Transorbital ultrasound measurement of the optic nerve sheath diameter (ONSD) as a screening tool for raised intracranial pressure in an acute care setting in childrenPadayachy, Vaishali January 2016 (has links)
Background: Acute care management of pediatric traumatic brain injury (TBI) can be challenging. Early and reliable diagnosis of intracranial pressure (ICP) in children following TBI is vital in optimizing outcome. Clinical findings of raised ICP can be non-specific and are often missed in minor injuries, leading to severe consequences. The use of a simple, quick, accurate, non-invasive technique to assess ICP can be invaluable in this setting. Based on the hypothesis that acutely raised ICP will result in an enlargement of the optic nerve sheath diameter (ONSD), this study aimed to demonstrate the efficacy of transorbital measurement of the ONSD as a routine screening tool in pediatric TBI. Methodology: This was a prospective observational analysis of a pediatric cohort of patients with head injury, treated in the trauma unit. All children included in the study were clinically assessed, and had indications for cranial computer tomography (CT) scan. All optic nerve sheath imaging was conducted by a single investigator, experienced in the use of ultrasound for emergency care. ONSD measurements were conducted using a high frequency, linear array probe. Patients were sedated and ONSD measurement was performed prior to or immediately after CT imaging. A total of 12 images were obtained in each patient, 3 axial and 3 sagittal images in each eye and the mean ONSD was calculated. ONSD measurements were analyzed in relation to clinical severity, CT findings of raised ICP and outcome of the patient.
Pattern and distribution of peripheral arterial disease in diabetic patients with critical limb ischemia (Rutherford Clinical Category 4-6)Motsumi, Mpapho January 2016 (has links)
Background: The literature tends to support the notion that diabetic patients typically suffer from tibio-peroneal artery occlusive disease (1) (2) (11) (5) (10) (8) with relative sparing of the foot arteries (1). This study seeks to investigate the pattern and distribution of peripheral artery occlusive disease and the arterial foot arch status in diabetic patients with critical limb ischaemia Methods: This is a one year prospective study -(January 2014 to December 2014) carried out on consecutive patients seen at Groote Schuur Hospital, Vascular Department. The inclusion criteria is: diabetic patients ≥18 years of age with critical limb ischemia who had pre- and post-intervention vascular imaging. The calculated minimum sample size of 63 limbs [756 patency levels (63x12)] was needed to achieve a power of 86% to detect a difference of 0.1900 (19%) with a target significance level of 0.05 (using PASS 11 software). The equality of distribution of categories was analyzed using the One sample Chi-square test (SPSS 22) with our Null hypothesis (N0) assuming that categories occur with equal proportions. In this case categories refers to the 5 patency levels used in this study. All 12 main arteries from infra-renal aorta to crural arteries had their patency levels graded from category 1 to category 5 (widely patent to occluded). The findings were then stratified according to gender, age group ( <40 years, 40-54 years and ≥ 55 years) and risk factor combinations [ Group1 = (DM, HPT, Dyslipidemia); Group 2= (DM, HPT, dyslipidemia, exsmoker); Group 3 = (DM, HPT, dyslipidemia, smoker)]. The three risk combination groups formed the majority of our study group (79%).
Development of adjacent segment disease following multilevel anterior cervical discectomy and fusion surgeryKrukonis, Christopher Edward 02 November 2017 (has links)
BACKGROUND: Cervical spondylosis, a degenerative disease of the spine, is a common medical condition that results in significant morbidity, loss of function, and financial burden on the healthcare system in the United States. The disease ranges in severity from axial pain, which is among the most common medical complaints encountered in healthcare, to severe neurological symptoms such a myelopathy and radiculopathy, which may require surgical intervention. Anterior cervical discectomy and fusion (ACDF) has been established as a gold standard for safe and effective surgical treatment of cervical spondylotic myelopathy (CSM) and/or radiculopathy. However, there are significant complications that are associated with surgical intervention, including the development of pathology at the spinal levels adjacent to the fusion level(s), known, as adjacent segment disease (ASD). LITERATURE REVIEW: ASD has been studied in ACDF surgery, however there are a limited number of large studies that evaluate the correlation between the number of fused spinal levels and the rate of development of symptomatic and radiographic ASD. Mechanisms for the pathogenesis of ASD have been proposed and some are supported by in vitro cadaveric studies, but there is not yet conclusive and strong in vivo evidence in the literature. PROJECT PROPOSAL: This retrospective cohort study will be comparing rates of ASD development following short segment (one and two-level), and long segment (three or more levels) ACDF in patients with a minimum of three years of follow-up. Patients are evaluated for ASD via review of electronic medical records, including operative reports, outpatient and hospital charts, and evaluation of imaging studies. Images are assessed for radiographic ASD using the Kellgren-Lawrence criteria, and these results are subsetquently evaluated for correlation with symptomatic ASD. This study aims at investigating the incidence rates and relative risk of developing ASD and evaluate for statistically significant difference using chi-square analysis. CONCLUSION: More research is still needed to confirm the mechanism of pathogenesis of ASD and determine the effect that length of fusion construct has on the incidence of this disease. Further information will help guide physicians in their clinical decision making in the surgical treatment of patients with ACDF and those that subsequently develop ASD.
