Browsing by Department "Division of General Surgery"

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    Open Access
    A 12-month retrospective descriptive analysis of a single helicopter emergency medical service operator in four South-African provinces
    (2023) Vlok, Neville; Stassen, Willem; Wylie Craig
    Introduction: Helicopter Emergency Medical Services (HEMS) forms an important role in integrated modern emergency medical services and have a suggested mortality benefit in certain patient populations, such as those affected by severe trauma or with time-sensitive pathologies in rural areas. Despite this, HEMS is an expensive resource used in South Africa and appropriate use and feasibility in low-to-middle income countries (LMIC) is highly debated. To maximise benefit, it is essential that the right patients be selected for HEMS. In order to evaluate this, the current practices first need to be described. The aim of this study was to describe a population of patients being transported by HEMS in South Africa, in terms of flight data, patient demographics, provisional diagnosis and clinical characteristics and interventions. Methods: A retrospective flight- and patient-chart review were conducted, extracting clinical and mission data of a private, single aeromedical operator in South Africa, over a 12-month period (July 2017 – June 2018) in Gauteng, Free State, Mpumalanga and North-West. Results: A total of 916 cases were included (203 primary cases, 713 interfacility transport (IFT)). The majority of the patients were male (n=548, 59.8%), suffered blunt trauma (n=379, 41.4%) followed by medical pathology (n=247, 27%) and neonatal transfers (n=184, 20.1%). Most flights occurred in daylight hours (n=729, 79.6%). Median mission times were 1-hour 53minutes for primary missions, and 3 hours 10 minutes for IFT cases. Median on-scene times were 26 minutes for primary cases and 55 minutes for IFT cases. Although many patients were transported with an endotracheal tube (n=428, 46.7%), more than a third did not have an advanced airway and received supplemental oxygen via other means (n=348, 37.9%). Almost half of patients received no respiratory support (n=414, 45.2%). No patients received fibrinolysis, defibrillation, cardioversion or cardiac pacing. Almost all patients received intravenous fluid therapy (n=867, 94.7%). The administration of sedation (n=430, 46.9%) and analgesia (n=329, 35.9%) were also common interventions. Conclusion: By describing current HEMS transport practices in one of the largest cohorts in Africa to date, a better understanding is gained of how HEMS is utilised daily. Apart from the lack of universal call out criteria and response to the high burden of trauma, HEMS seem to fulfil an important critical care transport role. Due to the lack of coordinated coronary care networks, it seems that cardiac pathologies are under-represented in this study and might have an important implication for crew training requirements.
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    Open Access
    A Cross Sectional Evaluation of a Shoulder and Elbow Fellowship in a Low to Middle Income Country: Fellows' Perspective
    (2022) Boskovic, Viseslav-Willy; Roche, Stephen
    Background: There is a growing trend towards sub specialization and fellowship training in orthopaedic surgery. Data from the United States has shown that over 90% of orthopaedic residents plan to pursue fellowship training and there is a trend in the orthopaedic job market toward seeking fellowship-trained orthopaedic surgeons. Objectives: This study aimed to elucidate graduate perceptions of how undertaking the shoulder and elbow fellowship offered by the Department of Surgery, University of Cape Town (UCT) impacted their professional and personal development and to identify potential means of improving the quality of the programme. Methods: A descriptive, cross-sectional survey analysis was performed using an online questionnaire posing questions related to various aspects of the training programme. Subjects consisted of nine qualified orthopaedic surgeons who had completed the UCT Shoulder and Elbow fellowship. Survey questions were predetermined through discussion and agreement among the researchers. Results: All emails sent drew responses to the survey. An overall good to excellent level of satisfaction with the various aspects of the training program was reported by the fellowship candidates. Post-fellowship increase in arthroscopic and open surgical skill level, as well as understanding of research, was found to be significant. The majority agreed that the fellowship had adequately prepared them for work in their current setting. The candidates strongly agreed that the fellowship enhanced their abilities, when compared to their peers, in pre-operative decision making, intra-operative decision making, formulating ethical judgements, operative surgical skills and teaching ability. Conclusion: The results confirm the positive impact of the fellowship on post-training levels of confidence across clinical, research, decision-making and educational domains by Fellows. The study highlights the benefits of post-graduate fellowship training with the analysis being broadly applicable to similar training programmes globally. It underscores the importance of continuous evaluation of fellowship programmes.
