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OBJECTIVE While high-velocity missile injury (gunshot) is associated with kinetic and thermal injuries, non-missile penetrating head injury (NMPHI) results in primary damage along the tract of the piercing object that can be associated with significant secondary complications. Despite the unique physical properties of NMPHI, factors associated with complications, expected outcomes, and optimal management have not been defined. In this study, the authors attempted to define those factors. METHODS Consecutive adult patients with NMPHI who presented to Tygerberg Academic Hospital (Cape Town, South Africa) in the period from August 1, 2011, through July 31, 2018, were enrolled in a prospective study using a defined treatment algorithm. Clinical, imaging, and laboratory data were analyzed. RESULTS One hundred ninety-two patients (185 males [96%], 7 females [4%]) with 192 NMPHIs were included in this analysis. The mean age at injury was 26.2 ± 1.1 years (range 18–58 years). Thirty-four patients (18%) presented with the weapon in situ. Seventy-one patients (37%) presented with a Glasgow Coma Scale (GCS) score of 15. Weapons included a knife (156 patients [81%]), screwdriver (18 [9%]), nail gun (1 [0.5%]), garden fork (1 [0.5%]), barbeque fork (1 [0.5%]), and unknown (15 [8%]). The most common wound locations were temporal (74 [39%]), frontal (65 [34%]), and parietal (30 [16%]). The most common secondary complications were vascular injury (37 patients [19%]) and infection (27 patients [14%]). Vascular injury was significantly associated with imaging evidence of deep subarachnoid hemorrhage and an injury tract crossing vascular territory (p ≤ 0.05). Infection was associated with delayed referral (> 24 hours), lack of prophylactic antibiotic administration, and weapon in situ (p ≤ 0.05). A poorer outcome was associated with a stab depth > 50 mm, a weapon removed by the assailant, vascular injury, and eloquent brain involvement (p ≤ 0.05). Nineteen patients (10%) died from their injuries. The Glasgow Outcome Scale (GOS) score was linearly related to the admission GCS score (p < 0.001). One hundred forty patients (73%) had a GOS score of 4 or better at discharge. CONCLUSIONS The most common NMPHI secondary complications are vascular injury and infection, which are associated with specific NMPHI imaging and clinical features. Identifying these features and using a systematic management paradigm can effectively treat the primary injury, as well as diagnose and manage NMPHI-related complications, leading to a good outcome in the majority of patients.

Previous literature indicates that the detection of haematuria on urine microscopy, to exclude bladder invasion by cervical cancer, has a high specificity. It also aids the evaluation of whether a ...

Chronic wounds are a serious and debilitating complication of diabetes. A better understanding of the dysregulated healing responses following injury will provide insight into the optimal time frame for therapeutic intervention. In this study, a direct comparison was done between the healing dynamics and the proteome of acute and obese diabetic wounds on days 2 and 7 following injury. Full thickness excisional wounds were induced on obese diabetic (B6.Cg-lepob/J, ob/ob, n = 14) (blood glucose 423.25 ± 127.92 mg/dL) and WT control (C57BL/6J, n = 14) (blood glucose 186.67 ± 24.5 mg/dL) mice. Histological analysis showed no signs of healing in obese DM wounds whereas complete wound closure/re-epithelisation, the formation of granulation tissue and signs of re-vascularisation, was evident in acute wounds on day 7. In obese DM wounds, substance P deficiency and increased MMP-9 activity on day 2 coincided with increased cytokine/chemokine levels within wound fluid. LC-MS/MS identified 906 proteins, of which 23 (Actn3, Itga6, Epb41, Sncg, Nefm, Rsp18, Rsp19, Rpl22, Macroh2a1, Rpn1, Ppib, Snrnp70, Ddx5, Eif3g, Tpt1, FABP5, Cavin1, Stfa1, Stfa3, Cycs, Tkt, Mb, Chmp2a) were differentially expressed in wounded tissue on day 2 (P < 0.05; more than two-fold) and 6 (Cfd, Ptms, Hp, Hmga1, Cbx3, Syap1) (P < 0.05; more than two-fold) on day 7. A large number of dysregulated proteins on day 2 was associated with an inability to progress into the proliferative stage of healing and suggest that early intervention might be pivotal for effective healing outcomes. The proteomic approach highlighted the complexity of obese DM wounds in which the dysregulation involves multiple regulatory pathways and biological processes.

The objective of the study was to determine whether all patients with spinal non-missile penetrating injuries (NMPIs) need to be managed at a tertiary neurosurgical centre. A retrospective analysis of clinical, demographic, and imaging records was performed on all NMPI patients referred to the Department of Neurosurgery at Tygerberg Academic Hospital in Cape Town, South Africa, between 1 January 2016 and 31 December 2019. Ninety-six patients were identified (94 males and 2 females) with 35 cervical, 60 thoracic, and 1 lumbar spinal stab. Eighty-six had an incomplete spinal cord injury. Six patients presented with cerebrospinal fluid (CSF) leak, all of which resolved spontaneously. MRI was performed in nine patients. Six patients had retained blades, of which 5 were removed in the emergency room (ER). Surgery was performed in two patients (cervical intramedullary abscess and a retained blade). Two patients developed meningitis, and one an intramedullary abscess. Twenty-two patients had associated injuries (pneumothorax, bowel injury). The average length of stay was 17 days, with 81% being unchanged neurologically. The average time from discharge to leaving the hospital was 11 days. Early management of NMPI should include prophylactic antibiotics and wound debridement and X-ray imaging to exclude retained blades. Bowel and lung injury must be managed accordingly. Tertiary neurosurgical referral is not routinely necessary and is only warranted for deteriorating neurology, retained blades not removable in the ER, and respiratory failure secondary to spinal cord injury. Complications include meningitis and persistent CSF leak, which should be referred timeously.

