Browsing by Subject "General Surgery"

Now showing 1 - 20 of 31
  • No Thumbnail Available
    Item
    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.
  • No Thumbnail Available
    Item
    Open Access
    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.
  • No Thumbnail Available
    Item
    Open Access
    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.
  • No Thumbnail Available
    Item
    Open Access
    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.
  • No Thumbnail Available
    Item
    Open Access
    An audit of patients undergoing gastroscopy at Mitchells Plain District Hospital, with a focus on substance use
    (2023) Mendes, Tome Azevedo; Gool, Ferhana
    Background: The association between peptic ulcers and the use of crystalline methamphetamine (Tik) is often anecdotally described. While available literature describes an association with duodenal ulceration, most research is predominantly observational and the aetiology is largely unexplained. Locally, the pattern of gastrointestinal disease among methamphetamine users, as well as the manner in which they present, remains poorly understood. With an increase in the use of methamphetamine globally, a better understanding of the gastrointestinal effects of this drug is crucial. Objective: To determine the relationship between substance users and findings at index oesophagogastroduodenoscopy (OGD). Methods: A prospective, single centre audit was conducted on patients requiring elective and emergency OGD during a two month period. Baseline demographics, risk factors, nature of presentation and endoscopic findings were recorded and comparisons were made between non-users and users of methamphetamine, cannabis, mandrax and/or heroin. A subanalysis was performed on methamphetamine users. Results: 174 patients were recorded with a median age of 51.5. Ten patients were substance users, with seven patients reporting methamphetamine usage. Substance users were significantly younger (median age 38 vs 53.5; p = 0.006) and more likely to be male (90% vs 34%; p = 0.00107;X 2 2.08). Eight out of the ten substance users presented with an UGIB, significantly higher than non-users (80% vs 13.4%; p < 0.001; x 2 24.4). Substance use had a significant association with the need for inpatient endoscopy (70% vs 29.3%; p = 0.015; x 2 5.8), as well as with emergency endoscopy (50% vs 9.1%; p = 0.0005; x 2 15.9). Duodenal ulcers were confirmed in seven patients (Figure 4), with three of these occurring in substance users and resulting in a significant association (30% vs 3.45%; p = 0.0005; x 2 11.9). Conclusion: Substance users requiring OGD represented a younger, male population group that had a significant association with presenting with an upper gastrointestinal bleed and with requiring emergency, inpatient endoscopy. In keeping with available literature, a strong association with duodenal ulcers was also described. While this study has described the pattern of upper gastrointestinal disease and manner of presentation among substance users, further dedicated research is required if the underlying aetiology is to be understood.
  • Thumbnail Image
    Item
    Open Access
    An evidence-based algorithm for the rapid diagnosis of tuberculosis in HIV positive patients presenting to emergency centres
    (2021) van Hoving, Daniël J; Meintjes, Graeme; Maartens, Gary; Kenge, Andre
    Background Tuberculosis remains a prevalent and deadly global disease. Diagnostic delays are partly due to reduced diagnostic performance of tuberculosis tests in HIV-positive people. The use of reliable pointof-care and near-patient diagnostic tests (e.g. urine lipoarabinomannan and point-of-care ultrasound) are increasingly being used and would benefit patients presenting to emergency centres by rapidly diagnosing HIV-associated tuberculosis. Methods Two studies were done: i) A systematic (Cochrane) review was done to determine the diagnostic accuracy of abdominal ultrasound for detecting abdominal tuberculosis or disseminated tuberculosis with abdominal involvement in HIV-positive individuals, and ii) A cross-sectional diagnostic study to derive a multi-parameter clinical decision tree, incorporating clinical information, point-of-care ultrasound features, chest x-ray and urine lateral flow lipoarabinomannan. The cross-sectional study was performed at the emergency centre of Khayelitsha