A crushing experience: The spectrum and outcome of soft tissue injury and myonephropathic syndrome at an Urban South African University Hospital

Introduction: Crush syndrome may follow soft-tissue injury with rhabdomyolysis and renal failure. The study assessed: the level of creatinine kinase (CK) associated with significant renal dysfunction; the correlation between body surface area (BSA) involved and CK level; correlation between BSA injury and renal dysfunction to identify at risk patients. Methods: Retrospective review of patients Tygerberg Hospital Trauma Service between January 2003 and December 2005 with a screening CK level >500 U/L. Data were captured on a proforma. BSA was scored charting body surface bruising using a rule-of-nines. The study was approved by the Departmental Research Committee. Results: Three hundred and thirty-four records were reviewed. The majority (89%) were men, mean age 30 years and average Revised Trauma Score 7.5 (SD = 0.35). Blunt trauma constituted 75%, combined 15% and penetrating injury 10%, with blunt force assault 64% of the total. CK of >8500 U/L predicted renal failure (p 18% predicting renal impairment. CK >5000 U/L had a worse outcome compared with the CK = 500–5000 U/L, with higher peak urea (17.2 vs. 12 mmol/L) and peak creatinine (2836 vs. 140 mmol/L) and rate of renal failure (20% vs. 8%). The penetrating group included vascular injuries with increased CK due to ischaemia–reperfusion injury but low BSA, due to mainly gunshot wounds (70%). Three patients (10%) developed renal failure and had abnormal CK levels (range 538–32,540 U/L). Conclusion: Screening CK accurately stratify patients at risk for myonephropathic syndrome. Early aggressive fluid loading can prevent renal failure. Adjunctive measures have not improved outcome or decreased the need for dialysis. Patients sustaining vascular and severe extremity injury from penetrating wounds may develop rhabdomyolysis and should be routinely screened with CK levels, urea and creatinine

Brachial artery injuries: A seven-year experience with a prospective database

Introduction: A Trauma Vascular Registry was established in 1998. The aim of the study was to review brachial artery injuries. Methods and Materials: Review of the prospective registry & case-notes of all identified Brachial Artery Injury. Data was captured on a proforma. Results: 177 brachial artery injuries were identified, 154 (87%) were male, 130 were due to stab wounds (73,4%) while gunshots or other sharp trauma accounted for 27 injuries (16,1%). 17 blunt injuries and 3 other injuries were noted. The mid-brachial artery was injured most frequently (113; 68,3%). Angiograms were only performed in five patients and diagnosis was by clinical examination in the remaining patients. 22% of patients had a concomitant nerve injury, while 9 had humerus fractures. Repair was by vein graft in 92 patients (52%), while a primary repair was performed in 80 (45,2%). Specialist Registrars performed 142 repairs (80,3%). Sixteen patients (9%) required forearm fasciotomy, with four cases of limb loss. Three of the cases of limb loss presented over 6 hours post-injury. Discussion and Conclusions: Brachial artery injuries are the commonest vascular injuries to the limbs, with a good prognosis, provided early repair is undertaken. Arteriography is usually unnecessary and limb loss is low, provided appropriate decompression of a compartment syndrome is performed, however in this group the limb loss rate is 25% compared to the overall of 2%. The repair of a brachial artery is a good training procedure for surgical trainees, associated with a low morbidity. © 2007 Springer.Revie

Imaging the oesophagus after penetrating cervical trauma using water-soluble contrast alone: Simple, cost-effective and accurate

Aim: This audit aims to gauge the safety and efficacy of iso-oncotic water-soluble contrast media as the sole imaging evaluation of the distal pharynx and cervical oesophagus after penetrating cervical trauma. Methods: A retrospective audit was performed over a 4-year period of all patients with penetrating cervical trauma to zones 1 and 2 of the neck who were subjected to imaging evaluation as part of a selective non-operative management policy for penetrating cervical trauma. The outcome was reviewed and the sensitivity, specificity and predictive values of the investigation were determined. The surgical management of identified injuries is also described. Results: Four hundred and sixty-five contrast studies were included with 11 studies positive for pathology (9 injuries, 2 incidental findings). Surgery was undertaken in 4 patients with cervical oesophageal injuries and conservative management was carried out in 5 cases of distal pharyngeal injury. No missed injuries and no significant adverse events were identified during the study period. Conclusion: A contrast study of the oesophagus with water-soluble iso-oncotic contrast media as the sole diagnostic imaging modality is safe (avoiding the risk of aspiration pneumonia), reliable (identifying all injuries) and cost-efficient (avoiding the need for additional expensive investigations) in cases of penetrating cervical trauma.Articl

