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Introduction: Although the benefits of thoracoscopic esophageal atresia repair (TEAR) are well documented, there has been resistance to the uptake of this approach in low- and middle-income countries. This study reviews a single unit's experience introducing TEAR in a South African state sector tertiary hospital. Method: We describe how we set up MIS for esophageal atresia (EA) at our centre. All neonates with EA managed at our institution from January 2016 to January 2022 were included. Excluded patients included those who were not operated on or if data was missing. We compared the different approaches for managing type C EA in our setting. We analyzed the data using the Mann-Whitney U test. Results: Sixty-five patients were managed with EA over the study duration. There were 54 patients who had type C EA. Thirty-nine patients underwent thoracotomy to repair the defect, and eighteen underwent TEAR, of which sixteen were completed thoracoscopically. There was a statistically significant difference in weight (p-value 0.035), gestational age (p-value 0.002), and age at operation (p-value 0.004) between the groups treated by TEAR and OEAR (open esophageal atresia repair). There was a small median difference in the operative time between TEAR and OEAR of 20 min. The mortality in the OEAR group was higher (20.5 %) compared to the TEAR group (5.5 %), with a p-value of 0.094. Conclusion: A dedicated quality improvement program focused on introducing MIS for EA can produce results comparable to the open procedure in an LMIC setting.

Introduction: Pediatric laparoscopic Nissen fundoplication (LNF) has become the standard approach at many centers. We developed a minimal access surgery (MAS) training curriculum to enhance the delivery of MAS for pediatric patients in a resource-limited setting. We reviewed our 10-year experience in implementing and performing LNF at our institution. Methods: We described the challenges of implementing MAS training for LNF and how we addressed them. Beneficial technical considerations were described. A retrospective review was performed on all pediatric LNFs performed. Results: We performed 268 LNFs. Specialists or trainees under supervision performed all LNFs. The trainee group performed 43 LNFs (16%). The median operative time for the specialists was 94 min (interquartile range [IQR] 50), and the trainee group was 140 min (IQR 62.5). The median number of cases performed until we improved operative time amongst the trainees was nine (IQR 3). There were seven repeat LNFs, and 11 cases were converted to open. The overall complication rate was 8.9%. A reduction in complications among specialists occurred over the years. The 30-day mortality post-LNF was 0.7%. Conclusion: LNF can be successfully introduced at a tertiary training centre in South Africa with good outcomes. A comprehensive quality improvement program, including MAS training, supported this.

Background: This project is part of a broader effort to develop a new electronic registry for ophthalmology in the KwaZulu-Natal (KZN) province in South Africa. The registry should include a clinical decision support system that reduces the potential for human error and should be applicable for our diversity of hospitals, whether electronic health record (EHR) or paper-based. Methods: Post-operative prescriptions of consecutive cataract surgery discharges were included for 2019 and 2020. Comparisons were facilitated by the four chosen state hospitals in KZN each having a different system for prescribing medications: Electronic, tick sheet, ink stamp and handwritten health records. Error types were compared to hospital systems to identify easily-correctable errors. Potential error remedies were sought by a four-step process. Results: There were 1307 individual errors in 1661 prescriptions, categorised into 20 error types. Increasing levels of technology did not decrease error rates but did decrease the variety of error types. High technology scripts had the most errors but when easily correctable errors were removed, EHRs had the lowest error rates and handwritten the highest. Conclusion: Increasing technology, by itself, does not seem to reduce prescription error. Technology does, however, seem to decrease the variability of potential error types, which make many of the errors simpler to correct. Contribution: Regular audits are an effective tool to greatly reduce prescription errors, and the higher the technology level, the more effective these audit interventions become. This advantage can be transferred to paper-based notes by utilising a hybrid electronic registry to print the formal medical record.

