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Neuilly-sur-Seine, France

Von Rahden R.P.,Clinical Unit | Von Rahden R.P.,University of KwaZulu - Natal
Southern African Journal of Anaesthesia and Analgesia | Year: 2014

Point-of-care devices offer an increasing number of analytical tests more quickly than laboratory analysis, but clinicians must be aware of the limitations of these devices, especially for critical threshold-level decisions. Glucometers are susceptible to a wide range of errors, and only a few haemoglobin-measuring devices have accuracy approaching that of laboratory analysis. Activated coagulation time remains a useful but error-prone test for heparin effects. Thromboelastography and thromboelastometry offer insight into coagulation defects superior to conventional assays. Multi-function testers provide cardiac enzyme and lactate analysis that is becoming vital for intraoperative decision-making. © SASA. Source

Lofgren E.,Karolinska Institutet | Mabesa T.,Inkosi Albert Luthuli Central Hospital | Hammarqvist F.,Karolinska Institutet | Hardcastle T.C.,Clinical Unit | Hardcastle T.C.,University of KwaZulu - Natal
South African Journal of Clinical Nutrition | Year: 2015

Objectives: The benefit of an early enteral nutrition start in critical ill patients is widely accepted. However, limited published data focus on trauma patients. This study aimed to investigate the effect of early enteral nutrition initiation on length of stay and mortality in an intensive care unit (ICU), as well as explore if enteral nutrition initiation could serve as a prognostic marker in trauma patients. Design: This was a retrospective audit of a prospective ethics-approved database (University of KwaZulu-Natal Biomedical Research Ethics Committee No BE207-09) which compared enteral nutrition to outcome. Setting: The setting was a level 1 trauma ICU in Durban, South Africa. Subjects: The subjects were critically ill trauma patients. Outcome measures: Demographic data, enteral nutrition timing, feed tolerance, and the outcome of early versus late initiation of enteral feeding were the outcome measures. Results: Nine hundred and fifty-two patients were included. Eight hundred and ninety-eight received enteral nutrition and were divided into three subgroups (tertiles T1-T3) according to their Injury Severity Score (ISS). The statistical analysis demonstrated that an early enteral nutrition start had a significant positive effect on both length of stay (13.7 vs. 16.4 days, p-value 0.00315) and mortality (9.5 % vs. 20.7 % p-value 0.0062). A multiple logistic regression model was developed, using multiple variables, to test the factors that affected the outcome. There was a significant effect on length of stay with an early enteral nutrition start in patients with a low to medium ISS (T1), and a highly significant effect on mortality in patients with a low to medium, and high, ISS (T1 and T2). Early initiation of enteral nutrition is strongly favoured in regression analyses. Conclusion: Patients in the trauma ICU benefit from an early enteral nutrition. The model used featuring the three independent variables, i.e. the day on which enteral nutrition is commenced, age and ISS, may serve as a prognostic marker with regard to length of stay and mortality in the ICU. © SAJCN. Source

Sofianos C.,Life Bedford Gardens Hospital | Oodit R.,University of Cape Town | Folscher D.,George Provincial Hospital | Potgieter A.,University of Cape Town | And 5 more authors.
South African Journal of Surgery | Year: 2015

