Malaria deaths as sentinel events to monitor healthcare delivery and antimalarial drug safety.

OBJECTIVES: To identify case management, health system and antimalarial drug factors contributing to malaria deaths. METHOD: We investigated malaria-related deaths in South Africa's three malaria endemic provinces from January 2002 to July 2004. Data from healthcare facility records and a semi-structured interview with patients' contacts were reviewed by an expert panel, which sought to reach consensus on factors contributing to the death. This included possible health system failures, adverse reactions to antimalarials, inappropriate medicine use and failing to respond to treatment. RESULTS: Approximately 177 of 197 cases met inclusion criteria for the study. Delay in seeking formal health care was significantly longer for patients who sought traditional health care [median 4; inter-quartile range (IQR) 3-7 days] than for patients who did not (median 3; IQR 1-5 days; P = 0.033). Patients with confirmed or suspected HIV/AIDS were significantly more likely to use traditional approaches (25%) than those with other comorbidities (0%; P = 0.002). Malaria was neither suspected nor tested for at a primary care facility in 23% of cases with adequate records. Initial hospital assessment was considered inadequate in 74% of cases admitted to hospital and in-patient monitoring and management was adequate in only 27%. There were 32 suspected adverse reactions to antimalarial therapy. CONCLUSION: A confidential enquiry into malaria-related deaths is a useful tool for identifying preventable factors, health system failures and adverse events affecting malaria case management.

Femoro-distal bypass surgery at Groote Schuur hospital--4-year retrospective study.

UNLABELLED: An analysis of the demographics and outcome of femoro-distal bypass in patients presenting with defined critical limb ischaemia at Groote Schuur Hospital, Cape Town, is presented. MATERIALS AND METHODS: A retrospective review was conducted between January 1998 and December 2001. During this period, 65 patients underwent femoro-distal bypass. Of these, 57 patients were analysed and 8 patients were excluded from the study because of incomplete medical records RESULTS: The median age of the patients in this study was 62 years, with a male-to-female ratio of 34:23. Twenty-eight patients (49%) were diabetic. An overall 2-year mortality of 19.2% was recorded. Reversed saphenous vein graft (RSVG) was used in 29 legs (50.9%) and in situ vein graft (ISVG) in 19 legs (33.3%). There was no statistically significant difference in the graft patency between the two methods (p = 0.39); the 2-year cumulative patency was 40% for the RSVG and 39% for the ISVG. In our unit only 2 factors influenced the outcome of femoro-distal bypass--local sepsis in the foot and an increased early postoperative ankle-brachial index (p < 0.05). Diabetes mellitus, gender, age and race had no influence on the outcome. This study showed that the site of the distal anastomosis had no effect on graft patency or limb salvage. At 2 years, the cumulative patency and limb salvage rates were 40% and 56% respectively. Of the 11 grafts with stenotic lesions requiring intervention, 6 were detected between 18 and 24 months. CONCLUSION: Management of critical limb ischaemia is a major part of the workload in our unit, with most patients undergoing primary amputation. The surgical outcome of femoro-distal bypass was largely influenced by local sepsis and early postoperative ABI. We found that more than half the stenotic lesions detected during graft surveillance occurred beyond 18 months postoperatively. This suggests that a graft surveillance programme should continue beyond 18 months.

Should knee-length replace thigh-length graduated compression stockings in the prevention of deep-vein thrombosis?

OBJECTIVE: To compare knee-length with thigh-length graduated compression stockings for correct application and rate of compliance when they are prescribed for the prevention of deep-vein thrombosis in surgical patients. METHODOLOGY: Patients who were prescribed graduated compression stockings were prospectively studied in three surgical units at Groote Schuur Hospital from February to June 1997. Knee-length stockings were prescribed in the colorectal unit, while the thigh-length variety were prescribed in the hepatobiliary and trauma units. Patients were observed for the correct application and size of stockings, and the presence of compression bands. A total of 72 patients were studied. RESULTS: One patient in the knee-length group and 7 patients in the thigh-length group were not wearing their stockings. Twenty-one of 30 patients (70%) in the knee-length group and 15 of 42 (35.7%) in the thigh-length group had correctly applied stockings (P = 0.009). CONCLUSIONS: Knee-length are more likely to be correctly applied than thigh-length stockings. Knee-length should replace thigh-length stockings in general surgical patients.

