Background. Cerebral gunshot wounds (CGSWs) represent a highly lethal form of traumatic brain injury, and triaging these patients is difficult. The prognostic significance of the serum lactate level ...in the setting of CGSWs is largely unknown.Objectives. To examine the relationship between elevated serum lactate levels and mortality in patients with isolated CGSWs.Methods. A retrospective review of the regional trauma registry was undertaken at the Pietermaritzburg Metropolitan Trauma Service, South Africa, over a 5-year period from 1 January 2010 to 31 December 2014. All patients with an isolated CGSW were included.Results. A total of 102 patients with isolated CGSWs were identified. Of these, 92.2% (94/102) were male. The mean age (standard deviation) was 29 (8) years, and the in-hospital mortality rate was 21.6% (22/102). The mean serum lactate level was significantly higher among non-survivors than among survivors (6.1 mmol/L v. 1.3 mmol/L; p
Introduction
This study focuses on a specific and often dramatic injury, namely gunshot wounds (GSW) of the head in order to determine whether there is a discrepancy in outcome between patients who ...sustain their injury in a rural setting and those who sustain it in an urban setting.
Materials and methods
This study involves a retrospective review of our prospectively maintained regional electronic trauma registry. All patients who sustained a cerebral GSW from January 2010 to December 2014 were reviewed.
Results
During the 5-year study period, a total of 102 patients sustained an isolated cerebral GSW. Ninety-two per cent (94/102) were male and the mean age was 29 years. Ninety-four per cent (94/102) of injuries were related to interpersonal violence. Of the 102 patients in the study, 54% (55/102) were urban and were transported directly to our trauma centre. The remaining 46% (47/102) were rural and were transported to a rural district hospital prior to being referred to our trauma centre. The time of injury was available in 60% (61/102) of patients. The mean time from injury to arrival for all patients was 11 h (SD 7). The mean time from injury to arrival was significantly shorter for urban versus rural, 6 h (SD 5) and 15 h (SD 5), respectively (
p
< 0.001). The median admission GCS score was significantly lower in rural compared to urban patients (
p
= 0.022). The need for neurosurgery, need for ICU admission or length of hospital stay was not significantly different between rural and urban patients. Rural patients have a fourfold higher mortality compared with urban patients (36 vs 9%,
p
= 0.001). Amongst survivors, there was no significant difference in median length of hospital stay or mean discharge GCS.
Conclusions
Cerebral GSWs are highly lethal injuries associated with significant mortality. Rural patients have a significantly longer transfer time, lower GCS on arrival and higher mortality than urban patients. Efforts should be directed at improving the pre-hospital EMS system in order to reduce delay to definitive care so that patient outcome can be optimised.
INTRODUCTION The purpose of this study was to audit our current management of colonic trauma, and to review our experience of colonic trauma in patients who underwent initial damage control (DC) ...surgery. METHODS All patients treated for colonic trauma between January 2012 and December 2014 by the Pietermaritzburg Metropolitan Trauma Service were included in the study. Data reviewed included mechanism of injury, method of management (primary repair PR, primary diversion PD or DC) and outcome (complications and mortality rate). Results A total of 128 patients sustained a colonic injury during the study period. Ninety-seven per cent of the injuries were due to penetrating trauma. Of these cases, 56% comprised stab wounds (SWs) and 44% were gunshot wounds (GSWs). Management was by PR in 99, PD in 20 and DC surgery in 9 cases. Among the 69 SW victims, 57 underwent PR, 9 had PD and 3 required a DC procedure. Of the 55 GSW cases, 40 were managed with PR, 9 with PD and 6 with DC surgery. In the PR group, there were 16 colonic complications (5 cases of breakdown and 11 of wound sepsis). Overall, nine patients (7%) died. CONCLUSIONS PR of colonic trauma is safe and should be used for the majority of such injuries. Persistent acidosis, however, should be considered a contraindication. In unstable patients with complex injuries, the optimal approach is to perform DC surgery. In this situation, formal diversion is contraindicated, and the injury should be controlled and dropped back into the abdomen at the primary operation. At the repeat operation, if the physiological insult has been reversed, then formal repair of the colonic injury is acceptable.
