Management of HIV Vasculopathy – A South African Experience

The aim of the study was to describe the presentation management and short term results of therapy (< 1 month) in patients admitted with HIV vasculopathy.Records were culled from a prospectively maintained data base on the Vascular Unit at Inkosi Albert Luthuli Hospital, Durban, South Africa between January 2005 and June 2009.226 patients were studied; 111 had aneurysms and 115 occlusive disease. 98% were African and ages ranged from 4–53 years (average 36); 90% were male. The CD4 count ranged from 1–930 cells/mm³ while serum albumin averaged 30 mMol/L.202 aneurysm presented in 111 participants; commonest sites were superficial femoral artery (40%) and carotid (25%). 82 patients had standard operative repair and 8 had stent grafts; 29 were not treated due to advanced disease.Within 30 days of operation the mortality was 9% with 5% developing graft sepsis and 11% pulmonary complications.Of 115 with occlusive disease, there were 2 distinct groups. 51 had no previous claudication and had acute thrombosis; no thrombophilia could be demonstrated. 64 had premature atherosclerotic disease. The majority presented with critical ischaemia.In the acute thrombosis group 15 (29%) had primary amputation, limb salvage was achieved in 13 (36%) and 4 died (11%). In the chronic occlusive group 30 (47%) had primary amputation, of 25 submitted to surgery limb salvage was achieved in 17 (68%).Low CD4 count and albumen levels did not correlate with mortality or complications.ConclusionSurgical therapy for aneurysm is worthwhile in the short term.Following occlusive disease there is a 25% overall salvage rate in the short term (< 1/12) but the long term outlook is uncertain.     

Postoperative pain management—practice guidelines

Establishment of an acute pain management programme is considered essential to reduce the incidence and severity of postoperative pain experiences of surgical patients in surgical wards. Several quality assurance standards and practice guidelines on pain management for professionals involved in the treatment of pain have been presented. Assessment of pain, using accepted approaches, should be undertaken at regular intervals at rest, during movements and at an appropriate interval after any intervention. It is essential to document pain scores and also to include assessment of patient satisfaction with the postoperative pain management provided so that pain and its treatment is made clearly visible in the clinical setting. A program for acute pain management should also include assessment of the adherence to the accepted postoperative pain management standards over time within the organization.     

The Effect of Diosmin Hesperidin on Intestinal Ischaemia — Reperfusion Injury

Aim: The effect of Diosmin Hesperidin on intestinal ischaemia reperfusion injury was evaluated in an experimental model in rats.

Material and methods: Forty Spraque-Dawley rats were divided into 4 groups of (n = 10) (sham, sham + Diosmin Hesperidin, Reperfusion, Reperfusion + Diosmin Hesperidin). Diosmin Hesperidin oral gavage was administrated at a dose of 50 mg/kg to rats 14 and 2 hours before the operation and 30 minutes of ischaemia and 30 minutes of reperfusion was performed in the groups when appropriate. Ileum samples were resected for histopathological evaluation and tissue malondialdehyde (MDA) and myeloperoxidase (MPA) level determination.

Results: Mean mucosal injury score of IR group (4,50 ± 0,23) was significantly higher than the other groups (p < 0.05). Although mean mucosal injury score of IR + DH group was higher than sham and sham + DH groups, difference was not statistically significant (p > 0.05). Tissue MDA and MPO activities of IR group were 45,55 ± 2.61 nmol/g/wet tissue and 1.68 ± 0.25 U/g/wet tissue respectively and were significantly higher than the other groups (p < 0.008). Although tissue MDA and MPO activities of IR + DH group was higher than sham and sham + DH groups, differences were not statistically significant (p > 0.008).

Conclusion: Diosmin Hesperidin seems to be effective in the prevention of intestinal reperfusion injury.     