Functional entrapment of the popliteal artery.

A case of functional entrapment missed at the initial angiogram is presented. The imaging of popliteal artery entrapment syndrome and functional entrapment is discussed. The importance of appropriate imaging is emphasized. The classification of popliteal artery entrapment syndrome is discussed and it is proposed that functional entrapment is added to the existing classification in the interest of consistent reporting.

The cost and benefit of prophylaxis against deep vein thrombosis in elective hip replacement. DVT/PE Prophylaxis Consensus Forum.

UNLABELLED: A consensus forum was convened to evaluate the economic considerations associated with prophylaxis against thrombo-embolic disease in patients undergoing hip replacement therapy in South Africa. This forum consists of orthopaedic surgeons, vascular surgeons and a statistician. METHODS: The forum was instructed to evaluate the economic costs of the commonly used forms of prophylaxis of thrombo-embolism in patients undergoing hip replacement surgery in South Africa, looking at short-term events only. The methods used for the prophylaxis of thrombo-embolism in South Africa were determined by a postal survey. A decision tree was constructed to determine the events that will occur after a clinical decision to use no prophylaxis. The probabilities of these events were then determined. Protocols for and costs of prophylaxis and treatment were established. With the decision tree and these costs, the cost of the various modalities of prophylaxis was then determined. RESULTS: The probability, determined by the forum, of developing a deep-vein thrombosis (DVT) when no prophylaxis is used was 0.5, with a mortality rate of 2.1%. The cost of this decision was R875. No prophylaxis given, but a venogram performed on day 7, reduced the mortality rate to 0.7%; however, this cost R3 017. The cost of low-molecular-weight heparin was R1 223 (probability 0.26, mortality rate 1.1%), while unfractionated heparin with a graduated compression stocking (GCS) cost R1 351 (probability 0.24, mortality rate 1%). Aspirin with a GCS cost R777 (probability 0.35, mortality rate 1.5%).

Abdominal aortic aneurysms in children.

Abdominal aortic aneurysms are rare in children. Causes include mycotic aneurysms, vasculitides (eg, Takayasu's arteritis), connective tissue diseases (eg, Marfan's syndrome, Ehlers-Danlos syndrome, and tuberous sclerosis) and traumatic false aneurysms. Four cases are described. Case 1 was a 12-year-old boy who presented with an acute unheralded rupture of the subdiaphragmatic aorta accompanied by lower limb paralysis and ischemia. Attempted repair failed because of extensive friability of the large arteries. Histological evaluation confirmed cystic medial necrosis despite Marfanoid phenotype. Cases 2 and 3 were boys aged 12 and 11 with Takayasu's arteritis who presented with hypertensive encephalopathy and heart failure. Although both had involvement of the origins of the renal arteries, one aneurysm was predominantly suprarenal and the other infrarenal. Currently both children are being managed successfully with antihypertensive therapy. Case 4 was a 5-year-old girl who presented with hypertension and a pulsatile abdominal mass after treatment of infective endocarditis 18 months previously. Arteriography and three-dimensional computed tomography confirmed an aneurysm (6 x 5 x 4 cm) arising from the aorta and involving the right renal artery. Aneurysmectomy, removal of a small ischemic right kidney, and Gore-Tex grafting resulted in cure of the hypertension and uneventful recovery. The present series confirms that rupture is a fatal complication, renovascular complications are common, and medical control of hypertension is an essential part of management. Management strategies need to be highly individualized, and may be successful without surgical intervention. Close clinical and ultrasound follow-up of those managed nonoperatively is essential.

The value of routine computed tomography of the brain in the pre-operative assessment of patients for carotid endarterectomy.