An audit of the workload of an acute surgery unit in a tertiary academic hospital before and after the closure of a referring community hospitalMoodie, Quintin Keith January 2015 (has links)
Aim: An audit of the workload of an Acute Care Surgery Unit in a Tertiary Academic Hospital and an assessment of the impact on this Unit by the closure of a busy Community Hospital. Background: The primary mission of the Acute Care Surgery service is to provide timely surgical assessment, operative and/or non-operative management of the acutely ill non-trauma surgical patient. Both locally and internationally, fewer surgeons are perusing general practice, opting instead for subspecialty training, with no or only minimal time spent in emergency surgical care. This is demonstrated for example by evidence that some colorectal surgeons refer diseases of the appendix to the general surgeon, reflecting the narrow point of care that is being practiced in certain fields of surgery. In many cases acute care surgery has been described as a multidisciplinary approach involving Emergency and Trauma Surgery, and Critical Care Medicine.(1-3) In South Africa the rules and regulation by the Health Professions Council stipulates the requirement of training and qualifying as a General Surgeon, before pursuing Fellowship training in a field of subspeciality. As treatment paradigms shift and surgical emergency disease management evolves, we need properly trained surgeons that are willing to pursue the optimal emergency care (surgical or non-operative) for specific conditions in patients presenting with these acute surgical emergencies.(2,4) Groote Schuur Hospital (GSH) is privileged in its provision of an Acute Care Surgical Unit (ACSU) that functions in a tertiary environment and is affiliated with the University of Cape Town (UCT), the leading ranked University on the African Continent. The ACSU in GSH has 28 dedicated beds, and functions as a secondary and tertiary level General Surgery Unit excluding all acute trauma care. Provision is also made for the management of primary level surgical diseases. A neighboring surgical referral hospital, GF Jooste Hospital (GFJH), has 90 dedicated surgery beds. It is a Community Hospital, which caters for primary and secondary level diseases. Acute care is also given to tertiary level trauma and emergency surgical diseases. The unit at GFJH will be closing to allow for a reconstruction of the building, and thus the patient population will require access to alternate facilities whilst awaiting the reopening. A subset of these patient will have to be accommodated at GSH.
The isolation, purification, tissue localization and identification of a glycoprotein found in the crude mucus gel of patients with carcinoma of the stomachNthato, Chirwa January 2008 (has links)
Includes bibliographical references (leaves 101-138). / The thin layer of crude mucus lining the human gastric mucosa protects the delicate gastric epithelium from the high shear forces associated with digestion. Gastric mucus is composed largely of water (>90%) and a complex mixture of organic components such as enzymes, various serum and cellular macromolecules, sloughed cells, bactericidal proteins, plasma proteins, inorganic ions and very importantly the mucins, that impart to it its gel-forming properties. Mucins are large heterogenous polymers that are difficult to characterize by traditional biochemical methods. However mucins from different regions of the body do share common features such as a low protein content of approximately 20% by weight and a carbohydrate content of 70 to 80% by weight. Mucins are characterized by a variable number of tandem repeat regions rich in serine, threonine and proline with the serine and threonine being potential sites for O-glycosylation. In contrast to the glycosylated region is the 'naked' region rich in cysteine and susceptible to proteolysis. The cysteine residues enable mucin monomers to form polymers by disulphide bridges. Alterations of mucin expression take place in gastric carcinomas. Our laboratory previously reported the presence of a 40-50 kDa glycoprotein in the mucus of patients with gastric cancer that associated with albumin. The primary aims of our study were to develop an antibody to this 40-50 kDa glycoprotein, and to determine the location of its expression in gastric tissue by the immunohistochemical method, ranging from normal, to premalignant to cancer. The final aim was to identify this unknown glycoprotein by proteomic analysis. The reactivity of the antibody to the mucin and its 40-50 kDa component was determined by Western Blotting.