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    Open Access
    A descriptive study of the use of troponin I testing at a Cape Town district hospital
    (2018) Gibson, Joshua Glynn; Malan, Jacques; Bruijns, Stevan
    Introduction: Troponin I tests have been shown to be accurate and are relied upon to assist in making critical decisions regarding patient care in patients presenting with chest pain. The tests are expensive, however, and so their rational use becomes extremely important in a budget-constrained public health sector. The aim of this study was to describe how Troponin I tests are used throughout Victoria Hospital, by a range of requesting clinicians, working in different specialties. Methods A cross-sectional, prospective design was employed, using multiple data sources. We collected a consecutive sample over a three-month period from Victoria hospital’s Emergency Centre using a dedicated data collection tool connected to use of the point-of-care troponin I test. We supplemented this prospective sample with outcome data, using the hospital’s electronic admission record. Results Three hundred and sixteen patient entries were included in the final results. The majority of Troponin tests were negative (70%). Discharge directly from Emergency Centre was 10% in Troponin I positive patients, 37,5% in Equivocal Troponin patients, and 65% in Troponin negative patients. Furthermore, patients were twice as likely to be transferred to a tertiary facility if their Troponin was positive (24%), compared to equivocal (10.4%) or negative (12%). Discussion Chest pain was the most common presenting complaint, with Acute Coronary Syndrome being the most common working diagnosis. The clinical management of patients varied considerably when comparing their Troponin I result. Troponin I appears to be used as an effective rule-out tool in the decision-making pathway.
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    Open Access
    A descriptive study of trauma patients transported by the KZN Helicopter Emergency Medical Services to the Durban Inkosi Albert Luthuli Central Hospital level one Trauma centre over a three - year period
    (2021) Pule, Marwala Simon; Hodkinson, Peter; Hardcastle, Timothy
    Background KwaZulu-Natal (KZN), a large province of South Africa has vast distances to referral centres and time to definitive treatment is key in trauma care. Helicopter Emergency Medical Service (HEMS) is an invaluable prehospital asset for the transport of time sensitive trauma. This study reviews the impact of HEMS in the management of trauma at Inkosi Albert Luthuli hospital (IALCH) which is the only public accredited level one trauma centre in the province. Methods A retrospective descriptive study of polytrauma patients transported by HEMS in KZN to IALCH over a three-year period from 01 January 2014 to 01 January 2017. Data was collected around patient demographics, transfer details and patient outcomes. Results Over the three-year period, 117 HEMS transfers were reviewed, with the majority being male (90.6%). Just 26% of HEMS transfers were direct from the scene, with the balance being interhospital transfers largely from distant regional hospitals around the province. Some 60% of injuries were causes by vehicle crashes, and 31% by intentional injury. Mortality was 30% which is reflective of the high severity of injury of the cohort. The injury severity scores (ISS) (median 26 overall) of those who died was higher (median 38) (p-value= 0.0002), and there were more interventions before and during transfer such as thoracostomy, ventilation and immobilization. Some 88% were admitted to ICU at IALH. Conclusions: HEMS in the KwaZulu Natal province was mainly used for long-distance transfer of major trauma patients which is an appropriate use of this essential service, given the single major trauma centre in the province. The majority of patients that were transported by HEMS had severe injury, which was also associated with increased mortality outcomes. Rational use of this essential but expensive resource will require clear policy around the role of HEMS and call out criteria in each setting.
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    Open Access
    A Four-Year Descriptive Analysis of Stroke in a Private Hospital in the Western Cape
    (2022) Govender, Sarojini; Stassen, Willem
    Background: Stroke is the second leading cause of death and disability globally, with an estimated 26% increase in stroke deaths between 1990 and 2010. The World Stroke Society estimated that one in six people will suffer a stroke in their lifetime. In 2010, stroke accounted for 5.9 million deaths, 71% of which was in low- to middle-income countries (LMICs) and is a major public health concern for Africa and other LMICs together with other non-communicable diseases. Communicable diseases such as HIV/AIDS, malaria, tuberculosis etc. are prioritised in Sub-Saharan Africa (SSA) and the healthcare expenditure has been mostly allocated to treat these. The cost of stroke care in hospital and out of hospital is quite alarming and the burden of stroke places an added burden on an already stretched healthcare budget. Objectives: To identify the different stroke types, risk factors, burden of stroke in a private hospital in terms of gender, age, and length of stay and to identify any associations of risk factors, age, types of strokes, mortality and treatment given. Methods: This descriptive study involved retrospective data from an electronic database which captured all stroke patients seen in the emergency unit during the study period. Data was verified, diagnosis made by CT, MRI scans or both. Results: The total number of 576 cases was included, 278 (48%) for ischaemic stroke, 72(12.5% for haemorrhagic stroke and 226 (39%) for TIA. No difference between gender and type of stroke was observed. Mortality was low, with 21 cases with a mortality rate of 3.6%. Given this low mortality rate, meaningful analyses on mortality could not be done. The most prevalent risk factors were hypertension (59.7%), diabetes (21.7%), hyperlipidaemia (29%), atrial fibrillation (11.1%) and ischaemic heart disease (10.8%). Following logistic regression, atrial fibrillation was found to be associated with ischaemic stroke (p = 0.01), and TIA (p = 0.08). No other risk factors had a statistically significant association with type of stroke in this sample. Conclusion: Ischaemic stroke is more prevalent compared to haemorrhagic stroke. As the population grows and life expectancy increases, the burden of stroke and its complications will also increase. Managing the modifiable risk factors may be key to managing the burden of stroke in Sub-Saharan Africa.
