BACKGROUND: Hypoxic ischaemic encephalopathy (HIE) is one of the major contributors to neonatal mortality and morbidity in developing countries. Scarcity of resources limits clinicians in optimally caring for these patients. Optimal utilisation of clinical tools such as the Thompson score (TS) can assist in improving care by classifying the severity of HIE followed by appropriate treatment OBJECTIVES: The primary objective was to study the correlation of the TS and early neonatal outcomes in infants with HIE who received therapeutic hypothermia (TH). Secondary objectives were to investigate the correlation of blood gas values with the TS, need for resuscitation with TS, target organ damage (TOD) with TS and the most common risk factors associated with HIE in Tembisa Provincial Tertiary Hospital (TPTH METHODS: This was a retrospective record review of infants admitted with HIE from January 2018 to August 2019 at the TPTH neonatal unit. Infants had to have successfully completed TH RESULTS: Ninety-three infants met the inclusion criteria, with 32,48 and 13 being classified into the mild, moderate and severe categories by TS, respectively. The median length of stay (LOS) was noted to rise with a rising TS, recorded to be 7, 8 and 9 days in the mild, moderate and severe groups, respectively. The mortality rate in the study was calculated to be 2.1%, and there was no significant difference across the groups (p=0.231). A need for antiseizure medication (ASM) on discharge was significantly associated with severe HIE (p=0.028). Hypertension was a frequent chronic illness, noted in 11.3% of the mothers. The most frequent perinatal risk factor was meconium aspiration (50.5%), followed by prolonged second stage of labour (PSSL) (17.2%). A higher TS (severe group) was associated with prolonged resuscitation for >10 minutes (p=0.001) and a need for adrenaline (p=0.008). The frequency of cardiac impairment, liver impairment and clinical seizures increased with a higher TS category (p=0.23, p=0.35 andp=0.51, respectively). On blood gas analysis, a low pH and a high base deficit were associated with severe HIE (p=0.027, p=0.061, respectively CONCLUSION: The TS is still a useful clinical tool in the era of TH as it is able to predict some early neonatal outcomes such as LOS and a need for ASM at discharge. It is also able to demonstrate increased frequency of duration of resuscitation and a need for adrenaline in severely encephalopathic infants compared with mild. A high TS is also associated with severe metabolic acidosis and increased frequency of TOD. Maternal hypertension, meconium-stained liquor and PSSL are the common risk factors for HIE at TPTH

Abstract Alternobaric facial palsy or paralysis is a neuropraxia of the seventh cranial nerve due to pressure changes. It occurs in the context of Eustachian tube dysfunction, facial nerve canal dehiscence, and changes in atmospheric pressure. It is considered a rare complication of barotrauma. Its prevalence is difficult to estimated, and this condition is probably underreported. The most common form of presentation includes facial weakness, ear fullness or pressure, hearing loss, otalgia, facial and lingual paresthesias. Most episodes are transient, lasting from minutes to a few hours, with a subsequent complete recovery. Among the possible differential diagnoses are peripheral and central causes of facial paralysis, which must be suspected due to the persistence of symptoms over time or the presence of other neurological signs or symptoms. The initial evaluation should include a complete otoneurological examination. Computed tomography of the temporal bone is useful for the visualization of facial canal dehiscence. Prevention of further episodes includes practicing effective equalization, Eustachian tube dysfunction treatment, and in certain specific cases, alternative middle ear ventilation methods such as tympanostomy tubes. Once facial paralysis is established, if spontaneous recovery does not occur, the use of corticosteroids is considered an option. A case of recurrent alternobaric facial paresis and a review of the literature are presented.