Background: Squamous carcinoma of the oesophagus (SCO) is the most common form of oesophageal cancer in South Africa (SA). Risk factors include male gender, smoking, alcohol consumption and low ...socio-economic status (SES). This study assessed the risk factors for SCO in KwaZulu-Natal. Methodology: Information on patients managed at Inkosi Albert Luthuli Central Hospital (IALCH), Durban, South Africa, between 1 October 2013 and 31 December 2014 was retrieved from a prospective database of Oesophageal Cancer (OC). Data collected included demographics, risk factors, symptoms and clinical findings. Results: One hundred and fifty-nine patients (159) with SCO were identified. The site of tumour location was in the middle 96 (60.4%), distal 42(26.4%) and proximal 17(10.6%) oesophagus. The male to female ratio was 1:1 with an age range of 22-93 years (mean 60.6; SD±12.1). Females were significantly older than males (p = 0.018). Eighty-eight per cent were Black African. Dysphagia was reported in 158 (99.4%) of patients and loss of weight in 149(95.5%). Thirty-six patients were HIV positive (age 52.8; SD±9.7) and significantly younger than those without HIV infection (age 61.2; SD±11.5). Most patients had low SES and poor dental health. Male patients were significantly more likely to use tobacco (p
Introduction The aim of this study was to examine and interrogate outcomes in trauma laparotomy in a South African trauma centre to determine whether systematic factors were associated with any ...discrepancies in outcome. Methods This was a retrospective review of a prospectively entered trauma registry undertaken at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa. The service has developed a hybrid electronic medical record system (HEMR) where clinical data were captured in real time, which were incorporated this into a database. Results During the period from December 2012 to July 2016, 562 patients underwent emergency laparotomy for trauma and the time and date of surgery was recorded in the HEMR. The mean age of all patients was 29.5 years. There were 256 operations during the weekend or over a public holiday, with a mortality of 8% (n = 21) compared with 306 during the week (mortality of 10%, n = 31). This difference was not statistically significant (P = 0.237). A total of 327 operations were performed at night (18:00 - 08:00) and 235 operations were performed during the day (08:00-18:00 Hours). This was a significant difference in mortality (10% (33) vs 7 % (16), P=0.013) These differences persisted if weekends and public holidays were separated out from normal working days. A total of 188 operations were performed on a week night, with a mortality of 11% (n = 20) and 121 operations were performed during a week day, with a mortality of 8% (n = 10). There were 139 operations on a weekend or public holiday night, with a mortality of 9% (n = 13). A total of 114 operations were performed on a weekend or public holiday day with a mortality of 7% (n = 8). A total of 208 procedures were performed with an consultant present. Of these, 32 patients (15%) died. A total of 368 procedures were performed without a consultant present and 8 (2%) died. Conclusions This study demonstrated a discrepancy in outcome for trauma laparotomy, depending on whether the operation was performed at night or during the day. The reasons for this are unclear, although the lack of consultant presence at night in comparison to during the day appears to be implicated.
Background
Left atrial appendage (LAA) closure (LAAC) by implantation of an occlusion device is an established cardiac intervention to reduce risk of stroke while avoiding intake of oral ...anticoagulation medication during atrial fibrillation. Cardiac interventions can alter local or systemic gene and protein expression. Effects of LAAC on systemic metabolism have not been studied yet.
Objectives
We aimed to study the effects of interventional LAAC on systemic metabolism.
Methods
Products of glycolysis, tricarboxylic acid and urea metabolism were analyzed by ESI-LC-MS/MS and MS/MS using the AbsoluteIDQ™ p180 Kit in plasma of 44 patients undergoing successful interventional LAAC at baseline (T0) and after 6 months (T1).
Results
During follow up, plasma concentrations of several parameters of glycolysis and tricarboxylic acid cycle (TCA) and urea metabolism increased (alanine, hexose, proline, sarcosine), while others decreased (aspartate, glycine, SDMA, serine). Multivariate linear regression analysis showed that time after interventional LAAC was an independent predictor for metabolite changes, including the decrease of SDMA (beta −0.19, p < 0.01) and the increase of sarcosine (beta 0.16, p < 0.01).
Conclusions
Successful interventional LAAC affects different pathways of the metabolome, which are probably related to cardiac remodeling. The underlying mechanisms as well as the long term effects have to be studied in the future.
A novel all-optical differential phase-shift keying wavelength converter based on semiconductor optical amplifier nonlinearities is demonstrated in the 25- to 40-Gb/s range with pseudorandom binary ...sequence of 2 7 -1, and its regenerative properties as well as the cascadability are discussed
Introduction
Accurate physical examination (PE) remains a key component in the assessment of penetrating thoracic trauma (PTT), despite the increasing availability of advanced radiological imaging. ...Evidence regarding the accuracy of PE in identifying significant pathology following PTT is limited.
Materials and methods
A retrospective review of 405 patients was undertaken over a twelve-month period to determine the accuracy of PE in identifying significant pathology (SP) subsequently confirmed on chest radiographs (CXRs) in patients who sustained stab injuries to the thorax.