Hospital, a South African district-level hospital in a high HIV-prevalence community, and resulted in three different publications. Consecutive HIV-positive adults presenting with ≥1 WHO tuberculosis symptoms were enrolled over a 16-month period (June 2016 to October 2017). Demographic and clinical information was recorded on a standardized data collection form. Point-of-care ultrasound was performed according to a standardized protocol. Urine lipoarabinomannan assays were done at point-of-care by emergency physicians and repeated in the laboratory. Chest x-rays were reviewed by a single radiologist using a standardized assessment form. The reference standard was a positive tuberculosis culture or Xpert MTB/RIF test on sputum, or appropriate extra-pulmonary samples. We compared diagnostic accuracy and reproducibility of urine lipoarabinomannan between point-ofcare readers and laboratory readers. We determined the diagnostic accuracy of individual point-ofcare ultrasound features, performed an external validation of the focused assessment with sonography for HIV/TB (FASH) protocol, and determined independent point-of-care ultrasound predictors of HIV-associated tuberculosis. We derived the decision tree model from multivariable logistic regression models. Results Abdominal ultrasound had a pooled sensitivity of 63% (95%CI 43-79; 5 studies, 368 participants; very low-certainty evidence) and a pooled specificity of 68% (95%CI 42-87; 5 studies, 511 participants; very low-certainty evidence) for bacteriologically confirmed tuberculosis. We screened 556 patients in the cross-sectional study of whom 414 (74.5%) were enrolled. The prevalence of microbiologically confirmed tuberculosis was 41.5% (n=172). Point-of-care and laboratory-performed urine lipoarabinomannan had similar sensitivity (41.8% vs 42.0%, P=1.0) and specificity (90.5% vs 87.5%, P=0.23). Moderate agreement was found between point-of-care and laboratory testing (k=0.62), but there was strong agreement between point-of-care readers (k=0.95) and between laboratory readers (k=0.94). Sensitivity and specificity of ≥1 individual point-of-care ultrasound feature were 73% (95%CI 65-79) and 54% (95%CI 47-60), and of the FASH protocol 71% (95%CI 64-78) and 57% (95%CI 50-63). Independent point-of-care ultrasound predictors identified were intra-abdominal lymphadenopathy of any size (aDOR 3.7; 95%CI 2.0-6.7), ascites (aDOR 3.0; 95%CI 1.5-5.7), and pericardial effusion of any size (aDOR 1.9; 95%CI 1.2-3.0). Two or more independent point-of-care ultrasound predictors had 33% (95%CI 27–41) sensitivity and 91% (95%CI 86-94) specificity. The best performing model included WHO screening symptoms ≥2, antiretroviral therapy use, urinary lipoarabinomannan, independently predictive point-of-care ultrasound features (ascites, any size pericardial effusion, any size intra-abdominal lymphadenopathy), and chest x-ray (c-statistic 0.82; 95%CI 0.78–0.86). Adding CD4 cell count did not improve the performance of the model. Classification And Regression Tree (CART) analysis positioned urinary lipoarabinomannan as the optimal screening test after WHO symptoms (75% true positive rate, representing 17% of participants). Conclusion An evidence-based algorithm for the rapid diagnosis of tuberculosis in HIV-positive patients presenting to an emergency centre was developed. Urinary lipoarabinomannan can be reliably performed at the point-of-care since there was no diagnostic accuracy advantage in laboratory-performed versus pointof-care–performed tests. The role of ultrasound in diagnosing HIV-associated tuberculosis had limitations. The low sensitivity of ultrasound (63% in the systematic review; 73% in the cross-sectional study) and the moderate discrimination (specificity 91%) of the presence of ≥2 independent point-ofcare ultrasound predictors indicate that point-of-care ultrasound results should be interpreted in combination with other diagnostic information. The derived decision tree can facilitate the immediate initiation of anti-tuberculosis treatment in about a quarter of patients among whom 75% would have a definitive diagnosis of tuberculosis regardless of CD4 cell count. The 30% false negative rate indicates that the algorithm should not be used to exclude tuberculosis. The performance of the decision tree needs to be further evaluated in settings with a different prevalence of HIV-associated tuberculosis.
