Biochemical markers in emergency thoracic surgery in penetrating trauma

BACKGROUND

Violent interpersonal acts account for a large proportion of unnatural deaths in South Africa. A significant proportion of unnatural deaths are due to penetrating thoracic trauma and preventable haemorrhage. Current indications for emergent thoracotomy are unreliable. We propose the use of lactate, shock index (SI) and base deficit (BD) as a triage tool in patients with penetrating thoracic injuries to identify those requiring surgical intervention.

METHODS

A review of the trauma registry of the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) was carried out between March 2011 and March 2016. Four hundred and ninety (490) patients were collected consisting of a non-operative group of 246 patients and an operative group of 244 patients. We compared lactate, SI and BD independently and within panels to ascertain which would best predict the need for operative intervention in these patients. Abnormal was defined as lactate ≥ 4 mmol/l, SI ≥ 0.8 and BD ≤ -4 mmol/l.

RESULTS

Of the 490 patients, lactate (p < 0.001), SI (p < 0.001) and BD (p < 0.001) differed significantly between operative and non-operative groups. Statistical significance was lost (p = 0.34) once BD was analysed in combination with lactate and SI. Lactate alone was a strong predictor of the need for intervention (area under the curve (AUC) = 0.814). The strongest predictor was a combined panel of lactate and SI (AUC = 0.8308, p < 0.001).

CONCLUSION

Lactate and SI in combination are useful as triage tools, and could assist in decision making, by predicting which patients are more likely to require surgical intervention.

Epigenetic regulation of miR-181c-5p in a cardiorenal mouse model with co-occurring thrombotic microangiopathy

Background

MiR-181c-5p is described to induce heart failure (HF), while its role in renal pathology and healthy mice is rather undetermined. Renal dysfunction is present in 40–60% of HF patients and associated with high morbidity and mortality rate.

Purpose

This study aims to investigate the role of miR-181c-5p in a new mouse model of metabolic cardiorenal disease (CRD). Our hypothesis states a protective effect of miR-181c-5p inhibition on HF development by regulation of Tgfbr1.

Methods

CRD was induced by feeding male C57BL/6J mice (n=20) a high-fat diet (HFD) and L-NAME in drinking water (5g/L) for 6 weeks, angiotensin-II was co-administered via osmotic minipumps (1000ng/kg/min) during the final 2 weeks. Healthy controls (n=16) were given normal chow and drinking water, and underwent sham-surgery. Mice were randomly assigned to weekly injections (40mg/kg) with miR-181c-5p antagomiR (INH) or scrambled control for the duration of the study. We assessed cardiac function (echocardiography, invasive hemodynamics), renal function (plasma creatinine), target expression (RT-qPCR), and histology.

Results

CRD animals showed mild systolic and diastolic cardiac dysfunction compared to healthy controls characterized by reduced dP/dt min (−4795±1164 vs −7728±1693 mmHg/s; p=0.01) and dP/dt max (6222±1069 vs 8706±1739 mmHg/s; p=0.038), and increased tau (9.88±3.09 vs 6.07±0.73 ms; p=0.02) with preserved ejection fraction (45±21 vs 51±8%; p=0.53). Histology shows cardiac fibrosis (2.5±0.3 vs 1.8±0.2% area; p=0.0004) and hypertrophy (0.11±0.03 vs 0.08±0.01g/cm; p=0.005). Renal dysfunction presents with kidney atrophy (0.07±0.006 vs 0.09±0.01g/cm; p=0.02), increased plasma creatinine (21±6 vs 10±5; p=0.01), renal fibrosis (0.26±0.22 vs 0.005±0.21% area; p=0.036) and glomerular abnormalities (glomerulosclerosis, hyperfiltration, mesangial matrix expansion, reduced podocyte number). CRD+INH animals had comparable cardiac phenotype to CRD (p&gt;0.05), except a significantly reduced cardiac output compared to healthy controls (6±3 vs 18±3 μl/s; p=0.035). Their renal phenotype was exacerbated with elevated glomerular damage (26±3 vs 18±9; p=0.04) and significantly increased mortality rate (50%) (Kaplan-Meier p=0.01) compared to healthy controls (0%) or CRD (20%), associated with increased occurrence of tubular atrophy, endothelial swelling and systemic thrombotic microangiopathy (TMA) that manifested in kidney and the heart. RT-qPCR analysis identified Vegf as potential target of miR-181c-5p in kidney and showed significantly reduced levels of Tgfbr1 in cardiac tissue of CRD+INH mice.

