Adult corrosive ingestions in the Pietermaritzburg Metropolitan Surgical Service

BACKGROUND

There is a paucity of data around corrosive ingestion in South Africa over the last three decades. As such, we set out to review our experience with adult corrosive ingestion in our tertiary gastrointestinal surgical service.

METHODS

A retrospective, quantitative review was performed. The parameters analysed were demographics, substance ingestion, ingestion time to first presentation to a healthcare facility, clinical presentation, severity of injury based on endoscopic classification, computed tomography (CT) findings, management and outcomes. Patients presenting within 72 hours with alarm symptoms underwent flexible upper endoscopy and injury severity grading. In patients presenting after 72 hours, a water-soluble contrast study was obtained prior to upper endoscopy. Patients with signs of sepsis, surgical emphysema or physiological instability were referred for urgent CT to exclude oesophageal perforation and mediastinitis.

RESULTS

Between January 2012 and January 2019, a total of 64 patients presented with a history of corrosive ingestion - 40 (31%) were males and 24 (19%) females. The average time from ingestion to presentation was 72 hours. In 78% of patients, the agents were intentionally ingested, whilst 22% claimed accidental ingestion. A quarter of the patients (21%) presented to the unit clinically unstable, requiring emergent cardiorespiratory support. Eight (12%) patients required urgent surgical intervention due to the extent of injury. Nine (14%) patients demised during the acute admission. Of this group, three patients had undergone surgical intervention, and six were managed conservatively. Eighty-five per cent of all patients survived their initial admission.

CONCLUSION

This paper has highlighted the problem of corrosive ingestion in our setting. It remains a complicated problem to manage associated with significant morbidity and mortality rates. The current trend in the assessment of these patients is increased use of CT scan to assess the extent of transmural necrosis. Our algorithms should change to reflect this contemporary approach.

Intravaginal Drug Delivery Systems to Treat the Genitourinary Syndrome of Menopause: Towards the Design of Safe and Efficacious Estrogen-loaded Prototypes

Estrogens locally delivered to the vagina by tablets, capsules, rings, pessaries, and creams are the most common and highly recommended platforms to treat the genitourinary syndrome of menopause (GSM). Estradiol, an essential estrogen, is routinely administered alone, or in combination with progestins, to effectively alleviate the symptoms associated with moderate to severe menopause when non-pharmacological interventions are not indicated. Since the risk and side effects of estradiol use depends on the administered amount and duration of use, the lowest effective dose of estradiol is recommended when long-term treatment is required. Although there is a wealth of data and literature comparing vaginally administered estrogen-containing products, there is a lack of information revealing the effect of the delivery system used and formulation constituent's attributes on the efficacy, safety, and patient acceptability of these dosage forms. This review therefore aims to classify and compare various designs of commercially available and non-commercial vaginal 17β-estradiol formulations and analyze their performance in terms of systemic absorption, efficacy, safety, and patient satisfaction and acceptance. The vaginal estrogenic platforms included in this review are the currently marketed and investigational 17β-estradiol tablets, softgel capsules, creams, and rings for the treatment of GSM, based on their different design specifications, estradiol loads, and materials used in their preparation. Additionally, the mechanisms of the effects of estradiol on GSM have been discussed, as well as their potential impact on treatment efficacy and patient compliance.

Can Nanomedicinal Approaches Provide an Edge to the Efficacy of Tyrosine Kinase Inhibitors?

Tyrosine kinase inhibitors (TKIs) are effective drug molecules for the treatment of various cancers. Nanomedicinal interventions and approaches may not only provide carrying capacities for TKIs but also potentially target tumor-specific environments and even cellular compartments. Nano-inspired drug delivery systems may hence enhance the efficacy of the drugs through enhanced tumour-availability resulting in greater efficacy and decreased side effects. A variety of nanosystems have been developed for the delivery of TKIs for the enhanced treatment of cancers, each with their own preparation methods and physicochemical properties. This review will therefore discuss the applicability of nano-interventions towards combination therapies, dose reduction, and greater potential treatment outcomes. The individual nanosystems have been highlighted with emphasis on the developed systems and their efficacy against various cancer cell lines and models.