  • No Thumbnail Available
    Item
    Open Access
    Analysis of non-ventriculoperitoneal shunts at Red Cross War Memorial Children's hospital
    (2023) De John, Byron; Enslin, J. M. N.; Figaji, A. A.
    Background: At Red Cross War Memorial Children's Hospital (RCCH) it is the preferred practice to use non-ventriculoperitoneal (non-VP) shunts when the peritoneum is ineffective or contraindicated for cerebrospinal fluid (CSF) diversion, and when endoscopy is not an option. The objective of this study is to evaluate the clinical course of patients having undergone these procedures. Method: A single centre retrospective review at RCCH wherein forty-three children with a total of 59 episodes of non-VP shunt placement over a 12-year period were identified for inclusion. Results: Twenty-five ventriculoatrial (VA) and 32 ventriculopleural (VPL) shunts were analysed with a median age at insertion of 2,9 (0,3-14,9) and 5,3 years (0,5-13,4) respectively. The median number of previous shunt procedures prior to VA or VPL shunt insertion was 6,0 (2-28) versus 4,5 (2-17) respectively. Three VA (12,0%) and three VPL (9,4%) shunt patients were lost to follow up. Of those remaining, 10 VA shunts (45,5%) compared to 19 (65,5%) VPL shunts required revision. One ventriculovesical and one ventriculocholecystic shunt were placed in the same patient after 21 and 25 shunt related procedures respectively, and both were revised within 3-weeks of insertion. Median shunt survival was 8 months longer for the VA compared to the VPL shunts, being 13,5 (0-67) and 5 months (0-118) respectively. Complications for VA shunts were low, with the overall shunt sepsis rate in the VA group at 4% (n=1) compared to 15,6% (n=5) in the VPL group. Conclusion: Our findings support that VA and VPL shunts are acceptable second-line options in an already compromised group of patients where safe treatment options are limited, provided attention is paid to the technical details specific to their placement.
  • Thumbnail Image
    Item
    Open Access
    Attitudes to adverse drug reactions and their reporting among medical practitioners
    (1987) Robins, A H; Weir, M; Biersteker, E M
    The adverse drug reaction (ADR) reporting rate within the medical profession is exceptionally low, and doctors' approaches and attitudes to ADRs were explored through personal structured interviews. The total sample comprised 104 doctors in private practice, divided into three groups: 59 general practitioners, 26 medical specialists and 19 surgical specialists. Certain differences emerged between the groups. The surgical group observed far fewer ADRs than the other groups and not a single member had ever reported an ADR. A significantly larger number of medical specialists considered it necessary to report an ADR to an outside agency, while general practitioners tended to believe that only newly released medicines required ADR reporting. However, few doctors of any specialty regarded ADR reporting as part of the action they would take in their handling of ADRs in practice. The commonest explanation advanced for the marked underreporting of ADRs was that unusual or serious reactions were very infrequent and the common or trivial ones did not warrant reporting. Apathy and indifference were rated as the next most pertinent influence in non-compliance, while such factors as fear of personal consequences (e.g. criticism, medicolegal action) and uncertainty about what to report were deemed to be relatively unimportant.
