Positive Postoperative Blood Cultures in Major Abdominal Surgery Patients Attending a Tertiary Hospital in Durban, South Africa

Background: Evidence from high-income countries suggests that bloodstream infection is an essential complication following major surgery. However, studies of bloodstream infections following major surgery in lower-income settings, particularly in Africa, are rare. This study aimed to determine the incidence of postoperative bloodstream infection and to explore any association with mortality in high-risk laparotomy patients in South Africa. Methods: This study was a retrospective study, reviewing 435 consecutive adults who underwent laparotomy at a South African tertiary hospital over a five-year period. Incident postoperative bloodstream infection, defined as a positive blood culture following surgery, was determined from laboratory reports in the patient’s medical chart. Source infections and the causative microorganisms were established from laboratory reports. Inpatient mortality was determined from the patient’s hospital discharge summary. Data were summarized using descriptive statistics. Potential associations between bloodstream infection and mortality were tested using the chi-square test.Results: The incidence of postoperative bloodstream infection was 7.4%. Klebsiella pneumoniae, Escherichia coli, and Staphylococcus aureus were isolated from 21.9%, 18.7%, and 15.6% of blood cultures. Mortality in patients with bloodstream infection was 46.9% vs. 16.1% in patients without bloodstream infection (p<0.001).Conclusions: Postoperative bloodstream infection is an essential complication following major abdominal surgery with K. pneumoniae, E. coli, and S. aureus being the most common causative agents. Bloodstream infection is associated with a higher risk of postoperative mortality. Further studies are recommended to confirm the findings and improve patient management

Large Bowel Perforation in Patients with Colorectal Cancer: A South African Perspective

Introduction: Large bowel perforation (LBP) occurs in up to 10% of colorectal cancer (CRC) patients and is a potential surgical emergency. Data on LBP in CRC patients from resource-limited countries are required to improve the management of this condition in these settings. Our study aimed to describe LBP amongst CRC patients in KwaZulu-Natal, South Africa. Materials and Methods: This was a descriptive sub-analysis of LBP data from an ongoing CRC registry. This study explores free and contained perforations and describes LBP characteristics, surgical management, histological findings, overall survival, and CRC recurrence. Results: Ninety-four out of 2523 CRC patients had LBP (3.7%). The median age was 53.0 years (interquartile range: 43.0–64.0). The male-to-female ratio was 1.4:1. Thirty-three patients (35.1%) had a coexisting bowel obstruction. Tumor site perforations occurred in 87 patients (92.6%) and were mostly in the sigmoid colon (36.2%). Perforations were contained in 77 patients (81.9%). Eighty-nine patients (94.7%) underwent resection (elective resection: 76/89 patients, 85.4%). The post-operative inpatient mortality rate was 2.2%. Most patients had Stage III CRC (46 patients, 48.9%) and moderately differentiated tumors (77 patients, 81.9%). Overall survival at 12 months following CRC diagnosis was 55.4%. The early recurrence rate for CRC disease was 5.4%. Conclusion: Tumor site perforations predominated, and most were contained. Patients were younger when compared with the international literature. We reaffirm that diastatic-free and contained perforations are two distinct clinical entities

Molecular Biogeography: Towards an Integrated Framework for Conserving Pan-African Biodiversity

BACKGROUND: Biogeographic models partition ecologically similar species assemblages into discrete ecoregions. However, the history, relationship and interactions between these regions and their assemblages have rarely been explored. METHODOLOGY/PRINCIPAL FINDINGS: Here we develop a taxon-based approach that explicitly utilises molecular information to compare ecoregion history and status, which we exemplify using a continentally distributed mammalian species: the African bushbuck (Tragelaphus scriptus). We reveal unprecedented levels of genetic diversity and structure in this species and show that ecoregion biogeographic history better explains the distribution of molecular variation than phenotypic similarity or geography. We extend these data to explore ecoregion connectivity, identify core habitats and infer ecological affinities from them. CONCLUSIONS/SIGNIFICANCE: This analysis defines 28 key biogeographic regions for sub-Saharan Africa, and provides a valuable framework for the incorporation of genetic and biogeographic information into a more widely applicable model for the conservation of continental biodiversity