Resumen La parálisis o paresia facial alternobárica es una neuropraxia del séptimo nervio cra-neal debido a cambios de presión. Se produce en el contexto de una disfunción de la trompa de Eustaquio, una dehiscencia canal del nervio facial y cambios en la presión atmosférica. Se considera una rara complicación de barotrauma. Su prevalencia es difícil de estimar y, probablemente, se encuentre subreportada. La forma de presentación más habitual incluye paresia facial, plenitud aural, hipoacusia, otalgia, parestesias faciales y linguales. La mayoría de los episodios son transitorios, con una duración entre minutos y algunas horas, con recuperación posterior completa. Entre los diagnósticos diferenciales se encuentran causas periféricas y centrales de paresia facial, las cuales hay que sospechar ante la persistencia de los síntomas en el tiempo o ante la presencia de otros signos o síntomas neurológicos. La evaluación inicial debe incluir un examen otoneurológico completo. La tomografía computarizada de hueso temporal favorece la visualización de posibles dehiscencias del canal del facial. La prevención de nuevos episodios incluye la práctica de ecualización efectiva, la resolución de la disfunción de la trompa de Eustaquio y en algunos casos específicos, métodos alternativos de ventilación del oído medio como la colocación de tubos de ventilación. Una vez instalada la parálisis facial, si no se produce recuperación espontánea, el uso de corticoides es una opción. Se presenta un caso de paresia facial alternobárica recurrente y una revisión de literatura.

BACKGROUND: Antibiotic dosing in critically ill patients is complicated by variations in the pharmacokinetics of antibiotics in this group. The dosing of imipenem/cilastatin is usually determined by severity of illness and renal function OBJECTIVES: To determine the correlation between estimated glomerular filtration rates (eGFRs) calculated with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and imipenem trough levels in critically ill patients METHODS: This prospective observational study was done in the surgical intensive care unit (ICU) at Steve Biko Academic Hospital, Pretoria, South Africa. Imipenem trough levels were measured by high-performance liquid chromatography and compared with eGFRs calculated with the CKD-EPI equation. Correlation was evaluated by the Pearson product-moment correlation coefficient RESULTS: The study population consisted of 68 critically ill patients aged between 18 and 81 years; 43 (63%) were male, and the mean weight was 78 kg (range 40 - 140). On admission, 30 patients (44%) had sepsis, 16 (24%) were admitted for trauma, and 22 (32%) were admitted for miscellaneous surgical conditions. Acute Physiology and Chronic Health Evaluation II (APACHE II) scores ranged from 4 to 39 (mean 18). The 28-day mortality rate was 29%. The mean albumin level was 16 g/L (range 7 - 25), the mean creatinine level 142 μmol/L (range 33 - 840), and the mean eGFR 91 mL/min/1.73 m² (range 6 - 180). Imipenem trough levels ranged between 3.6 and 92.2 mg/L (mean 11.5). The unadjusted Pearson product-moment correlation coefficient between eGFR and imipenem trough level was -0.04 (p=0.761 CONCLUSION: Considering the high mortality rate of sepsis in ICUs and the rapid global increase in antimicrobial resistance, it is crucial to dose antibiotics appropriately. Owing to the variability of antibiotic pharmacokinetics in critically ill patients, this task becomes almost impossible when relying on conventional dosing guidelines. This study found that eGFRs do not correlate with imipenem blood levels in critically ill patients and should not be used to determine the dose of imipenem/cilastatin. Instead, the dose should be individualised for patients through routine therapeutic drug monitoring

BACKGROUND. The drug levels and clearances of imipenem in critically ill patients are not comprehensively described in current literature, yet it is vital that adequate levels be achieved for therapeutic success. OBJECTIVES. To determine the proportion of critically ill patients treated with imipenem/cilastatin with sub-therapeutic imipenem plasma levels, and to compare the clinical outcomes of those patients with therapeutic levels with those who had sub-therapeutic levels. Methods. Trough imipenem plasma levels of 68 critically ill patients from a surgical intensive care unit were measured using a validated high-performance liquid chromatography method. Imipenem trough levels were compared with the minimum inhibitory concentration (MIC) of the causative bacterial agents, based on a target value of 100% time above MIC (/T >MIC). RESULTS. The proportion of participants with sub-therapeutic imipenem levels was 22% (95% confidence interval (CI) 13% - 34%). The 14- and 28-day mortality rates in the sub-therapeutic group were 33% and 40%, respectively, compared with 19% (p=0.293) and 26% (p=0.346), respectively, in the therapeutic group. Sub-therapeutic imipenem plasma levels are associated with adjusted hazard ratio of 1.47 (95% CI 0.55 - 3.91). CONCLUSIONS. The lower proportion of critically ill patients with sub-therapeutic imipenem plasma levels in this study compared with previous studies may be attributed to the practice of higher dosages and the administration method of extended infusions of imipenem/ cilastatin in our setting. The results demonstrate a trend of higher mortality in patients with sub-therapeutic imipenem levels, although the results were not statistically significant at this sample size.