BACKGROUND AND PURPOSE Little is known about the epidemiological features of amyotrophic lateral sclerosis (ALS) in sub-Saharan Africa, and data from the region are limited to clinical series or case reports. The aim of the study was to investigate the incidence rate and presentation of ALS in an ethnically diverse region of South Africa. METHODS We performed a 4-year prospective incidence study in the Western Cape Province of South Africa between 1 July 2014 and 30 June 2018, and used a two-source capture-recapture method for case ascertainment. Age- and sex-adjusted incidence rates (ASAIRs) were calculated using the 2010 US population as the reference. RESULTS A total of 203 incident cases were identified over the study period, resulting in a crude incidence rate (IR) of 1.09 [95% confidence interval (CI) 0.94-1.24] per 100 000 person-years in the at-risk population (aged >15 years). Capture-recapture analysis resulted in an estimated IR of 1.11 (95% CI 1.01-1.22) per 100 000 person-years. The ASAIR was 1.67 (95% CI 1.09-2.26) overall; 1.99 (95% CI 1.60-2.39) for men and 1.37 (95% CI 1.06-1.68) for women. When analysed separately, there was a substantial difference in ASAIRs between the different population groups, with the highest in the European ancestry group (2.62; 95% CI 2.49-2.75), the lowest in the African ancestry group (0.56, 95% CI 0.0-1.23), and an ASAIR in between these two in the mixed ancestry group (1.09, 95% CI 0.80-1.37). CONCLUSION The overall incidence of ALS in the Western Cape Province of South Africa appears to be lower than in North African and Western countries, but higher than in Asian countries. As suggested by previous epidemiological studies, ALS may be less frequent in people of African ancestry.

Acute and chronic stressors are common triggers of human mental illnesses. Experimental animal models and their cross-species translation to humans are critical for understanding of the pathogenesis of stress-related psychiatric disorders. Mounting evidence suggests that both pharmacological and non-pharmacological approaches can be efficient in treating these disorders. Here, we analyze human, rodent and zebrafish (Danio rerio) data to compare the impact of non-pharmacological and pharmacological therapies of stress-related psychopathologies. Emphasizing the likely synergism and interplay between pharmacological and environmental factors in mitigating daily stress both clinically and in experimental models, we argue that environmental enrichment emerges as a promising complementary therapy for stress-induced disorders across taxa. We also call for a broader use of novel model organisms, such as zebrafish, to study such treatments and their potential interplay.

Background Severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2)-induced infection, the cause of coronavirus disease 2019 (COVID-19), is characterized by acute clinical pathologies, including various coagulopathies that may be accompanied by hypercoagulation and platelet hyperactivation. Recently, a new COVID-19 phenotype has been noted in patients after they have ostensibly recovered from acute COVID-19 symptoms. This new syndrome is commonly termed Long COVID/Post-Acute Sequelae of COVID-19 (PASC). Here we refer to it as Long COVID/PASC. Lingering symptoms persist for as much as 6 months (or longer) after acute infection, where COVID-19 survivors complain of recurring fatigue or muscle weakness, being out of breath, sleep difficulties, and anxiety or depression. Given that blood clots can block microcapillaries and thereby inhibit oxygen exchange, we here investigate if the lingering symptoms that individuals with Long COVID/PASC manifest might be due to the presence of persistent circulating plasma microclots that are resistant to fibrinolysis. Methods We use techniques including proteomics and fluorescence microscopy to study plasma samples from healthy individuals, individuals with Type 2 Diabetes Mellitus (T2DM), with acute COVID-19, and those with Long COVID/PASC symptoms. Results We show that plasma samples from Long COVID/PASC still contain large anomalous (amyloid) deposits (microclots). We also show that these microclots in both acute COVID-19 and Long COVID/PASC plasma samples are resistant to fibrinolysis (compared to plasma from controls and T2DM), even after trypsinisation. After a second trypsinization, the persistent pellet deposits (microclots) were solubilized. We detected various inflammatory molecules that are substantially increased in both the supernatant and trapped in the solubilized pellet deposits of acute COVID-19 and Long COVID/PASC, versus the equivalent volume of fully digested fluid of the control samples and T2DM. Of particular interest was a substantial increase in α(2)-antiplasmin (α2AP), various fibrinogen chains, as well as Serum Amyloid A (SAA) that were trapped in the solubilized fibrinolytic-resistant pellet deposits. Conclusions Clotting pathologies in both acute COVID-19 infection and in Long COVID/PASC might benefit from following a regime of continued anticlotting therapy to support the fibrinolytic system function.

Major incidents account for a vast number of consequences, whether it be individual morbidity and mortality or economic disruption and expense. Because of the infrequent nature, it poses a variety of unique risks and challenges for individual emergency medical services systems. Air ambulances are usually dispatched based on the clinical presentation of an individual patient who needs emergent critical care intervention. The response to a major incident is unusual and infrequent, but the benefit of tasking air ambulances to such incidents has been described by various authors. Here, such a response is described in a low- to middle-income country that saw the immediate tasking of 2 separate air ambulances to a single, multivehicle collision with multiple injured patients that occurred near a small, rural hospital not capable of treating critically ill patients. The benefits of tasking of the air ambulance in the sense of additional expertise as well as potential other nonclinical benefits are discussed and described here.