Conclusion

This study demonstrates a detrimental effect of miR-181c-5p inhibition on renal function in a CRD mouse model, driven by glomerular damage and TMA through Vegf signaling. Despite identification of Tgfbr1 as potential target of miR-181c-5p in the heart, cardiac function was rather unaffected.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): University of Antwerp

Triple-negative breast cancer - a retrospective audit of 151 cases seen at the Charlotte Maxeke Johannesburg Academic Hospital Breast Unit

BACKGROUND

Triple-negative breast cancer (TNBC) is an aggressive, rapidly lethal subgroup of breast cancer which disproportionately affects women of African descent. Lacking hormone receptor expression and human epidermal growth factor receptor 2 (HER2) overexpression, it is difficult to treat. Despite an initial good response to chemotherapy, relapse is common and survival short. The aim of this study of treatment-naïve women with TNBC was examination of clinicopathological characteristics and any association of these with patient demographics.

METHODS

Demographic data was captured together with the clinical, pathological and histological features of the cancers. Statistical analysis was performed.

RESULTS

Of the 960 patients entered in the database of the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) Breast Unit (BU) over a 3-year period, 151 (15.7%) had TNBC. All patients were female aged 25 to 98 years, and 60.3% were postmenopausal (mean age 64 years). The majority (80.2%) self-identified as black African. Most patients had clinical stage 3 disease, and 17.2% had distant metastases. One hundred women were HIV negative, 35 positive and 20 untested. Tumour biology revealed high-grade morphology in 70% of cases with a mean Ki-67 value of 60%. Forty patients died within 18 months of entry in the database.

CONCLUSION

In this series, most patients with TNBC were older, postmenopausal women. This patient cohort may represent a non-basal subtype of TNBC but gene expression profiling was not available. Tumours were locally advanced, rapidly proliferative but not associated with HIV status. The short survival times emphasise the importance of neoadjuvant chemotherapy as soon as the diagnosis of TNBC is made.

Triple-negative breast cancer - a retrospective audit of 151 cases seen at the Charlotte Maxeke Johannesburg Academic Hospital Breast Unit

BACKGROUND: Triple-negative breast cancer (TNBC) is an aggressive, rapidly lethal subgroup of breast cancer which disproportionately affects women of African descent. Lacking hormone receptor expression and human epidermal growth factor receptor 2 (HER2) overexpression, it is difficult to treat. Despite an initial good response to chemotherapy, relapse is common and survival short. The aim of this study of treatment-naive women with TNBC was examination of clinicopathological characteristics and any association of these with patient demographics. METHODS: Demographic data was captured together with the clinical, pathological and histological features of the cancers. Statistical analysis was performed. RESULTS: Of the 960 patients entered in the database of the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) Breast Unit (BU) over a 3-year period, 151 (15.7%) had TNBC. All patients were female aged 25 to 98 years, and 60.3% were postmenopausal (mean age 64 years). The majority (80.2%) self-identified as black African. Most patients had clinical stage 3 disease, and 17.2% had distant metastases. One hundred women were HIV negative, 35 positive and 20 untested. Tumour biology revealed high-grade morphology in 70% of cases with a mean Ki-67 value of 60%. Forty patients died within 18 months of entry in the database. CONCLUSION: In this series, most patients with TNBC were older, postmenopausal women. This patient cohort may represent a non-basal subtype of TNBC but gene expression profiling was not available. Tumours were locally advanced, rapidly proliferative but not associated with HIV status. The short survival times emphasise the importance of neoadjuvant chemotherapy as soon as the diagnosis of TNBC is made.

A national, multicentre web-based point prevalence survey of antimicrobial use and quality indices among hospitalised paediatric patients across South Africa

OBJECTIVES

Data on antimicrobial consumption among the paediatric population in public hospitals in South Africa is limited. These needs to be addressed to improve future use and reduce antimicrobial resistance rates. Consequently, the objective is to quantify antimicrobial usage;and identify and classify which antimicrobials are used in the peadiatric population in public sector hospitals in South Africa according to World Health Organiosation (WHO) AWaRe list of antimicrobials METHODS: Conduct a point prevalence survey among 18 public sector hospitals from nine provinces using a newly developed web-based application. The data will be analysed according to the WHO AwaRe list to guide future quality improvement programmes.