BACKGROUND. Since 2000, South Africa (SA) has had a relatively static neonatal mortality rate, estimated to be 12/1 000 live births, with complications of prematurity being the leading cause of neonatal mortality. Survival to hospital discharge of small infants has improved over the last few decades; however, this is more marked in developed countries where neonatal intensive care, nasal continuous positive airway pressure, mechanical ventilation and surfactant are available to the majority of infants. OBJECTIVES. The primary objective was to determine overall mortality of very low-birthweight and extremely low birthweight (ELBW) infants in the neonatal unit at Steve Biko Academic Hospital (SBAH). Secondary objectives were to determine the frequency of major morbidities, identify factors associated with morbidity and mortality, determine survival without major morbidity, and whether birthweight can accurately predict outcome. METHODS. This was a retrospective cross-sectional study of infants with a birthweight of 500 - 1 499 g who had been admitted to the neonatal unit of SBAH between June 2016 and May 2017. RESULTS. Overall survival to hospital discharge was 75.7%, with only 17.7% of infants weighing <750 g surviving. Survival without major morbidity was 35.1%. Small-for-gestational age, invasive ventilation, and culture-positive early-onset sepsis were associated with an increased risk of mortality, whereas higher birthweight and the use of nCPAP decreased mortality in multivariable analysis. CONCLUSION. Although the overall survival of infants weighing <1 500 g is comparable to other large SA public hospitals, survival of ELBW infants is poor, while these are the infants that require the most interventions, placing a heavy burden on limited resources. However, it remains difficult to recommend a cut-off weight for potentially life-saving interventions.

BACKGROUND: Successful extubation of mechanically ventilated patients is essential for the physiotherapist to succeed in respiratory rehabilitation of the patient. Delay in the weaning process increases the complication rate of mechanical ventilation. A variety of parameters are used as predictors of extubation readiness, but the association between muscle strength (deltoid, neck flexor muscle group and trapezius), endurance and extubation readiness has not been determined OBJECTIVES: The aim of the study was to determine if muscle strength and endurance can be used as possible predictors of successful extubation in mechanically ventilated patients. The objectives were to determine if muscle strength measured with the Oxford grading scale can be used as a possible predictor, and if muscle endurance measured with the MOTOmed letto2 cycle ergometer can be used as a possible predictor METHODS: During the pilot study, 37 subjects were recruited. Deltoid, neck flexors and trapezius muscle strength was tested using the Oxford grading scale and respiratory muscle strength using maximum inspiratory and expiratory pressures. Endurance was determined by riding the MOTOmed letto2 cycle ergometer for 5 minutes with the upper limbs RESULTS: Muscle strength of the deltoid and the neck flexor muscle group tested with the Oxford grading scale was associated with successful extubation respectively, (p=0.022; p=0.019). Muscle endurance tested with the MOTOmed letto2 cycle ergometer also demonstrated an association with successful extubation (p=0.014 CONCLUSION: Future studies with larger sample sizes are recommended