The recent rise in migration from Africa through the Mediterranean basin into Europe has resulted in an increased incidence of uncommon diseases such as schistosomiasis and genito-urinary tuberculosis, which were previously largely unknown in this region. This study aimed to evaluate the insight of European urologists into diagnosing and managing these disease conditions and to determine whether they were adequately prepared to deal with the changing disease spectrum in their countries. A survey including specific questions about the diagnosis and management of ‘tropical’ urological diseases was distributed among urologists working in Europe and Africa. Multivariate logistic regression models were performed to detect the continent (African or European) effect on knowledge of and insight into tropical urological diseases. A total of 312 surveys were administered. African and European respondents accounted for 109 (36.09%) and 193 (63.91%) respondents, respectively. The multivariate logistic regression analysis demonstrated a significant deficiency in the knowledge of tropical urological diseases in the European cohort compared with the African cohort (p

ObjectivesTo describe the epidemiology and concordance of bone health in a population-based sample of Australian parent-child dyads at child age 11–12 years.DesignPopulation-based cross-sectional study (the Child Health CheckPoint) nested between waves 6 and 7 of the Longitudinal Study of Australian Children (LSAC).SettingAssessment centres in seven cities around Australia, February 2015–March 2016.Participants: of all participating CheckPoint families (n=1874), bone data were available for 1222 dyads (1271 children, 50% girls; 1250 parents, 86% mothers).Outcome measuresPeripheral quantitative CT (pQCT) of the non-dominant leg scanned at the 4% (distal) and 66% (mid-calf) tibial sites. Stratec XCT 2000 software generated estimates of bone density, geometry and polar stress-strain index.Parent-child concordance were assessed using Pearson’s correlation coefficients and multivariable linear regression models. Percentiles were determined using survey weights. Survey weights and methods accounted for LSAC’s complex sampling, stratification and clustering within postcodes.ResultsConcordances were greater for the geometric pQCT parameters (periosteal circumference 0.38, 95% CI 0.33 to 0.43; endosteal circumference 0.42, 95% CI 0.37 to 0.47; total cross-sectional area 0.37, 95% CI 0.32 to 0.42) than density (cortical density 0.25, 95% CI 0.19 to 0.30). Mother-child and father-child values were similar. Relationships attenuated only slightly on adjustment for age, sex and body mass index. Percentiles and concordance are presented for the whole sample and by sex.ConclusionsThere is strong parent-child concordance in bone geometry and, to a lesser extent, density even before the period of peak adolescent bone deposition. This geometrical concordance suggests that future intergenerational bone studies could consider using pQCT rather than the more commonly used dual X-ray absorptiometry (DXA).

The human skeleton reflects an individual’s biocultural life-course, recording information on diet, health, and stress. Using new methods for inferring phys-iological stress during the foetal, infant, and childhood periods, this chapter investigates the early lives of two subadult individuals through the lens of the maternal-infant nexus from the Neolithic site of Man Bac in Vietnam. We apply a novel approach that incorporates stable isotopic evidence for weaning and diet, with a quantitative method of identifying and measuring linear enamel hypoplasia to assess physiological stress during development. These case studies are interpreted within a bioarchaeology of infant- and child-care theoretical model approach that focuses on the maternal-infant nexus, and incorporates information on fertility, palaeopathological data, archaeological data on the natural and social environment, and social organisation.

Extracorporeal life support is the utilisation of advanced techniques to sustain circulatory and/or ventilatory functions in critically ill patients when standard therapies fail. It is well established in high-income countries. There is increasing literature supporting its application in refractory cardiac arrest with a potential reversible cause, a procedure also known as extracorporeal cardiopulmonary resuscitation (eCPR). Two cases where eCPR was successfully utilised in a busy (>30 000 visits per year) private South African emergency department are described here, the first such cases to be reported on the African continent. The first patient had a life-threatening cardiac arrhythmia due to toxin ingestion, and the second a refractory ventricular fibrillation due to acute myocardial infarction. In both these cases the cardiac arrest was witnessed, occurred in the emergency department, and failed to respond to standard advanced resuscitative measures. Both the patients were discharged neurologically intact. Although it is effective, the benefit of this advanced method of resuscitation in a low- to middle-income country is debated.

Thalassemias are inherited blood disorders that are found in high prevalences in the Mediterranean, Southeast Asia and the Pacific. These diseases provide varying levels of resistance to malaria and are proposed to have emerged as an adaptive response to malaria in these regions. The transition to agriculture in the Holocene has been suggested to have influenced the selection for thalassemia in the Mediterranean as land clearance for farming encouraged interaction between Anopheles mosquitos, the vectors for malaria, and human groups. Here we document macroscopic and microscopic skeletal evidence for the presence of thalassemia in both hunter-gatherer (Con Co Ngua) and early agricultural (Man Bac) populations in northern Vietnam. Firstly, our findings demonstrate that thalassemia emerged prior to the transition to agriculture in Mainland Southeast Asia, from at least the early seventh millennium BP, contradicting a long-held assumption that agriculture was the main driver for an increase in malaria in Southeast Asia. Secondly, we describe evidence for significant malarial burden in the region during early agriculture. We argue that the introduction of farming into the region was not the initial driver of the selection for thalassemia, as it may have been in other regions of the world.

