Voorspelling van oorlewing in 'n chirurgiese intensiewesorgeenheid

Doel: Om die voorspellingswaarde van , 14 bestaande voorspellings programme op chirurgiese intensiewesorgpasiente te toets en om n oorlewingsvoorspellingsmodel vir die chirurgiese intensiewesorgeenheid (ClSE) te ontwikkel wat as instrument kan dien om kliniese besluitneming te vergemaklik. Ontwerp: Retrospektiewe en prospektiewe versameling en rekenarisering van kliniese, fisiologiese en biochemiese veranderlikes. Student se t-toets, logistiese regressie, sensitiwiteits- en spesifisiteitsberekening met behulp van tweerigting tabelle. Plek: Chirurgiese  Intensiewesorgeenheid, H. F. Verwoerd-hospitaal, Pretoria. Pasientpopulasie: Retrospektiewe deel van studie: 188 pasiente; prospektiewe deel: 104 pasiente. Bevindingsmaatstawwe: Statisties betekenisvolle verskille tussen die tellings van oorlewendes en nieoorlewendes. Aanvaarbare sensitiwiteit en spesifisiteit van ontwikkelde model. Resultate: AI 14 bestaande voorspellingsprogramme beskik oor die vennoe om te onderskei tussen die opnamedagtellings van oorlewendes en nie-oorlewendes en het, by implikasie, dus prognostiese geldigheid. Die statistiese betekenisvolheid geassosieer met die onderskeie programme het gewissel van P < 0.01 tot P < 0.0001. 'n Reeks van opeenvolgende oorlewingsvoorspel1ingsmodelle, ontwikkel deur logistiese regressie-analise op die bes passende voorspellingsprogramme, het uiteindelik gelei tot die ontwikkeling van 'n model met 'n sensitiwiteit van 93% en 'n spesifisiteit van 66%. Gevolgtrekking: Verskeie bestaande voorspellingsprogramme kan bydra tot kliniese besluitneming. Voorspellingsmodelle hieruit ontwikkel moet voor implementering herhaaldelik op opeenvolgende groepe van die teikenpopulasie getoets word. Beide die programme en die modelle behoort as bykomstige prognostiese ondersteuningsfaktore gebruik te word eerder as absolute aanduidings van uitkoms.S Afr Med J 1996: 86: 1417 -142

The open abdomen : Part 2 : Management of the open abdomen using temporary abdominal closure

Management of the open abdomen is a complex undertaking, as it not only involves difficult wound healing but also the prevention of many serious local and systemic complications. In this article the different types of temporary wound closure methods and their pros and cons are discussed. It appears from our experience that specific negative-pressure dressings produce the best outcomes with regard to morbidity and mortality, as they are adapted to address the particular needs of different grades of open abdomen.http://www.woundhealingsa.co.za/index.php/WHS

The need for pharmaceutical care in an intensive care unit at a teaching hospital in South Africa

BACKGROUND. The role of the pharmacist has evolved over the last 2 decades beyond traditional functions such as stock control and dispensing. OBJECTIVES. To describe the functions performed by a clinical pharmacist while based in a surgical and trauma intensive care unit of a teaching hospital. METHODS. An operational research study that included indications of programme success was conducted. Interventions to assess therapy and achieve definite outcomes to satisfy patients’ medicine needs were documented for 51 patients over a study period of 8 weeks. RESULTS. A total of 181 interventions were suggested by the pharmacist, with 127 (70%) accepted and implemented by the medical and nursing staff of the unit. The most frequent interventions were related to: untreated medical conditions (15.5%), appropriate therapy or course (13.8%), investigations indicated or outstanding (12.2%), and inappropriate doses and dosing frequency (11%). Interventions were also made regularly to address system errors or non-compliance and factors hindering therapeutic effect. Of the 250 h the pharmacist spent in the ward, most time was used for pharmaceutical care (28%) and ward rounds (21%) with members of the multidisciplinary team. CONCLUSIONS. The study results demonstrated that a clinical pharmacist’s contribution to patient care at ward level resulted in improved monitoring of pharmacotherapy. Medicine-related problems were identified and addressed.The authors would like to acknowledge Prof. Herman Schoeman for the statistical analysis of the data.Department of Pharmacy, Medunsa campushttp://www.sajcc.org.za/index.php/SAJCCam201

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

Antimicrobial susceptibility of gram-negative pathogens isolated from patients with complicated intra-abdominal infections in South African hospitals (SMART Study 2004-2009) : impact of the new carbapenem breakpoints