Population structuring in Southern Africa zebras

Bibliography: leaves 157-172

The association between preoperative clinical risk factors and in-hospital strokes and death following carotid endarterectomy in South African patients

Background: Current surgical management of carotid artery disease includes carotid endarterectomy (CEA). In-hospital strokes and death following CEA might be associated with preinduction blood pressure (BP) measurements and other clinical risk factors.Method: The aim of our study was to determine whether or not there is an association between preinduction BP, other clinical risk factors, and in-hospital strokes or death following CEA in a cohort of South African patients. We collected data from medical records relating to clinical risk factors in patients, preinduction BP measurements, and in-hospital strokes and death, following CEA. The association between preinduction BP and clinical risk factors, and postoperative neurological morbidity and mortality, was analysed using univariate statistical methods.Results: Our cohort consisted of 76 patients who underwent CEA. Eight of these patients had in-hospital strokes or death following their surgery. An association between a history of hypertension or other clinical risk factors and an in-hospital stroke and death was not identified in these 76 CEA patients following univariate analysis. However, patients with preinduction BP within the lowest or highest quartile for preinduction BP were at a significantly increased risk of an in-hospital stroke and death following their surgery (p-value = 0.003). A subanalysis of patients who were hypertensive also showed this univariate association (p-value = 0.003).Conclusion: It is possible that extremes of preinduction BP might be associated with in-hospital strokes and death in CEA patients following their surgery, although further research is required to confirm this.Keywords: carotid endarterectomy, carotid stenosis, mortality, strokes, surger

INCIDENCE AND FACTORS ASSOCIATED WITH BLOOD TRANSFUSION IN A SAMPLE OF SOUTH AFRICAN PATIENTS UNDERGOING PRIMARY HIP ARTHROPLASTY: A RETROSPECTIVE DATABASE STUDY.

Background: Despite improvements in arthroplasty and blood conservation practices, surgical blood loss remains a challenge. The blood products used to address perioperative bleeding are scarce and should be effectively managed. Our study objectives were to 1) establish the cumulative incidence of peri-operative transfusion in a sample of South African primary hip arthroplasty patients and 2) identify factors associated with transfusions. Methods: This study was a sub-analysis of an existing database of 174 adult primary hip arthroplasty patients who underwent surgery at Inkosi Albert Luthuli Central Hospital between 01 January 2015 and 30 June 2016. A retrospective chart review process was used to collect the data analyzed using descriptive statistical methods, Mann-Whitney testing, and Chi-squared testing. The study outcome was perioperative blood transfusion, defined as receipt of at least 1 unit of packed red cells anytime between the surgical incision and discharge from the hospital. Results: The incidence of perioperative blood transfusion was 13.8% (95%CI: 9.0-19.8%). The median number of blood units received was 2.0 (Range: 1.0-4.0) units.  The proportion of patients who received blood transfusions was higher in those who had longer surgery (41.7% vs. 14.7 % p=0.002) or received postoperative thromboprophylaxis (91.7% vs. 68% p=0.017). Conclusion: The incidence of perioperative blood transfusion observed in our study of patients undergoing primary hip arthroplasty was within range of that reported in international studies. Longer surgery and postoperative thromboprophylaxis are potentially important predictors of perioperative transfusion following hip arthroplasty in our setting. We recommend further research to confirm our findings

Fibroadenoma of the breast in a South African population -a pilot study of the diagnostic accuracy of fine needle aspirate cytology and breast ultrasonography

