Caesarean section is a common surgical procedure, accounting for almost a third of all surgical procedures in low- middle-income countries. Enhanced recovery after Caesarean section (ERAC) programmes are rarely implemented in resource-limited settings. This study evaluated a tailored enhanced recovery programme's impact on quality of recovery after elective Caesarean section in a Johannesburg public hospital. This was a prospective, observational, before-after cohort study. Fifty-two patients (aged ≥18 yr) undergoing elective Caesarean section were analysed, comprising a pre-ERAC cohort (n=25), analysed from 8 to 22 April 2024 and a post-ERAC cohort (n=27), analysed from 3 to13 June 2024. The primary outcome was postpartum recovery measured by the Obstetric Quality of Recovery-10 score. There was a significant improvement in Obstetric Quality of Recovery-10 scores post-ERAC, with a difference in medians of 9 between cohorts (95% confidence interval: 6-14; P<0.001). There was also a significant reduction in opioid consumption with a median decrease of 10 mg oral morphine equivalent in the post-ERAC cohort in the first 24 h after operation (95% confidence interval: -26 to 6; P<0.001). Time to urinary catheter removal, time to first oral intake, time to first mobilisation, and preoperative fasting for liquids all showed significant improvement in the post-ERAC cohort. There was no difference in length of stay and other secondary outcomes. This study demonstrates that ERAC implementation in a resource-limited setting is feasible and can enhance maternal recovery after elective Caesarean section. These findings highlight the potential for ERAC programs to significantly improve patient-centred outcomes in low-middle income countries.

Paediatric anaemia is a major public health problem affecting millions of children globally, with a high prevalence in low- and middle-income countries. There is limited data on the prevalence of preoperative anaemia in healthy paediatric surgical patients presenting for routine surgery. The primary aim of the study was to describe the prevalence and severity of anaemia. Secondary aims were to describe the association between anaemia and demographic variables, nutritional status, and deworming status in these children. This was a prospective, cross-sectional study and included children aged 6 months to 11 years, American Society of Anaesthesiologists (ASA) physical status classification 1 and 2, presenting for elective surgical and diagnostic procedures performed under sedation or general anaesthesia at two tertiary hospitals in Johannesburg between January and May 2024. Anaemia was defined using age-specific cohorts according to the 2001 World Health Organization (WHO) definition of paediatric anaemia. Screening was done using the point-of-care haemoglobin device HemoCue®. Univariate statistical associations were performed using χ² tests for categorical variables, and Wilcoxon rank sum tests for continuous variables. Multivariable logistic regression was used to assess associations between demographic variables (age, sex, nutritional status, deworming status) and the presence of anaemia. In addition, Spearman’s correlation was performed as an exploratory test. P-values <0.05 were considered statistically significant. A total of 290 children with a median age of 4.2 (2.2–7.1) years were included in the study. The prevalence of anaemia was 31.4% (95% confidence interval [CI] 26.1–37.1). Anaemia was classified as mild in 57.1% (95% CI 46.3–67.5), moderate in 40.7% (95% CI 30.5–51.5), and severe in 2.2% (95% CI 0.3–7.7). A significant association was found between age and the likelihood of anaemia (adjusted odds ratio 0.61, 95% CI 0.35–1.05). There were no significant associations found with sex, nutritional status, and deworming status. There is a notable prevalence of preoperative anaemia in paediatric patients in this South African middle income country. Children under the age of 5 years have the highest prevalence overall. The majority of patients have mild anaemia. Identifying anaemia at the surgical visit provides a valuable opportunity for health education and promotion.

Introduction: Spontaneous subarachnoid haemorrhage (SAH) is caused by a ruptured aneurysm in most cases. In 15% of cases, no vascular abnormality can be found. This subset is classified according to blood distribution, which can be perimesencephalic or non-perimesencephalic. Perimesencephalic subarachnoid haemorrhage (PM-SAH) is the least common phenomenon. It has a favourable prognosis with negligible long-term complications. A high index of suspicion is needed to identify this group of patients. This report highlighted the current consensus for managing these patients. It also highlighted the need for further research as no cause has been identified.Patient presentation: A 35-year-old male developed PM-SAH during physical exertion. He had no risk factors and was well below the described age of being in the 6th decade of life.Management and outcome: The patient was admitted to an intensive care unit and had digital subtraction angiography performed within the prescribed 24 h–48 h. This modality digitally subtracts radiopaque structures such as bones to enhance the visibility of blood vessels. Treatment was symptomatic, and a course of nimodipine was completed. The clinical course was uncomplicated, and the patient recovered fully.Conclusion: Perimesencephalic subarachnoid haemorrhage is a benign condition once aneurysmal causes have been excluded. As PM-SAH follows a diagnosis of exclusion, the initial monitoring and management follow the same principles of an aneurysmal SAH.Contribution: In this uncommon phenomenon of PM-SAH described in this case, an even more uncommon anatomical variant, namely a superior cerebellar artery fenestration, has been identified. This possibly highlights the role that vascular anatomical variants play in this condition, where no cause has been identified.