Addington Hospital

Hyperglycaemia is common in hospitalised patients. Acute illness or injury may result in glucose intolerance and insulin resistance leading to hyperglycaemia. There is a lack of data on the incidence and impact of early hyperglycaemia in critically ill patients in South Africa (SA). To determine the incidence of hyperglycaemia within 48 hours of admission to a multidisciplinary SA ICU and to determine if there was any association between blood glucose level and ICU outcomes. This was a retrospective observational study of patients admitted to ICU at King Edward VIII Hospital from November 2021 to August 2022. All blood glucose values were recorded within the first 48 hours of admission. The primary outcome was ICU mortality, with secondary outcomes including ICU length of stay (LOS), ventilator days (LOV), renal replacement therapy (RRT) and wound infection. A total of 177 patients were included in the study. Hyperglycaemia with a blood glucose of more than 10 mmol/L within 48 hours of ICU admission occurred more frequently in those who died in ICU (79.5%) v. ICU survivors (60.1%) (p=0.026). Hyperglycaemia was associated with an increase in ICU LOS, LOV and wound infection. No statistically significant relationship was found between hyperglycaemia and RRT. Hypoglycaemia within 48 hours of ICU admission was also associated with an increased ICU mortality. Extremes of blood glucose were associated with increased ICU mortality. We recommend a moderate glycaemic control target of 6 - 10 mmol/L in resource-limited settings. The study provides insight into associations with blood glucose level in a multidisciplinary critical care population in South Africa. Hyperglycaemia is common in critically ill patients in South Africa and is associated with severity of illness. Hypergylcaemia is associated with increased ICU mortality, ICU length of stay, length of ventilation and wound sepsis. Hypoglycaemia was also associated with increased ICU mortality. Based on the findings of this study, moderate glycaemic control, with avoidance of hypoglycaemia remains a reasonable strategy for critically ill patients in South Africa.

Aneurysmal subarachnoid hemorrhage (aSAH) is a severe stroke subtype with high morbidity and mortality, particularly in low- and middle-income countries. Endovascular treatment is underused in Africa due to resource constraints. This study evaluates clinical characteristics, radiological findings, treatment outcomes, and long-term follow-up of aSAH patients treated endovascularly at a South African quaternary hospital. A retrospective analysis of 445 aSAH patients treated endovascularly at the Inkosi Albert Luthuli Central Hospital (2012-2021) was conducted. Inclusion criteria were spontaneous aSAH confirmed by computed tomography/lumbar puncture and saccular aneurysm identified via computed tomography angiogram. Data on demographics, clinical presentation, World Federation of Neurological Societies and Modified Fisher grades, aneurysm characteristics, treatments, complications, and outcomes (modified Rankin Scale [mRS] and Raymond-Roy Occlusion Classification [RROC]) were analyzed. Logistic regression identified predictors of mortality, hydrocephalus, and vasospasm. Median age was 47 years (67% female, 75% Black African). Most (81%) had World Federation of Neurological Societies grades 1-3; 90% had anterior circulation aneurysms (median size 5.7 mm). Of 217 patients with known human immunodeficiency virus status, 48% were living with human immunodeficiency virus. Coil embolization (59%) and balloon-assisted coiling at 21% were common. At discharge, 73% achieved mRS 0-3 and 84% RROC 1. Long-term, 82% had mRS 0-3 and 90% RROC 1. Mortality was 8.3%. Complications included hydrocephalus (36%), vasospasm (22%), and meningitis (10%). Predictors of mortality included hydrocephalus and intraoperative complications; absence of intraventricular hemorrhage was protective. This study, the largest in an African cohort, confirms safety, efficacy, and durability of endovascular management of aSAH in resource-constrained settings, supporting its expansion in Africa.

ABSTRACTIntroductionThis clinical practice guideline from the Explosive Weapons Trauma Care Collective (EXTRACCT) group provides a review of current best practice for the management of urogenital injury after blast injury due to unexploded ordinance and improvized explosive devices. In particular, landmine‐related blasts are a continuing problem and this plagues lower‐income and middle‐income regions disproportionately.MethodsAn expert literature review of current practice is presented.ResultsThe guideline provides assessment, resuscitation, and definitive management based on injury severity for the internal urological organs and for the external genitalia. Imaging and surgical techniques are described for the surgeon relatively unfamiliar with the management of urogenital trauma.ConclusionUrogenital trauma is seldom fatal but combined with other injuries may cause severe morbidity and mortality. Best practice management is required in resource‐constrained settings.

