Pandemic infl uenza A (H1N1) 2009: a case series from intensive care units in Port Shepstone, South Africa

This article presents a series of seven ventilator-dependent patients with pandemic in. uenza A (H1N1) 2009 and one with seasonal in. uenza at two hospitals – a government regional hospital and a private hospital – in the Ugu District, KwaZulu-Natal. The clinical features of these patients are described, and an attempt is made to highlight the problems encountered in managing such patients in a regional South African setting.Keywords: pandemic influenza A (H1N1) 2009; intensive care; critical care; influenza swine fl

Postoperative neuromuscular function following non-depolarising muscle blockade in patients at Inkosi Albert Luthuli Central Hospital, Durban

Background: Residual neuro-muscular blockade after the end of general anaesthesia may occur when non-depolarising muscle relaxant (NDMR) drugs are used. Train-of-four (TOF) stimulation is used to quantify the degree of residual paralysis, with a TOF ratio of less than 0.9 postoperatively associated with increased morbidity in patients. The aim of this study was to survey the degree of residual paralysis in patients in the post-anaesthesia care unit (PACU) at Inkosi Albert Luthuli Central Hospital (IALCH), Durban, over the survey period.Methods: This cross-sectional observational study was performed over a two-month period at IALCH, assessing the postoperative neuromuscular function of patients who had received NDMR drugs (rocuronium (n = 64) or cisatracurium (n = 6)) intraoperatively. Muscle function was assessed using acceleromyography and TOF stimulation, utilising a TOF Watch SX device, with function grouped according to previously defined targets as less than a ratio of 0.7, less than a ratio of 0.9 and less than a ratio of 1.0.Results: Recovery to a TOF ratio of less than 0.7, 0.9 or 1.0 was observed in 5 (7.1%), 20 (28.6%) and 44 (62.9%) of patients respectively.Conclusions: Although the results obtained compare favourably with other studies in similar patient populations, a considerable subset of patients still arrive in the PACU with inadequate return of neuromuscular function.Keywords: post-anaesthesia, postoperative residual curarisation, postoperative residual weakness, residual block, residual neuromuscular block, residual paralysi

Intraoperative management of ETT and LMA cuff pressures: a survey of anaesthetists’ knowledge, attitude and current practice

Background: Endotracheal tubes and laryngeal mask airway devices are routinely used during anaesthesia. Inappropriate inflation of cuffs has been shown to cause postoperative airway morbidity, and limiting the pressure decreases the incidence of pharyngo-laryngeal complications. Subjective measurements of cuff pressures correlate poorly to actual pressures, yet the use of objective cuff manometry is not routinely practised. The aim of this study was to determine current clinical practice of cuff inflation as well as the knowledge and attitude of anaesthetists in the University of KwaZulu-Natal (UKZN) Discipline of Anaesthesiology and Critical Care.Methods: This was a descriptive, observational study and data were collected using an anonymous self-administered questionnaire from practising anaesthetists in the UKZN Discipline of Anaesthesiology and Critical Care.Results: A total of 160 anaesthetists participated. The minimal occlusive volume test (38.8%) and the pilot balloon palpation technique (36.3%) were most commonly used. Most participants felt it was important to accurately measure ETT (84.8%) and LMA (56.1%) cuff pressures and that using a cuff manometer should be mandatory (76%). Reasons for not using it routinely included manometers not being readily available. Gaps in knowledge and education were also identified.Conclusion: There is increasing importance placed on quality assurance. Clinical practice varies widely among practitioners with the only consistency being the omission of cuff manometers during routine intraoperative management, despite their proven benefit and efficacy. The authors propose recommendations to facilitate the routine intraoperative use of cuff manometers.Keywords: anaesthesia, cuff manometer, endotracheal, intracuff pressure, intubation, laryngeal mask airway, sore throat, tracheo-laryngeal complication

Perceptions of final-year UKZN medical students about anaesthesia as a specialty choice

Background: South Africa suffers from a drastic shortage of anaesthesiologists. This shortage has a major impact on the provision of safe, timeous and appropriate surgery for the population. One factor implicated in this shortage may be the difficulty in appropriate recruitment of trainees.Methods: A questionnaire-based cross-sectional study was conducted among the final-year medical students at the University of KwaZulu-Natal (UKZN), for the year 2013.Results: At total of 112 final-year medical students participated in the study. The majority (93%) of the medical students would like to specialise in the future. Anaesthesiology ranked fourth in popularity among the specialties presented to the students. The students’ opinion of the key positive attributes of anaesthesiology was that it was interesting (26.8%), mentally challenging (22.3%) and afforded good working hours (18.8%). The key negative attributes of anaesthesiology highlighted by the students were that it was boring (21.4%), stressful (20.5%) and frightening (15.2%). The biggest influence on the medical students’ perceptions of anaesthesiology was the medical school rotation, with the need for longer duration of exposure, highlighted by 24 (21.4%) of the students.Conclusion: The perceptions of medical students concerning anaesthesia are multi-faceted, with the undergraduate anaesthetic rotation viewed as the biggest influence on their perceptions regarding anaesthesia. All anaesthetists should strive to improve the discipline profile, change the misconceptions and enhance the attractiveness of the specialty amongst medical students from foundation level upwards.Keywords: anaesthesia, education, medical students, perceptions, workforce shortag

Is there a role for melatonin in the ICU?