A nano-enclatherated-gel-composite for the treatment of alcohol abuse and addiction

Alcoholism is a highly prevalent disease, with successful rehabilitation being poor due to irrepressible cravings that result in relapse. This study developed and analysed an intramuscular injection capable of providing a sustained release of disulfiram over one month. Statistically optimized disulfiram-loaded nanomicelles were prepared and incorporated into a thermosensitive gel resulting in a nano-enclatherated-gel-composite (NEGC). The nanomicelle system demonstrated a drug loading capacity and entrapment efficiency of 33.66% and 50.98%, respectively, with a sustained release of 65% of the administered disulfiram achieved after 28 days through the thermosensitive hydrogel. Additionally, ex vivo release studies have been undertaken using rat muscle tissue with in vivo biodistribution, plasma levels, histopathology and myotoxicity following oral disulfiram administration and intramuscular NEGC administration also assessed in Sprague-Dawley rats. Results obtained in this study have indicated that the designed delivery system has the potential to successfully release disulfiram in a sustained manner for the treatment of alcohol abuse.

Avoiding the diagnostic pitfalls of a pancreatic cystic lesion

Cystic pancreatic lesions present a diagnostic challenge. Accurate characterisation of an isolated cystic pancreatic lesion is therefore vital as this dictates the management strategy which may vary from radical resection to simple observation. This report describes how a detailed preoperative assessment led to the correct diagnosis of an isolated pancreatic lesion and appropriate safe and curative surgical management.

Targeted Delivery of Amantadine-loaded Methacrylate Nanosphere-ligands for the Potential Treatment of Amyotrophic Lateral Sclerosis

PURPOSE

This study aimed to develop and analyse poly(DL-lactic acid)-methacrylic acid nanospheres bound to the chelating ligand diethylenetriaminepentaacetic acid (DTPA)  for the targeted delivery of amantadine in Amyotrophic Lateral Sclerosis (ALS).

METHODS

The nanospheres were prepared by a double emulsion solvent evaporation technique statistically optimized employing a 3-Factor Box-Behnken experimental design. Analysis of the particle size, zeta potential, polydispersity (Pdl), morphology, drug entrapment and drug release kinetics were carried out.

RESULTS

The prepared nanospheres were determined to have particle sizes ranging from 68.31 to 113.6 nm (Pdl ≤ 0.5). An initial burst release (50% of amantadine released in 24 hr) was also obtained, followed by a prolonged release phase of amantadine over 72 hr. Successful conjugation of the chelating ligand onto the surface of the optimised nanospheres was thereafter achieved and confirmed by TEM. The synthesized modified nanospheres were spherical in shape, 105.6 nm in size, with a PdI of 0.24 and zeta potential of -28.0 mV. Conjugation efficiency was determined to be 74%. In vitro and ex vivo cell study results confirmed the intracellular uptake of the modified nanospheres by the NSC-34 cell line and the non-cytotoxicity of the synthesized nanospheres.

CONCLUSIONS

Biocompatible amantadine-loaded nanospheres were successfully designed, characterized and optimized employing the randomized Box-Behnken statistical design. Delivery of amantadine over 72 hrs was achieved, with the nanospheres being of a size capable of internalization by the NSC- 34 cells. This article is open to POST-PUBLICATION REVIEW. Registered readers (see "For Readers") may comment by clicking on ABSTRACT on the issue's contents page.

Drug Delivery Strategies for Antivirals against Hepatitis B Virus

Chronic hepatitis B virus (HBV) infection poses a significant health challenge due to associated morbidity and mortality from cirrhosis and hepatocellular cancer that eventually results in the breakdown of liver functionality. Nanotechnology has the potential to play a pivotal role in reducing viral load levels and drug-resistant HBV through drug targeting, thus reducing the rate of evolution of the disease. Apart from tissue targeting, intracellular delivery of a wide range of drugs is necessary to exert a therapeutic action in the affected organelles. This review encompasses the strategies and techniques that have been utilized to target the HBV-infected nuclei in liver hepatocytes, with a significant look at the new insights and most recent advances in drug carriers and their role in anti-HBV therapy.

Self-Expanding Metal Stent (SEMS) insertion: Fluoroscopy versus pure endoscopic technique - A cost comparison

Oesophageal cancer is a disease with significant morbidity and mortality, and in South Africa most patients present with advanced disease.1 Self-expanding metal stents (SEMS) are now widely used in the palliation of oesophageal cancer, and in most institutions SEMS are deployed under fluoroscopic guidance. In our institution, we use an exclusive endoscopic deployment technique which is comparable to the traditional fluoroscopic technique in terms of safety and efficacy.2-4 We undertook a study to compare the two techniques with respect to their time- and cost-effectiveness.

