Approach to the diagnosis and management of snakebite envenomation in South Africa in humans: Special patient groups and surgical aspects

This article explores the management of snakebite to vulnerable patient groups, namely children and pregnant women as well as providing detail on the current best practice when caring for venom ophthalmia and surgical wounds resulting from snakebite. Finally, the optimal free-to-use medical record for accurate documentation of snakebite incidents is provided for use by South African practitioners.

Approach to the diagnosis and management of snakebite envenomation in South Africa in humans

Snake bite management is largely driven by expert opinion and consensus, however there are a few large retrospective studies and RCT's that have improved the quality of medical guidance currently available. South African snakes are different in the venomous potential and it behooves the hospital provider and the average medical practitioner to know the current best practice concepts concerning assessment, treatment and antivenom use. The recent SASS meeting in July 2022 provided an update and national consensus from which this Hospital Care document is derived.

Introductory Editorial

This is the introduction article and editorial that will address the latest approaches to safe management of snakebite in South Africa and shares the evidence and expert consensus from the recent South African Snakebite Symposium (SASS) meeting held in July 2022.

736 REAL-TIME MOBILITY DATA FROM WEARABLE DEVICES PREDICTING FALLS RISK IN OLDER ADULTS

Introduction

Falls are a common cause of injuries in people over 65 years, usually resulting in life-threatening or life-altering sequalae for affected individuals. Falls risk assessment typically requires a face-to-face evaluation delivered by a trained professional in a clinical setting, thus limiting their application for many older people with falls. Therefore, there is a need for a remote monitoring system (RMS) that captures mobility data to assess comprehensively an older individual’s true falls risk undertaking their everyday activities in their usual environment.

Methods

A pilot study was conducted with 16 participants over 65 years classified as high (n = 9) or low falls risk (n = 7) based on their fall’s history. A RMS was developed, which combines inertial measurement unit (IMU) data from a wearable device and online real-time Machine Learning (ML) to generate a two-stage fall risk assessment. In stage one, a ML activity motion classifier identified raw IMU data from participants as either, walking, resting or transitional movements (turning or sitting to standing). In stage two, previously classified motion segments were analysed by a ML fall-risk classifier, providing an objective risk assessment based on gait characteristics during everyday motion. Falls incidence was recorded prospectively at one year follow-up.

Results

The motion classifier achieved an 94.8% accuracy in differentiating between resting, walking and transitional movements. The fall risk classifier initially trained with retrospective fall history data achieved an 87.5% accuracy with 88.9% sensitivity and specificity, which is comparable to other accurate classifiers in published literature. The fall risk classifier retrained with prospective one year follow-up data achieved a 73% accuracy which was superior to the 67% accuracy of the Timed Up and Go test for falls prediction.

Conclusion

Our study shows the potential of a machine-learning remote monitoring system using information from mobility data to classify an older person’s falls’ risk.

The spectrum and outcome of paediatric emergency surgical admissions - a regional hospital analysis

BACKGROUND: Improving emergency surgical care for children requires information on the causes of admissions and the variables affecting outcome. There is a lack of such data in the South African context. METHODS: This retrospective study was conducted from January 2016 to December 2017. Data was collected on all children (< 12 years of age) requiring admission with emergency surgical conditions. Infrastructure and staffing ratios were determined prior to data collection. Information was sourced from admission and discharge books, patient files and theatre registers. Variables of age, sex, referral source, diagnosis, length of stay, surgical treatment and outcome including death were collected. RESULTS: Four hundred and thirty-five of the 1 048 children (42%) admitted were in the 0-2-year age group. Trauma (258), sepsis (564) and burns (226) were the main causes. The median hospital stay was 3 days (IQR 2-5), however, for burns patients, the median stay was 4 days (IQR 2-9). Surgery was performed on 279 (27%) admissions. Eight (0.8%) died, six of which were due to burns. Clinical status prior to death was poorly documented. A dedicated high care unit and burns isolation rooms were lacking. Surgeon/population and child/nurse ratios were respectively 1.48/100 000 and 7-12/1. CONCLUSION: This study found that the emergency paediatric surgical burden is significant. Sepsis and trauma combined are the leading cause of emergency admissions. Burns had the highest mortality. Although mortality was low, improvements of staff to patient ratios and the institution of an early warning system could reduce mortalit

Petrous apex pneumatisation in children: a radiological study

OBJECTIVE

This study aimed to investigate petrous apex pneumatisation in children, as an understanding of petrous apex pneumatisation is useful in the diagnosis and surgical management of middle-ear disease.

METHODS

Computed tomography head scans from 1700 patients aged 0-16 years were assessed. Petrous apex bone and air cell volumes were calculated to determine the degree of petrous apex pneumatisation. Scans were analysed for communicating tracts between the middle ear and petrous apex.

RESULTS

Petrous apex pneumatisation was found in 21.0 per cent of patients. Positive relationships were found between age and petrous apex pneumatisation prevalence (rs = 0.990, p < 0.001), and between age and degree of petrous apex pneumatisation (rs = 0.319, p < 0.001). Petrous apex pneumatisation prevalence did not significantly differ by sex or ethnicity. Communicating tracts were identified in 84.3 per cent of patients with petrous apex pneumatisation, most commonly anterior to the otic capsule.

CONCLUSION

In children, the prevalence and degree of petrous apex pneumatisation increases with age, but prevalence is not affected by sex or ethnicity.