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    A histopathological and genomics study of the mutated human FAM111B gene related POIKTMP disease
    (2023) Tambwe, Nadine; Arowolo, Afolake
    Fibrosis is a pathological feature of many chronic inflammatory diseases, eventually leading to organ failure and death. POIKTMP is a rare, multi-organ fibrosing disease which is associated with mutations of the human FAM111B gene. FAM111B gene codes for a protein whose function is not well characterized. Therefore, elucidating the mechanism of FAM111B or its mutations in POIKTMP is beneficial to understanding the complexities surrounding this multisystemic fibrosing disease. The study sought to understand the pathogenesis of fibrosis, its role in POIKTMP and its causative gene mutation: FAM111B Y621D. First, Sanger sequencing was used to confirm the presence of the FAM111B Y621D mutation using DNA isolated and amplified from post-mortem FFPE tissues of a POIKTMP patient first described with the disease in South African Following that, qRT-PCR was employed to assess gene expression changes between the patient and the familial control. The RT2 Profiler Human fibrosis PCR Array was then used to associate POIKTMP and 84 known fibrotic markers to propose a possible fibrotic pathway associated with POIKTMP disease using mRNA from the lung and skin POIKTMP patient tissues. Gene-set enrichment analysis (GSEA) using Enrichr, a computational GSEA tool, was used to predict enrichment analysis between the identified upregulated fibrosis markers and the FAM111B gene. Finally, Immunohistochemistry was used to identify cellular and sub-cellular protein distribution of FAM111B and other fibroproliferative markers of interest to annotate pathological changes. The results from this study validated the FAM111B Y621D mutation in the affected tissues. Next, FAM111B mRNA was shown to be downregulated in the lungs and skeletal muscle tissues of the POIKTMP patient. The human fibrosis PCR array experiments identified eight upregulated fibrotic markers: MMP3, MMP13, PDGFA, ITGB-1, THBS-2, COL3A1, TGFβ3, and CCN2 in the patient lungs and skin tissues, which were validated by qRT-PCR. Furthermore, these genes with FAM111B form a gene-list that was used in interrogating various gene-set libraries in the gene-set enrichment analysis. FAM111B was enriched in some gene-set libraries within the Diseases/Drugs and Cell type categories. The GSEA terms enriched within these libraries are the pathways associated with SARS-COVID-19 perturbations and cell/tissue types related to the small intestine, breast, oesophagus, thyroid, smooth muscle and stromal cells of some of these organs. Lastly, immunohistochemistry results corroborated this study's mRNA expression analysis by showing that FAM111B was more highly expressed in the skin than in the lung patient. TGF-β1 and Ki-67 markers were 12 assessed from protein expression, which resulted in higher expression in the POIKTMP patient skin tissue than in the lungs. Altogether, our data suggest that FAM111B and mutations in this gene play a pivotal role in POIKTMP and other fibrosing organ diseases, representing a potential disease biomarker and possible therapeutic target in POIKTMP and other fibrotic disorders.
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    Open Access
    A manikin-based simulation study of a dispatch operator directed CPR algorithm within the Western Cape setting and the self- reported comfort around its execution
    (2021) De Caires, Leonel Paulo; Stassen, Willem; Evans, Katya
    Background: There is little data in Africa regarding dispatch guided telephonic CPR. This study looks at the quality of CPR performed when compared to AHA guidelines, by untrained laypersons when given telephonic CPR instructions using the Western Cape EMS Guidecards algorithm for telephone assisted CPR. Methods: In this prospective observational, simulation study, participants were given telephonic hands-only CPR instructions using the Western Cape EMS Guidecards. CPR quality (hand placement, rate, depth and chest recoil) was analysed and then followed by a questionnaire looking at the self-reported comfort regarding the execution of said instructions. Results: Overall quality of CPR by participants (n=50) was suboptimal with no participant complying with current CPR guidelines. Demographic factors influenced quality where males pushed on average deeper (40.8mm vs 28.5mm, p=0.004) when compared to females. Correct hand placement and chest exposure were directly related to the caregivers' home language with English making it more likely to correctly perform these instructions (p=0.01 and p=0.002, respectively). Self-reported comfort had no effect on executed CPR quality. Conclusion: The quality of CPR performed by laypersons, when directed by a call-taker using the Western Cape Provincial EMS Guidecards Algorithm, can be suboptimal in terms of compression rate, depth, full chest recoil and baring of the chest. There is an urgent need to find more effective ways, in the Western Cape EMS, to improve executed CPR quality when guided by a trained telephone operator.