  • Thumbnail Image
    Item
    Open Access
    Building a model for development of a national trauma registry: designing and implementing standardised trauma form at regional hospitals in Tanzania
    (2021) Sawe, Hendry; wallis, Lee A; Coats, Timothy
    Background: Trauma registries are vital to a well-organized trauma system. However, registries are non-existent in most low and middle-income countries, largely due to the difficulty of reliably capturing patient-level data. The aim of this thesis was to develop and implement a context appropriate standardised trauma form incorporating the World Health Organization Data Set for Injury, for both clinical documentation and use in a trauma registry. Methods: This mixed methods participatory action research utilised Susman and Evered's approach to develop and implement a standardised trauma form, using its five steps: diagnosis, action planning, intervention, evaluation and specifying learning. In the diagnosis phase, an assessment of baseline documentation was performed. In the action-planning phase, focus group discussion revealed the barriers and facilitators to completing documentation. Then, in the actiontaking phase, semi structured interviews, training of health care providers, and feedback enabled the development, review, pilot, and implementation of a standardised trauma form. In the evaluation phase, we compared the number and types of variables captured after the form was implemented to the baseline collection. Finally, we specified learning to inform the next steps in the amplification of the observed impact. Results: The diagnosis phase established that many injury variables were not captured routinely at the participating regional hospitals. Analysis of barriers and facilitators and feedback on perceptions of providers toward using standardised documentation informed the development, piloting, modification, training of providers and implementation of a context appropriate standardised trauma documentation form for clinical charting and data capture. Implementation of the standardised trauma form was associated with improved capture of injury variables from baseline pre-implementation (33.6%), during 30-days initial pilot (86.4%) and after seven months post implementation (96.3%). The providers reported the form was user-friendly, resulted in less time documenting, and served as a guide to managing trauma patients. Conclusions: Through participatory action research a contextually appropriate, standardised trauma documentation form was successfully developed and implemented, yielding marked improvement in the capture of essential injury variables. This model can serve as a working guide to other low- and middle-income countries seeking to establish sustainable national injury registries.
  • Thumbnail Image
    Item
    Open Access
    Clinical correlations to distinguish from milder forms of obstructive sleep apnoea syndrome using overnight oximetry to prioritize adenotonsillectomy in a low resource setting
    (2022) Mlauzi, Raphael; Peer, Shazia
    Background: In resource-poor settings with limited surgical services, it is essential to identify and prioritise children with severe and very severe obstructive sleep apnoea syndrome (OSAS) to expedite surgery. McGill's Oximetry Score (MOS) has been validated against polysomnography for OSAS and is affordable and easy to use. Aims: The aim of this study was to assess the correlation of tonsillar size and clinical symptoms with MOS grade 3 or 4, to identify who requires overnight oximetry and who to prioritise for adenotonsillectomy. Methods: Children with suspected OSAS were recruited from the otolaryngology clinic at the Red Cross War Memorial Children‟s Hospital. Demographics, symptom screening scores (SSS), patient characteristics, overnight oximetry (OO), echocardiography and MOS scores (graded 1- 4) were recorded. Multivariate modified-Poisson regression models were used to examine correlations of patient characteristics „with grade 3 or 4 MOS. Results: One-hundred-and-three children were analysed, 38% were female, and median (IQR) age was 3.8 (2.5-5.3) years. Increased tonsil size was associated with a 60% increased risk of grade 3 or 4 MOS, risk ratio (RR) 1.59, 95% CI 1.10-2.29 (p=0.014). Children with witnessed apnoeic events during sleep had 1.3 times increased risk of MOS Grade 3 or 4, RR 1.31, 95% CI (p=0.033). A significant correlation was shown with grade 3 or 4 MOS, RR 1.15, 95% CI 1.03-1.27 (p=0.010) by combining tonsillar size with the following symptoms: apnoeic events; struggling to breathe during sleep and; needing to stimulate the child to breathe. Conclusion: Identifying children with suspected OSAS who require overnight oximetry can be performed using a simple 3-question screening tool: witnessed apnoeic events, struggling to breathe and the need to shake them awake to breathe. This is more precise with an additional clinical finding of grade 3 or 4 tonsils. These children should have surgery expedited. Any child with a MOS 3 or 4 score on OO needs to have expedited surgery.