The prevalence of sodium abnormalities in moderate to severe traumatic brain injury patients in a level 1 Trauma unit in Durban

BACKGROUND

The prevalence of sodium abnormalities in the moderate to severe brain injury patient is not known in the South African population.

METHOD

Patients admitted to the trauma intensive care unit between January 2013 and June 2015 with moderate to severe traumatic brain injury were included in the study. Descriptive statistics, tests of association and tests of differences were used.

RESULTS

There were 184 patients with 143 (77.7%) males and 41 (22.3%) females. Abnormal sodium was present in 126 (68.4%), 61 of whom had hyponatremia and 65 hypernatremia, a prevalence of 33.1% and 35.3% respectively. Of the 65 patients with hypernatremia, 52 (80%) had dehydration, 7 (10.7%) had diabetes insipidus (DI) and 6 (9.3%) had hyperosmolar therapy as the cause. Of the 61 patients with hyponatremia, the commonest cause was fluid overload in 47 patients (77.1%) with SIADH in 11 (18%) and CSWS in 3 (4.9%). Death occurred in 34 (18.5%) patients and diagnosis was found to be significantly associated with mortality (p = 0.01), the most common diagnoses amongst those who died being dehydration (29.4%), fluid overload (17.7%) and DI (14.7%).

CONCLUSION

The prevalence of sodium abnormalities was 126 (68.4%) patients of whom 61 (33.1%) had hyponatremia and 65 (35.3%) hypernatremia. In those patients who survived, a later onset was related to a better outcome. The GOS in DI tended to be worse.

Cervical collars and immobilisation: A South African best practice recommendation

INTRODUCTION

The consequences of spinal injury as a result of trauma can be devastating. Spinal immobilisation using hard trauma boards and rigid cervical collars has traditionally been the standard response to suspected spinal injury patients even though the risk may be extremely low. Recently, adverse events due to the method of immobilisation have challenged the need for motion restriction in all trauma patients. International guidelines have been published for protection of the spine during transport and this article brings those guidelines into the South African context.

RECOMMENDATIONS

Trauma patients need to be properly assessed using both an approved list of high and low risk factors, as well as a thorough examination. They should then be managed accordingly. Internationally validated assessment strategies have been developed, and should be used as part of the patient assessment. The method of motion restriction should be selected to suit the situation. The use of a vacuum mattress is the preferable technique, with the use of a trauma board being the least desirable.

CONCLUSION

The need for motion restriction in suspected spinal injury should be properly evaluated and appropriate action taken. Not all trauma patients require spinal motion restriction.

The in vitro effect of xylitol on chronic rhinosinusitis biofilms

INTRODUCTION

Biofilms have been implicated in chronic rhinosinusitis (CRS) and may explain the limited efficacy of antibiotics. There is a need to find more effective, non-antibiotic based therapies for CRS. This study examines the effects of xylitol on CRS biofilms and planktonic bacteria.

METHODS

Crystal violet assay and spectrophotometry were used to quantify the effects of xylitol (5% and 10% solutions) against Staphylococcus epidermidis, Pseudomonas aeruginosa, and Staphylococcus aureus. The disruption of established biofilms, inhibition of biofilm formation and effects on planktonic bacteria growth were investigated and compared to saline and no treatment.

RESULTS

Xylitol 5% and 10% significantly reduced biofilm biomass (S. epidermidis), inhibited biofilm formation (S. aureus and P. aeruginosa) and reduced growth of planktonic bacteria (S. epidermidis, S. aureus, and P. aeruginosa). Xylitol 5% inhibited formation of S. epidermidis biofilms more effectively than xylitol 10%. Xylitol 10% reduced S. epidermidis planktonic bacteria more effectively than xylitol 5%. Saline, xylitol 5% and 10% disrupted established biofilms of S. aureus when compared with no treatment. No solution was effective against established P. aeruginosa biofilm.

CONCLUSIONS

Xylitol has variable activity against biofilms and planktonic bacteria in vitro and may have therapeutic efficacy in the management of CRS.

Erratum to: The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections

[This corrects the article DOI: 10.1186/s13017-017-0141-6.].

Positron emission tomography/computed tomography scanning for the diagnosis of occult sepsis in the critically injured

BACKGROUND

Although the site of nosocomial sepsis in the critically ill ventilated patient is usually identifi able, it may remain occult, despite numerous investigations. The rapid results and precise anatomical location of the septic source using positron emission tomography (PET) scanning, in combination with computed tomography (CT), has promoted this modality as the diagnostic tool of choice for pyrexias of unknown origin.

METHOD

The objective of this study was to report our experience using PET/CT scanning for the localisation of a septic focus in critically injured patients in whom no source could be identifi ed using conventional investigations.

RESULTS

Two patients with gunshot wounds and two who had sustained multiple fractures following motor vehicle collisions developed pyrexias of unknown origin during their stay in the trauma intensive care unit. Routine screening for a septic focus was unrewarding, and 18F-fl uorodeoxyglucose PET/CT scanning was used to identify the possible source. PET/CT scanning identifi ed the septic focus in all patients. Abscesses were drained successfully in those with penetrating trauma and in one with blunt polytrauma. Pulmonary tuberculosis, not apparent on initial radiology, was identifi ed using PET/CT in one patient with blunt thoracic trauma.

CONCLUSION

PET/CT scanning appears to both confi rm and localise the source of sepsis in a variety of pathologies in critically ill patients who develop pyrexias for which no source can be identifi ed by conventional screening techniques.