McPherson, Deidre Estelle Kathleen
Background: Human immunodeficiency virus (HIV) infection and trauma are significant contributors to the burden of disease in South Africa. There is an increase in prevalence of HIV sero-positivity in trauma patients. However, there are conflicting reports about the influence of HIV in outcomes after trauma or surgery. Although HIV and the acquired immunodeficiency syndrome (AIDS) can potentially affect outcomes, there have been few studies comparing trauma outcomes in HIV positive versus HIV negative patients. To the best of our knowledge, there have been no studies to date that have compared HIV positive and HIV negative patients with penetrating (gunshot or stab) abdominal wounds requiring an explorative laparotomy. The purpose of this study was to determine whether the outcome of hemodynamically stable patients undergoing explorative laparotomy for penetrating abdominal trauma differed in HIV positive patients versus HIV negative patients. Methods: This was an observational prospective study over a 16-month period from February 2016 to May 2017. All hemodynamically stable patients with penetrating abdominal trauma requiring a laparotomy were included in the study. To evaluate the impact of HIV on outcome, the mechanism of injury, the HIV-status, age, the penetrating abdominal trauma index (PATI), and the revised trauma score (RTS) were entered into a binary logistic regression model. Outcome parameters were in-hospital death, morbidity (defined as one or more distinct complications) during hospitalization was graded as per Clavien-Dindo classification of complications, admission to intensive care unit (ICU), relaparotomy within 30 days, and length of stay longer than 30 days. Variables were sought in bivariate analysis. Results: A total of 209 patients, 94% male, with a mean age of 29 ± 10 years were analysed. Twenty-eight patients (13%) were HIV positive. The mean CD4 count in the HIV positive group was 401 ± 254. The two groups were comparable except for race; 79% were black in the HIV positive group vs. 41% in the HIV negative group. All patients underwent explorative laparotomy of which 10 (4.8%) laparotomies were negative. There were two (0.96%) deaths, both in HIV negative group. The complication rate was 34% (n=72). There was no association between CD4 count and complications (p=0.234). Twenty-nine patients (14%) were admitted to the ICU. A higher PATI, advancing age, and a lower RTS were significant risk factors for worsened outcome. After 30 days, 12 patients (5.7%) were still in hospital. PATI was the single independent predictor in multivariate analysis. Twenty-four patients (11%) underwent a second laparotomy and the PATI was again the only significant predictor of outcome. Conclusion: The incidence of HIV in our cohort is 13%, which is similar to the reported incidence of HIV in the Western Cape of 15%. There were no significant baseline differences between the HIV positive and negative groups. Our results further showed that HIV status was not an independent predictor for morbidity, admission to ICU, relaparotomy, prolonged hospital stay or mortality. The patient's HIV status does not influence their outcomes in penetrating abdominal trauma.
A review of living donor liver transplantation: why is regeneration more rapid in the recipient compared to the donor?Ibirogba, Sheriff B January 2009 (has links)
Includes bibliographical references (leaves 54-62). / Living donor liver transplantation (LDLT) is now well established and performed on a routine basis in many major centres around the world. LDLT is feasible because of the capacity of both the remnant donor liver and the transplanted partial liver to undergo liver regeneration. However it has been demonstrated that liver regeneration in the recipient is rapid, whereas restoration of liver mass in the donor is delayed. This discrepancy in the rate of regeneration could be due to the presence of hepatotrophic factors and the use of immunosuppression in the recipient. The aims of the studies were to determine if hepatotrophic factors and immunosuppression (Cyclosporine) could modify the restoration of the liver mass after partial hepatectomy in rats.