  • No Thumbnail Available
    Item
    Open Access
    Clinical outcomes in patients with paracetamol ingestion treated with a two-bag n-acetylcysteine regimen in the emergency centre of khayelitsha hospital
    (2023) Mbanga, Kedibone; Khan, Waseela
    Introduction: Paracetamol is frequently ingested for intentional self-poisoning. N-acetylcysteine (NAC) is administered to patients at risk of developing hepatotoxicity and was historically administered using a three-bag intravenous regimen. A change towards a two-bag NAC regimen was initiated at Khayelitsha Hospital. The aim of the study was to describe the clinical outcomes in patients with a history of paracetamol ingestion who were treated with the two-bag NAC regimen. A descriptive comparison to a historical cohort of patients treated with the three-bag NAC regimen was also made. Methods: A retrospective chart review was conducted to assess a 6-month clinical audit. Summary statistics were used to describe all variables. Results: Overall, 57 patients were included (mean age 26 years, 83% female). The median ingested dose (10 g) was similar between the regimens. An empiric indication occurred more in patients receiving the two-bag regimen (84.0% versus 50.0%). The median paracetamol level (231 umol/L) and the proportion of confirmed paracetamol toxicity (32%) were less in the two-bag regimen. A delay in initiating the first NAC infusion occurred in 22 (38.6%) patients. Forty adverse effects were recorded in 22 (38.6%) patients and a higher proportion occurred in the two-bag regime (44.0% vs. 34.4%). Nausea and vomiting occurred frequently (n=30, 52.7%), which were comparable for both regimens. The prevalence of hepatotoxicity after receiving NAC was 8.8% (n=5). Conclusion: A large number of patients were empirically started on NAC with a higher incidence of adverse reactions in the two-bag NAC than in the three-bag NAC regimen in contrast to existing evidence. However, there was a reduction in treatment delay in the two-bag NAC regimen compared to the three-bag NAC regimen.
  • No Thumbnail Available
    Item
    Open Access
    Common Arterial Trunk Repair at the Red Cross War Memorial Hospital, Cape Town: A 20-year review of surgical practice and outcomes
    (2023) Moodley, Allen; Brooks, Andre
    BACKGROUND: A description of the post-operative outcomes following Common Arterial Trunk (CAT) repair over 20 years before and following the transition to nonconduit repair. Primary outcomes were 30-day and overall, in-hospital mortality for paediatric patients who underwent CAT repair at Red Cross War Memorial Children's Hospital (RCWMCH). Secondary outcomes encompassed (a) Incidence of postoperative complications and (b) medium-term outcomes, including reinterventions, late deaths, and loss to follow-up. METHOD: A single-centre retrospective study of all consecutive patients who undertook the repair of CAT from January 1999 to December 2018 at RCWMH. Patients with an interrupted aortic arch or previous pulmonary artery banding were excluded. RESULTS: Fifty-four patients had CAT repair during the study period. Thirty-four (63.0%) patients had a conduit repair, and 20 (37.0%) patients had a non-conduit repair. There were 2 intraoperative deaths. Thirty-day in-hospital mortality was 22.2%. Overall, in-hospital mortality was 29.6%. Twenty-nine (55.8%) of fifty-two patients suffered a postoperative complication. A total of 38 patients were followed up post-hospital discharge with 11 patients (28.9%) lost to follow-up and 8 (21.1%) late mortalities observed. The actuarial survival for the conduit group was 77.5%, 53.4% and 44.5% at 6, 12 and 27 months respectively and non-conduit group was 58.6% at 6 months. The overall freedom from revision surgery between the conduit group and non-conduit group was 5 66.2% vs 86.5%, 66.2% vs 76.9% and 29.8% vs 64.1% at 1, 2 and 8 years respectively. CONCLUSIONS: No difference in postoperative mortality between the conduit and non-conduit repair. Reintervention rates were lower in the non-conduit group.