Extra-pulmonary tuberculosis (EPTB), caused by Mycobacterium tuberculosis, is the leading cause of communicable disease-related deaths in people with human immunodeficiency virus (HIV) worldwide and in South Africa. Mycobacterium tuberculosis disseminates haematogenously from an active primary lung focus and may affect extra-pulmonary sites in up to 15% of patients. Extra-pulmonary TB may present with a normal chest radiograph, which often causes a significant diagnostic dilemma. This review describes the main sites of involvement in EPTB, which is illustrated by local imaging examples.

BACKGROUND: The safety and adverse event rate of supraglottic airway (SGA) devices for cesarean delivery (CD) is poorly characterized. The primary aims of this review were to determine whether the first-pass success was higher and time to insertion for SGA was faster than endotracheal intubation for elective CD. The secondary aim was to determine the airway-related adverse event rate associated with SGA use compared to endotracheal intubation in elective CD under general anesthesia (GA). METHODS: Six databases were systematically searched until September 2019. Included studies reported on the use of SGA in comparison to endotracheal tube intubation. A comparative meta-analysis between SGA and endotracheal intubation was performed using RevMan 5.3 software. Dichotomous outcomes were reported using an odds ratio (OR) with 95% confidence interval (CI). The results for continuous outcomes were reported using a weighted mean difference (WMD) with 95% CI. RESULTS: Fourteen studies with 2236 patients compared SGA and endotracheal intubation. Overall, there was no statistically significant difference in first-attempt success rate (OR = 1.92; 95% CI, 0.85-4.32; I = 0%; P = .44). There was no clinically significant difference in time to insertion (WMD = -15.80 seconds; 95% CI, -25.30 to -6.31 seconds; I= 100%; P = .001). Similarly, there was no difference in any adverse event rate except sore throat which was reduced with the use of an SGA (OR = 0.16; 95% CI, 0.08-0.32; I= 53%; P < .001). CONCLUSIONS: Despite the reasonable insertion success rate and safety profile of SGAs demonstrated in this meta-analysis, the analysis remains underpowered and therefore inconclusive. At present, further studies are required before the use of an SGA as the first-line airway for an elective CD can be recommended.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects of apnoeic oxygenation before intubation in adults in the operating theatre, emergency department, intensive care unit (ICU), or pre‐hospital settings. Primary objective To assess the effect of oxygenation compared with no oxygenation during the apnoeic phase of intubation on length of hospital stay and peri‐intubation critical desaturation, in adults in pre‐hospital, emergency department, intensive care and operating theatre environments. Critical desaturation will be deemed to be a reduction in saturation of pulse oximetry (SpO(2)) to less than 80%. Secondary objectives To assess the effect of oxygenation compared with no oxygenation during the apnoeic phase of intubation on the incidence of desaturation (SpO(2) below 93%), lowest recorded SpO(2), ICU length of stay, first‐attempt intubation success rate and adverse event rate during intubation (e.g. cardiac arrhythmia), in adults in pre‐hospital, emergency department, intensive care and operating theatre environments.

Introduction Hydrocephalus occurs in 85% of patients with tuberculous meningitis (TBM). Ventriculoperitoneal shunt (VPS) insertion is first-line treatment for relieving increased intercranial pressure. VPS obstruction secondary to increased protein levels in cerebrospinal fluid (CSF) is a known complication. Objective To ascertain if there is a difference in protein levels 1) between cranial and lumbar CSF, and to quantify levels associated with VPS obstruction, and 2) obtained from lumbar puncture vs. ventricular CSF. Method A 30-year retrospective analysis was undertaken. CSF protein levels were statistically analysed to determine correlation between these levels and VPS obstruction. Results Of 214 children and 376 adults who underwent VPS insertion for TBM, respectively 27.5% and 25.5% sustained blocked VPS. The mean protein level in CSF collected from the non-obstructed group was 1.76 g/l, compared to 2.94 g/l in the obstructed group. The mean CSF protein level from intraoperative ventricular vs. lumbar puncture samples in the VPS obstruction group was respectively 2.471 g/l and 2.474 g/l. Conclusion Patients with increased protein levels in CSF are at a high risk of VPS blockage. In these patients, temporary measures should be employed until CSF protein levels decrease.

BackgroundGlobally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients are often overlooked in health systems. Essential Emergency and Critical Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low cost and low complexity for the identification and treatment of critically ill patients across all medical specialties. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19.MethodsIn a Delphi process, consensus (>90% agreement) was sought from a diverse panel of global clinical experts. The panel iteratively rated proposed treatments and actions based on previous guidelines and the WHO/ICRC’s Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent and feasible package of clinical processes plus a list of hospital readiness requirements.ResultsThe 269 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 requirements, plus additions specific for COVID-19.ConclusionThe study has specified the content of care that should be provided to all critically ill patients. Implementing EECC could be an effective strategy for policy makers to reduce preventable deaths worldwide.