Design and evaluation of an oral multiparticulate system for dual delivery of amoxicillin and Lactobacillus acidophilus

AIM

A delayed-release dual delivery system for amoxicillin and the probiotic Lactobacillus acidophilus was developed and evaluated.

MATERIALS & METHODS

Statistical optimization of a cross-linked denatured ovalbumin protective matrix was first synthesized using a Box-Behnken experimental design prior to encapsulation with glyceryl monostereate. The encapsulated ovalbumin matrix was thereafter incorporated with amoxicillin in a gastro-resistant capsule. In vitro characterization and stability analysis of the ovalbumin and encapsulated components were also performed Results: Protection of L. acidophilus probiotic against the bactericidal effects of amoxicillin within the dual formulation was determined.

CONCLUSION

The dual formulation in this study proved effective and provides insight into current microbiome research to identify, classify and use functional healthy bacteria to develop novel probiotic delivery technologies.

It's not inside, it's on top! - An unusual cause of right iliac fossa pain

Rectus sheath haematoma (RSH) is an uncommon cause of acute abdominal pain, but can mimic a variety of acute surgical conditions. Computed tomography (CT) provides the diagnosis and avoids unnecessary procedures.

Practices employed by audiologists in the management of adult patients with multidrug-resistant tuberculosis in South Africa

Introduction: Aminoglycosides used for treating multidrug-resistant (MDR) tuberculosis are ototoxic, leading to a need for audiological monitoring. While audiologists monitor ototoxicity, currently there are no guidelines on monitoring in the South African context. Therefore, the findings of this study might help to motivate the establishment of a more in-depth ototoxicity monitoring policy, which facilitates uniformity among audiologists managing patients with MDR tuberculosis. Therefore, the study aimed to describe the audiological practices employed by audiologists in the management of adult patients with MDR tuberculosis in South Africa.Method: A descriptive survey design was used. A questionnaire was developed and included elements of the American Speech-Language and Hearing Association (1994) guidelines for monitoring ototoxicity. Ninety-three audiologists contributed data to this study. Descriptive statistics were used in the analysis of the data.Results: Sixty-eight percent (%) of the respondents were aware of the international guidelines, 93% provided pre-treatment counselling and 87% conducted a baseline assessment. Nineteen per cent of the respondents conducted high-frequency audiometry, while 74% carried out a monthly evaluation, 72% performed a full audiological assessment after the cessation of the MDR tuberculosis treatment, and 96% conducted post-treatment counselling. Modifications to the international guidelines include not conducting speech and immittance audiometry, as well as testing certain frequencies. The reasons for these modifications include limited specialised equipment, time constraints, large caseloads and understaffed departments.Conclusion: There are no explicit guidelines on ototoxicity monitoring in South Africa. Consequently, audiologists are having to modify the international guidelines. Thus, there is no consistency in managing patients with MDR tuberculosis. This highlights the need for South Africa to develop context-relevant ototoxicity monitoring guidelines to appropriately manage patients with MDR tuberculosis.

A gastro-resistant ovalbumin bi-layered mini-tablet-in-tablet system for the delivery of L actobacillus acidophilus probiotic to simulated human intestinal and colon conditions

Objectives

The viability of probiotic bacteria during formulation processes and delivery is vital to ensure health benefits. This study focuses on the use of gastro-resistant denatured ovalbumin for the targeted delivery of probiotic Lactobacillus acidophilus to simulated human intestinal and colon conditions through a bi-layered mini-tablet-in-tablet system (BMTTS).

Methods

The BMTTS consists of two gastro-resistant ovalbumin mini-tablets containing L. acidophilus suspended in lactose and eudragit S100 for targeted intestinal and colonic delivery respectively. Luminescence has been utilized to ensure probiotic viability during formulation processes in addition to determining all probiotic release profiles. The mechanism of probiotic release from the ovalbumin matrix was ascertained using mathematical modelling and molecular docking studies. Magnetic resonance imaging and differential scanning calorimetry are also included as part of the in-vitro characterization of the ovalbumin system.

Key findings

The BMTTS was effective in the delivery of L. acidophilus to simulated human intestinal and colon conditions. Formulation processes were furthermore determined to maintain probiotic viability. Statistical analysis of the release data noted a significant effect of pH denaturation on the release properties of ovalbumin. Magnetic resonance imaging results have indicated a decrease in ovalbumin matrix size upon exposure to simulated intestinal fluid. Molecular docking studies carried out depicted the interaction and binding positions inherent to the ovalbumin–pancreatic trypsin interaction complex indicating the possible enzymatic degradation of ovalbumin leading to the release of the probiotic from the protein matrix.