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    Open Access
    A prospective, longitudinal, observational study to assess the health-related quality of life of patients with pancreatic ductal adenocarcinoma in the South African context
    (2022) Kotze, Urda Karin; Jonas, Eduard; Krige, Jake
    Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive visceral malignancy originating from pancreatic duct cells. Despite advances in detection, diagnostic procedures and surgical and oncologic treatment, the overall prognosis remains dismal. GLOBOCAN 2020 ranks PDAC as the 7 th leading cause of all cancer deaths. There are no reliable statistics on the incidence of PDAC in South Africa. The National Cancer Registry South Africa of 2017 reports that PDAC accounts for 0.53% and 0.58% of all cancers in females and males respectively. However, this low incidence may be due to underreporting, as the diagnoses are based on positive histology which are performed on only a small proportion of PDAC patients reported by the National Health Laboratory Service (NHLS), only one of several laboratories in South Africa. The overall 5-year survival rate for all PDAC patients is reported to be less than 5%, and the overall median survival is 4-7 months from the time of diagnosis. Surgical resection offers the only chance of cure, but as few as 10% of patients are treated with curative intent with 5-year survival rates of 15-25%. A median survival of 2.8-5.7 months has been reported for patients with metastatic disease. Early symptoms of PDAC such as loss of appetite, weight loss and fatigue are vague and non-specific, which often leads to a delay in the diagnosis. Approximately 80% of patients who have PDAC involving the head of the pancreas present with painless jaundice. In those with advanced disease other digestive symptoms such as loss of weight, nausea and vomiting, bloating, altered bowel habits and backache are prominent. Because of the severity of symptoms, the small proportion of patients who are eligible for curative treatment, and the dismal overall survival, palliative treatment is an important component of the overall treatment of PDAC. In this respect information provided by health-related quality of life (HRQOL) assessments, which refer to the subjective experiences and perceptions of patients regarding their health, illness, and medical interventions, and how these affect their everyday life and functioning, are invaluable for planning and assessing the effect of palliative treatment. HRQOL assessment quantifies not only the actual symptoms but also the effect of the disease on a person in his or her totality. Many studies that report on HRQOL in PDAC are conducted in sponsored clinical trials and are guided by regulatory requirements. These studies typically include highly selected cohorts defined by strict inclusion and exclusion criteria, and results do not reflect HRQOL in the larger unselected patient population. Several nonclinical trial PDAC HRQOL studies have been done both in patients who underwent an operation and those who received palliative treatment. The prognostic value of HRQOL parameters have also been investigated. Very little data are available on the HRQOL of PDAC patients in low- and middle-income countries (LMICs), and to our knowledge no data have been published on the HRQOL of PDAC patients in South Africa. The aim of this research was to assess HRQOL in a South African PDAC patient cohort presenting at a major hepato-pancreato-biliary (HPB) academic referral centre, and to determine the possible clinical applications of HRQOL outcomes in the management of these patients, treated with either curative or palliative intent. The European Organisation for Research and Treatment of Cancer (EORTC)-QLQ-C30 and EORTC-QLQ-PAN26 instruments were used in a longitudinal design study to allow for comparisons with baseline (BL) reports at regular intervals, thereby identifying statistically significant and clinically meaningful changes that may have occurred over time. As in previous publications, a high mortality and decreasing compliance over time in both the curative intended and palliative cohorts were noted. In contrast to patients who underwent an operation in whom the functional and symptom scales and scores fluctuated notably between time points, the same remained relatively stable in the patients who received palliative treatment. Some interesting observations regarding the possible prognostic value of HRQOL outcomes in the respective treatment groups need to be further investigated in larger patient cohorts. Some of the lessons learnt in this study from a LMIC, may be of value in planning subsequent tumour-related HRQOL studies in LMICs, regardless of tumour type.
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    Open Access
    A Retrospective Audit Of Biojet® Prostate Fusion Biopsies Amongst Patients Seen In A High-Volume Private Referral Centre In Cape Town Between January 2017 And April 2020
    (2023) Patel, Bhavinkumar; Kaestner, Lisa-Ann
    Introduction: The field of prostate cancer has seen a dramatic change in its approach to diagnosis, from the advent of PSA in the 1980s to the transrectal ultrasound guided 12 core biopsies with a false negative rate of approximately 30%. Recent advances in this field involve fusing MRI images with real-time ultrasound images to guide the surgeon. The aim of the study was to evaluate the performance of Biojet® prostate fusion biopsy system in a high-volume private referral centre. Methods: Retrospective observational audit of men who presented to a private urology practice in Cape Town for Biojet® prostate fusion biopsy based on clinical suspicion for prostate cancer. Data were collected as per the recommendations of the Standards of Reporting for MRI-targeted Biopsy Studies (START) of the Prostate group and anonymously entered onto a Redcap database. Results: The median age of the patient population was 64 (SD 9.124) years. The median PSA level was 6.5 ng/ml (IQR- 4.7). Most patients (78/135) had a clinical stage of T1c (57%). In the biopsy naïve group, a total of 103 PIRADS lesions were identified. Amongst the PIRADS 3 lesions 15/28 lesions (53%) had a positive cancer diagnosis. Of the PIRADS 4 lesions 37/60 lesions (62%) had a positive cancer diagnosis and in the PIRADS 5 group 13/15 lesions (87%) had a positive cancer diagnosis. 21 of the 42 men (50%) with a previous negative prostate biopsy had a positive cancer diagnosis using the Biojet® prostate fusion biopsy. Conclusion: In this study the Biojet® prostate fusion biopsy performed similar to other international studies however the pickup rate of cancer in those who had a previous negative biopsy was higher than those seen in the other global studies.