  • No Thumbnail Available
    Item
    Open Access
    Comparing mortality calculators for emergency laparotomy in Cape Town
    (2023) Awasthi, Neha; Rayamajhi, Shreya
    Introduction Emergency laparotomies (EL) are high risk surgeries, a result consistent across multiple national databases and audits. Risk prediction calculators (RPC) were developed to accurately stratify risk of mortality in these emergency patients, often frail prior to surgery. Access to post-operative care including high-care and Intensive Care Unit is limited in LMIC hospitals. Aims and Methods To determine the risk of mortality following surgery using three risk prediction calculators – namely National Emergency Laparotomy Audit's New Risk Prediction Calculator (NELANRPC), Portsmouth Physiological and Operative Society Score (P-POSSUM), and African Surgical Outcomes Study (ASOS) to 215 patients who underwent non-trauma EL in a tertiary level hospital in South Africa. Results Mortality on post-operative day 30 in this cohort was 24.2%. Colorectal resections were most performed and had the highest mortality rate (30.6%). For risk prediction calculators, the NRPC had the largest AUC-ROC (0.86 95% CI, 0.803 to 0.920), followed by P-POSSUM (0.84 95% CI, 0.780 to 0.899), and ASOS (0.806 95% CI, 0.74 to 0.87) having the least.
  • No Thumbnail Available
    Item
    Open Access
    Deep Neck Space Infections In Infants At A Tertiary Referral Centre: A Case Review
    (2023) Moyo, Charles; Peer, Shazia
    Background: Persistent upper respiratory tract infections in infants can lead to retropharyngeal lymphadenitis. If untreated, they can progress to deep neck space infections (DNSI). Objective: To review surgical management of DNSI in infants, and to determine optimum timing of surgical drainage, and sequelae thereof. Methods: A retrospective study of infants presenting with DNSI, was conducted at Red Cross War Memorial Children's Hospital, Cape Town, between May 2018 to March 2022. Medical folders were reviewed, data collected included demographics, clinical presentation, investigations, management, and post-operative course. Ethics approval was obtained prior to commencement. Results: Six children with DNSI were identified, aged between 3-12 (average 6.7) months. None had any preceding comorbidities; 2/6 (33%) children incidentally tested positive for Covid-19; 4/6 (67%) had preceding URTI, 3/4 (75%) having commenced antibiotics prior to presentation. Common clinical findings were neck swelling in 5/6 (83%) and fever in 6/6 (100%); stridor in 4/6 (67%) and dysphagia in 3/6 (50%). The average white cell count (WCC) was 21.5 (range 12.6-34.3) *109 /L. 3/6 infants had measured procalcitonin levels between 0.23-2.74 (average 1.10) ng/ml. DNSI was identified on CT imaging in all cases in the following deep spaces: retropharyngeal 6/6 (100%); parapharyngeal 4/6 (67%); superior mediastinum 5/6 (83%); anterior cervical 2/6 (33%); posterior mediastinum 1/6 (17%) and paratracheal 1/6(17%). Abscess size of more than 3cm with airway displacement was seen in all cases. 5/6 (83%) infants underwent surgical intervention within 24hours of presentation. Delayed surgical intervention in 1/6 (17%) resulted in “antibioma” formation and delayed surgical drainage. Methicillin sensitive staphylococcus aureus (MSSA) was cultured in 5/6 (83%) cases; no organisms were identified in the remaining case. 5/6 (83%) were managed post-operatively in the ICU for 3-9 (average 5.8) days. Empiric intravenous therapy was commenced in all cases, namely, Co-Amoxiclav (4/6) and Piperacillin/Tazobactam (2/6). Amikacin was additionally administered in 1 case for presumed nosocomial respiratory infection prior to DNSI management. Culture-directed therapy modified treatment to Cephalexin/Flucloxacillin in 2/6 cases. Neck drains were removed after an average of 2.8 (range 1-6) days when output was minimal. Duration of hospital stay was 13 (range 5-19) days. There were no mortalities. Conclusion: DNSI is a rare but serious complication of progressive retropharyngeal lymphadenitis resulting from non-resolving or worsening URTIs in infants. This was observed in all six cases. Typical presentation includes neck swelling, fever, and airway compromise often requiring prompt airway management with source control. Recommended management includes CT imagining of head, neck and chest to determine extent of spread, appropriate intravenous antibiotics, and prompt surgical drainage. Medical therapy alone can risk antibioma formation, with inevitable surgical clearance of sepsis.