RESULTS

1261 paediatric patient files were reviewed with 49.7% (627/1261) receiving at least one antimicrobial, with 1013 antimicrobials prescribed overall. The top five antimicrobials included ampicillin (16.4%), gentamycin (10.0%), amoxicillin and enzyme inhibitor (9.6%), ceftriaxone (7.4%), and amikacin (6.3%). Antimicrobials from the Access classification were the most used (55.9%) with 3.1% being from the Reserve classification. The most common infectious conditions were pneumonia (21.3%; 148/1013) and clinical sepsis (16.0%; 111/1013). Parenteral administration (75.6%) and prolonged surgical prophylaxis (66.7%; 10/15) were common and concerns. 28% of the paediatric patients had cultures requested for them before antimicrobial treatment (284/1013) however only 38.7% (110/284) of culture results were available in the files.

CONCLUSION

Overall, antimicrobial prescribing is common among paediatric patients in South Africa. Interventions should be targeted at improving antimicrobial prescribing, including surgical prophylaxis, and encouraging greater use of oral antibiotics.

A point prevalence survey of antimicrobial utilisation patterns and quality indices amongst hospitals in South Africa; findings and implications

Objectives: Antimicrobial use is growing, driven mainly by rising demands in developing countries. Knowing how antimicrobials are prescribed is important. Consequently, we undertook a point prevalence survey (PPS) quantifying antimicrobial consumption among 18 public sector hospitals across South Africa.Method: A purpose-built web-based application was used to collect PPS data.Results: Out of 4407 adult patients surveyed, 33.6% were treated with an antimicrobial. The most frequently prescribed groups were a combination of penicillins including β-lactamase inhibitors. Amoxicillin combined with an enzyme inhibitor accounted for 21.4% total DDDs. In the medical and surgical wards, Access antimicrobials (54.1%) were mostly used, while in the ICU, Watch antimicrobials (51.5%) were mostly used. Compliance with the South African Standard Treatment Guidelines and Essential Medicines List was 90.2%; however, concerns with extended use of antimicrobials for surgical prophylaxis (73.2% of patients).Conclusion: The web-based PPS tool was easy to use and successful in capturing PPS data since the results were comparable to other PPS studies across Africa. High use of amoxicillin combined with an enzyme inhibitor, possibly because it was among the broad-spectrum antimicrobials in the Access group. The findings will assist with future targets to improve antimicrobial prescribing among public sector hospitals in South Africa.

Development of a web-based application to improve data collection of antimicrobial utilization in the public health care system in South Africa

Objective

Determining antimicrobial utilization patterns in hospitals can be a challenge given personnel and resource constraints with paper-based systems. A web-based application (APP) was developed in South Africa to address this, building on a recent point prevalence survey (PPS) using a paper-based system. Consequently, there was a need to test and evaluate the ease of use of a newly developed app and potential time saving versus paper-based methods for PPS. The findings can be used to further refine the APP.

Methods

The developed app was tested in a large academic public hospital in a PPS in South Africa. During data collection, the app was evaluated for functionality on 35 variables and subsequently refined. After data collection, the app was evaluated in terms of its time-saving potential and ease of use.

Results

181 patient’s files were surveyed across 13 wards in the hospital, with the antimicrobial usage findings similar to the previous paper-based study in the same hospital. The median age for males was 45.5 years and 42 years for females. Overall 80 out of 181 (44%) patients received antibiotics. Whilst 38% (12 out of 31) of patients in the adult surgical ward received antimicrobials, the prevalence was the highest (78%) in the pediatric medical wards. All the data collectors were confident in using the app after training and found the tool is not complex at all to use. In addition, the time taken to plan for the study and to collect data was considerably reduced. Reduced time spent in data collection and analysis is important for timely instigation of quality improvement programs in resource limited settings.

Conclusions

All data collectors would recommend the app for future PPSs. Several concerns with data entry were identified, which have now been addressed. The app development has been successful and is now being deployed across South Africa as part of a national PPS as well as wider.

[Hemorrhagic fever with renal syndrome group outbreak caused by Sochi virus.]