Objective: Trypophobia refers to the fear of, or aversion to, clusters of holes. We assessed clinicalfeatures of trypophobia and investigated whether it most resembled a specific phobia or obsessive-compulsive disorder.Methods: An online survey was conducted to gather information on sociodemographic variables,course and duration, severity, associated features, comorbid psychiatric diagnoses, and levels ofpsychological distress and impairment in individuals with trypophobia. The survey also exploredwhether such individuals experienced more fear or disgust, and whether symptoms showed moreresemblance to a specific phobia or to obsessive-compulsive disorder. Associations of symptomseverity and duration with degree of impairment were investigated.Results: One hundred and ninety-five individuals completed the questionnaire. Symptoms werechronic and persistent. The most common associated comorbidities were major depressive disorderand generalized anxiety disorder. Trypophobia was associated with significant psychological distressand impairment. The majority of individuals experienced disgust rather than fear when confronted withclusters of holes, but were more likely to meet DSM-5 criteria for specific phobia than for obsessive-compulsive disorder. Symptom severity and duration were associated with functional impairment.Conclusions: Given that individuals with trypophobia suffer clinically significant morbidity andcomorbidity, this condition deserves further attention from clinicians and researchers.Keywords: Trypophobia; specific phobia; obsessive-compulsive disorder; internet survey

Myocarditis, inflammation of the heart muscle, affects all demographics and is a major cause of sudden and unexpected death in young people. It is most commonly caused by viral infections of the heart, with coxsackievirus B3 (CVB3) being among the most prevalent pathogens. To understand the molecular pathogenesis of CVB3 infection and provide strategies for developing treatments, we examined the role of a key nuclear pore protein 98 (NUP98) in the setting of viral myocarditis. NUP98 was cleaved as early as 2 h post-CVB3 infection. This cleavage was further verified through both the ectopic expression of viral proteases and in vitro using purified recombinant CVB3 proteases (2A and 3C), which demonstrated that CVB3 2A but not 3C is responsible for this cleavage. By immunostaining and confocal imaging, we observed that cleavage resulted in the redistribution of NUP98 to punctate structures in the cytoplasm. Targeted siRNA knockdown of NUP98 during infection further increased viral protein expression and viral titer, and reduced cell viability, suggesting a potential antiviral role of NUP98. Moreover, we discovered that expression levels of neuregulin-1 (NRG1), a cardioprotective gene, and presenilin-1 (PSEN1), a cellular protease processing the tyrosine kinase receptor ERBB4 of NRG1, were reliant upon NUP98 and were downregulated during CVB3 infection. In addition, expression of these NUP98 target genes in myocardium tissue not only occurred at an earlier phase of infection, but also appeared in areas away from the initial inflammatory regions. Collectively, CVB3-induced cleavage of NUP98 and subsequent impairment of the cardioprotective NRG1-ERBB4/PSEN1 signaling cascade may contribute to increased myocardial damage in the context of CVB3-induced myocarditis. To our knowledge, this is the first study to demonstrate the link between NUP98 and the NRG1 signaling pathway in viral myocarditis.

Cerebrovascular accidents (CVAs) including strokes and transient ischaemic attacks (TIAs) form a major portion of perioperative morbidity in patients undergoing coronary artery bypass graft (CABG) surgery. The aim of this article was to: (I) to examine the relationship between providing increased intraoperative partial pressure of arterial oxygen (PaO 2 ) and the risk of perioperative CVA following CABG surgery; (II) to examine the relationship between intraoperative PaO 2 and other perioperative adverse outcomes. This was a retrospective cohort study involving 2,253 consecutive CABG patients located within a single cardiothoracic unit of a tertiary hospital. All patients underwent CABG surgery. A multivariate analysis was undertaken to assess the relationship between the PaO 2 (intra-operative mean and nadir) and its associated risk of perioperative CVA. Results were reported as odds ratios (OR) with 95% confidence interval (95% CI). There was a significant (but clinically limited) inverse correlation between average intra-operative PaO 2 and reducing peri-operative CVA (OR 0.99; P=0.029; 95% CI: 0.98–1.00), indicating a reduction in stroke risk with increasing PaO 2 . There was no significant association with PaO 2 nadir and CVA. There was no significant association between increasing hyperoxia and the following adverse events: pneumonia, prolonged postoperative ventilation, perioperative myocardial infarction or cardiac arrest, sternal wound infection, sepsis and renal failure. We report a significant inverse correlation between increasing average intra-operative PaO 2 and reducing peri-operative CVA. Further, hyperoxia was not associated with any adverse effects or infective outcomes. This finding is likely to have preventative and therapeutic implications through reducing stroke risk.

To the Editor, We read with interest the paper by Dhillon and colleagues1 which provided a high-quality propensity-matched observational study of perioperative outcomes in patients with hypertrophic cardiomyopathy (HCM). This study showed no difference in what they defined as ‘hard outcomes’ such as myocardial infarction, stroke and death. They did however show an increased incidence of composite end …

This case is the first report of an en bloc transplantation of a horseshoe kidney in South Africa. The graft anatomy included complete fusion of the lower poles of the two kidney units with a single artery and vein associated with each unit. The thick isthmus of the graft kidney was supplied by a single, large caliber anomalous artery. Bench work (total duration 160 minutes) included the preparation of a short segment of donor aorta and IVC (containing the renal vessels) which were anastomosed to the recipient common iliac artery and common iliac vein respectively. The artery of the isthmus was anastomosed to the recipient right internal iliac artery. The graft was placed intraperitoneally. Cold ischaemia time was 15 hours, warm ischaemia time 144 minutes, total procedure time 450 minutes and estimated blood loss 1100 ml. Renogram ( 99m Tc MAG-3) on days 1, 3 and 14 postoperatively revealed ATN. Hospital stay was 17 days and nadir creatinine at 6 weeks was 77 μmol/l.