Background. Inguinal hernia repair is the most frequent general surgical procedure. These guidelines aim to improve and standardise practice. They apply to adult patients only. This is a summary of the key points in the document. The authors strongly recommend the guidelines be read thoroughly. Clinical. The diagnosis is almost always a clinical one. Imaging is seldom required and should only be requested at specialist level. Referral. Routine referral of men with uncomplicated, minimally symptomatic, reducible hernias. All hernias should be repaired wherever possible as most patients ultimately come to surgery. Urgent referral of all women and men with irreducible hernias is recommended and emergency referral is used for patients with obstruction or strangulation. Patients with hernia recurrences should be referred to a surgeon with an interest in hernia surgery. Peri-operative. Anticoagulation. It is recommended to continue aspirin, but stop clopidogrel 5 - 7 days before surgery. Warfarin should be stopped 5 days before, and bridging with low-molecular weight heparin (LMWH) should be done if the patient has a high thromboembolic risk. Hair removal. Shaving should be avoided. If needed, clipping is recommended. Antibiotic prophylaxis is not routinely recommended; however, it should be used in high-risk groups (recurrence, age >70, immunocompromised, obese, diabetes mellitus (DM), catheterised patients). Anaesthesia. General anaesthetic (GA) is required for laparoscopic repair, although it is feasible to do a totally extraperitoneal (TEP) repair under spinal anaesthesia. Open repair could be performed under local anaesthesia in all patients with reducible unilateral hernias, especially ASA III/IV, the elderly and those with multiple comorbidities. Patients with morbid obesity, incarcerated hernias, and very anxious patients should have a GA. Spinal anaesthesia is not recommended. Day-case surgery should be offered to all patients, where feasible. Surgery. Laparoscopic repair is the treatment of choice for all inguinal hernias including primary unilateral hernias. The contralateral side should always be inspected for an occult hernia, but repair should only be performed if a defect exists. Prophylactic repair is not advised. There are no data to recommend transabdominal preperitoneal (TAPP) over TEP repairs or vice versa. The Lichtenstein repair is the preferred technique for open repairs. The Shouldice repair may be considered if there is gangrenous bowel and resection is required. All groin hernias must be repaired with a mesh. A regular polypropylene or polyester mesh is adequate for all open and laparoscopic hernia repairs. Special circumstances. If the initial operation was an open repair, then the operation for a recurrence should be laparoscopic, and vice versa. Strangulated hernias may be repaired with open or laparoscopic methods but the bowel should always be inspected. A femoral hernia should always be excluded in women with a groin hernia. Patients presenting with hernias in pregnancy should be managed conservatively, with a planned postpartum repair. Complications. Include seroma (which is common but often insignificant clinically), haematoma (which should be managed conservatively unless causing tension of skin), urinary retention, ischaemic orchitis, infection, and chronic groin pain. In patients with mesh infection it is not always essential to remove the mesh. Aftercare. Patients may return to work and driving after 1 week. Source

Aaben C.,Karolinska Institutet | Hammarqvist F.,Karolinska Institutet | Mabesa T.,Inkosi Albert Luthuli Central Hospital | Hardcastle T.,Clinical Unit | Hardcastle T.,University of KwaZulu - Natal
South African Journal of Clinical Nutrition | Year: 2015

Objectives: The aim of the study was to compare the incidence of complications in patients receiving enteral and parenteral nutrition (PN), and review how the early initiation of enteral feeding and early achievement of caloric goal would affect the incidence of complications. Design: The design was a retrospective audit of an ethics-approved prospective trauma registry and electronic medical record. Setting: The setting was a level one trauma centre intensive care unit. Subjects: One thousand and two consecutively treated patients were selected from 1 096 in the database. Outcome measures: Demographic data, nutrition, route of administration, time of initiation and complications in the form of sepsis, pneumonia and feed intolerance, were determined. Results: Patients receiving total PN (TPN) during their length of stay had a hazard ratio of 9.11 for the development of sepsis, compared to patients who were solely fed via the enteral route (p-value <0.001). The patients who reached their nutritional goal late showed a hazard ratio of 2.67 for the development of sepsis, compared to patients who reached the goal early (p-value < 0.001). Patients with late initiation of feeding also had a greater risk of developing sepsis, with a hazard ratio of 2.41, compared to patients with early initiation (p-value < 0.001). Patients achieving the nutritional goal late had a 17.9% increased risk of developing pneumonia (p-value < 0.001). Conclusion: This study confirms previous findings that the use of TPN is a strong predictor of the development of sepsis, compared to enteral nutrition. Causality linkage should be made with caution owing to the study design. © SAJCN. Source

Motsohi T.S.,University of Cape Town | Isaacs A.A.,University of Cape Town | Manga N.,University of Cape Town | Le Grange C.,University of Cape Town | And 5 more authors.
South African Family Practice | Year: 2015

Background: Very limited published data exist on the spectrum of mental health disorders encountered at primary health care (PHC) facilities in South Africa. Methods: The original data from a recent study were analysed with regard to its useful set of data on patients with mental disorders in primary care clinics in Cape Town. Results: Schizophrenia and bipolar disorder accounted for the majority of visits, with common mental disorders (depression, anxiety disorders, substance use disorders) accounting for only a minority of visits. Furthermore, the mental health population in the study had significantly fewer chronic disease co-morbidities than the non-mental health patients. Conclusion: There is an urgent need to screen better for common mental disorders in primary care patients in South Africa, and to screen for chronic medical diseases in patients with serious mental illness. © 2015 The Author(s). Source

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