BACKGROUND

Hemorrhagic fever with renal syndrome (HFRS) occupies a leading place among natural focal human diseases in the Russian Federation. Sporadic incidence of HFRS-Sochi has been annually recorded in the Krasnodar Territory since 2000. The group outbreak of the HFRS-Sochi was first registered in Gelendzhik in the fall of 2013.

METHODS

Serological methods were used: indirect immunofluorescence, enzyme immunoassay, FRNT in Vero cells, and methods for the viral RNA detection: PCR and RT-PCR.

RESULTS

Data of clinical, epidemiological, immunological and molecular studies of 3 out of 4 cases in HFRS-Sochi outbreak are presented. Severity of the disease correlated with early gastrointestinal disorders appearance. Patient MA gastrointestinal disorders were joined on day 3 of a fever. Clinical and laboratory studies revealed signs of kidneys, liver, pancreas damage, bilateral hydrothorax, bilateral polysegmental pneumonia and polyneuropathy. As a result of long-term treatment, the patient recovered. Patient AA had gastrointestinal disturbances the next day after fever onset. The patient was not saved, despite early hospitalization. Hantavirus antigen and RNA were detected in the lung tissues 2 out of 10 Black-Sea field mice captured in the affected area, as well as in the organs of deceased patient. The most severe clinical course of the disease in close relatives, son and father, with a fatal outcome in the latter case may be the result of genetic features. The severity and outcome of the disease was not depend on day of hospitalization and correlated with the early manifestations of gastrointestinal disorders.

CONCLUSIONS

Presented data confirm high virulence and pantropism of the Sochi virus, as well as the epidemiological role of Black-Sea field mouse (Apodemus ponticus) as the host of the Sochi virus and the source of human infection.

Determination of Total Vitamin C in Fruit Juices and Related Products by Liquid Chromatography: Interlaboratory Study

A interlaboratory study was conducted to evaluate a liquid chromatographic (LC) procedure for the determination of total vitamin C in foods at levels of 5–60 mg/100 g. Emphasis was placed on fruit juices, although selected foods were also included in the study. Following dissolution of sample in water, endogenous dehydroascorbic acid was converted to ascorbic acid by precolumn reduction with dithiothreitol at neutral pH. Total ascorbate was determined by C18 reversed-phase LC with a phosphate eluent at pH 2.5, incorporating dithiothreitol to maintain vitamin C in the reduced form, and UV detection at 254 nm. Seven types of fruit juices and foods were tested by 19 collaborators in 7 countries. Three duplicate juices and foods met the criteria for Youden pairs and yielded repeatability relative standard deviation of 5.80–14.66%. Reproducibility relative standard deviation ranged from 6.36 to 35.54% (n = 10) with HORRAT values of 0.82–4.04. The LC method is suitable for routine use in fruit products and foods containing &gt;5 mg/100 g vitamin C and is recommended for further validation by AOAC INTERNATIONAL and International Fruit Juice Union.

Suture material use and procurement: an audit of a public hospital surgical system in Gauteng, South Africa

BACKGROUND

Surgical systems are integral to successful, safe and cost effective clinical practice and must balance surgical demands on consumable items and their costs. Suture material is a key consumable resource, and was evaluated in an audit of consumable use and cost as well as the procurement systems within the South African Gauteng public health care sector.

AIMS

To determine suture use and cost in the four commonest general surgical procedures - abdominal wall closure, mastectomy, appendicectomy and inguinal hernia repair - in three academic Gauteng hospitals. Performance and availability were evaluated as a secondary aim in suture material use.

METHOD

A prospective observational study. Suture use was documented by the surgeon at the time of the procedure and qualitative investigation at relevant hospital departments determined suture material procurement and expenditure.

RESULTS

The surgeons in three facilities documented consistent material type and average number of units used; however, in some cases there was a lack of availability of appropriate material and breakage of generic material intraoperatively. There is no consistent and consolidated electronic record-keeping of suture stock and cost in all three hospitals, therefore cost of suture material used was not obtainable.

CONCLUSION

Clinical deficiencies in availability and quality of material may have adverse implications for patient health, healthcare costs and budgets through procedure-related complications and should be investigated. There is a lack of communication between the financial management, procurement officers, hospital and theatre stores and theatre staff. It is suggested that clinical protocols and system-based strategies be put in place to manage surgical consumables.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Incidental cancer in multinodular goitre post thyroidectomy

BACKGROUND

The risk of malignancy in patients with multinodular goitre (MNG) is approximately 7.2%. The gold standard for diagnosis of thyroid cancer is fine-needle aspiration biopsy (FNAB). Unsuccessful, inconclusive or suspicious results mandate further investigations. The concern is that with a benign FNAB result there is no indication for surgery unless the patient has compression symptoms or cosmetic issues, but the risk of missed malignancy is nevertheless present.