Introduction: We developed a home-based laparoscopic suturing simulation (HBLSS) technique, which is intended to improve the impact of a structured laparoscopic training course. Method: A group of sixteen students were provided with the educational video, and after two weeks, all students were observed and timed performing a laparoscopic reef knot. The students were then randomized into two cohorts. The exclusive video group continued using the video for a further two weeks. The second group were shown the HBLSS technique and told to use this in conjunction with the video for a further two weeks. Results: The entire cohort had an initial median time to form an intracorporeal reef knot of 190 s (range 459, IQR 128). After two additional weeks of using the educational video exclusively, the median time was reduced to 85 s (range 282, IQR 125), whereas the HBLSS and educational video group had a median post-training time of 28.5 s (range 36, IQR 18.5). There was a clear statistical difference between the exclusive video group and the HBLSS and video group (P = 0.008). There was also an improvement from the movement of both instruments to one instrument, reduced crossing of instruments and reduced transverse movement in the HBLSS and video group. Conclusion: A combination of video-based teaching and HBLSS was associated with improved laparoscopic intra-corporeal knot-tying skills in comparison to the exclusive video-based teaching. This reflects the importance of imparting both cognitive and psychomotor skills to students practising laparoscopic surgery.

Abstract Methane (CH4) is a climate‐relevant trace gas that is emitted from the open and coastal oceans in considerable amounts. However, its distribution in remote oceanic areas is largely unknown. To fill this knowledge gap, dissolved CH4 was measured at nine stations at 75°S in the Ross Sea during austral summer in January 2020. CH4 undersaturation (mean: 82 ± 20%) was found throughout the water column. In subsurface waters, the distribution of CH4 mainly resulted from mixing of water masses and in situ consumption, whereas the CH4 concentrations in the surface mixed layer were mainly driven by air–sea exchange and diapycnal diffusion between the surface and subsurface layers, as well as consumption of CH4. With a mean air–sea CH4 flux density of −0.44 ± 0.34 μmol m−2 d−1, the Ross Sea was a substantial sink for atmospheric CH4 during austral summer, which is in contrast with most oceanic regions, which are known sources.

In the current era of rapid climate change, accurate characterization of climate-relevant gas dynamics-namely production, consumption, and net emissions-is required for all biomes, especially those ecosystems most susceptible to the impact of change. Marine environments include regions that act as net sources or sinks for numerous climateactive trace gases including methane (CH4) and nitrous oxide (N2O). The temporal and spatial distributions of CH4 and N2O are controlled by the interaction of complex biogeochemical and physical processes. To evaluate and quantify how these mechanisms affect marine CH4 and N2O cycling requires a combination of traditional scientific disciplines including oceanography, microbiology, and numerical modeling. Fundamental to these efforts is ensuring that the datasets produced by independent scientists are comparable and interoperable. Equally critical is transparent communication within the research community about the technical improvements required to increase our collective understanding of marine CH4 and N2O. A workshop sponsored by Ocean Carbon and Biogeochemistry (OCB) was organized to enhance dialogue and collaborations pertaining to marine CH4 and N2O. Here, we summarize the outcomes from the workshop to describe the challenges and opportunities for near-future CH4 and N2O research in the marine environment.

Background: This paper describes the development and implementation of a unique laparoscopic suturing course in a resource-constrained setting and reviews the initial experience with the program. Methods: This study describes the development of Grey's laparoscopic suturing course (GLSC) and reviews the questionnaires and feedback over the past year. Results: The GLSC has been run for over a year and has enrolled 47 participants. Most participants were registrars, followed by consultants and medical officers, and most participants had limited minimal access surgery (MAS) experience. Only three had previously undertaken a formal course or observership. The mean result for the pre-course test was 50%, and for the post-course test, 88%. During the skills laboratory session, every participant competently performed intra-corporeal suturing. The entire group unanimously agreed that the GLSC should be recommended for all surgical trainees in the evaluation form. All participants expressed interest in an advanced MAS course. Conclusion: We have demonstrated that developing a local MAS suturing course with limited resources and industry support during the Covid 19 pandemic is possible. It has benefited a large group of trainees thus far and hopefully will become part of the curriculum of surgical trainees in South Africa.