In the last decade, there have been significant developments in the understanding of the hormone melatonin in terms of its physiology, regulatory role and potential utility in various domains of clinical medicine. Melatonin’s purported properties include, among others, regulation of mitochondrial function, anti-inflammatory, anti-oxidative and neuro-protective effects, sleep promotion and immune enhancement. As such, its role has been explored specifically in the critical care setting in terms of many of these properties. This review addresses the physiological basis for considering melatonin in the critical care setting as well as the current evidence pertaining to its potential utility.http://www.sajcc.org.zadm2022Critical Car

The role of laboratory testing in hospitalised and critically ill COVID-19-positive patients

The COVID-19 pandemic has placed healthcare resources around the world under immense pressure. South Africa, given the condition of its healthcare system, is particularly vulnerable. There has been much discussion around rational healthcare utilisation, ranging from diagnostic testing and personal protective equipment to triage and appropriate use of ventilation strategies. There has, however, been little guidance around use of laboratory tests once COVID-19 positive patients have been admitted to hospital. We present a working guide to rational laboratory test use, specifically for COVID-19, among hospitalised patients, including the critically ill. The specific tests, the reasons for testing, their clinical usefulness, timing and frequency are addressed. We also provide a discussion around evidence for the use of these tests from a clinical perspective.The Critical Care Society of Southern Africahttp://www.sajcc.org.za/index.php/SAJCCam2021Critical Car

Starch safety in resuscitation

The Western Cape Department of Health (WC DoH) has taken a decision to withdraw all intravenous fluids (IVFs) containing hydroxyethyl starch (HES) from hospitals in the Western Cape, with similar action contemplated in the Free State and Gauteng. This was in response to recommendations from: The European Medicines Agency's Pharmacovigilance Risk Assessment Committee (EMA PRAC) that HES IVFs be withdrawn from clinical use. The United Kingdom Medicines and Healthcare Products Regulatory Agency (MHRA) which has issued a recall of all HES IVFs in the UK. The United States Food and Drug Administration which advises that HES IVFs be used with caution in ICU, cardiac surgery and patients with known kidney disease or coagulopathy. Further advice was that HES should be stopped if coagulopathy or renal dysfunction develops, as well as that renal function should be monitored for 90 days after HES administration.http://www.samj.org.zaam2013ay201

The Critical Care Society of Southern Africa consensus statement on ICU triage and rationing (ConICTri)

BACKGROUND: In South Africa (SA), intensive care is faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience daily the consequences of limited resources. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are frequently necessary in SA, particularly in the publicly funded health sector. PURPOSE: The purpose of this consensus statement is to examine key questions that arise when considering the status of ICU resources in SA, and more specifically ICU admission, rationing and triage decisions. The accompanying guideline in this issue is intended to guide frontline triage policy and ensure the best utilisation of intensive care in SA, while maintaining a fair distribution of available resources. Fair and efficient triage is important to ensure the ongoing provision of high-quality care to adult patients referred for intensive care. RECOMMENDATIONS: In response to 14 key questions developed using a modified Delphi technique, 29 recommendations were formulated and graded using an adapted GRADE score. The 14 key questions addressed the status of the provision of ICU services in SA, the degree of resource restriction, the efficiency of resource management, the need for triage, and how triage could be most justly implemented. Important recommendations included the need to formally recognise and accurately quantify the provision of ICU services in SA by national audit; actively seek additional resources from governmental bodies; consider methods to maximise the efficiency of ICU care; evaluate lower level of care alternatives; develop a triage guideline to assist policy-makers and frontline practitioners to implement triage decisions in an efficient and fair way; measure and audit the consequence of triage; and promote research to improve the accuracy and consistency of triage decisions. The consensus document and guideline should be reviewed and revised appropriately within 5 years. CONCLUSIONS: In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, recommendations and a guideline have been developed to guide policy-making and assist frontline triage decision-making in SA. These documents are not a complete plan for quality practice but rather the beginning of a long-term initiative to engage clinicians, the public and administrators in appropriate triage decision-making, and promote systems that will ultimately maximise the efficient and fair use of available ICU resources.http://www.samj.org.zapm2020SurgeryCritical Car

An Integrated TCGA Pan-Cancer Clinical Data Resource to Drive High-Quality Survival Outcome Analytics

For a decade, The Cancer Genome Atlas (TCGA) program collected clinicopathologic annotation data along with multi-platform molecular profiles of more than 11,000 human tumors across 33 different cancer types. TCGA clinical data contain key features representing the democratized nature of the data collection process. To ensure proper use of this large clinical dataset associated with genomic features, we developed a standardized dataset named the TCGA Pan-Cancer Clinical Data Resource (TCGA-CDR), which includes four major clinical outcome endpoints. In addition to detailing major challenges and statistical limitations encountered during the effort of integrating the acquired clinical data, we present a summary that includes endpoint usage recommendations for each cancer type. These TCGA-CDR findings appear to be consistent with cancer genomics studies independent of the TCGA effort and provide opportunities for investigating cancer biology using clinical correlates at an unprecedented scale. Analysis of clinicopathologic annotations for over 11,000 cancer patients in the TCGA program leads to the generation of TCGA Clinical Data Resource, which provides recommendations of clinical outcome endpoint usage for 33 cancer types

Driver Fusions and Their Implications in the Development and Treatment of Human Cancers.

Gene fusions represent an important class of somatic alterations in cancer. We systematically investigated fusions in 9,624 tumors across 33 cancer types using multiple fusion calling tools. We identified a total of 25,664 fusions, with a 63% validation rate. Integration of gene expression, copy number, and fusion annotation data revealed that fusions involving oncogenes tend to exhibit increased expression, whereas fusions involving tumor suppressors have the opposite effect. For fusions involving kinases, we found 1,275 with an intact kinase domain, the proportion of which varied significantly across cancer types. Our study suggests that fusions drive the development of 16.5% of cancer cases and function as the sole driver in more than 1% of them. Finally, we identified druggable fusions involving genes such as TMPRSS2, RET, FGFR3, ALK, and ESR1 in 6.0% of cases, and we predicted immunogenic peptides, suggesting that fusions may provide leads for targeted drug and immune therapy