Mall, Anwarul Haq
It has been reported that there is a 100% incidence of ulceration of the squamous pars oesophagea of the pig's stomach following bile duct ligation. The reproducibility of this model has made possible its use in the investigation of the biochemical aspects of mucus secretion in both the normal state and at various states of ulceration. The main findings are summarised below: Mucus scrapings of the cardiac gland region of the pig stomach had a higher water and total protein content in the pre-ulcerated, ulcerated and post-ulcerated states. Gel chromatography on Sepharose CL-4B indicated larger amounts of degraded mucins relative to native mucins in the samples obtained from pre-ulcerated, ulcerated and post-ulcerated stomachs, as compared with the normal and control samples. The amounts of purified mucins obtained after isopycnic centrifugation in CsCl and gel chromatography on Sepharose CL-2B decreased from the normals and controls to the bile duct-ligated pigs. An analysis on SDS-PAGE revealed a considerable degree of proteolytic degradation of the pig gastric mucins in the bile duct-ligated pigs as compared with the normal and control animals. Staining reagents specific for both the protein and the carbohydrate components of the mucus glycoprotein were employed in gel electrophoresis, which also revealed the presence of contaminating protein, viz. haemoglobin, pepsin, albumin and smaller glycoproteins, to a greater extent in the ulcerated than in the normal and control states. Since pig gastric mucins contain 75% of carbohydrate, the determination of the proportions of monosaccharide constituents was essential. This was performed by GLC analysis of the alditol acetate derivatives of the sugars, which were characterised by mass spectrometry as well as by their retention times, relative to standards, on both packed and capillary columns. The most striking changes indicated by the GLC analyses were a decrease in the fucose content of the mucins from the normal to the ulcerated states and an increase in the proportion of N-acetylglucosamine in mucins from sham-operated animals. The control (sham-operated) pig behaved very similarly to the normal pig for up to 24 hours after the surgical procedure. At 48 hours, however, slight changes resembling those following bile duct ligation occurred. This could be due to the trauma of the sham-operation, which involved the surgical insertion of a cannula in the body region of the pig's stomach. It is possible that, under such stress biosynthesis of the mucins may be affected.
Laparoscopy (to detect occult diaphragm injury) versus clinical and radiological follow up to detect diaphragm injury and herniation, in patients with asymptomatic left thoracoabdominal stab wounds : A prospective randomized controlled studyMalherbe, Gideon F January 2015 (has links)
Background: The need to exclude occult diaphragmatic injury in left thoracoabdominal (TA) stab wounds continues to be controversial. Current trauma guidelines recommend either routine diagnostic thoracoscopy or laparoscopy and repair of an injury if found. Objective: To determine if asymptomatic patients with left sided (TA) stab wounds can be safely treated with careful clinical and chest X-ray follow up to ascertain healing of occult injuries. Methods: A parallel-group, prospective, randomized control study was conducted at the Trauma Centre at the Groote Schuur Hospital from 01 September 2009 through to 01 November 2014. All patients with asymptomatic left TA stab wounds included in the trial were randomized into two groups. Group A underwent diagnostic laparoscopy to exclude a diaphragm injury, and Group B underwent clinical and radiological follow up. Results: Twenty-seven patients were randomized to Group A (n=27) and thirty-one to Group B (n=31). All patients were young males with a median age of 26 years (range from 18 to 48). The incidence of occult diaphragm injury in group A was 29%. Occult injuries found at laparoscopy were all repaired. All patients in group 2 had normal chest X-rays and no symptoms at their last visit. The mean follow up time was 24 months (range of 0 to 58). There was no morbidity nor mortality associated with the conservative management of occult diaphragmatic injuries. The mean hospital stay for the patients in Group A was 5 days (SD 1.3), compared to a mean hospital stay of 2.9 days (SD, 1.5) p < 0.001, in Group B. Conclusions : Clinical and radiological follow up is feasible and appears to be safe in patients with occult diaphragm injuries after left TA stab wounds.
Spence, Richard Trafford
As surgery assumes a greater position in the global health agenda, the need to not only improve access to surgical care but also improve the quality of surgical care, is paramount. Surgical quality improvement programmes have been shown to reduce morbidity and mortality following surgery. A key first step to the design and implementation of a structured surgical quality improvement programme is the collection and analysis of high-quality data. To quote Dr. Margaret Chan, the director general of the World Health Organisation, '…the real need (in global health) is to close the data gaps, especially in low and middle-income countries, so that we no longer have to rely heavily on statistical modeling for data on disease burden.' In this thesis it was hypothesized that emerging m-Health technology, defined as medical and public health practices supported by the use of mobile devices, would provide a solution to close such data gaps. Various m-Health applications were used to develop three databases describing the outcomes of major surgery performed within the Cape Metro West health district during the study period. After reviewing the design and analytical rationale of the American College of Surgeons National Surgical Quality Improvement Programme and Trauma Quality Improvement Programme, these de novo databases were used to develop three quality improvement programmes designed for local implementation: The Essentials programme for general and vascular surgery, a Procedure-targeted programme and a trauma quality improvement programme. Key to these programmes was the derivation and validation of prediction rules which reliably estimate the probability of an adverse outcome following major surgery in a risk-adjusted manner. Such rules promote internal and external benchmarking over time to identify opportunities for quality improvement and critically appraise the impact of any corrective action implemented. In order to improve the quality of surgical care we provide, a continuous cycle of monitoring, assessment, and management should be performed routinely. This thesis provides some guidance of how this can be done within the Cape Metro West health district.
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