Recommendations for the acute and long-term medical management of low-trauma hip fractures

Hip fractures are the most serious complication of osteoporosis and are associated with high morbidity and mortality. Generally, patients who sustain osteoporotic hip fractures are older adults who have a number of comorbiddiseases which predispose them to perioperative complications, disability and death. Furthermore, patients who survive a hip fracture are at higher risk of a subsequent fracture. The morbidity and mortality of hip fractures can be substantially reduced by a structured multidisciplinary approach to pre- and postoperative management. This review will focus on the epidemiology of hip fractures, predictors of mortality and the acute and long-term management of hip fractures

Starvation ketoacidosis in pregnancy presenting as euglycaemic high anion gap metabolic acidosis: A case report highlighting the significance of early recognition and prompt intervention

Starvation ketoacidosis (SKA) constitutes an important consideration in the pregnant patient who presents with profound metabolic acidosis. Pregnancy-related changes predispose the patient to develop SKA following relatively short periods (12 - 14 hours) of ‘starvation’. Patients also typically look clinically well in relation to the significant metabolic derangements that accompany the condition. Prompt recognition and early institution of appropriate therapy is therefore extremely important in terms of optimising maternal and fetal outcome. We describe a pregnant patient with SKA who presented with profound euglycaemic ketoacidosis that resolved rapidly following the early initiation of appropriate therapy. Furthermore, appropriate therapy resulted in our patient avoiding the need for an emergency caesarean section, which is often reported in this scenario. The ensuing discussion addresses SKA in pregnancy, the unique features of our patient, and management considerations from a maternal and fetal perspective. We also discuss the various causes of ketoacidosis such as diabetic ketoacidosis (DKA), euglycaemic DKA, alcohol-induced euglycaemic ketoacidosis and SKA in pregnant patients

Starvation ketoacidosis in pregnancy presenting as euglycaemic, high anion gap metabolic acidosis: A case report highlighting the significance of early recognition and prompt intervention

Starvation ketoacidosis (SKA) constitutes an important consideration in the pregnant patient who presents with profound metabolic acidosis. Pregnancy-related changes predispose the patient to develop SKA following relatively short periods (12 - 14 hours) of ‘starvation’. Patients also typically look clinically well in relation to the significant metabolic derangements that accompany the condition. Prompt recognition and early institution of appropriate therapy is therefore extremely important in terms of optimising maternal and fetal outcome. We describe a pregnant patient with SKA who presented with profound euglycaemic ketoacidosis that resolved rapidly following the early initiation of appropriate therapy. Furthermore, appropriate therapy resulted in our patient avoiding the need for an emergency caesarean section, which is often reported in this scenario. The ensuing discussion addresses SKA in pregnancy, the unique features of our patient, and management considerations from a maternal and fetal perspective. We also discuss the various causes of ketoacidosis such as diabetic ketoacidosis (DKA), euglycaemic DKA, alcohol-induced euglycaemic ketoacidosis and SKA in pregnant patients

The Durban World Congress Ethics Round Table conference report: I. Differences between withholding and withdrawing life-sustaining treatments

Introduction: Withholding life-sustaining treatments (WHLST) and withdrawing life-sustaining treatments (WDLST) occur in most intensive care units (ICUs) around the world to varying degrees. Methods: Speakers from invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were approached to participate in an ethics round table. Participants were asked if they agreed with the statement "There is no moral difference between withholding and withdrawing a mechanical ventilator." Differences between WHLST and WDLST were discussed. Official statements relating to WHLST and WDLST from intensive care societies, professional bodies, and government statements were sourced, documented, and compared. Results: Sixteen respondents stated that there was no moral difference between withholding or withdrawing a mechanical ventilator, 2 were neutral, and 4 stated that there was a difference. Most ethicists and medical organizations state that there is no moral difference between WHLST and WDLST. A review of guidelines noted that all but 1 of 29 considered WHLST and WDLST as ethically or legally equivalent. Conclusions: Most respondents, practicing intensivists, stated that there is no difference between WHLST and WDLST, supporting most ethicists and professional organizations. A minority of physicians still do not accept their equivalency

