Symptomatic hepatothorax presenting 25 years after penetrating thoracoabdominal injury.

Hepatic herniation through the diaphragm is a rare finding. It generally occurs due to a congenital diaphragmatic abnormality or blunt trauma resulting in a diaphragmatic defect. Making the diagnosis is difficult, as there are few definitive clinical signs and chest radiograph (CXR) findings may be non-specific. To our knowledge, only a single case report exists of penetrating right diaphragm injury leading to hepatic herniation. A 42-year-old man presented to the emergency department of a regional hospital with hyperglycaemia and exertional dyspnoea. He was diagnosed with diabetes mellitus type 2. He gave a history of smoking for 15 pack-years, was negative for retroviral disease and had no history of pulmonary tuberculosis. He had no significant surgical history but reported being stabbed with a knife in 1995. The point of entry was below the level of the nipple in the right anterior axillary line. At the time, he was treated with an intercostal drain and discharged home. CXR showed a right-sided chest mass. We considered a differential diagnosis of pulmonary consolidation, diaphragm eventration or hepatothorax. Computerized tomography of the chest and abdomen demonstrated apparent intrathoracic extension of the right liver lobe and partial attenuation of the superior vena cava and right atrium due to a mass effect. The upper border of the liver abutted the aortic arch. Surgical treatment options were discussed. The patient declined surgery and will be followed up as an outpatient.

Changes in surgical practice in 85 South African hospitals during COVID-19 hard lockdown.

BACKGROUND: In preparation for the COVID-19 pandemic, South Africa (SA) began a national lockdown on 27 March 2020, and many hospitals implemented measures to prepare for a potential COVID-19 surge. OBJECTIVES: To report changes in SA hospital surgical practices in response to COVID-19 preparedness. METHODS: In this cross-sectional study, surgeons working in SA hospitals were recruited through surgical professional associations via an online survey. The main outcome measures were changes in hospital practice around surgical decision-making, operating theatres, surgical services and surgical trainees, and the potential long-term effect of these changes. RESULTS: A total of 133 surgeons from 85 hospitals representing public and private hospitals nationwide responded. In 59 hospitals (69.4%), surgeons were involved in the decision to de-escalate surgical care. Access was cancelled or reduced for non-cancer elective (n=84; 99.0%), cancer (n=24; 28.1%) and emergency operations (n=46; 54.1%), and 26 hospitals (30.6%) repurposed at least one operating room as a ventilated critical care bed. Routine postoperative visits were cancelled in 33 hospitals (36.5%) and conducted by telephone or video in 15 (16.6%), 74 hospitals (87.1%) cancelled or reduced new outpatient visits, 64 (75.3%) reallocated some surgical inpatient beds to COVID-19 cases, and 29 (34.1%) deployed some surgical staff (including trainees) to other hospital services such as COVID-19 testing, medical/COVID-19 wards, the emergency department and the intensive care unit. CONCLUSIONS: Hospital surgical de-escalation in response to COVID-19 has greatly reduced access to surgical care in SA, which could result in a backlog of surgical needs and an excess of morbidity and mortality.

Efficacy and patterns of use of antimicrobial prophylaxis for gunshot wounds in a South African hospital setting: an observational study using propensity score-based analyses.

BACKGROUND: Limited evidence supports the efficacy of antimicrobial prophylaxis (AP) in prevention of gunshot woundrelated (GSW-related) infection in resource restricted areas. At Tygerberg Hospital, South Africa, it is standard care for GSW patients to receive one dose of broad-spectrum AP. For various reasons, this protocol is not consistently followed. This study aimed to assess the efficacy of AP in the reduction of in-hospital GSW-related infection and to identify opportunities for practice improvement. METHODS: All patients admitted with GSW over a three-month period were eligible for inclusion. Patients who did and did not receive AP were identified retrospectively the morning of admission; thereafter, data was collected prospectively. Data regarding circumstances of the incident, injury characteristics, type of AP and surgery was obtained. The occurrence of in-hospital GSW-related infection was recorded over 30 days or until discharge. Propensity score matching (PSM) and inverse probability weighting (IPW) methods were utilised to assess the effect of AP on the prevention of GSW-related infection. RESULTS: 165 consecutive patients were assessed, of which 103 received AP according to protocol within 12 hours of admission. PSM showed a reduced in-hospital GSW infection risk of 12% (95% CI, 0.2-24%, p = 0.046) with AP. IPW showed that AP reduced the risk for infection by 14% (95% CI, 3-27%, p = 0.015). CONCLUSIONS: Providing AP to GSW patients in a civilian setting appeared to result in a modest but clinically relevant lower risk of in-hospital GSW-related infection. In this study setting, optimisation of AP for all patients with GSWs should significantly lower the burden of wound infection.