BACKGROUND. Advances in intra-abdominal pressure (IAP) measurement have enabled better monitoring and physiological manipulation of patients with intra-abdominal hypertension or abdominal compartment syndrome. This study aimed to determine the correlation between transvesical (TV), transgastric (TG) and direct transperitoneal (TP) IAP monitoring at different IAPs in porcine models. OBJECTIVES. To assess the statistical agreement between TV, TG and TP pressure monitoring in a pneumoperitoneum and an intestinal obstruction intra-abdominal hypertension model at different IAPs. METHODS. Fifty-nine pigs were divided into six groups: a control group (Cr; n=5), three pneumoperitoneum groups at pressures of 20 mmHg, 30 mmHg, and 40 mmHg (Pn20, Pn30, Pn40; n=40), and two intestinal-occlusion groups at pressures of 20 mmHg and 30 mmHg (Oc20, Oc30; n=14). IAP was simultaneously measured in each pig using the three methods at different times. The control group did not have any intervention to increase the IAP. Intra-class correlation was used to assess agreement between the methods. RESULTS. At pressures >20 mmHg, all three methods showed good correlation with each other (Pn20=0.87; Pn30=0.96; Pn40=0.88; Oc20=0.69; Oc30=0.86). Correlation between TP and TG (Cr=0.0; Pn20=0.85; Pn30=0.94; Pn40=0.90; Oc20=0.78; Oc30=0.78); TP and TV (Cr=0.0; Pn20=0.83; Pn30=0.95; Pn40=0.86; Oc20=0.59; Oc30=0.88); and importantly between TV and TG (Cr=0.0; Pn20=0.95; Pn30=0.98; Pn40=0.88; Oc20=0.69; Oc30=0.91) was good. CONCLUSION. All three measurement methods showed good correlation at pressures >20 mmHg and were unaffected by the type of IAP model. These results suggest that either transvesical or transgastric pressure measurements can be used for IAP measurement when TP pressures are >20 mmHg.

BACKGROUND. In Africa, data on the relationship between oncogenic human papillomavirus (HPV) types, immune status and cervical preinvasive lesions are lacking. METHODS. We investigated low-risk (lrHPV) and high-risk (hrHPV) HPV types in a cohort of women with cervical intraepithelial neoplasia (CIN) II/III confirmed on histological examination, in an urban setting with a high prevalence of HIV infection. RESULTS. Of 270 women with confirmed CIN II/III, 45 were HIV-negative and 225 HIV-positive. HIV-infected women had significantly more HPV type infections, including all HPV (p<0.001) and hrHPV (p=0.014) types. The prevalences of one or more hrHPV type/s were 93.3% and 92.9% in HIV-negative and positive patients, respectively. The most prevalent hrHPV type among HIV-negative women was HPV 16, followed by HPV 52, 31, 35 and 58. Among HIV-positive women, HPV 16 was followed by HPV 58, 35, 51 and 52. Not yet qualifying for highly active antiretroviral therapy (HAART) (CD4 count >350 cells/μL) or having received HAART for ≥12 months were negatively associated with HPV 18, 33, 45, 51, 52, 59 and 82. CONCLUSIONS. In South Africa, burdened by the HIV pandemic, high numbers of high- and low-risk HPV type infections are present in women with cervical preneoplasia. HPV type distribution differs among varying levels of HIV-induced immune depletion.

BACKGROUND: The time from birth to the first paediatric surgical consultation of neonates with gastroschisis is a predictor of mortality in developing countries. This is contrary to findings in the developed world. We set out to document this relationship within our population. METHODS: Neonates with gastroschisis who were transferred to Steve Biko Academic Hospital within the study period were included. The association between mortality and demographic, clinical and biochemical variables was assessed. Significant variables after univariate analysis were subjected to multivariate regression. RESULTS: Sixty patients were included. The mortality rate was 65%. Mean transfer time and distance were 14.9 hours and 225km. Forty-eight per cent of the neonates were either clinically dehydrated or in hypovolaemic shock on arrival. It was shown through univariate analysis that female sex, appropriate weight for gestational age, hydration status, gestation, transfer time, serum urea, base deficit and serum bicarbonate (HCO3) were significant predictors of mortality. Only female sex, appropriate weight for gestational age and serum HC03 were shown to be significant using multivariate analysis. CONCLUSION: Our high mortality rate was not due to lengthy transfer times. The poor clinical condition of the patients on arrival at our hospital, which relates to deficiencies in the neonatal transfer system, had a direct impact on the survival of neonates with gastroschisis.