BACKGROUND: The Study for Monitoring Antimicrobial Resistance Trends (SMART) follows trends in resistance among aerobic and facultative anaerobic gram-negative bacilli (GNB) isolated from complicated intra-abdominal infections (cIAIs) in patients around the world. METHODS: During 2004–2009, three centralized clinical microbiology laboratories serving 59 private hospitals in three large South African cities collected 1,218 GNB from complicated intra-abdominal infections (cIAIs) and tested them for susceptibility to 12 antibiotics according to the 2011 Clinical Laboratory Standards Institute (CLSI) guidelines. RESULTS: Enterobacteriaceae comprised 83.7% of the isolates. Escherichia coli was the species isolated most commonly (46.4%), and 7.6% of these were extended-spectrum b-lactamase (ESBL)-positive. The highest ESBL rate was documented for Klebsiella pneumoniae (41.2%). Overall, ertapenem was the antibiotic most active against susceptible species for which it has breakpoints (94.6%) followed by amikacin (91.9%), piperacillin-tazobactam (89.3%), and imipenem-cilastatin (87.1%), whereas rates of resistance to ceftriaxone, cefotaxime, ciprofloxacin, and levofloxacin were documented to be 29.7%, 28.7%, 22.5%, and 21.1%, respectively. Multi-drug resistance (MDR), defined as resistance to three or more antibiotic classes, was significantly more common in K. pneumoniae (27.9%) than in E. coli (4.9%; p < 0.0001) or Proteus mirabilis (4.1%; p < 0.05). Applying the new CLSI breakpoints for carbapenems, susceptibility to ertapenem was reduced significantly in ESBL-positive E. coli compared with ESBL-negative isolates (91% vs. 98%; p < 0.05), but this did not apply to imipenem-cilastatin (95% vs. 99%; p = 0.0928). A large disparity between imipenem-cilastatin and ertapenem susceptibility in P. mirabilis and Morganella morganii was documented (24% vs. 96% and 15% vs. 92%, respectively), as most isolates of these two species had imipenem-cilastatin minimum inhibitory concentrations in the 2–4 mcg/mL range, which is no longer regarded as susceptible. CONCLUSIONS: This study documented substantial resistance to standard antimicrobial therapy among GNB commonly isolated from cIAIs in South Africa. With the application of the new CLSI carbapenem breakpoints, discrepancies were noted between ertapenem and imipenem-cilastatin with regard to the changes in their individual susceptibilities. Longitudinal surveillance of susceptibility patterns is useful to guide recommendations for empiric antibiotic use in cIAIs.Merck & Co., Inc.http://www.liebertpub.com/overview/surgical-infections/53/am2013ay201

Starch safety in resuscitation

This correspondence is in response to the article: Parrish A, Blockman M, Starch safety in resuscitation − when will we ever learn? S Afr Med J 2013;103(6):365-367. [http://dx.doi.org/10.7196/samj.6969] in three parts:1. Starch safety in resuscitation: Withdrawal of hydroxyethyl starch solutions − a plea for evidence. R E Hodgson, G A Richards, A C Lundgren, M G L Spruyt, J P Pretorius, L R Mathiva, R Dickerson, P D Gopalan 2. Starch safety in resuscitation: Plea for evidence. M F M James, I A Joubert, J L Piercy3. Starch safety in resuscitation: Response from A Parrish and M Blockma

Understanding continent-wide variation in vulture ranging behavior to assess feasibility of Vulture Safe Zones in Africa: Challenges and possibilities

Protected areas are intended as tools in reducing threats to wildlife and preserving habitat for their long-term population persistence. Studies on ranging behavior provide insight into the utility of protected areas. Vultures are one of the fastest declining groups of birds globally and are popular subjects for telemetry studies, but continent-wide studies are lacking. To address how vultures use space and identify the areas and location of possible vulture safe zones, we assess home range size and their overlap with protected areas by species, age, breeding status, season, and region using a large continent-wide telemetry datasets that includes 163 individuals of three species of threatened Gyps vulture. Immature vultures of all three species had larger home ranges and used a greater area outside of protected areas than breeding and non-breeding adults. Cape vultures had the smallest home range sizes and the lowest level of overlap with protected areas. Rüppell\u27s vultures had larger home range sizes in the wet season, when poisoning may increase due to human-carnivore conflict. Overall, our study suggests challenges for the creation of Vulture Safe Zones to protect African vultures. At a minimum, areas of 24,000 km2 would be needed to protect the entire range of an adult African White-backed vulture and areas of more than 75,000 km2 for wider-ranging Rüppell\u27s vultures. Vulture Safe Zones in Africa would generally need to be larger than existing protected areas, which would require widespread conservation activities outside of protected areas to be successful

Health benefits, costs, and cost-effectiveness of earlier eligibility for adult antiretroviral therapy and expanded treatment coverage: a combined analysis of 12 mathematical models.