Changes in surgical practice in 85 South African hospitals during COVID-19 hard lockdown

Background. In preparation for the COVID-19 pandemic, South Africa (SA) began a national lockdown on 27 March 2020, and many hospitals implemented measures to prepare for a potential COVID-19 surge.Objectives. To report changes in SA hospital surgical practices in response to COVID-19 preparedness.Methods. In this cross-sectional study, surgeons working in SA hospitals were recruited through surgical professional associations via an online survey. The main outcome measures were changes in hospital practice around surgical decision-making, operating theatres, surgical services and surgical trainees, and the potential long-term effect of these changes.Results. A total of 133 surgeons from 85 hospitals representing public and private hospitals nationwide responded. In 59 hospitals (69.4%), surgeons were involved in the decision to de-escalate surgical care. Access was cancelled or reduced for non-cancer elective (n=84; 99.0%), cancer (n=24; 28.1%) and emergency operations (n=46; 54.1%), and 26 hospitals (30.6%) repurposed at least one operating room as a ventilated critical care bed. Routine postoperative visits were cancelled in 33 hospitals (36.5%) and conducted by telephone or video in 15 (16.6%), 74 hospitals (87.1%) cancelled or reduced new outpatient visits, 64 (75.3%) reallocated some surgical inpatient beds to COVID-19 cases, and 29 (34.1%) deployed some surgical staff (including trainees) to other hospital services such as COVID-19 testing, medical/COVID-19 wards, the emergency department and the intensive care unit.Conclusions. Hospital surgical de-escalation in response to COVID-19 has greatly reduced access to surgical care in SA, which could result in a backlog of surgical needs and an excess of morbidity and mortality

Guideline summary: appropriate use of tigecycline.

Tigecycline, the first of a new class of broad-spectrum antibiotics (the glycylcyclines), has been licensed in South Africa for the parenteral treatment of adult patients with complicated intra-abdominal infections (cIAIs) and complicated skin and soft-tissue infections (cSSTIs). This article serves as a summary of the guideline on the appropriate use of tigecycline, published in mid-2010 as a collaborative effort by representatives of the Association of Surgeons of South Africa, the Critical Care Society of Southern Africa, the Federation of Infectious Diseases Societies of Southern Africa, the South African Thoracic Society and the Trauma Society of South Africa.

Guideline: appropriate use of tigecycline.

INTRODUCTION: Tigecycline, the first of a new class of antibiotics, the glycylcyclines, was licensed in South Africa for the parenteral treatment of adult patients with complicated intra-abdominal infections (cIAIs) and complicated skin and soft-tissue infections (cSSTIs). METHODS: A multidisciplinary meeting representative of the Association of Surgeons of South Africa, the Critical Care Society of Southern Africa, the Federation of Infectious Diseases Societies of Southern Africa, the South African Thoracic Society and the Trauma Society of South Africa was held to draw up a national guideline for the appropriate use of tigecycline. Background information reviewed included randomised controlled trials, other relevant publications and local antibiotic susceptibility patterns. The initial document was drafted at the meeting. Subsequent drafts were circulated to members of the working group for modification. OUTPUT: The guideline addresses several important aspects of the new agent, summarising key clinical data and highlighting important considerations with the use of the drug. The recommendations in this guideline are based on currently available scientific evidence together with the consensus opinion of the authors. CONCLUSION: This statement was written out of concern regarding the widespread misuse of antibiotics. Its primary intention is to facilitate heterogeneous use of antibiotics as a component of antibiotic stewardship and to highlight the appropriate use of tigecycline in particular.

Investigating the ultrastructure of platelets of HIV patients treated with the immuno-regulator, Canova: a qualitative scanning electron microscopy study.