Introduction: This analysis retrospectively reviews a tertiary trauma service's experience with missed injuries over a decade. Methods: The Pietermaritzburg Metropolitan Trauma Service (PMTS) has accumulated electronic data on all admissions since 2012. This data informs the monthly morbidity and mortality conference, where adverse events are discussed. Records of all missed injuries were reviewed. Results: During the study period there were 17 254 individual patient admissions and 4 624 surgical procedures. A total of 159 missed injuries were identified. Ninety-six were injuries missed on investigation; 60 were missed on CT, 27 missed on x-ray, 1 on blood test, and 8 occurred during an unknown investigation. Thirty-nine injuries were missed during surgery; including thirteen colonic, five small bowel, five gastric, four duodenal, three vascular and three diaphragmatic injuries. Twenty-four injuries were missed on initial assessment, the majority of which were soft tissue injuries. Intraoperative missed injuries resulted in the greatest morbidity. Conclusion: Missed injuries remain a problem in modern trauma care. Injuries missed during initial clinical assessment and on imaging must be excluded by detailed secondary surveys and in depth review of all imaging. Injuries missed at operation carry greater morbidity than those missed outside the operating room. Ongoing vigilance is necessary to reduce the incidence of these injuries.

Cecilia Lazea,1 Laura Damian,2 Romana Vulturar,3 Calin Lazar1 1Department Pediatrics I, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania; 2Department of Rheumatology, County Emergency Clinical Hospital Cluj-Napoca, Centre for Rare Musculoskeletal Autoimmune and Autoinflammatory Diseases, Cluj-Napoca, Romania; 3Department of Molecular Sciences, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, RomaniaCorrespondence: Cecilia Lazea, Department Pediatrics I, University of Medicine and Pharmacy “Iuliu Hatieganu”, 68, Motilor street, Cluj-Napoca, 400370, Romania, Email cicilazearo@yahoo.com; cecilialazea@umfcluj.roObjective: The aim of this study is to describe a group of Romanian children with periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA) syndrome.Materials: This consisted of 39 children diagnosed with PFAPA syndrome according to Thomas’ criteria (eight patients with an age at diagnosis < 1 year and 31 patients with an age at diagnosis > 1 year).Methods: Retrospective analysis of the patients with PFAPA syndrome was focused on clinical features, laboratory findings and therapeutic methods. Comparison between the two groups divided by age at onset was also investigated.Results: Median age at onset was 1.58 years, and median age at diagnosis was 2.97 years. The mean interval between episodes was 35.5 days and the mean duration per febrile episode was 4.1 days. The median diagnosis delay was 2.42 years. The patients presented pharyngitis (100%), adenitis (94.8%) and aphthous lesions (66.7%). The frequency of febrile attacks was higher in children with an age at diagnosis under 1 year (p = 0.0287). Younger age was associated with the presence of aphthae. The mean value of C-reactive protein (CRP) was 7.9mg/dl and the mean value of leucocytes was 14,839/mm3. In 95% of patients given oral corticosteroids, remission of symptoms was reported within 24 h. In three patients, tonsillectomy was performed with complete remission of the disease.Conclusion: We present a cohort of children with PFAPA syndrome, with clinical and laboratory features similar to those described in the literature. Febrile attacks had a higher incidence in children with younger age at the onset of the disease. The patients had a favorable response to corticosteroids.Keywords: PFAPA syndrome, periodic fever, child