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

Effects of Water-Level Management on Nesting Success of Common Loons

Water-level management is widespread and illustrates how contemporary climate can interact directly and indirectly with numerous biological and abiotic factors to influence reproductive success of wildlife species. We studied common loons, an iconic waterbird sensitive to timing and magnitude of waterlevel changes during the breeding season, using a before-after-control-impact design on large lakes in Voyageurs National Park (Minnesota, USA), to assess the effect of anthropogenic changes in hydroregime on their nesting success and productivity. We examined multiple competing a priori hypotheses in an information-theoretic framework, and predicted that magnitude of changes in loon productivity would be greater in the Namakan Reservoir, where water-level management was altered to mimic a more natural hydroregime, than in Rainy Lake, where management remained relatively unchanged. We determined outcomes from 278 nests during 2004–2006 by performing boat-based visits every 3–5 days, and measuring hydrologic, vegetative, and microtopographic covariates. Relative to comparably collected data for 260 total loon pairs during 1983–1986, productivity (chicks hatched/territorial pair) increased 95% in the Namakan Reservoir between the 2 time periods. Nest success declined in both lakes over the 2 study periods but less so in the Namakan Reservoir than in Rainy Lake. Flooding was a primary cause of nest failures (though second nests were less likely to flood). Nest predation appears to have increased considerably between the 2 study periods. Top-ranked models suggested that timing of nest initiation, probability of nest flooding, probability of nest stranding, and probability of nest success were each related to 2–4 factors, including date of initiation, timing of initiation relative to peak water levels, changes in the elevation of the nest edge, maximum waterlevel change between initiation and peak water levels, and maximum water-level change between initiation and nest outcome. The top model for all variables except stranding each garnered \u3e82% of total model weight. Results demonstrate that water-level management can be altered to benefit productivity of common loons. However, nuanced interactions between land-use change, invasive species, human development, recreation, climate change, and recovery of top predators may often complicate both management decisions and interpretation of water-level impacts on wildlife

South African Guidelines on the Determination of Death

Death is a medical occurrence that has social, legal, religious and cultural consequences requiring common clinical standards for its diagnosis and legal regulation.The following document compiled by the Critical Care Society of Southern Africa outlines the core standards for determination of death in the hospital context. It aligns with the latest evidence-based research and international guidelines and is applicable to the South African context and legal system.The aim is to provide clear medical standards for health care providers to follow in the determination of death, thereby promoting safe practices and high-quality care through the use of uniform standards. Adherence to such guidelines will provide assurance to medical staff, patients, their families and the South African public that the determination of death is always undertaken with diligence, integrity, respect and compassion, and is in accordance with accepted medical standards and latest scientific evidence

The Critical Care Society of Southern Africa guidelines on the allocation of scarce critical care resources during the COVID-19 public health emergency in South Africa

Letter by Gopalan et al. on article by Singh and Moodley (Singh JA, Moodley K. Critical care triaging in the shadow of COVID-19: Ethics considerations. S Afr Med J 2020;110(5):355-359. https://doi.org/10.7196/SAMJ.2020.v110i5.14778); and response by Singh and Moodle

The Durban World Congress Ethics Round Table Conference Report: III. Withdrawing Mechanical ventilation-the approach should be individualized

Purpose: The purpose of this study is to determine the approaches used in withdrawing mechanical ventilator support. Materials and methods: Speakers from the invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were asked to provide a detailed description of individual approaches to the process of withdrawal of mechanical ventilation. Results: Twenty-one participants originating from 13 countries, responded to the questionnaire. Four respondents indicated that they do not practice withdrawal of mechanical ventilation, and another 4 indicated that their approach is highly variable depending on the clinical scenario. Immediate withdrawal of ventilation was practiced by a large number of the respondents (7/16; 44%). A terminal wean was practiced by just more than a third of the respondents (6/16; 38%). Extubation was practiced in more than 70% of instances among most of the respondents (9/17; 53%). Two of the respondents (2/17; 12%) indicated that they would extubate all patients, whereas 14 respondents indicated that they would not extubate all their patients. The emphasis was on tailoring the approach used to suit individual case scenarios. Conclusions: Withdrawing of ventilator support is not universal. However, even when withdrawing mechanical ventilation is acceptable, the approach to achieve this end point is highly variable and individualized