BACKGROUND: Serious infections in children are difficult to determine from symptoms and signs alone. Fever is both a marker of insignificant viral infection, as well as more serious bacterial sepsis. Therefore, seeking markers of invasive disease, as well as culture positivity for organisms, has been a goal of paediatricians for many years. In addition, the avoidance of unnecessary antibiotics is important in this time of emerging multiresistant micro-organisms. OBJECTIVE: To ascertain whether acute-phase reactant tests predict positive culture results. METHODS: A prospective, cross-sectional study over a 1-year period included all documented febrile children under the age of 5 years (with an axillary temperature >38°C) who presented to Steve Biko Academic Hospital, Pretoria, with signs and symptoms of pneumonia, meningitis and/or generalised sepsis. Every child had clinical signs, chest radiograph findings, urine culture, blood testing (full blood count, C-reactive protein, procalcitonin) and blood culture results recorded. RESULTS: A total of 63 patients were enrolled, all of whom had an axillary temperature >38°C. C-reactive protein, procalcitonin and white cell count did not predict the presence of positive blood culture or cerebrospinal fluid culture results, nor infiltrates on chest radiographs. No statistically significant correlations were found between the duration of hospital stay and the degree of fever (p=0.123), white cell count (p=0.611), C-reactive protein (p=0.863) or procalcitonin (p=0.392). CONCLUSION: Biomarkers do not seem to predict severity of infection, source of infection, or duration of hospitalisation in children presenting to hospital with fever. The sample size is however too small to definitively confirm this viewpoint. This study suggests that clinical suspicion of serious infection and appropriate action are as valuable as extensive testing.

BACKGROUND: Pneumocystis jiroveci pneumonia is still a common cause of severe disease in HIV-infected infants <5 months of age. Despite attention to the prevention of mother-to-child transmission programme in South Africa (SA), HIV testing remains incomplete and infants are still at risk. The management of Pneumocystis pneumonia requires ventilation strategies and combination antibiotics. METHODS: A prospective but open intervention was performed on all HIV-exposed patients admitted with severe pneumonia to the paediatric intensive care unit (PICU) at Steve Biko Academic Hospital, SA, during a 3-year period from January 2009 to December 2011. All patients were treated with ampicillin, amikacin, co-trimoxazole, prednisone and intravenous gancilovir. Highly active antiretroviral therapy (HAART) was initiated in the PICU as soon as tuberculosis was excluded and HIV status confirmed with an HIV viral load (VL). Routine blood and tracheal specimens were cultured for bacteria and tested by direct fluorescent antigen testing for P jiroveci. Cytomegalovirus (CMV) VL was tested. All infants were ventilated in a standard fashion and none were oscillated. RESULTS: A total of 87 patients were admitted during the 3-year period. Of these, 29 patients were excluded from the study because they were HIV-unexposed. Ten patients died during the 3-year period. In a multivariate analysis of the presence or absence of P jiroveci, HIV VL, CD4 count, timing of HAART initiation and CMV VL, no single factor was documented to influence mortality. CONCLUSION: Mortality from Pneumocystis pneumonia continues to decrease in this PICU. No single factor is responsible and yet all therapeutic strategies contribute to survival. A national policy and guideline is urgently required.

BACKGROUND: Asthma and allergic rhinitis affect 15% and 38% of South African (SA) children, respectively. The housedust mite (HDM) is the most significant indoor aeroallergen. Typical HDM species include Dermatophagoides pteronyssinus, D. farinae and Blomia tropicalis. Conventional skin-prick testing (SPT) panels only test for Dermatophagoides. B. tropicalis has been described in the tropical and subtropical regions, but is not routinely tested for in SA. OBJECTIVE: To ascertain the significance of B. tropicalis as an aeroallergen in northern coastal KwaZulu-Natal Province (KZN), a tropical environment, and in Johannesburg in the highveld, where the climate is milder and less humid. METHODS: Children aged 1 - 18 years with features of allergic rhinitis and/or asthma were recruited over a 6-month period from Alberlito Hospital in northern KZN and the Clinton Clinic in Johannesburg. SPTs included Dermatophagoides and B. tropicalis. Sensitisation was defined as a wheal 3 mm greater than the negative control. RESULTS: Eighty-five subjects were included, 50 in northern KZN and 35 in the Johannesburg arm; 52% of subjects in northern KZN and 3% in Johannesburg were sensitised to B. tropicalis, with a significant difference between these centres (p<0.05). Of the 52% sensitised to B. tropicalis in northern KZN, half were sensitised only to B. tropicalis. CONCLUSION: There is a high prevalence of B. tropicalis allergy in the tropical northern KZN region and a much lower prevalence in the Johannesburg region. Routine testing for B. tropicalis allergy should be employed in northern KZN.