Conclusions

The BMTTS has been determined to be effective in the protection and delivery of probiotic L. acidophilus to simulated human intestinal and colonic conditions. Molecular docking analysis has noted that pancreatin exerts a significant effect on probiotic release from the gastro-resistant ovalbumin matrix.

A review of the advancements in probiotic delivery: Conventional vs. non-conventional formulations for intestinal flora supplementation

Probiotic delivery systems are widely used nutraceutical products for the supplementation of natural intestinal flora. These delivery systems vary greatly in effectiveness to exert health benefits for a patient. Probiotic delivery systems can be categorized into conventional, pharmaceutical formulations, and non-conventional, mainly commercial food-based, products. The degree of health benefits provided by these probiotic formulations varies in their ability to deliver viable, functional bacteria in large enough numbers (effectiveness), to provide protection against the harsh effects of the gastric environment and intestinal bile (in vivo protection), and to survive formulation processes (viability). This review discusses the effectiveness of these probiotic delivery systems to deliver viable functional bacteria focusing on the ability to protect the encapsulated probiotics during formulation process as well as against harsh physiological conditions through formulation enhancements using coatings and polymer enhancements. A brief overview on the health benefits of probiotics, current formulation, patient and legal issues facing probiotic delivery, and possible recommendations for the enhanced delivery of probiotic bacteria are also provided. Newer advanced in vitro analyses that can accurately determine the effectiveness of a probiotic formulation are also discussed with an ideal probiotic delivery system hypothesized through a combination of the two probiotic delivery systems described.

Current management of large bowel injuries and factors influencing outcome

BACKGROUND

Colonic and intra-peritoneal rectal injuries may be managed by primary repair and extra-peritoneal rectal injuries by diverting colostomy. This study was undertaken to document our experience with this approach and to identify factors which might impact on outcome.

PATIENTS AND METHODS

Prospective study of all patients treated for colon and rectal injuries in one surgical ward at King Edward VIII hospital, Durban, over a 7-year period (1998-2004). Demographic data, clinical presentation, findings at laparotomy and outcome were documented.

RESULTS

Of 488 patients undergoing laparotomy, 177 (36%) had injuries to the colon and rectum with age 29.8+/-10.9 years. Injury mechanisms were firearms (118) stabs (54) and blunt trauma (5). Delay before laparotomy was 10+/-9.3 h. Complication and mortality rates were 36% and 17%, respectively. 68 patients (38%) required ICU management. Shock on admission and increased transfusion requirements were associated with a significantly increased mortality. Patients with delay < or = 12 h before laparotomy had a higher mortality rate than those with delay >12 h. The mortality rate increased with the number of associated injuries and it was higher the higher the Injury Severity Score (ISS); it was similar for stabs, firearms and blunt trauma. Hospital stay was 9.5+/-9.2 days.

CONCLUSION

We reaffirm that primary repair is appropriate for colonic and intra-peritoneal rectal injuries and that extra-peritoneal rectal injuries require diverting colostomy. Shock on admission, increased blood transfusion requirements, associated organ injury and severity of the injury were associated with high mortality.

Notification of occupational diseases by general practitioners in the Western Cape

BACKGROUND

Notification of occupational diseases to the Department of Labour (and in limited situations to other agencies) is an important aspect of surveillance and planning for interventions as well as compensation. A survey of general practitioners (GPs) was conducted to assess their knowledge and practice with regard to reporting of occupational diseases.

DESIGN

Descriptive telephonic survey.

SETTING

Independent general practices in the Western Cape.

PARTICIPANTS

One hundred and forty GPs were randomly selected from a provincial sampling frame of 1,000 GPs.

MAIN OUTCOME MEASURES

Knowledge of notification procedures for occupational diseases, and problems encountered with the reporting system.

RESULTS

Of a total of 109 GPs interviewed, 75% had diagnosed more than one case of occupational disease in the last 6 months. Twenty-four per cent of the total (95% confidence interval (CI) 16-32%) indicated that they were aware of the notification requirements, and 5% (95% CI 0.8-9%) knew the appropriate legislation. Only one GP notified the appropriate authority once the diagnosis was made. Factors influencing their reporting practice included lack of guidelines for diagnosis of common work-related conditions, lack of information regarding referral channels, problems with communicating with the patient and employer, and poor knowledge of the reporting process itself. Lack of motivation as a result of poor feedback on cases reported and the labour-intensive administration required, were also cited as factors.