Supplemental Digital Content is available in the text., Background: The Earfold system, a new treatment for the correction of prominent ears, consists of 3 components: the Earfold implant, the Earfold introducer, and the Prefold positioner. Methods: This is an interim report based on an ongoing analysis of safety in a series of patients treated for prominent ears with the Earfold implant between February 2013 and September 2014. Safety was assessed based on adverse event reports and the need for implant revision; follow-up is ongoing. Results: Seven surgeons used 1,200 Earfold implants to treat 403 patients (ages, 7–70 years; 63% male); the time since the initial implant procedure now ranges from 30 to 48 months. To date, 145 patients (36%) have returned for a follow-up visit (mean, 7.7 months [range, 1–34 months]). Adverse events requiring intervention have affected 39 of 403 (9.7%) patients; these include implant revisions (n = 17 [4.2%], most often due to implant visibility), skin erosion over the implant (n = 15 [3.7%]), and infection (n = 7 [1.7%]). Bleeding, recurrence of prominence, hematoma, deformity, or adverse scarring did not occur. Conclusions: This interim analysis has shown that Earfold prominent ear correction system is associated with relatively few adverse events that require intervention; a small number of patients experienced infection, implant extrusion, or implant visibility that required revision. Most adverse events were related to either patient selection or technical errors at implantation. It is expected that with continued use of Earfold by surgeons experienced in otoplasty, the adverse event incidence will decrease.

Attention deficit hyperactivity disorder (ADHD) is a heterogeneous behavioural disorder that affects 3-15 % of children worldwide. Spontaneously hypertensive rats (SHR) display the major symptoms of ADHD (hyperactivity, impulsivity and poor performance in tasks that require sustained attention) and are widely used to model the disorder. The present study aimed to test the hypothesis that SHR have a diminished capacity to generate ATP required for rapid synchronized neuronal firing, failure of which might lead to disturbances in neurotransmission that could contribute to their ADHD-like behaviour. Duplicate pooled (n = 5) samples of prefrontal cortex and striatum of prepubertal (35-day-old) SHR and Wistar Kyoto (WKY) rats were subjected to iTRAQ labeling and matrix-assisted laser desorption/ionization tandem mass spectrometry (MALDI-MS/MS). The MS/MS spectra were analyzed with ProteinPilot using the Ratus ratus database. Proteins detected with >95 % confidence were tested. SHR had decreased levels of several proteins involved in energy metabolism, cytoskeletal structure, myelination and neurotransmitter function when compared to WKY. Differences in protein levels between SHR and WKY were similar in prefrontal cortex and striatum, suggesting global changes in cortico-striato-thalamo-cortical circuits.

No abstract available.

Evidence for a standard x-ray study and cast immobilization in emergency department (ED) management and follow-up of children with bicycle spoke injury (BSI) is absent.To describe the injury pattern and outpatient follow-up and care of ED patients with BSI. In addition, patient characteristics predicting the presence of a fracture and long-term follow-up were assessed.This was a retrospective study including BSI patients9 years of age. Kruskal-Wallis test was used to compare groups with a fracture, soft tissue injury, and mild skin abrasion. Multivariable logistic regression analysis was used to identify independent predictors of a fracture and long-term outpatient follow-up.Twenty-three percent of 141 included patients had a fracture, with a median (interquartile range) follow-up of 27 (23-40) days. For soft tissue injury and mild abrasions this was 9 (6-14) and 7 (5-9) days, respectively (p0.001). No clinical variables could predict a fracture. Fifty-six (40%) patients required no further care after the first outpatient visit at ∼1 week. Triage category yellow and swelling were independent predictors for more than one outpatient visit, besides presence of fracture. Corrected odds ratios (95% confidence interval) were 2.42 (0.99-5.88) and 4.76 (1.38-16.39), respectively. Only 12% of 141 patients had none of these predictors at ED presentation.A quarter of ED patients with BSI have a fracture with no clinical signs that could predict the presence of a fracture, justifying a standard x-ray study in ED management. Only 12% of ED patients with BSI have no fracture and no signs that predict long-term follow-up. In this group, further studies are warranted to investigate the benefit of cast immobilization for fractures and soft tissue injury.

Dihydrotestosterone (DHT) is regarded as the most potent natural androgen and is implicated in the development and progression of castration resistant prostate cancer (CRPC). Under castrate conditions, DHT is produced from the metabolism of the adrenal androgen precursors, DHEA and androstenedione. Recent studies have shown that the adrenal steroid 11β-hydroxyandrostenedione (11OHA4) serves as the precursor to the androgens 11-ketotestosterone (11KT) and 11-ketodihydrotestosterone (11KDHT). In this study we comprehensively assess the androgenic activity of 11KT and 11KDHT. This is the first study, to our knowledge, to show that 11KT and 11KDHT, like T and DHT, are potent and efficacious agonists of the human androgen receptor (AR) and induced both the expression of representative AR-regulated genes as well as cellular proliferation in the androgen dependent prostate cancer cell lines, LNCaP and VCaP. Proteomic analysis revealed that 11KDHT regulated the expression of more AR-regulated proteins than DHT in VCaP cells, while in vitro conversion assays showed that 11KT and 11KDHT are metabolized at a significantly lower rate in both LNCaP and VCaP cells when compared to T and DHT, respectively. Our findings show that 11KT and 11KDHT are bona fide androgens capable of inducing androgen-dependant gene expression and cell growth, and that these steroids have the potential to remain active longer than T and DHT due to the decreased rate at which they are metabolised. Collectively, our data demonstrates that 11KT and 11KDHT likely play a vital, but overlooked, role in the development and progression of CRPC.