The objective of our participatory case study of community health worker (CHW) integration was to describe the role of CHWs in two local health departments (LHDs). Study partners co-developed an interview guide based on an existing framework. Fourteen staff participated in interviews. CHWs build community trust for LHDs, provide LHD core services, identify community concerns and priorities, and address social determinants of health. Integration barriers include hiring protocols, lack of understanding of the CHW role, inadequate compensation, and sustainable funding. The study identified key factors for an integration process that promotes the effectiveness, wellbeing, and sustainability of the workforce.

BackgroundPollen monitoring has been discontinuously undertaken in South Africa, a country with high biodiversity, a seasonal rainfall gradient, and nine biomes from arid to subtropical. The South African Pollen Monitoring Network was set up in 2019 to conduct the first long‐term national aerospora monitoring across multiple biomes, providing weekly reports to allergy sufferers and healthcare providers.MethodsDaily airborne pollen concentrations were measured from August 2019 to August 2021 in seven cities across South Africa. Updated pollen calendars were created for the major pollen types (>3%), the average Annual Pollen Index over 12 months was calculated, and the results were compared to available historical data.ResultsThe main pollen types were from exotic vegetation. The most abundant taxa were Poaceae, Cupressaceae, Moraceae and Buddleja. The pollen season start, peak and end varied widely according to the biome and suite of pollen taxa. The main tree season started in the last week of August, peaked in September and ended in early December. Grass seasons followed rainfall patterns: September–January and January–April for summer and winter rainfall areas, respectively. Major urban centres, for example, Johannesburg and Pretoria in the same biome with similar rainfall, showed substantive differences in pollen taxa and abundance. Some major differences in pollen spectra were detected compared with historical data. However, we are cognisant that we are describing only 2 years of data that may be skewed by short‐term weather patterns.ConclusionsDifferences in pollen spectra and concentrations were noted across biomes and between geographically close urban centres. Comparison with historical data suggests pollen spectra and seasons may be changing due to anthropogenic climate change and landscaping. These data stress the importance of regional and continuous pollen monitoring for informed care of pollinosis.

Skin and soft tissue infections (SSTIs) are common presentations in the emergency department. However, this is less common after contact with contaminated saltwater or freshwater. This review presents the diagnosis and management of water-related soft tissue sepsis in this vulnerable and difficult-to-treat subgroup of necrotizing soft tissue sepsis. A summative literature overview is presented regarding bacterial and fungal SSTI after contact with contaminated water, with practical diagnostic and management aspects. The literature indicates that these wounds and infections remain difficult to treat. An approach using appropriate diagnostic tools with both medical and surgical management strategies is provided. SSTIs due to water contamination of wounds involve unusual organisms with unusual resistance patterns, and require a nuanced and directed diagnostic approach with an adaptation of the usual antibiotic or antifungal selection to achieve a successful cure, along with aggressive debridement and wound care.

In this paper, we report on the utility of merging Participatory Action Research (PAR) with System Dynamics (SD) as a locus for stimulating transformation in a large-scale hospital academic setting. This is significant because it provides points of cross fertilisation whereby the two frameworks act synergistically with each other to create high leverage interventions for change, which may otherwise not have been apparent. Coupled within a SD auspice, there was a synergistic blend of uncovering an overall ecological view of the public health care system. The PAR methodology is located within the epistemological realm of critical theory and constructivism, whereby facilitating positive social change is viewed to be the key outcome of such research. This outcome has been confirmed by the researchers prioritizing the necessity for a departure from the traditional expert-led health system, evolving into one which supports the empowerment of patients and health-care workers as a necessity. However, the implementation of the improvements has not been as straightforward as initially projected. Some of the challenges included the slow assimilation of proposed solutions for planned care and paucity of key engagement from upstream stakeholders. The value of this paper can potentially serve to encourage key stakeholders in public health care systems to consider viewing health care complexity through the lens of PAR and SD.