Results
Ninety-seven per cent (372/405) of patients were males, and the mean age was 24 years. The weapons involved were knives in 98 % (398/405), screwdrivers in 1 % (3/405) and unknown in the remaining 1 %. Fifty-nine per cent (238/405) of all injuries were on the left side. There were 306 (76 %) SPs identified on CXR. Ninety-nine (24 %) CXRs were entirely normal. Based on PE alone, 223 (55 %) patients were thought to have SPs present, 182 (45 %) patients were thought to have no SPs. The overall sensitivity of PE in identifying SPs was 68 % (63–73, 95 % CI), with a specificity of 86 % (77–92, 95 % CI). The PPV of PE was 94 % (90–97, 95 % CI) and the NPV was 47 % (39–54, 95 % CI). The sensitivity of PE for identifying a pneumothorax was 59 % (51–66, 95 % CI), with a specificity of 96 % (89–99, 95 % CI) and the sensitivity of PE for identifying a haemothorax was 79 % (72–86, 95 % CI), with a specificity of 96 % (89–99, 95 % CI).
Conclusions
PE is inaccurate in identifying SPs in PTT. The increased reliance on advanced radiological imaging and the subsequent reduced emphasis on PE may have contributed to rapid deskilling amongst surgical residents. The importance of PE must be repeatedly re-emphasised.
Background. Evidence of the effects of HIV infection and clinical stage on the duration of refeeding and treatment (DRT) and the rate of weight gain (RWG) in severely malnourished children remains ...inconclusive.Objectives. To determine whether the RWG and DRT differ by baseline clinical characteristics, and to assess the effect of HIV status and disease stage on the relationship between these two clinical outcomes.Methods. This was a retrospective record review of 346 patiens discharged between 2009 and 2013 following treatment for severe acute malnutrition (SAM) at two rural hospitals in South Africa.Results. A third of the sample was HIV-positive, the RWG (measured as g/kg/day) was significantly slower in HIV-positive patients compared with HIV-negative cases (mean 5.2, 95% confidence interval (CI) 4.47 - 5.93 v. mean 8.51; CI 7.98 - 9.05; pinfection had a significantly slower RWG (mean 3.97; CI 2.33 - 5.61) compared with those at stages I (mean 7.64; CI 6.21 - 9.07) (pII (mean 5.87; CI 4.74 - 6.99). The mean DRT was longer in HIV-positive cases and those at advanced stages of HIV infection. HIV-positive cases were renourished and treated for almost 3.5 times longer than their HIV-negative counterparts to achieve a moderate RWG (5 - 10 g/kg/day).Conclusion. This study highlights the need to reconsider energy requirements for HIV-positive cases at different clinical stages, for more rapid nutritional recovery in under-resourced settings where prolonged hospitalisation may be a challenge.
Introduction:
This study used data from a prospectively maintained trauma database to assess the level of systolic blood pressure at which mortality rates for trauma begin to increase and to compare ...systolic blood pressure with base deficit as a predictor of outcome.
Methodology:
The Pietermaritzburg Metropolitan Trauma Service maintains a prospective digital trauma registry. All trauma patients admitted to the service for the period January 2012–January 2015 were included. Analysis was performed on systolic blood pressure relative to a number of selected markers of outcome and a variety of physiological parameters.
Results:
Out of an original data set of 2974 trauma patients, a total of 169 elective patients, 799 patients with isolated traumatic brain injury, and 27 patients with incomplete data were excluded to leave a sample size of 2148 patients. Of these, 1830 (85.2%) were males and 318 (14.8%) were females. The mean age (standard deviation) was 31.8 (12.0) years. The median age (interquartile range) was 29 (23–37) years. There were 89 deaths in this cohort (4.1%). The median systolic blood pressure (interquartile range) was 123 (112–136) mmHg. The median base deficit was −1.4 (interquartile range: −4.5 to 1). The inflection curves below with fitted non-linear curve clearly show the upward change in mortality frequency around a systolic blood pressure of ⩽110 mmHg as well for a base deficit below −5. A cutoff of <110 for systolic blood pressure yields a high sensitivity and very high positive predictive value of 82% (95% confidence interval: 81–84) and 98% (95% confidence interval: 97–98), but low specificity (56%) and negative predictive value (12%), respectively. Similar optimal cutoff analysis for base deficit versus mortality suggests base deficit >4.8 as a good predictor area under the curve (0.82; 95% confidence interval: 0.75–0.88). This cutoff yields a high sensitivity of 80% (95% confidence interval: 78–82), moderate specificity of 75% (95% confidence interval: 62–85), very high positive predictive value of 98% (95% confidence interval: 97–99) but low negative predictive value of 17% (15–28).
Conclusion:
The data suggest that traumatic shock starts to become manifest at a systolic blood pressure of 110 mmHg and that a systolic blood pressure reading of 90 mmHg represents an advanced state of shock. Systolic blood pressure by itself is a poor predictor of mortality and outcome. Base deficit appears to be a far better predictor of mortality than systolic blood pressure. Future models to categorize shock will have to combine vital signs with biochemical markers of hypoperfusion.
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