Objectives:. Trauma is a leading cause of death worldwide and in South Africa. We aimed to quantify the in-hospital trauma mortality rate in Pietermaritzburg, South Africa. Background:. The in-hospital trauma mortality rate in South Africa remains unknown, and it is unclear whether deficits in hospital care are contributing to the high level of trauma-related mortality. Methods:. All patients hospitalized because of trauma at the Department of Surgery at Grey’s Hospital, Pietermaritzburg Metropolitan Trauma Service, were prospectively entered in an electronic database starting in 2013 and the data were retrospectively analyzed. The trauma service adheres to Advanced Trauma Life Support and the doctors have attended basic and advanced courses in trauma care. The primary outcome was in-hospital mortality. Results:. Of 9795 trauma admissions, 412 (4.2%) patients died during hospital care between January 2013 and January 2019. Forty-six percent died after road traffic accidents, 19% after gunshot wounds, 13% after stab wounds, and 10% after assaults. Sixteen percent were classified as avoidable deaths due to inappropriate care and resource limitations. Fifty percent died because of traumatic brain injury and 80% of them were unavoidable. Conclusions:. In conclusion, the in-hospital trauma mortality rate at a South African trauma center using systematic trauma care is lower than that reported from other trauma centers in the world during the past 20 years. Nevertheless, 16% of death cases were assessed as avoidable if there had been better access to intensive care, dialysis, advanced respiratory care, blood for transfusion, and improvements in surgery and medical care.

Oxygen minimum zones (OMZs) have been suggested as a suitable niche for the oxygen-sensitive process of biological fixation of dinitrogen (N2) gas. However, most N2 fixation rates reported from such waters are low. This low N2 fixation activity has been proposed to result from the unusual community of N2 fixers, in which cyanobacteria were typically underrepresented. The Northern Benguela Upwelling System (North BUS) is part of one of the most productive marine ecosystems and hosts a well-developed OMZ. Although previous observations indicated low to absent N2 fixation rates, the community composition of diazotrophs needed to understand the North BUS has not been described. Here, we present a first detailed analysis of the diazotrophic diversity in the North BUS OMZ and the Angola tropical zone (ATZ), based on genetic data and isotope speciation. Consistent with a previous study, we detected a slight N deficit in the OMZ, but isotope data did not indicate any active or past N2 fixation. The diazotroph community in the North BUS was dominated by non-cyanobacterial microbes clustering with members of gamma-proteobacteria, as is typical for other OMZ regions. However, we found a strikingly high diversity of Cluster III diazotrophs not yet described in other OMZs. In contrast to previous observations, we could also identify cyanobacteria of the clades Trichodesmium sp., UCYN-A and Cyanothece sp., in surface waters connected to or above the OMZ, which were potentially active as shown by the presence of genes and transcripts of the key functional marker gene for N2 fixation, nifH. While the detection of diazotrophs and the absence of active N2 fixation (based on isotopic speciation) are consistent with other OMZ observations, the detected regional variation in the diversity and presence of cyanobacteria indicate that we still are far from understanding the role of diazotrophs in OMZs, which, however, is relevant for understanding the N cycle in OMZ waters, as well for predicting the future development of OMZ biogeochemistry in a changing ocean.

Red blood cell (RBC) transfusion is associated with recipient inflammation and infection, which may be triggered by excessive circulating iron. Iron chelation following transfusion may reduce these risks. The aim of this study was to evaluate the effect of deferoxamine on circulating iron and inflammation biomarkers over time and in vitro growth of Escherichia coli (E. coli) following RBC transfusion in dogs with atraumatic hemorrhage. Anesthetized dogs were subject to atraumatic hemorrhage and transfusion of RBCs, then randomized to receive either deferoxamine or saline placebo of equivalent volume (n = 10 per group) in a blinded fashion. Blood was sampled before hemorrhage and then 2, 4, and 6 h later. Following hemorrhage and RBC transfusion, free iron increased in all dogs over time (both p < 0.001). Inflammation biomarkers interleukin-6 (IL6), CXC motif chemokine-8 (CXCL8), interleukin-10 (IL10), and keratinocyte-derived chemokine (KC) increased in all dogs over time (all p < 0.001). Logarithmic growth of E. coli clones within blood collected 6 h post-transfusion was not different between groups. Only total iron-binding capacity was different between groups over time, being significantly increased in the deferoxamine group at 2 and 4 h post-transfusion (both p < 0.001). In summary, while free iron and inflammation biomarkers increased post-RBC transfusion, deferoxamine administration did not impact circulating free iron, inflammation biomarkers, or in vitro growth of E. coli when compared with placebo.