Merkel cell carcinoma is a highly aggressive neuroendocrine carcinoma that most commonly arises in sun-exposed skin. Established risk factors include advanced age, fair skin, chronic ultraviolet light exposure and immunosuppression. Merkel cell polyomavirus infection is implicated in a subset of cases. Primary extracutaneous Merkel cell carcinoma is exceedingly rare. We report a case of Merkel cell carcinoma of the anorectum in a 44-year-old woman of Indian descent with no apparent risk factors. She presented with rectal bleeding and worsening perineal discomfort. A polypoid tumor was identified in the anal canal. No cutaneous lesions were detected. Histopathology revealed a small round blue cell tumor with neuroendocrine features. Immunohistochemistry for CK20, synaptophysin, CD56, neurofilament and SATB2 were positive while CK7, CDX2 and TTF1 were negative. Polymerase chain reaction and immunohistochemistry were negative for Merkel cell polyomavirus. Merkel cell carcinoma should be considered in the differential diagnosis of a high grade neuroendocrine carcinoma at an unusual site such as the anorectum in this case. Correct diagnosis of Merkel cell carcinoma at an extracutaneous site is crucial because it should prompt careful evaluation for a skin primary and it may make the patient eligible for immune checkpoint inhibitor therapy.

Background: The prevalence of diabetes mellitus (DM) in South Africa (SA) is 12.80% and is rising, while that of HIV infection remains the highest globally (13%). Literature varies on the associations between glycaemic control and age in patients living with DM (PLWD). Through effective anti-retroviral treatment (ART), HIV-infected patients can now live longer and develop co-morbidities as experienced by HIV-uninfected patients. Identification of challenges faced in diabetes control within the various age groups would help in developing strategies that can be implemented in order to provide effective diabetes care to patients as they age.Objectives: This study aimed to determine an association between age and diabetes control in an HIV endemic area.Methods: Data from standardised clinic sheets were used from the DM clinic at Edendale Hospital, Pietermaritzburg, South Africa, from January 1, 2019 to December 31, 2019. Statistical analysis was done.Results: This study had 957 PLWD with 146 PLWD who were HIV-infected (PLWDH). Older age was associated with improved mean glycated haemoglobin (HbA1c) levels after adjusting for glomerular filtration rate (GFR) (r = −0.141, p < 0.001; before adjustment: r = −0.108; p = 0.001). HIV-infected patients had lower mean HbA1c levels than their HIV-uninfected counterparts while age was positively associated with patients’ BMI (r = 0.246, p < 0.001). PLWDH with a mean HbA1c > 7% were significantly younger than those with HbA1c ≤ 7% (47.38 years vs. 52.77 years, p = 0.013). GFR declined with age: PLWD with GFR < 60 ml/minute were significantly older than those with GFR ≥ 60 ml/minute (62.72 years vs. 48.30 years, p < 0.001), this remaining significant after factoring in for HIV infection and hypertension.Conclusion: Younger PLWD have poorer glycaemic control and are likely to develop diabetes-related complications later in life. Notably, younger PLWDH also had poorer glycaemic control, which places them at increased cardio-metabolic risk from sequelae of both the HIV infection and DM. This study highlights that more emphasis needs to be placed on diabetes education and management in the younger age categories of both PLWD and PLWDH.

IntroductionIn the daily practice of pacemaker insertion, the occurrence of atrial and ventricular lead switch at the pacemaker box header is a rare and unintentional phenomenon, with less than five cases reported in the literature. The lead switch may have dire consequences, depending on the indication for the pacemaker. One of these consequences is pacemaker syndrome, in which the normal sequence of atrial and ventricular activation is impaired, leading to sub-optimal ventricular filling and cardiac output. It is important for the attending physician to recognise any worsening of symptoms in a patient who has recently had a permanent pacemaker inserted. In the case of a dual-chamber pacemaker, switching of the atrial and ventricular leads at the pacemaker box header should be strongly suspected. We present an unusual case of pacemaker syndrome and right ventricular-only pacinginduced left ventricular systolic dysfunction in a patient with a dual-chamber pacemaker.