BACKGROUND: Few studies have described children with spinal multidrug-resistant tuberculosis (MDR-TB). Treatment involves surgery and medical care with long courses of drug therapy. METHODS: Hospital and laboratory records at Brooklyn Chest and Tygerberg Children's Hospitals, Cape Town, South Africa, were analysed (January 2004 until December 2010) searching for children treated for MDR spinal TB. RESULTS: Of the 11 children identified, 4 were excluded. Of the 7 remaining, 5 were boys; median age: 8 years, median delay to treatment initiation: 36 weeks. Among them one child died, five have completed treatment and one is near the end of therapy. Medications were well-tolerated and although two of the surviving children have spinal deformity, none have significant neurological deficit. CONCLUSIONS: The diagnosis of spinal MDR-TB is often delayed in children, frequently leading to advanced disease and severe vertebral damage. Children tolerate therapy well and, once identified, it is a condition that can be treated successfully.

Background/Aim: Few studies have investigated how patients feel about traumatic injuries to teeth. Dentists may focus on treating an injury and neglect to address how the patient views the severity, or aesthetics. Addressing these issues may improve trauma management and communication between dentists and patients. The aim of the study was to compare children's, adolescents' and young adults' perceptions of common dental injuries to the maxillary central incisor teeth. Materials and methods: A cross-sectional study was conducted with 138 participants selected by convenience sampling and divided into 6- to 10-year, 11- to 17-year and 18- to 24-year age groups. Participants were shown six coloured photographs of traumatic injuries to central incisors and asked four questions. Data were analysed using SPSS. Group differences were evaluated using Mann-Whitney U and Kruskal-Wallis H tests. Results and Conclusions: There were statistically significant differences between the 6- to 10-year and 18- to 24-year age groups as to which traumatic injury would hurt the most (P Language: en

A pilot study evaluating the use in paediatric polytrauma of the STATSCAN, a low-radiation dose, fan-beam digital radiography unit (Lodox Systems, Sandton, South Africa). Over 3 months, 23 polytrauma patients treated at the Emergency Unit of the Red Cross Children's Hospital in Cape Town, South Africa, were imaged on the STATSCAN. Image quality, diagnostic equivalence and clinical efficiency were compared with a computed radiography (CR) system (Fuji FCR 5000, Fuji Photo Film, Tokyo, Japan). The STATSCAN antero-posterior bodygram correlated well technically and diagnostically with CR, showing 96% of the fractures in the cohort. It allowed superior visualisation of the trachea and main bronchi and imaging was, on average, 13% faster than CR. The STATSCAN could play an important role in paediatric polytrauma. The clinical significance of its superior demonstration of the trachea and main bronchi requires further evaluation.

Meconium pseudocyst is a rare complication of fetal bowel perforation in utero, following extravasation and localised containment of meconium within the intra-peritoneal cavity.

Synovial sarcoma is a malignant, predominantly juxta-articular, soft-tissue tumour representing approximately 10% of all soft-tissue sarcomas. Frequently initially incorrectly diagnosed as a benign lesion, it should be considered as a diagnosis when a young adult patient presents with a calcified juxta-articular soft-tissue mass of insidious onset.

We present four patients who had sustained a traumatic dislocation of the atlanto-occipital joint. The diagnosis was initially missed in two patients. One patient, who was neurologically intact, was treated non-operatively. The remaining three recovered neurologically after an occipitocervical fusion. Early recognition of the injury, especially in multiply-injured patients with head injuries, and timely management may improve survival and neurological recovery.

U.G.H. syndrome is a known complication of IOL implantation associated with the use of anterior and rarely, posterior chamber intraocular lenses. It is due to mechanical excoriation of the angle or iris by the haptics or optic of an IOL and consists of uveitis, glaucoma and hyphema (U.G.H.). The advised therapeutic approach is explantation of the IOL. Following implantation of a posterior chamber IOL, three patients presented with bleeding into the posterior chamber, one associated with glaucoma. No patient had signs of uveitis. We decided to address the symptoms and not to explant the IOL. We believe that this constitutes a variant of the 'classical' U.G.H. syndrome, namely an incomplete posterior U.G.H. (I.P.U.G.H.) syndrome, in which explanation of the I.O.L. is not compulsory.

Neurological complications of the prone position have been well documented. Post-operative paraplegia and neurological deterioration unrelated to the site of surgery after proning in spinal surgery is a rare but potentially devastating complication. We describe the case of a 47 year old female who underwent an L4/5 discectomy and posterior instrumented fusion. A few hours after surgery she developed bilateral lower limb weakness with a T11 sensory level. Post-operative MRI revealed an acute disc herniation at the T11/12 level with associated spinal cord compression. This was not present on the pre-operative imaging. A subsequent T11/12 discectomy and instrumented fusion was performed and the patient's motor and sensory function returned to normal.