OBJECTIVE: To determine the prevalence of brain infarcts and other intracranial pathology on computed tomography (CT) in patients with greater than 50% internal carotid artery stenosis. DESIGN: Descriptive study of CT findings. SETTING: Referral-based cohort at Groote Schuur Hospital. PARTICIPANTS: Sixty-three patients aged 40-82 years who had CT of the head prior to carotid endarterectomy. MAIN OUTCOME MEASURES: Prevalence of brain infarct in patients presenting with transient ischaemic attack (TIA) or stroke, and yield of unsuspected intracranial pathology other than ischaemic necrosis. RESULTS: Brain infarcts were diagnosed in 54% of patients presenting with TIA and in 73% of patients with stroke. True-positive CT scans were present in only 19% and 44% of patients with TIA and stroke, respectively. A single incidental frontal lobe granuloma, unrelated to the patient's clinical presentation, was noted. CONCLUSIONS: In the selected group of patients referred for carotid endarterectomy, routine use of CT of the head is not indicated and can be reserved for cases with extraordinary clinical features.

Venous thrombectomy in patients presenting with iliofemoral vein thrombosis after renal transplantation.

In this study 14 patients presented with 15 episodes of iliofemoral vein thrombosis after renal transplantation. Seven patients (group 1) had viable renal grafts and were treated with conventional anticoagulation. Eight patients (group 2) had non-viable renal grafts and were subjected to graft nephrectomy and simultaneous venous thrombectomy without anticoagulation. The patients in group 2 had rapid resolution of the signs and symptoms of the iliofemoral vein thrombosis, and noninvasive vascular investigation at follow-up revealed competent and patent deep veins in all patients. In contrast, only 50% of the patients in group 1 had normal venous studies at follow-up. We recommend that renal transplant recipients who develop iliofemoral vein thrombosis and nonviable allograft postoperatively should be subjected to venous thrombectomy at the time of graft nephrectomy.

Chylous ascites following abdominal aortic surgery.

Chylous ascites is an extremely rare complication of abdominal aortic surgery. A case with a successful outcome is presented, followed by a review of the 17 published cases. Chylous ascites can result in nutritional imbalance, immunological deficit and respiratory dysfunction. Paracentesis confirms the diagnosis and provides symptomatic relief. Conservative management, beginning with a low-fat diet and medium-chain triglyceride (MCT) supplementation, is recommended, changing to total parenteral nutrition if unsuccessful. Failure of non-operative treatment may necessitate the need for laparotomy and ligation of leaking lymphatics or peritoneovenous shunting.

Abdominal aortic aneurysmectomy in a renal transplant patient.

Standard surgical techniques were modified to allow continued perfusion of a renal allograft during resection of a large symptomatic abdominal aortic aneurysm. Neither hypothermic perfusion nor temporary bypass were employed. No alteration in renal function was observed and the patient remains well. Complex methods of renal allograft protection are probably unnecessary when transplant recipients undergo aortic reconstruction. However simple modifications or technique can substantially reduce renal ischaemic time and further add to the safety of the procedure.

Successful treatment of infected thoracoabdominal aortic graft by percutaneous catheter drainage.

A large perigraft abscess infected with Klebsiella sp. developed around a woven Dacron prosthesis inserted into a patient at high-risk with a leaking thoracoabdominal aortic aneurysm. Percutaneous insertion of a sump drainage catheter under ultrasound guidance accompanied by local and systemic antibiotic therapy was the only reasonable management option. Two years later the patient remains well with no evidence of sepsis on clinical examination, hematologic studies, computerized tomography or indium 111 labeled autologous leucocyte imaging. This technique may be successful in selected high-risk situations.

Equilibrium radionuclide angiocardiography prior to elective abdominal aortic surgery.