BACKGROUND: New WHO guidelines recommend ART initiation for HIV-positive persons with CD4 cell counts ≤500 cells/µL, a higher threshold than was previously recommended. Country decision makers must consider whether to further expand ART eligibility accordingly. METHODS: We used multiple independent mathematical models in four settings-South Africa, Zambia, India, and Vietnam-to evaluate the potential health impact, costs, and cost-effectiveness of different adult ART eligibility criteria under scenarios of current and expanded treatment coverage, with results projected over 20 years. Analyses considered extending eligibility to include individuals with CD4 ≤500 cells/µL or all HIV-positive adults, compared to the previous recommendation of initiation with CD4 ≤350 cells/µL. We assessed costs from a health system perspective, and calculated the incremental cost per DALY averted ($/DALY) to compare competing strategies. Strategies were considered 'very cost-effective' if the$/DALY was less than the country's per capita gross domestic product (GDP; South Africa: $8040, Zambia:$1425, India: $1489, Vietnam:$1407) and 'cost-effective' if $/DALY was less than three times per capita GDP. FINDINGS: In South Africa, the cost per DALY averted of extending ART eligibility to CD4 ≤500 cells/µL ranged from$237 to $1691/DALY compared to 2010 guidelines; in Zambia, expanded eligibility ranged from improving health outcomes while reducing costs (i.e. dominating current guidelines) to$749/DALY. Results were similar in scenarios with substantially expanded treatment access and for expanding eligibility to all HIV-positive adults. Expanding treatment coverage in the general population was therefore found to be cost-effective. In India, eligibility for all HIV-positive persons ranged from $131 to$241/DALY and in Vietnam eligibility for CD4 ≤500 cells/µL cost $290/DALY. In concentrated epidemics, expanded access among key populations was also cost-effective. INTERPRETATION: Earlier ART eligibility is estimated to be very cost-effective in low- and middle-income settings, although these questions should be revisited as further information becomes available. Scaling-up ART should be considered among other high-priority health interventions competing for health budgets. FUNDING: The Bill and Melinda Gates Foundation and World Health Organization

Critical care admission of South African (SA) surgical patients: Results of the SA Surgical Outcomes Study

Background. Appropriate critical care admissions are an important component of surgical care. However, there are few data describing postoperative critical care admission in resource-limited low- and middle-income countries.Objective. To describe the demographics, organ failures, organ support and outcomes of non-cardiac surgical patients admitted to critical care units in South Africa (SA).Methods. The SA Surgical Outcomes Study (SASOS) was a 7-day national, multicentre, prospective, observational cohort study of all patients ≥16 years of age undergoing inpatient non-cardiac surgery between 19 and 26 May 2014 at 50 government-funded hospitals. All patients admitted to critical care units during this study were included for analysis.Results. Of the 3 927 SASOS patients, 255 (6.5%) were admitted to critical care units; of these admissions, 144 (56.5%) were planned, and 111 (43.5%) unplanned. The incidence of confirmed or strongly suspected infection at the time of admission was 35.4%, with a significantly higher incidence in unplanned admissions (49.1 v. 24.8%, p&lt;0.001). Unplanned admission cases were more frequently hypovolaemic, had septic shock, and required significantly more inotropic, ventilatory and renal support in the first 48 hours after admission. Overall mortality was 22.4%, with unplanned admissions having a significantly longer critical care length of stay and overall mortality (33.3 v. 13.9%, p&lt;0.001).Conclusion. The outcome of patients admitted to public sector critical care units in SA is strongly associated with unplanned admissions. Adequate ‘high care-dependency units’ for postoperative care of elective surgical patients could potentially decrease the burden on critical care resources in SA by 23%. This study was registered on ClinicalTrials.gov (NCT02141867)

Visual Performance Fields: Frames of Reference

Performance in most visual discrimination tasks is better along the horizontal than the vertical meridian (Horizontal-Vertical Anisotropy, HVA), and along the lower than the upper vertical meridian (Vertical Meridian Asymmetry, VMA), with intermediate performance at intercardinal locations. As these inhomogeneities are prevalent throughout visual tasks, it is important to understand the perceptual consequences of dissociating spatial reference frames. In all studies of performance fields so far, allocentric environmental references and egocentric observer reference frames were aligned. Here we quantified the effects of manipulating head-centric and retinotopic coordinates on the shape of visual performance fields. When observers viewed briefly presented radial arrays of Gabors and discriminated the tilt of a target relative to homogeneously oriented distractors, performance fields shifted with head tilt (Experiment 1), and fixation (Experiment 2). These results show that performance fields shift in-line with egocentric referents, corresponding to the retinal location of the stimulus