Background: The triple assessment of clinical breast exam (CBE), fine needle aspirate cytology (FNAC) and breast ultrasonography (US) is used in many settings for the diagnosis of fibroadenoma (FA). The diagnostic accuracy of FNAC and US for FA in South African (SA) women with palpable breast masses (PBM) is unknown.Objective: To report the diagnostic accuracy of FNAC/US for FA in SA women with PBM. Methods: We conducted a retrospective pilot diagnostic study of 91 women who presented with PBM to a SA regional academic hospital. Data for CBE, US, unguided FNAC, and open biopsies was collected from study participant medical records and analyzed using diagnostic accuracy tables. Results: A total of 57/91 (62.6%) study participants had uninterpretable FNAC results. No study participants had uninterpretable US results. The overall diagnostic accuracy of FNAC for FA was 36.3% (95% Confidence Interval - CI: 27.1-46.5%). The overall diagnostic accuracy of US for FA was 83.5% (95% CI: 74.6-89.8%). Conclusion: The yield of interpretable test results for FNAC was poor in our study. The diagnostic accuracy of US for FA appears to be superior to that of FNAC. Omission of FNAC from the triple assessment in our setting should be considered. .Keywords: Fibroadenoma, diagnosis, breast ultrasonography, fine needle aspirate cytology

Admissions for pulmonary embolism at a tertiary South African hospital

Background: Published reports of pulmonary embolism (PE) from South African (SA) settings are rare. We sought to address this paucity in the literature.Methods: This case series (CS) involved 61 adult patients admitted to a tertiary SA hospital over a five-year period with a primary diagnosis of PE. Data related to patient demographics, PE presentation, risk factors, treatment, and inpatient mortality were collected, and then analysed using descriptive statistics.Results: Most of our CS were aged &lt;65 years (86.9%), female (67.2%), and of black African ethnicity (73.8%). Dyspnoea and chest pain were the most common symptoms (86.9% and 41.0%, respectively). Common clinical signs included tachypnea (47.5%) and tachycardia (42.6%). Common established risk factors were cardiac failure (49.2%) and obesity (27.9%). Massive, submassive, and minor PE, was diagnosed in 8.2%, 62.3%, and 8.2% of patients, respectively. Most patients received anticoagulation therapy (95.1%), with thrombolysis and embolectomy performed only in smaller proportions (24.6% and 11.5%) of patients. Inpatient mortality was 23.0%. Most patients who died had submassive PE.Conclusion: We provide a report of PE cases from a SA setting. Our findings have important implications related to the management of PE in SA

Ultrasound features of Cytotoxic venomous snake bite and implications for surgical management – A systematic review

Background: Snake bite is an important, yet often neglected health problem in many regions of the world. Cytotoxic venomous snake bites (VSB) have the potential to induce significant tissue injury, resulting in compartment syndrome. This research sought to provide a summary of ultrasound features of VSB, with the aim of improving management in afflicted patients. Methods: A systematic review of 2 electronic medical literature databases was performed. Pre-defined eligibility criteria were used to identify relevant published case series (sample size 10 or more) which reported on ultrasound features of VSB. Screening of the reference lists of eligible manuscripts was also performed. Results: Two case series reporting on ultrasound studies of cytotoxic VSB were included in this review. One study was from the United States and the other study was from South Africa. Children under 12 years comprised a large proportion of VSB victims (92.3% in the American study and 33.3% in the South African study). The majority of VSB victims were male (76.9% in the American study and 57.1% in the South African study). Snake species involved were Crotaline/rattlesnakes (American study) and adders or cobras (South African study). In both studies, VSBs were located on the upper limbs. The most common ultrasound finding in both studies was subcutaneous oedema. The deep muscular appears to be minimally affected in cytotoxic VSB. Conclusion:  Ultrasound features of cytotoxic envenomation were consistent between studies. Ultrasonography provides useful information which can be used to supplement the information obtained during the external clinical examination of cytotoxic VSB and can be used to identify patients with a risk of compartment syndrome who might require surgery. Recommendation: Ultrasonography should be performed as one of the primary investigations when patients present with VSB