BACKGROUND: Cervical cancer is preventable, but still highly prevalent in South Africa (SA). Screening strategies in the country have been ineffective, and new ways to prevent the disease are needed. OBJECTIVES: To investigate the feasibility of linking cervical cancer screening in adult women to human papillomavirus (HPV) vaccination in schoolgirls. METHODS: Ten primary schools in the South-West District of Tshwane, Gauteng Province, SA, took part in the study. Cervical cancer and HPV vaccine information was provided to schoolgirls and their parents. Consented schoolgirls were vaccinated and their female parents were invited to participate in self-screening. RESULTS: Among 1 654 girls invited for vaccination, the consented and invited uptake rates were 99.4% and 64.0%, respectively. Vaccine completion rates were higher in schools where the vaccination programme was completed in the same calendar year than in those where it was administered over two calendar years. Of 569 adult females invited, 253 (44.5%) returned screen tests; 169 (66.8%) tested negative and 75 (29.6%) positive for any high-risk HPV (hrHPV). There were no differences in level of education, employment status or access to healthcare between women with positive and those with negative screen results. CONCLUSIONS: Implementation of HPV vaccination in a primary school-based programme was successful, with high vaccine uptake and completion rates. Self-screening reached the ideal target group, and it is possible to link cervical cancer screening to the cervical cancer vaccine by giving women the opportunity of self-sampling for hrHPV testing. This is a novel and feasible approach that would require some adaptive strategies.

INTRODUCTION: There are few published data from South Africa (SA) on the outcomes ofblack HIV-positive patients receiving chronic haemodialysis. METHODS: This retrospective study compared the incidences of vascular and infectious morbidity and mortality in black HIV-positive patients with those in a group of HIV-negative patients matched for ethnicity, age and gender. All the patients were receiving chronic haemodialysis in the medically insured healthcare sector of SA. RESULTS: The incidence of tuberculosis and hospital admission rates for vascular access-related infections were significantly higher in the HIV-positive group than the HIV-negative group. The HIV-positive group had significantly lower albumin (p<0.05) and haemoglobin levels (p<0.01), but this did not impact on mortality. Survival in both groups was excellent. In the HIV-positive group, viral suppression rates were suboptimal with <50% of patients on antiretroviral therapy completely virally suppressed. CONCLUSION: This study has shown that black HIV-positive patients receiving chronic haemodialysis in a healthcare-funded environment in SA have excellent overall survival in spite of higher hospital admission rates and higher infectious morbidity compared with HIV-negative patients.

BACKGROUND. The kinesio-taping method, which is becoming increasingly popular, may provide support and stability to joints and muscles without inhibiting range of motion. OBJECTIVE. The aim of the study was to determine the effect of kinesio-taping of the gluteus medius muscle on x-factor (torso-pelvic separation), ball flight distance and accuracy (smash factor ratio). A specific aim was to determine whether a correlation exists between hip abduction strength and x-factor, ball distance and accuracy. METHODS. This study is a one group pretest-posttest quasi-experimental design which took place at a golf facility. Twenty-nine amateur golfers with handicap of scratch ±2, who were between the ages of 18- and 25-years, participated in this study. Biomechanical outcomes were recorded with and without kinesio-tape applied on the gluteus medius muscle of the trail leg. Biomechanical golf swing analysis with the iClub™ Body Motion System determined the x-factor at the top of the backswing. Ball flight distance and accuracy were measured with FlightScope® and dominant hip abduction strength was measured with the MicroFET Hand-held Dynamometer. RESULTS. Kinesio-tape is effective in improving the relative hip abduction strength (p<0.001), although the effect size was small (Cohen's d=0.24). With regard to the biomechanical outcome measures, namely x-factor (p=0.28), ball flight distance (p=0.53) and accuracy (p=0.1), there was no significant improvement. CONCLUSION: Even though the relative hip abduction strength was improved, there was no effect on golf swing biomechanics. This can be explained due to the fact that x-factor, ball flight distance and accuracy are dependent on a combination of body movements to produce the golf swing.