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    Open Access
    A retrospective description of a 12 month caseload at four private emergency centres in South Africa
    (2023) King, Jonathan; Hodkinson, Peter
    Introduction In South Africa, private emergency departments (ED) are often the first port of call for a substantial proportion of the population served by the private healthcare sector. This study aims to describe the number, acuity and chief complaint of patients that presented to a sample of urban private EDs within South Africa. Methods A retrospective review of patient data from January 2018 to December 2018 was performed for four private facilities from a large private healthcare group. Data collected include demographics, time of arrival, disposal, triage score and presenting complaint. Results A total of 71079 patients presented to the four facilities. The South African Triage Scale (SATS) scores were as follows: red (5%), orange (11%), yellow (65%) and green (19%). Patients arrived mostly during the day (08:00-17:00 (54%)), evening (17:00-22:00 (27%)) and night (22:00-08:00 (19%)). Disposal of patients included admission (14%), discharge (77%), transfer to another facility (2%) and those who left without being seen (3%). The most frequent presenting complaints included gastrointestinal complaints, falls, respiratory issues, fever, traffic accidents and chest pain. Conclusion This study is the first description of the caseload and case mix in private EDs in South Africa. The most common presenting complaints were gastrointestinal and respiratory, with chest pain being the commonest red triaged complaint. Such complaints are similar to international data. In contrast, trauma related to assault is ranked 20th in private as opposed to 1st in the public sector. Admission rates are in keeping with US data, but lower than SA public, UK and Australia. Lastly, many green patients are follow ups which likely relates to the fee-for-service nature of the private sector and continuum of care fulfilled by ED doctors.
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    A retrospective descriptive analysis of critical care transfers in the private sector of South Africa
    (2022) Venter, Monique; Stassen, Willem
    Background: Critical Care Transfers (CCTs) are necessitated by the growing prevalence of high acuity patients who require upgrade of care to multidisciplinary teams from less equipped referring facilities. Due to the high acuity of the critical care transfer patient, specialised teams with advanced training and equipment are called upon to undertake these transfers. The specialised and dedicated teams are utilized to mitigate and treat adverse events during transfers, which is found in the especially vulnerable, high acuity patients. Internationally, the insufficient data relating to CCTs has been repeatedly reported as a concern due to the increased number of critical care transfers being undertaken and the high acuity of the patients, along with the reported high number of adverse events that occur during such transfers. The inherent understanding of the potential effects, and therefore needs of the critical care transfer patient, are affected due to the paucity of international, but more specifically, local data relating to CCTs. Methods: This observational cohort study with a retrospective descriptive design samples all non-neonatal, critical care transfers completed for a one-year period (1 January 2017 – 31 December 2017) from the dedicated CCT of the two largest national emergency medical services in South Africa. Data were extracted from patient report forms by trained data extractors and subjected to descriptive analysis. Results: A total of 1839 patients were transferred between the two services (excluding the neonatal cohort). A total of 3143 diagnoses were recorded, yielding an average of ~2 diagnoses per patient. The most prevalent primary diagnosis was Cardiovascular Disease (n=457, 25%), followed by infection (n=180, 10%) and Head Injury (n=133, 7%). Patients had an average of ~3 attachments, with the most prevalent being patient monitoring (n=2856, 155%). The second most prevalent attachment was Peripheral Intravenous Lines (n=794, 43%) of patients, followed by mechanical ventilation (n=496, 27%). A total of 2152 medications were required during transport, yielding an average of ~1 medication or infusion per patient transported. The most common medications recorded were CNS Depresants (n=588; 32%), followed by Analgesics (n=482, 26%), and a further 17% of patients required Inotropic / Vasoactive agents (n=320, 17%). Conclusion: This study provides insight into the demographics, most prevalent diagnoses and interfacility transfer monitoring needs of patients being transported in South Africa by two private dedicated critical care transport services. The results of this study should be used to inform future specialised critical care transport courses and qualifications, as well as the scopes of practice of providers undertaking critical care transfers.
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    A retrospective review of complications in a South African neurocritical care unit over one year
    (2024) Kgaodi, Bakang Abiot; Semple, Patrick; Arnold-Day, Christel
    Background: The establishment of a Neurocritical Care Unit (NCCU) is well described in offering benefits to patients1,2. These units are optimised to care for patients with pathologies involving the brain and spine. Complications peculiar to such units in Low- and Middle-income countries (LMICs) are relatively undocumented. Objectives: To determine the complications in a NCCU at Groote Schuur Hospital (GSH) over 1 year and their association with ICU length of stay (LOS) and mortality. Methods: A retrospective review of complications of patients admitted to the NCCU at GSH from 01 January 2020 to 31 December 2020 as per NCCU patient data registry (HREC: R012/2015). Results: 850 patients, predominantly males (61.2% for HC and 68.1% for ICU), were admitted to the NCCU with a median age of 43 years (HC) and 41 years (ICU). The overall complication incidence rate was 38.2%. The statistically significant complications (p-value <0.05) were metabolic and electrolyte abnormalities as well as infection (including VAPs, SSIs and CLABSIs) and DVTs. The most common complication was metabolic abnormalities (28.2%), specifically derangements in sodium homeostasis. LOS was shown to have a statistically significant association with number of complications. Mortality did not have a statistically significant association with number of complications. Conclusion: Complications in a dedicated NCCU in South Africa are mostly electrolyte disturbances and infections. The complications are associated with increased LOS but not with increased risk of mortality.
