often not possible, for lack of time to provide sufficient information. The mental capacity of the subject or parent may be compromised by the impending emergency, and freedom of choice is threatened by the time pressure to consent. 2) Video recording of the inevitable medical errors raises issues of whether participating staff may be identifiable and accountable, affecting their willingness to participate in such research. The approach to staff participation and identification is reviewed. 3) The use of video data for education threatens the privacy of research subjects. The ethics of maintaining privacy is balanced with the ethics of using the data to improve practice of resuscitation. 4) The research subjects (patients, or the staff whose performance is being monitored) must be defined. 5) There are legal and ethical aspects of management and ownership of data. 6) The role of the Human Research Ethics Committee in protecting the research subject and possibly the medicolegal interests of the hospital is discussed. This paper reviews the literature and discusses the issues.

A randomised placebo controlled trial of oral misoprostol in the third stage of labour.

OBJECTIVE: To compare oral misoprostol 400 microg with placebo in the routine management of the third stage of labour. DESIGN: A double-blind placebo controlled trial. Setting The labour ward of an academic hospital in Johannesburg, South Africa with 7000 deliveries per annum. PARTICIPANTS: Low-risk women expected to deliver vaginally. METHODS: Women in labour were randomly allocated to receive either misoprostol 400 microg orally or placebo after the birth. Conventional oxytocics were given immediately if blood loss was thought to be more than usual. Postpartum blood loss in the first hour was measured by collection in a special flat plastic bedpan. Side effects were recorded. MAIN OUTCOME MEASURES: Measured blood loss > or = 1000 ml within the first hour after birth. Use of additional oxytocics. RESULTS: The groups were well matched. Measured blood loss > or = 1000 ml occurred in 15/250 (6%) after misoprostol and 23/250 (9%) after placebo (relative risk 0.65; 95% confidence interval 0.35-1.22). The difference may have been reduced by the greater use of conventional oxytocics in the placebo group, which was statistically significant for intravenous oxytocin infusion (2.8% vs 8.4%, relative risk 0.33, 95% confidence interval 0.14-0.77). Shivering was more common in the misoprostol group (19% vs 5%, relative risk 3.69; 95% confidence interval 2.05-6.64). CONCLUSIONS: Shivering has been shown in this study to be a specific side effect of misoprostol administered orally in the puerperium. No serious side effects were noted. Misoprostol shows promise as a method of preventing postpartum haemorrhage. Because of the potential benefits for childbearing women, particularly those in developing countries, further research to determine its effects with greater certainty should be expedited.

PIP: A randomized, double-blind study conducted at a teaching hospital in Johannesburg, South Africa, assessed oral misoprostol administration in the third stage of labor as a method of preventing postpartum hemorrhage. Women expected to deliver vaginally were randomly allocated to receive either 400 mcg of oral misoprostol (n = 250) or placebo (n = 250) immediately after delivery. Oxytocics were given if blood loss was perceived to be excessive. Blood loss of 1000 ml or above occurred in 15 women (6%) in the misoprostol group and in 23 controls (9%) (relative risk, 0.65; 95% confidence interval, 0.35-1.22; p = 0.18). The failure of this difference to attain statistical significance may reflect the greater rate of oxytocic use in the placebo group (8.4%) than in the misoprostol group (2.8%). Shivering was more common in the misoprostol group (19%) than the placebo group (5%). There were no other side effects. The potential of misoprostol to prevent postpartum hemorrhage merits further investigation, especially in developing countries where such an intervention could reduce maternal mortality and morbidity.