Queen Nandi Regional Hospital

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.

Global surgery broadly refers to a rapidly expanding multidisciplinary field concerned with providing better and equitable surgical care across international health systems. Global surgery initiatives primarily focus on capacity building, advocacy, education, research, and policy development in low- and middle-income countries (LMICs). The inadequate surgical, anesthetic, and obstetric care currently contributes to 18 million preventable deaths each year. Hence, there is a growing interest in the rapid growth of artificial intelligence (AI) that provides a distinctive opportunity to enhance surgical services in LMICs. AI modalities have been used for personalizing surgical education, automating administrative tasks, and developing realistic and cost-effective simulation-training programs with provisions for people with special needs. Furthermore, AI may assist with providing insights for governance, infrastructure development, and monitoring/predicting stock take or logistics failure that can help in strengthening global surgery pillars. Numerous AI-assisted telemedicine-based platforms have allowed healthcare professionals to virtually assist in complex surgeries that may help to improve surgical accessibility across LMICs. Challenges in implementing AI technology include the misrepresentation of minority populations in the datasets leading to discriminatory bias. Human hesitancy, employment uncertainty, automation bias, and role of confounding factors need to be further studied for equitable utilization of AI. With a focused and evidence-based approach, AI could help several LMICs overcome bureaucratic inefficiency and develop more efficient surgical systems.

HIV and hepatitis B virus (HBV) prevalence are both high in KwaZulu-Natal, South Africa. HIV coinfection negatively affects HBV prognosis and can increase the likelihood of HBV mother-to-child transmission (MTCT). In an early HIV infant treatment intervention cohort of HIV-transmitting mother-child pairs in KwaZulu-Natal, we characterized maternal HBV prevalence and screened infants at risk. Infants were treated for HIV MTCT at birth, and combination regimens incidentally active against HBV were initiated within 21 days. Maternal samples (N = 175) were screened at birth for HBV infection (HBV surface antigen [HBsAg]), exposure to HBV (HBV anti-core IgG), and vaccination responses (HBV anti-S positive without other HBV markers). Infants of mothers who were HBV positive were screened for HBsAg at 1 and 12 months. Evidence of HBV infection was present in 8.6% (n = 15) of maternal samples. Biomarkers for HBV exposure were present in 31.4% (n = 55). Evidence of HBV vaccination was uncommon in mothers (8.0%; n = 14). Despite prescription of antiretroviral therapy (ART) active against HBV, HBV DNA was detectable in 46.7% (7/15) of mothers who were HBsAg positive. Three mothers had HBV viral loads >5.3 log10 IU/mL, making them high risk for HBV MTCT. Screening of available infant samples at 1 month (n = 14) revealed no cases of HBV MTCT. At 12 months, we identified 1 HBV infection (1/13), and serologic evidence of vaccination was present in 53.8% (7/13) of infants. This vulnerable cohort of HIV-transmitting mothers had a high prevalence of undiagnosed HBV. Early infant ART may have reduced the risk of MTCT in high-risk cases. Current HBV guidelines recommend ART prophylaxis, but these data underline the pressing need to increase availability of birth dose vaccines.

Introduction: Potassium Permanganate (KMnO4) is an uncommon cause of caustic ingestion in teenagers and adults; only case reports are found in the recent literature. At Ngwelezana Hospital in South Africa, KMnO4 ingestion is not an uncommon indication for admission. KMnO4 is readily available as used in most households and recommended for medicinal purposes by traditional health practitioners. Aim: To ascertain the reasons for KMnO4 ingestion, the extent and severity of injury as determined by upper gastro-intestinal studies, and patient outcomes in comparison with the available global literature. Methods: We performed a retrospective study of 26 teenage and adult patients, admitted to our adult wards following KMnO4 ingestion. Data collected on patient demographics, reason for KMnO4 ingestion, and quantity ingested. Oral inspection and upper gastro-intestinal study findings recorded with grading (Zargar) of corrosive injury to oesophagus and stomach. Patients’ outcome and duration of hospital stay documented. Results: There were 73% females and 27% males, with an average age of 23 years. Reasons for ingestion included parasuicide (84%), accidental ingestion (8%), and for relief of abdominal pain (8%). The vast majority (96%) swallowed KMnO4 in solution rather than in solid form. The volume and concentration of KMnO4 taken was difficult to quantify. Oral discoloration, oedema, and ulceration were found in 58%. Gastro-intestinal endoscopy was performed in 92%; abnormalities were demonstrated in 68% (oesophageal injury 14%, oesophageal and gastric injuries 14%, gastric injury alone 41%). Oesophageal injuries: n = 6; Zargar grade 1—83%, Zargar grade 2A—17%. Gastric injuries: n = 12; Zargar grade 1—42%, Zargar grade 2A—33%, Zargar grade 2B—25%. Average hospital stay was 2.9 days (range 2–8 days). There were no mortalities and no complications at 6 weeks. Conclusion: KMnO4 ingestion by teenagers and adults is not uncommon in our setting, mostly related to suicide attempts and most often taken in liquid form. KMnO4 was possibly of a low concentration as no systemic complications were noted and there were milder gastric and oesophageal injuries as compared to case reports from elsewhere of mucosal necrosis following ingestion of KMnO4.