Equilibrium radionuclide angiocardiography (ERNA) was employed preoperatively in 183 patients undergoing elective abdominal aortic reconstruction to measure left ventricular ejection fraction (LVEF) and to detect abnormal regional wall movement. Abnormal ejection fractions were virtually confined to the 97 patients who had clinical, electrocardiographic or radiographic evidence of heart disease. An operative mortality of 8.7% was recorded. Major cardiac events (defined as myocardial infarction, cardiac failure or malignant ventricular arrhythmia) occurred in 15 of 86 abdominal aortic aneurysm patients (17.4%) and six of 96 (6.25%) patients with aorto-iliac occlusive disease. Patients with an abdominal aortic aneurysm and abnormal LVEF or regional wall motion abnormality were more likely to suffer a cardiac event (p less than 0.001), the event rate exceeding 60% in patients whose LVEF was less than 35%. An abnormal LVEF failed to predict a cardiac event in patients with aorto-iliac occlusive disease. While not indicated in patients lacking clinical evidence of heart disease, ERNA can refine the assessment of cardiac risk, particularly in patients with previous myocardial infarction and define a high risk group in whom aortic reconstruction should be avoided except for the most compelling of indications.

Thrombotic side-effects of lower limb venography. The use of heparin-saline flush.

In a prospective study of 256 postoperative patients, bilateral lower limb venography was performed using meglumine iothalamate followed by heparin-saline flushing of the deep veins, and the complications of the procedure were assessed. No patient developed clinical evidence of deep-vein thrombosis after the venogram. In 117 patients fibrinogen uptake was performed 24 hours after the venogram. A new positive area on the uptake scan developed in 3 patients (2.6%). Local swelling or haematoma at the injection site occurred in 15 patients (5.9%), cellulitis in 2 (0.8%) and minor contrast reactions in 6 (2.3%). There were no major reactions and no procedure-related mortality. The reasons for the wide variation in the reported incidence of post-venogram thrombosis are considered and the importance of heparin-saline flushing of the deep veins to prevent this complication is discussed.

Lower limb vein trauma: a long-term clinical and physiological assessment.

The aim of this study was to assess the long-term clinical and physiological sequelae of lower limb venous trauma in a civilian practice. Twenty-six patients who had undergone surgery for lower limb venous trauma (median elapsed time 19.5 months) underwent assessment. Injuries had been sustained to the external iliac, common femoral superficial femoral and popliteal veins in two, four, nine and eleven limbs respectively. Using clinical assessment, photoplethysmography recovery time, the presence of popliteal reflux and venographic evidence of thrombosis, the final outcome was graded as good, fair or poor. Fourteen patients had pedal oedema, including two with a postphlebitic limb. The overall photoplethysmography recovery time (mean and s.d.) was 20.6 (8.7) s in the injured and 32.1 (6.7) s in the non-injured limbs (P = 0.002). Patients with a venographically occluded vein had a shorter photoplethysmography recovery time than those in whom the vein was patent (13.4 (5.6) versus 21.6 (8.7) s; P = 0.07). Popliteal reflux was present in 12 injured limbs. Seven of 12 venograms performed on limbs with a vein repair had evidence of previous thrombosis. Vein ligation carried considerable morbidity and all end-to-end anastomoses initially failed. In retrospect, saphenous vein grafts were too narrow for the recipient veins and panel grafts might have been more appropriate. Overall 11 of 26 patients (42 per cent) had a poor result. The repair of choice is a saphenous vein patch for lesser injuries and a saphenous panel graft for major injuries. Vein ligation should be avoided unless another life-threatening injury demands priority.

Pancreatic somatostatinoma: presentation with recurrent episodes of severe hyperglycaemia and ketoacidosis.

A 47-year-old woman was admitted on four occasions over a four-year period with severe hyperglycaemia associated with marked ketoacidosis. She had weight loss with hepatomegaly and ultrasonography indicated a pancreatic tumour which was shown to be a somatostatinoma. Resection resulted in prolonged survival. The biochemical and morphological features of this rare tumour are presented, and an explanation for the unusual presentation of a somatostatinoma with episodes of ketoacidosis is given.

Septicaemia resulting from inadvertent intravenous administration of enteral nutrient solution. A case report.

Septicaemia caused by inadvertent intravenous administration of enteral nutrition solution (ENS) is a potentially lethal complication of continuous enteral tube feeding. This report highlights the problem and makes a plea for administration sets that are not compatible with intravenous cannulas, and more stringent national bacteriological standards of preparation of ENS.