Traumatic abdominal wall hernia - Four cases and a review of the literature

Objective. To review blunt traumatic abdominal wall hernias (TAWHs) in our institution. Method. Retrospective review of blunt abdominal trauma cases over a 6-month period. Results. Four patients with TAWH were identified. The mean age was 36 years. Three had been involved in vehicular collisions, and 1 had been assaulted with a large stone. All were diagnosed on presentation, 3 by computed tomography scan and 1 clinically. Two were repaired as emergencies, and 1 was repaired after 4 months. The 4th patient refused surgery. Conclusion. This uncommon injury requires a high index of suspicion and a low threshold for intervention. CT scan offers the best imaging potential.Revie

Cryptic species within the cosmopolitan desiccation-tolerant moss Grimmia laevigata

The common cushion moss Grimmia laevigata (Bridel) Bridel grows on bare rock in a broad range of environments on every continent except Antarctica. As such, it must harbor adaptations to a remarkably broad set of environmental stresses, the extremes of which can include very high temperatures, prolonged nearly complete desiccation, and high ultraviolet B (UVB) exposure. Yet, like many mosses, G. laevigata shows very little morphological variability across its cosmopolitan range. This presents an evolutionary puzzle, the solution to which lies in understanding the phylogeographic structure of this morphologically simple organism. Here we report the results of an analysis of amplified fragment length polymorphisms (AFLPs) in G. laevigata, focusing on individuals from the California Floristic Province. We found evidence that populations within California constitute two distinct geographically overlapping cryptic species. Each clade harbors multiple private alleles, indicating they have been genetically isolated for some time. We suggest that the existence of cryptic species within G. laevigata, in combination with its life history, growth habits, and extreme desiccation tolerance, makes this moss an ideal research tool and a candidate for a biological indicator of climate change and pollution

The Global Alliance for Infections in Surgery: defining a model for antimicrobial stewardship-results from an international cross-sectional survey

Contains fulltext : 177987.pdf (publisher's version ) (Open Access)BACKGROUND: Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world. METHODS: A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery. RESULTS: The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4-6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p < 0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%). CONCLUSION: The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal

2018 WSES/SIS-E consensus conference: Recommendations for the management of skin and soft-tissue infections

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections. SSTIs are a frequent clinical problem in surgical departments. In order to clarify key issues in the management of SSTIs, a task force of experts met in Bertinoro, Italy, on June 28, 2018, for a specialist multidisciplinary consensus conference under the auspices of the World Society of Emergency Surgery (WSES) and the Surgical Infection Society Europe (SIS-E). The multifaceted nature of these infections has led to a collaboration among general and emergency surgeons, intensivists, and infectious disease specialists, who have shared these clinical practice recommendations. © 2018 The Author(s)

It is time to define an organizational model for the prevention and management of infections along the surgical pathway: a worldwide cross-sectional survey

BACKGROUND: The objectives of the study were to investigate the organizational characteristics of acute care facilities worldwide in preventing and managing infections in surgery; assess participants' perception regarding infection prevention and control (IPC) measures, antibiotic prescribing practices, and source control; describe awareness about the global burden of antimicrobial resistance (AMR) and IPC measures; and determine the role of the Coronavirus Disease 2019 pandemic on said awareness. METHODS: A cross-sectional web-based survey was conducted contacting 1432 health care workers (HCWs) belonging to a mailing list provided by the Global Alliance for Infections in Surgery. The self-administered questionnaire was developed by a multidisciplinary team. The survey was open from May 22, 2021, and June 22, 2021. Three reminders were sent, after 7, 14, and 21 days. RESULTS: Three hundred four respondents from 72 countries returned a questionnaire, with an overall response rate of 21.2%. Respectively, 90.4% and 68.8% of participants stated their hospital had a multidisciplinary IPC team or a multidisciplinary antimicrobial stewardship team. Local protocols for antimicrobial therapy of surgical infections and protocols for surgical antibiotic prophylaxis were present in 76.6% and 90.8% of hospitals, respectively. In 23.4% and 24.0% of hospitals no surveillance systems for surgical site infections and no monitoring systems of used antimicrobials were implemented. Patient and family involvement in IPC management was considered to be slightly or not important in their hospital by the majority of respondents (65.1%). Awareness of the global burden of AMR among HCWs was considered very important or important by 54.6% of participants. The COVID-19 pandemic was considered by 80.3% of respondents as a very important or important factor in raising HCWs awareness of the IPC programs in their hospital. Based on the survey results, the authors developed 15 statements for several questions regarding the prevention and management of infections in surgery. The statements may be the starting point for designing future evidence-based recommendations. CONCLUSION: Adequacy of prevention and management of infections in acute care facilities depends on HCWs behaviours and on the organizational characteristics of acute health care facilities to support best practices and promote behavioural change. Patient involvement in the implementation of IPC is still little considered. A debate on how operationalising a fundamental change to IPC, from being solely the HCWs responsibility to one that involves a collaborative relationship between HCWs and patients, should be opened