In malaria-endemic developing countries, plagued with malnutrition, patients undergoing chloroquine (Q) treatment on prolonged basis often consume ethanol (E) regularly. This may constitute a serious health problem. The objective of this study was to investigate whether concurrent administration of E and Q under conditions of protein malnutrition may impact negatively on biochemical parameters. An experimental study was conducted to investigate biochemical effects of E and/or Q associated with protein malnutrition in adult male Sprague Dawley rats. Two groups of adult male Sprague-Dawley rats were fed either normal protein diet (NP, 15%) or low protein diet (LP, 6%). Each diet group includes the controls (NPC, LPC), chloroquine- (Q); [NPQ; LPQ], ethanol- (E); [NPE; LPE} or both chloroquinine and ethanol (NPEQ; LPEQ) treated groups. Chloroquine diphosphate (10mg, kg-1 body weight per rat) was administered intramuscularly, on days 0, 10, 20, and 30 to appropriate groups, while 6% E in drinking water was provided ad libitum to Etreated groups. Drinking water was given to Q-treated groups, and physiological saline was injected to E-treated groups. After 40 days, blood was collected, under ether anesthesia, by cardiac puncture for biochemical analysis. Results showed that concurrent treatment of E and Q slightly decreased TP and albumin (Alb) levels in LPEQ-rats compared to LPC, LPE and LPQ rat groups. Furthermore, TP level was substantially and significantly elevated in NPEQ-rats compared to LPEQ, NPE and NPQ rat groups. Ethanol and Chloroquine interaction exacerbated ALP and ALT activities in LPEQ-rats compared to NPEQ- rats. Urea depression was enhanced in LPEQ- than in NPEQ-rats. Creatinine levels were increased in all treatment groups. The results suggest increased toxic effect of concurrent intake of E and Q in LP- fed rats. The findings show that LP dietary intake potentiates adverse effects of combined E and Q. This has implications for clinical practice, especially in poor malaria endemic countries where prevalence of protein malnutrition is often high, and patients who consume alcohol while on chloroquine, are at greater risk of severe toxic effect of combined E and Q intake.

Background Few studies address the use of paediatric highly active antiretroviral therapy (HAART) in Africa. Methods We performed a retrospective cohort study to investigate preliminary outcomes of all children eligible for HAART at Sinikithemba HIV/AIDS clinic in KwaZulu-Natal, South Africa. Immunologic, virologic, clinical, mortality, primary caregiver, and psychosocial variables were collected and analyzed. Results From August 31, 2003 until October 31, 2005, 151 children initiated HAART. The median age at HAART initiation was 5.7 years (range 0.3–15.4). Median follow-up time of the cohort after HAART initiation was 8 months (IQR 3.5–13.5). The median change in CD4% from baseline (p < 0.001) was 10.2 (IQR 5.0–13.8) at 6 months (n = 90), and 16.2 (IQR 9.6–20.3) at 12 months (n = 59). Viral loads (VLs) were available for 100 children at 6 months of which 84% had HIV-1 RNA levels ≤ 50 copies/mL. At 12 months, 80.3% (n = 61) had undetectable VLs. Sixty-five out of 88 children (73.8%) reported a significant increase (p < 0.001) in weight after the first month. Eighty-nine percent of the cohort (n = 132) reported ≤ 2 missed doses during any given treatment month (> 95%adherence). Seventeen patients (11.3%) had a regimen change; two (1.3%) were due to antiretroviral toxicity. The Kaplan-Meier one year survival estimate was 90.9% (95%confidence interval (CI) 84.8–94.6). Thirteen children died during follow-up (8.6%), one changed service provider, and no children were lost to follow-up. All 13 deaths occurred in children with advanced HIV disease within 5 months of treatment initiation. In multivariate analysis of baseline variables against mortality using Cox proportional-hazards model, chronic gastroenteritis was associated with death [hazard ratio (HR), 12.34; 95%CI, 1.27–119.71) and an HIV-positive primary caregiver was found to be protective against mortality [HR, 0.12; 95%CI, 0.02–0.88). Age, orphanhood, baseline CD4%, and hemoglobin were not predicators of mortality in our cohort. Fifty-two percent of the cohort had at least one HIV-positive primary caregiver, and 38.4% had at least one primary caregiver also on HAART at Sinikithemba clinic. Conclusion This report suggests that paediatric HAART can be effective despite the challenges of a resource-limited setting.

Fifty-five adults who had sustained a tibial fracture, or a femoral fracture, or both, were subjected to a double-blind randomised study to determine the efficacy of methylprednisolone in treating the fat embolism syndrome. This drug maintained arterial oxygen levels, stabilised or reduced the serum level of free fatty acids, and decreased the risk of the fat embolism syndrome in a statistically significant proportion of patients. Gurd's criteria for the diagnosis of the fat embolism syndrome were found inadequate. Other more sensitive criteria for early diagnosis and effective management were determined. There were no deaths or serious morbidity in our series.

(1) Seedling recruitment of closed cone (serotinous) Proteaceae was surveyed in thirty-one burnt areas in mature mountain fynbos of the Southern Cape, South Africa. (2) The number of seedlings per pre-burn individual (parent) varied greatly from fire to fire. (3) This variability could be partially explained by pre-burn densities since these were frequently negatively correlated with number of seedlings per parent. (4) Seedling recruitment differed significantly with season of fire. The most successful seedling establishment followed autumn burns. Summer burns were often less favourable and had a greater variability from fire to fire. Winter and spring burns lead to very poor seedling establishment, mostly well below replacement levels, so that successive fires in these seasons would rapidly lead to local extinction. (5) Density-dependent regulation of seedling populations is apparently due to the reduction of the reproductive effort, and thus seed reserves, per individual with increased pre-burn crowding. (6) The causes of seasonal variation, which appear to be density independent, have not been satisfactorily explained though they are important for the prediction of fire succession in all Proteaceae which store seed in the canopy.