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    A retrospective review of post-intubation sedation and analgesia practices in a South African private ambulance service
    (2021) de Kock, Joalda Marthiné; Stassen, Willem; Buma, Chloe Ashton
    Introduction: Adequate post-intubation sedation and analgesia (PISA) practices are important in the pre-hospital setting where vibration and noise of the transport vehicle may contribute to anxiety and pain in the patient. Inadequate post-intubation practices may lead to long-term detrimental effects in patients. Despite this, these practices are poorly described in the prehospital setting. This study aims to describe the current pre-hospital PISA practices in a private South African emergency medical service. Methodology: Patient report forms (PRF) of intubated patients between 1 Jan 2017 and 31 Dec 2017 from a single private ambulance service were reviewed. Data was analysed descriptively. Correlations were calculated with Spearman's Rank correlations and group differences were calculated with Independent T tests and Mann-Whitney U tests. Significant correlations were entered into a binomial regression model to determine predictive value of receiving PISA. Results: The number of PRFs included for analysis was 437. Of these, 69% of patients received some type of PISA. The estimated time from intubation to 1st PISA ranged from 9 to 12 minutes. There were statistically significantly more PISA interventions in patients who had received Rocuronium (p< 0.01). There was weak but significant correlation between the number of interventions and the mean arterial pressure, (rs = 0.17, p< 0.01) and Glasgow Coma Scale (rs = -0.15, p< 0.01) prior to intubation, along with the transport time to hospital (rs = 0.23, p< 0.01). Conclusion: The PISA practices in the South African pre-hospital setting is comparable to international pre-hospital settings. The time to 1st PISA appears to be shorter in the SA setting. There is an increased number of interventions in the patients who received Rocuronium, which may indicate practitioners being mindful of wakeful paralysis. Practitioners also take the level of consciousness and blood pressure prior to intubation into account when administering PISA. Longer transport times attribute to patients receiving more PISA interventions.
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    A Retrospective Review of the Technical Success of Endoscopic Stenting for Malignant Gastric Outlet Obstruction
    (2022) Tait, Déan; Chinnery, Galya
    Introduction: Palliation of patients with advanced and irresectable malignancies causing gastric outlet obstruction (GOO) with the endoscopic placement of a self-expanding metal stent (SEMS) has become standard. Internationally, technical success rates are high. This study reviewed endoscopic stent placement for malignant GOO compared to other international high-volume endoscopy units, looking into local success rates, pathology, and patient demographics. Methods: A retrospective review of patients presenting to the Groote Schuur Hospital Upper Gastrointestinal Unit with irresectable malignant GOO between 1 March 2018 and 31 August 2021 was performed, evaluating demographics, technical success, pathology, and immediate and late stent complications. Results: One hundred and fourteen patients, 44 (38.6%) female and 70 (61.4%) male, were referred for palliative stenting of malignant GOO; distal obstructive gastric cancer (74.6%) and obstructing pancreatic malignancies (14.9%) being the two most frequent indications. Median age was 63.5years (IQR: 53.25-70) with 48.2% having at least one comorbidity and 48.3% performance scores of 3 or 4. The majority (96; 85.7%) required only one stent, 15 patients (13.4%) had a second stent placed, and one patient required four stents. In total, 132 stent insertion attempts were undertaken. With primary placement, three technical failures were experienced. One stent was initially incorrectly placed but immediately correctly repositioned, while two failed insertions were referred for surgical gastrojejunostomy, equating to a technical success rate of 97.4%.Four immediate stent insertion related complications occurred (3.1%), two related to sedation, one stent placed too distally requiring repositioning and an oesophagogastric junction perforation with procedural death. Fifteen late-stent complications occurred with thirteen stent blockages due to tumour in-growth (10%), one stent fracture and one stent with poor radial expansion. The stent blockages occurred between 3 to 548 days after placement (median 107 days, IQR: 80 – 275 days). Salvage stenting was 100% successful in the 14 cases with late stent complications that required re-stenting. Conclusion: Technical insertion success rates of primary and salvage duodenal stenting for malignant GOO are on par with international high-volume units. The leading pathology locally is gastric adenocarcinoma, with palliative stenting remaining a feasible and accessible option.