OBJECTIVE

To determine the prevalence and histological features of incidental cancers in patients who had thyroidectomy for MNG.

METHOD

Records of patients who underwent thyroidectomy between January 2005 and December 2010 at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa, were retrospectively reviewed. Data retrieved included demographic characteristics of the patients, type of thyroidectomy, thyroid function test results, FNAB cytology and final histology results.

RESULT

A total of 166 thyroidectomies were performed on 162 patients, the majority (139) of whom were females. The mean age was 46 years (range 15 - 79 years). A total of 120 pre-operative FNABs were available for analysis, 78 of which were suggestive of benign nodular goitre; 70 benign FNAB results were histologically confirmed to be MNG after thyroidectomy. Incidental malignancy was found in four of 70 cases of MNG (5.7%); all were papillary carcinomas, predominantly (75.0%) the follicular variant.

CONCLUSION

The risk of missing cancer in patients with MNG was 5.7%. The commonest histological subtype of thyroid cancer found in MNG was papillary carcinoma.

[Actual problems of hemorrhagic fever with renal syndrome]

From 2000 to 2011 85 600 cases of hemorrhagic fever with renal syndrome (HFRS) were registered in Russian Federation. Epidemically active foci of HFRS infection are located generally in temperate latitudes of the European part and the Far East. In the Far East regions whose fraction of all the HFRS disease cases in Russia is around 2%, the causative agents of the infection are Hantaan, Amur, Seoul hantaviruses, the natural reservoir for those are striped field mouse, Korean field mouse and brown rat. In the European part of Russia the causative agent of the infection are Puumala hantavirus as well as 2 genetic subtypes of Dobrava virus, the main reservoirs of those in the nature are bank vole, striped field mouse and Black Sea field mouse, respectively. 9 strain of Puumala and 10 strains of Dobrava virus were isolated. Based on sequencing of Dobrava virus strains significant differences were detected between Dobrava virus strains isolated from Black Sea field mouse from Sochi and striped field mouse from Lipetsk Region. Cultural inactivated vaccine against HFRS was developed and completed preclinical trials.

[Discovery, clinical and etiological characteristic of hemorrhagic fever with renal syndrome in the subtropical zone of Krasnodar region]

Twenty-six patients with hemorrhagic fever with renal syndrome (HFRS) were revealed as a result of serological examination of 582 patients with fever living around Sochi town. Etiologic role of Dobrava virus subtype as the cause of HFRS was assessed by immunofluorescent and ELISA assays, and neutralization test. The principal host of this virus and source of infection for humans is Caucasian forest mouse Apodemus ponticus. HFRS morbidity was sporadic and not dependent from patients' occupation and season. Comparative analysis of clinical and laboratory data from HFRS cases caused by DOB/Sochi and DOB/Lipetsk subspecies, as well as Puumala virus showed higher proportion of severe forms of disease in patients with HFRS from Sochi.

Het die Sielkunde as wetenskaplike projek misluk?

Die vraag of Sielkunde as wetenskaplike projek gefaal het, hou verband met die Sielkunde as teoretiese wetenskap en word bevestigend beantwoord. Na 100 jaar as selfstandige wetenskap is die Sielkunde nog steeds 'n preparadigmatiese wetenskap. Dit word toegeskryf aan die voorrang wat natuurwetenskaplike metodiek, die Cartesiaanse dualisme wat die kanker van die Sielkunde is, en aan die feit dat die sielkundige nie met sy priměre belewing van die fenomeen van ondersoek begin nie, maar met konstruksies van die werklikheid wat on- krities uit (meesal) die natuurwetenskappe oorgeneem word. Geen een van die drie hoofrigtings en ook nie strukturalisme of sisteemteorie is in staat om 'n paradigma te lewer nie en dit word aan die hand gedoen dat daar weer eens na die filosofiese antropologie gekyk en weer besin word oor die ware aard van die sielkundige studieveld. Dat 'n fenomenologiese of hermeneutiese sielkunde wel 'n paradigma kan lewer, word as moontlikheid gestel.