The effect of labor and/or ovariectomy on rodent continence mechanism—The neuronal changes

Many women develop stress urinary incontinence (SUI) after childbirth, but the exact neuronal changes are largely unknown. This study is designed to identify the neuronal changes associated with pregnancy, delivery and ovariectomy. A total of 10 virgin and 48 pregnant rats were used. Cystometry and stress/sneeze tests were performed in the virgin once and the pregnant rats at certain time points. Postpartum the rats were equally grouped as follows: group I: delivery, group II: delivery + ballooning, group III: delivery + ovariectomy, group IV: delivery + ballooning + ovariectomy. Tissues from bladder, bladder neck, and urethra were analyzed by immunostaining for PGP 9.5, CGRP, SP, NPY, VIP, TH, n-NOS. We found complex innervation changes in the different tissue samples. Since the bladder neck and the mid-urethra play an important role in the continence mechanism the neuronal changes in these areas contribute to the observed functional changes.Supported in part by the Deutsche Forschungsgemeinschaft (grant Si 679/1–1) and the National Health Institute of Health grant 2 R01 DK51374 and a grant from the Montgomery Street Foundation.     

The current management of tibial fractures: are clinical guidelines effective?

BACKGROUND: The production of clinical guidelines is increasing and will continue to do so with the introduction of clinical governance. In 1997, the British Orthopaedic Association (BOA) and the British Association of Plastic Surgeons (BAPS) published joint guidelines on the management of open tibial fractures. It is not known whether these guidelines reached their target audience, or indeed influenced clinical practice. METHODS: We determined the effectiveness of these guidelines by sending a postal questionnaire survey to 172 orthopaedic surgeons. RESULTS: Only 57% of consultants were aware of the guidelines, 70% of registrars and 25% of staff grades. Less than 29% of orthopaedic consultants would choose to consult the plastic surgical team pre-operatively in the management of an open tibial fracture and only 43% would seek plastic surgical involvement at all. The primary aim of increasing multidisciplinary communication has not been achieved. CONCLUSIONS: The awareness of, and adherence to, these guidelines is sub-optimal. This clearly has implications for both the future management of open tibial fractures and the further production of guidelines.     

The Küntscher Society: the South American perspective

This paper reviews the beginning of the South American Council of the Küntscher International Society, a group of enthusiastic South American Orthopaedic Surgeons committed to teach the principles and advances of intramedullary nailing technique in this part of the world. The goals, current and future educational activities are highlighted.     

A review of guidelines on benign prostatic hyperplasia and lower urinary tract symptoms: are all guidelines the same?

OBJECTIVE: To compare overall and methodological quality with content in national and supra-national Clinical Practice Guidelines (CPGs) on benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS), as the purpose of CPGs is to reduce unwanted variation in practice and improve patient care by setting agreed standards based on the best available evidence. METHODS: An electronic search was used to identify Internet-based national and supra-national CPGs on BPH and LUTS available in 2001. Two independent assessors analysed the content and appraised the methodological quality of the CPGs using an existing and validated instrument (St. George's Hospital Medical School Health Care Evaluation Unit Appraisal Instrument) comprising 37 items grouped into three broad areas, i.e. rigour of development, context and content, and clinical application. RESULTS: Eight CPGs were suitable for appraisal; there was much variation in overall and methodological quality. There was agreement that a patient history and physical examination (including a digital rectal examination) should be used in all symptomatic men. In addition, patients' symptoms should be assessed using a validated symptom score, e.g. the International Prostate Symptom Score. There was considerable variation in the number and type of diagnostic tests recommended for routine assessment. CPGs scoring low on the appraisal instrument (indicating poor overall and methodological quality) were more likely to recommend more diagnostic tests than those scoring high. There was general agreement between the guidelines on the treatment of BPH/LUTS and the importance of the patient's involvement in making management decisions. Guideline quality was independent of local health resources and publication year. CONCLUSION: The overall and methodological quality of CPGs on BPH/LUTS varies considerably. There appears to be an inverse relationship between guideline quality and the number of diagnostic tests recommended for routine assessment. Using CPGs of high quality may prevent men with BPH/LUTS being exposed to tests of doubtful utility. Although this may reduce both resource use and exposure to potential harm, moving to a more minimalist approach to diagnosis may itself be potentially harmful to patients.     

Fuel tanker fire disaster — South Sudan experience

In the last 15 years 26 incidents involving transport of fuel have been recorded from 17 countries throughout the world. More than 1,300 people have died, and at least 791 have received burn injuries. One such devastating event was attended by the senior author in South Sudan.These incidents have been more common in third world countries and have proved a major problem for the local health services.This paper summarises the experience in South Sudan in addition to principle issues and possible causative factors then suggests relevant preventative measures to reduce similar incidents in the future.