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    A retrospective single centre audit on gastric gastrointestinal stromal tumours over a period of fifteen years
    (2022) Kuhn, Suzanne; Chinnery, Galya
    Introduction: Gastrointestinal stromal tumours (GIST) are the commonest tumour of mesenchymal origin; favour the stomach, and account for a very small percentage of gastrointestinal tract tumours. Methods: In this retrospective audit of GISTs presenting to the Groote Schuur Hospital surgical and oncological multidisciplinary team (MDT) between 2004 – 2019, gastric GISTs were evaluated as regards presentation, gastric anatomical position, histological subtype with risk stratification, management and outcomes. Results: Of 126 GIST tumours presenting to this MDT, 82 originated in the stomach. Complete histopathological records could be obtained for 64. With an average of 59 years (50 male: 32 female), 18 (28%) presented with a herald bleed. Other common presentations included anaemia, epigastric mass and pain. The tumours were predominantly found in the body and fundus (64%), with a spindle cell subtype predominance (41%). The association between cancer cell subtype and gastric position was not significantly different (p=0.728). Cystic degeneration was found on 11 (17%) analyzed and cell necrosis on 12 (18%). These findings were not related to larger tumor size or prognosis. Five required downstaging with Imatinib prior to surgery. Thirty-seven patients underwent a surgical procedure: 24 wedge resections and 12 anatomical resections. Risk stratification was performed with the modified National Institutes of Health (NIH/Fletcher) score. Twenty-eight cases had inaccurate mitotic counts and couldn't be scored, 17 scored high risk, 9 intermediate risk, 9 low risk and 1 very low risk. Ten patients died of metastatic disease, 34 were discharged with no disease progression after 3 years, 1 patient with disease progression currently remains on Imatinib, and 19 were lost to follow up. Conclusion: Gastric GISTs appear to have a predilection for the proximal stomach; it is unsure whether this is purely due the greater surface area. The spindle cell subtype dominated in the proximal gastric GISTs. Cystic degeneration and cell necrosis did not seem to be related to larger tumours or outcomes.
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    A survey of the attitude towards research and research education among South African Ophthalmology trainees
    (2020) du Toit, Linett; du Toit, Nagib
    Background Completing a research dissertation or Master of Medicine (MMed) degree during ophthalmology specialist training has now become compulsory in order to qualify as an ophthalmologist in South Africa. At a national level there is currently no co-ordinated effort to standardize research training and resources for trainees. Objectives The primary objective was to determine if South African ophthalmology trainees were interested in doing research. Secondary objectives were to determine: whether they felt that their current research training was adequate; whether a national web-based research support system would be desirable; and whether such a support platform would stimulate involvement in further research once training was completed. Methods A questionnaire was designed and anonymously completed by the trainees in each training unit in South Africa. Categorical responses were summarized using crude and weighted means with 95% confidence intervals (CI). Free text responses were analyzed thematically using an inductive approach. Results Out of 81 trainees (registrars) in South Africa at the time of the survey, 64 fully completed the questionnaire - a response rate of 79%. Seventy-two percent (95% CI 57% to 87%) of the trainees reported that they were interested in doing research. Only 28% (95% CI 18% to 41%) of respondents felt that their current research training was adequate. Ninety five percent (95% CI 86% to 99%) of trainees advocate a web-based support platform would be beneficial an eighty six percent (95% CI 74% to 93%) reported such would motivate them to continue to do research once their training was complete. The themes from the qualitative data were in keeping with the quantitative results and identified variation between training institutions in terms of available research resources, supervision and allocated time to perform research. Conclusion The trainee ophthalmologists in South Africa are interested in performing research. They feel that their current research training programs are inadequate. There is a strong need for nationally standardised research guidance to eliminate the current variation between training institutions. Guidance on dedicated time allocation to complete the research component of training should be provided by regulatory bodies. A proposed web-based support system may be a good option to standardize selected available research resources and provide equal access to all trainees nationally as well as to supplement research output during and after specialist training. Further research should address the reported lack of supervision and elucidate additional barriers to performing research in South Africa.
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    Acetabular reconstruction using a ?Cone Cup? prosthesis in a series of 13 patients
    (2023) Klopper, Schalk; Hilton, Thomas
    Background Endoprosthetic reconstruction of major pelvic bone loss in oncology and revision arthroplasty surgery is associated with high complication rates. However, comparative data for reconstructive methods are limited. We present short-term clinical, radiological, and functional outcomes of the implantcast MUTARSâ LUMICâ prosthesisfor acetabular reconstruction after major pelvic bone resection orloss. Methods Retrospective folder review from December 2019 to June 2022. Minimum follow up was 12 months. The inclusion criterion was all patients who underwent acetabular reconstruction with the implantcast MUTARSâ LUMICâ cone cup prosthesis. Results Thirteen patients were included in the study. The indication for pelvic resection was a primary bone tumour in five patients, metastatic bone disease in five and failed arthroplasty in three. Complications included 2 patients with dislocation, 3 with infection, and 1 with both. The overall complication rate was 46%. Median MSTS scores at 12 months assessed in 8 patients was 20.75 of 30 points. Conclusion Our results are in agreement with other series, highlighting the problems of instability and deep infection. Patients without complications had an acceptable functional outcome.