There is no conclusive evidence to guide surgical management in the presence of multiple colonic injuries as opposed to a single colonic injury, and whether multiple colonic suture lines are associated with worse outcomes than single suture lines. We reviewed the outcomes of penetrating colonic trauma in relation to whether patients had single versus multiple colonic suture lines (primary repair or anastomosis) following laparotomy. A retrospective study was conducted at a major trauma centre in South Africa from 2012-2020 for all patients over 18years who had sustained penetrating colon injury. 541 cases were included: 409 with single suture line and 54 with multiple suture lines. There were no differences between groups in terms of mechanism of injury (gunshot vs stab; p = 0.328), Injury Severity Score (p = 0.071), or Penetrating Abdominal Trauma Index (p = 0.396). Admission lactate was worse for multiple suture line patients (p = 0.049), but no other blood gas parameters were different, and there was no higher incidence of damage control surgery (p = 0.558) or ICU admission (p = 0.156) for this group. There was a higher rate of diversion in the multiple suture line group (p < 0.001). Univariable logistic regression did not show an increased risk of gastro-intestinal complications, suture line leak rate, or mortality for multiple suture lines compared to single. It appears that there is no appreciable difference in outcome between patients with a single colonic suture line compared to patients with more than one suture line following trauma laparotomy. In light of this, each injury should be treated on its own merit, in the context of the patient's overall physiological condition, without undue fear of leaving the patient with more than one colonic suture line. However, judicious use of diversion remains advisable.

Female children and adults typically generate more efficacious immune responses to vaccines and infections than age-matched males, but also suffer greater immunopathology and autoimmune disease. We here describe, in a cohort of > 170 in utero HIV-infected infants from KwaZulu-Natal, South Africa, fetal immune sex differences resulting in a 1.5–2-fold increased female susceptibility to intrauterine HIV infection. Viruses transmitted to females have lower replicative capacity (p = 0.0005) and are more type I interferon-resistant (p = 0.007) than those transmitted to males. Cord blood cells from females of HIV-uninfected sex-discordant twins are more activated (p = 0.01) and more susceptible to HIV infection in vitro (p = 0.03). Sex differences in outcome include superior maintenance of aviraemia among males (p = 0.007) that is not explained by differential antiretroviral therapy adherence. These data demonstrate sex-specific innate immune selection of HIV associated with increased female susceptibility to in utero infection and enhanced functional cure potential among infected males.

An elderly female with multiple comorbidities was involved in a pedestrian vehicle accident and sustained blunt chest trauma, arriving at a resource-poor hospital in rural South Africa. She had multiple bilateral rib fractures with a unilateral flail segment that caused her to develop respiratory failure. She was intubated and sent to the intensive care unit (ICU) for ventilation. She developed hospital and ventilator acquired pneumonia. She subsequently had hypoxic arrests on two separate occasions and two failed extubations. Despite inadequate access to provisions, this patient was taken to theatre for rib fracture fixation as an attempt to improve her lung function and get her off the ventilator. She was extubated two days after the procedure and discharged from ICU 4 days thereafter. On her follow-up, she reported that she had returned to normal daily living and tasks.

A 36-year-old man who had been bitten on his left index finger by a snake identified as a boomslang (Dispholidus typus) presented with haematemesis and hypovolaemic shock. Coagolopathy was presumed, and the platelet count was 2 × 10⁹/L. Findings on upper endoscopy included oesophageal petechial haemorrhages, severe haemorrhagic gastritis and an antral ulcer. The patient was successfully managed using freeze-dried plasma, packed red blood cells, isotonic crystalloids and polyvalent antivenom.

AIM: To assess the functional and cosmetic outcome of displaced supracondylar fractures in children treated by closed reduction and plaster backslab. METHOD: We retrospectively reviewed 53 patients with Gartland type II and type III fractures that were treated by closed reduction (Blount's technique) and immobilisation in a collar and cuff and above-elbow plaster backslab between December 2011 and May 2012. The mean age was 6.6 years. The mean follow-up time was 12 weeks (range, 6-20). All open injuries and undisplaced fractures were excluded from the study. Flynn's criteria were used to assess functional and cosmetic outcome. RESULTS: The median loss of motion was 10 degrees and the median change in carrying angle was 4 degrees. Fifty-one patients (96.2%) had satisfactory results, with 87% graded as excellent or good according to the Flynn's criteria for grading of the carrying angle. A range of motion of 100 degrees was achieved in 92.5% of patients at 12 weeks. CONCLUSION: This method appears to produce less satisfactory results in comparison to closed reduction and fixation with Kirschner wires (K-wires), but it does provide satisfactory results according to Flynn criteria with regard to cosmetic deformity and range of motion at short-term follow-up. It is an acceptable and safe option with which to treat displaced supracondylar fractures.