CONCLUSION

Although the majority of GPs diagnose occupational diseases, knowledge and practice regarding notification are poor. Recommendations to overcome obstacles to notification include a simplified, uniform notification system, adequate training and support of GPs, and timeous feedback to GPs.

Factors influencing phenytoin-induced gingival enlargement

AIM

To ascertain the prevalence and severity of phenytoin-induced gingival enlargement (PIGE) as well as the relationship between PIGE and risk factors.

METHOD

An outpatient population of patients on phenytoin treatment and attending the epilepsy clinic at Prince Mshiyeni Memorial Hospital (PMMH) in Durban, South Africa, was requested to participate. A structured questionnaire was used to collect data on patients' demographics, social habits (e.g., drinking and smoking), dental and oral hygiene practices and medication history. Gingival enlargement, dental plaque and gingival bleeding was also measured to assess gingival health. Venous blood was collected for serum folate and phenytoin serum levels measurements. A regression analyses was then undertaken to ascertain the association between PIGE and the risk factors. Factors tested for correlation were serum phenytoin and folate levels, age, bacterial plaque, gingival inflammation, toothbrushing, smoking and alcohol consumption. The association between PIGE and the risk factors was assessed either individually, i.e., as a single entity or in combination--multifactorially.

RESULTS

Of the 134 patients studied, 62% had PIGE scores > or = 1, while 8% had a PIGE score of zero. With the exception of plaque, which showed a moderate association with PIGE (r=0.4), no other factor on its own was statistically significantly related to PIGE. In the multiple linear regression analysis, factors which on their own did not have a strong influence became more important. Bacterial plaque (p=0.0001), younger age (p=0.01) and higher free serum phenytoin levels (p= 0.03), were associated with PIGE. Although known to be associated with periodontal diseases, smoking and alcohol, (p=0.03 and p=0.04 respectively), appeared to give some protection against PIGE.

CONCLUSION

Risk factors associated with PIGE may have a synergistic effect. Bacterial plaque, however, appears the most important determinant of PIGE severity. This latter finding emphasises the importance of instituting a preventive plaque-control programme, particularly in young patients on phenytoin therapy.

Safer blood--supplementation of blood products with anti-HBs

An enzyme-linked immunosorbent assay (ELISA) was developed for the detection and quantitation of antibodies (anti-HBs) to the surface antigen of the hepatitis B virus (HBsAg). The ELISA uses HBsAg as the solid phase, and, after conjugation to horseradish peroxidase, also as the conjugate. Conditions for this assay were optimized and a rapid (1.5 hours) ELISA has evolved which works very satisfactorily for the large-scale screening of donated blood. We have used this ELISA to examine donated blood in Natal and concluded that we cannot initiate a programme of anti-HBs supplementation of parenteral blood products without hyperimmunization and plasmapheresis of selected, voluntary donors.

Rapid purification of HBsAg from human plasma

A method is described for the rapid isolation of purified HBsAg from infected donor plasma. This method uses polyethylene glycol precipitation and a single isopycnic ultracentrifugation step in which the gradient is formed in situ. It works equally well using a small swingout rotor or a zonal rotor.

Mouse monoclonal anti-HBs and its use in the screening of donated blood by Elisa

A method is described for the production of mouse monoclonal antibodies to HBsAg. 4 clones produced antibodies directed at the a and one at the d determinant of HBsAg. These antibodies were conjugated to horse radish peroxidase and used in an Elisa for the detection of HBsAg in donated blood. Antibody C10 produced conjugate which rendered the Elisa as sensitive as a commercially obtainable immunoradiometric assay with which it was compared. Conditions for this assay were optimised and it may be used as a rapid (1 h) test for detecting HBsAg-positive blood. It is practicable to read this Elisa by eye instead of photometrically and it can be thus used under field conditions or in emergencies.

ELISA solid phase: partial denaturation of coating antibody yields a more efficient solid phase

We have examined conditions which will improve the solid phase in ELISAs for HBsAg and ferritin in human serum. Sheep and rabbit antibodies were used. It was found that pre-exposure of antibody to low pH, 3 M urea and temperatures as high as 82 degrees C will enhance ELISA colour in these assays. Further experiments indicate that these conditions perturb the structure of the antibody molecules and results in the exposure of new hydrophobic regions. It is speculated that these more hydrophobic molecules can bind to regions on the plastic surface normally not coated by non-perturbed molecules.