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    Adherence to and effectiveness of guidelines for routine investigations of adult patients with mental and behavioural disturbances
    (2023) Jere, Solomon; Hendrikse, Clint
    Background The process of medical clearance aims to exclude a general medical condition as an underlying cause for the mental and behavioural disorder and involves routine screening with special investigations. Mitchells Plain District Hospital's emergency centre follows the Western Cape Provincial guidelines when screening for general medical conditions in these patients. Adherance and effectiveness of these guidelines is unknown. Aim This study aimed to determine the effectiveness of and adherance to the Western Cape Provincial guidelines for routine investigations of adult patients with mental and behavioural disturbances presenting to a district level emergency centre. Methods This descriptive study was conducted at Mitchells Plain Hospital in Cape Town, South Africa. Data was collected from existing electronic registries over a 6-month period. Adult mental health care users were risk stratified into the probability of having a general medical condition according to provincial guidelines and the results of their special investigations were described against their outcome. Results Of the 688 patients included in this study, 66% had abnormal vital signs and of the 312 patients who received special investigations, 56% were abnormal, including 18% who were clinically significantly abnormal. Abnormal special investigations changed the clinical outcome for 3 (<1%) patients. Adherence to the provincial guidelines was reasonable (82%) but non-adherence resulted in numerous unnecessary investigations. Conclusion The results of this study support the existing evidence that clinical assessment and clinician gestalt should guide the need for special investigations and that there is no benefit to routine screening in the EC. The results also demonstrate reasonable adherence to the current guidelines even though this rarely changed patients' outcome. Decisions were based on clinical findings and clinician gestalt, and not abnormal special investigations or vital signs – which were both prevalent.
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    Adherence to Standard Operating Procedure for patients with Acute Cervical Spine Dislocated Injuries: A case of a teaching central referral hospital in South Africa
    (2022) Ayik, Goud; Kruger, Nicholas
    1.1.1 Aims: To analyse the impact that the adoption of our institutional standard operating procedure (SOP) for cervical spine dislocations had on the timing of closed reduction at our hospital. 1.1.2 Patients and methods: The study was a retrospective review of patients who presented to our institution with cervical dislocation injuries and were managed with closed reduction. The patient records of acute cervical spine dislocations from 2015 to 2018, Data from the Acute Spinal Cord Injury database along with patient's demographic information were gathered and compared. Participants within the study time frame were diagnosed with a cervical facet dislocation based on clinical examination findings and radiological confirmation. Patients who had reduction performed at other referring hospitals were excluded from the study. 1.1.3 Results: The practice within all tertiary hospitals in the Western Cape is to perform closed reduction of cervical fracture dislocations as soon as possible after injury. In this study the time between injury and closed reduction before introducing the SOP was13 h 13 min and after introducing the SOP, the time increased to an average of 14 h 28 min. The main cause of delay was the transfer time from the site of injury to emergency ward. Other reasons for the delay include missed diagnosis, orthopaedic registrar unavailability, and incomplete reduction bed. 1.1.4 Conclusion: This study found that the time taken for orthopaedic management of cervical dislocations increased by an hour after introduction of the SOP. Additionally, the overall time to reduction also increased This was due to delays in transfer to the emergency ward and referral to Orthopaedics. We recommend that in our setting, reduction could be initiated within an hour of patient arrival, if emergency ward doctors rapidly identified the problem and commenced cervical traction when the orthopaedic team was not immediately available. Our impression was that there was poor adherence to the new SOP guidelines on time management by the trauma team, and possibly transport delays prior to hospital admission. A further study to investigate the bottlenecks of the referral system is advisable.
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    An 8-year retrospective review of Pyogenic Liver Abscesses at Groote Schuur Hospital, Cape Town, South Africa
    (2023) Govender, Nieleshen; Kloppers, Jacobus
    Pyogenic liver abscess (PLA) is the most common abdominal solid organ abscess with significant associated morbidity and mortality (2-30%). High variance in the causative organism exists therefore identifying the responsible pathogens and providing targeted therapy is needed for optimal outcomes. This study aims to describe patient variables, outcomes and the local microbiome to guide future empiric antibiotic protocols. Methods We performed a retrospective review of 121 patients with PLA from 2012 to 2020 at Groote Schuur Hospital. We analyzed patient demographics, microbiology results from cultures of PLA (bile, percutaneous aspiration or intra-operative sampling) and blood samples, empiric antibiotic regimens used, interventions and outcomes. Results The five most common organisms cultured were Escherichia coli [26 (21%)], Klebsiella pneumoniae [24 (19.8%)], Pseudomonas aeruginosa [12 (9.9%)], Anaerobic organisms Isolated [11 (9%)] and Enterobacter cloacae Complex [7 (5.1%)]. Twenty different regimens were used to treat PLA. Primary intervention (antibiotics alone, percutaneous drainage, open surgery) was successful in 72 patients (60%). Further intervention was required in 49 patients (40%). Open surgical drainage was required in 16 patients (13%). 30-day mortality was 9.1% (n=11). Biliary sepsis was the most common cause of PLA (31%). Our study showed Gentamicin [52 isolates (65%)], Ciprofloxacin [49 isolates (61%)] and Co-Amoxiclav [46 isolates (46%)] to be the most effective in covering the five most common isolates. Conclusion Optimal PLA management remains challenging with multiple combinations of empiric antibiotic regimens initiated. Local data on the topic is sparse and this research is hypotheses generating for future research to improve outcomes. Abstract word count: 250 words