The resistance of HIV strains to the available antiretroviral medication has become a major problem in the world today. This has forced researchers to investigate the possible use of alternative drugs such as homeopathic medicine (e.g. immunomodulators) to enhance the immune system of patients infected with HIV. Canova is an immunomodulator of herbal origin which is known to stimulate the host defense against several pathological states through the activation of the immune system. Blood platelets play an important role in homeostasis, thrombosis and the immune response by forming platelet aggregates. The ultrastructure of platelet aggregates of patients with HIV has been studied previously using SEM to determine the effect of HIV on the platelet morphology. Membrane blebbing and ruptured platelet membranes were observed which is indicative of apoptosis, revealing that HIV patients may develop thrombocytopenia as a result of peripheral platelet destruction. The aim of the current study was to investigate the effect of HIV on the morphology of platelets from patients treated with the immuno-modulator, Canova, compared to control individuals and HIV patients not on the Canova treatment. Blood was drawn from the individuals and the coagula were formed by adding human thrombin to the platelet rich plasma. Examination was done using SEM. CD4 counts were also determined. Slight morphological changes were seen when comparing the fibrin networks from the control, untreated HIV patients and the Canova-treated HIV patients, suggesting that HIV does not impact on the fragility of fibrin networks. In HIV patients there are bleb-like bulges on the membrane of platelets as well as membrane breakages visible on the aggregate, whereas in the Canova-treated patients membrane blebbing is far less pronounced and there are large areas of intact, smooth membranes with visible canalicular areas, suggesting that Canova protects the membranes of platelets and that blebbing does not appear in such great proportions as was found in the untreated HIV group. These results support and provide ultrastructural evidence for the results seen in previous research, where it is seen that Canova protects the immune system of immuno-compromised patients by keeping the ultrastructure intact thereby preventing the devastating cyto-destructive effects of HIV disease.

Abdominal tuberculosis: still a potentially lethal disease.

The findings in a 4-yr survey of 82 patients with abdominal tuberculosis are described and compared with those encountered in previous surveys. Fourteen cases of intestinal, 11 of mesenteric-lymphnodal, and 57 of peritoneal tuberculosis were identified. The disease occurred essentially in patients living under worsening socioeconomic conditions, and 51 of them had associated pulmonary tuberculosis. Symptoms and clinical findings were again nonspecific, but newer imaging, endoscopic, and other invasive procedures were helpful in establishing a definite diagnosis. In addition, adenosine deaminase determination showed great promise as a noninvasive diagnostic procedure in patients with tuberculous ascites. The six hospital deaths in the series highlight the hazard of potentially lethal delays in early diagnosis and treatment, even in centers with a high awareness of the disease.

Dry beriberi: unusual complication of prolonged parenteral nutrition.

An adult with Crohn's disease on home total parenteral nutrition (TPN) for 8 months presented with peripheral neuropathy and ataxia. The patient was found to be deficient of thiamine. A prompt symptomatic response to intravenous thiamine suggests that the patient had the chronic form of dry beriberi. To our knowledge, this variety of beriberi in a patient on TPN has not previously been reported.

A survey of the intestinal nematodes of Bushmen in Namibia.

Studies in Namibia revealed prevalence rates of 63% for hookworm and 35% for Trichuris in 31 Bushmen, 4-65 years of age, who were encamped in the Kaudom Game Reserve. The study also revealed prevalence rates of 85% for hookworm, 25% for Strongyloides, and 1% for Trichuris in 103 children, 6-17 years of age, attending 5 schools in Bushmanland. The 25% Strongyloides infection rate is one of the highest prevalences recorded in southern Africa. The Trichuris infections in the Kaudom group appeared to be autochthonous, and this population did not harbor Strongyloides. Regular contact with pans in summer and boreholes at any time probably facilitated the acquisition of infections in wet and fecally polluted sites. Thirteen spurious Physaloptera infections were recorded.

Dettol (chloroxylenol and terpineol) poisoning in a pregnant patient. A case report.

A 30-year-old woman who was 28 weeks pregnant was admitted to hospital after deliberate ingestion of 300 ml Dettol. The patient's management and that of Dettol overdose are discussed.

Apnoeic diving safety--experimental approaches to oxygen augmentation.

A study was undertaken to determine whether a volume of oxygen injected from a 100 ml syringe and inhaled during a 10 m ascent would be exhaled again fully or partially by two experienced male divers. Each performed one apnoeic dive with and another without O2 augmentation. Analyses of mouth gas showed that the injected O2 had disappeared when the divers reached the surface. Any movement of the injected O2 to the alveoli through an open glottis probably resulted from simple diffusion as well as from agitation and mixing of gases by simulated respiratory activity. High-frequency positive-pressure ventilation applied by several authors, whereby sufficient gas exchange is achieved by oscillating small tidal volumes at frequencies of up to 900 per minute, may substantiate this possibility. The injected O2 was found also to have disappeared from the alveolar gas, shown by a comparison of O2 fraction differences between augmented and non-augmented dives. Injection and inhalation of the additional O2 will raise the partial pressure of O2 in the alveoli and increase oxygen transfer across the alveolar membrane into the blood, with more molecules being taken up within seconds during the ascent time. O2 augmentation in larger volumes during apnoeic diving could lead to a burst lung and must be regarded with suspicion. There is evidence that O2 augmentation by means of a small syringe attached to a trained diver's snorkel will help prevent apnoeic blackout.