  • Thumbnail Image
    Item
    Open Access
    Derivation and validation of a severity scoring tool for COVID-19 illness in low-resource setting
    (2021) Pigoga, Jennifer L; wallis, Lee A
    Background The COVID-19 pandemic has profoundly impacted some of the most vulnerable populations in lowresource settings (LRS) across the globe. These settings tend to have underdeveloped healthcare systems that are exceptionally vulnerable to the strain of an outbreak such as SARS-CoV-2. LRS-based clinicians are in need of effective and contextually appropriate triage and assessment tools that have been purpose-designed to aid in evaluating the severity of potential COVID-19 patients. In the context of the COVID-19 crisis, a low-input severity scoring tool could be a cornerstone of ensuring timely access to appropriate care and justified use of critically limited resources. Aim and objectives The aim of this research was to develop and validate a tool to assist frontline providers in rapidly predicting severe COVID-19 disease in LRS. To achieve this aim, the following objectives were defined: identify existing methods of risk stratification of suspected COVID-19 patients worldwide; establish predictors of severe COVID-19 illness measurable in LRS; derive a risk stratification tool to assist facility-based healthcare providers in LRS in evaluating in-hospital mortality risk; and validate tool SST in the African setting using real-world data. Methods To achieve the aim of this dissertation, quantitative and review methodologies were employed across four studies. First, a scoping review was conducted to identify all studies describing screening, triage, and severity scoring of suspected COVID-19 patients worldwide. These tools were then compared to usability and feasibility standards for LRS emergency units, to determine viable tool options for such settings. Following this, a systematic review and meta-analysis were undertaken to evaluate existing literature for associations between COVID-19 illness severity, and historical characteristics, clinical presentations, and investigations measurable in LRS. Three online databases were searched to identify all studies assessing potential associations between clinical characteristics and investigations, and COVID-19 illness severity. Data for all variables that were statistically analysed in relation to COVID19 disease severity were extracted and a meta-analysis was conducted to generate pooled odds ratios for individual variables' predictive abilities. In the third study, machine learning was used on data from a retrospective cohort of Sudanese COVID-19 patients to derive the AFEM COVID-19 Mortality Score (AFEM-CMS), a contextually appropriate mortality index for COVID-19. Following this, a fourth study was conducted with a more recent Sudanese dataset to validate the tool. Results The scoping review identified COVID-19 risk stratification 23 tools with potential feasibility for use in LRS. Of these, none had been validated in LRS. The systematic review then identified 79 eligible articles, including data from 27713 individual patients with laboratory-confirmed COVID-19. A total of 202 features were studied in relation to COVID-19 severity across these articles, of which 81 were deemed feasible for assessment in LRS. Meta-analysis of two demographic features, 21 comorbidities, and 21 presenting signs and symptoms with appropriate data available identified 19 significant predictors of severe COVID-19, including: past medical history of stroke (pOR: 3.08 (95% CI [1.95, 4.88])), shortness of breath (pOR: 2·78 (95% CI [2·24-3·46])), chronic kidney disease (pOR: 2.55 (95% CI [1.52-4.29])), and presence of any comorbidity (pOR: 2.41 (95% CI [2.01-2.89])). These significant predictors of severe COVID-19 were then considered for inclusion in the AFEM-CMS. Data from 467 COVID-19 patientsin Sudan were used to derive two versions of the tool. Both include age, sex, number of comorbidities, Glasgow Coma Scale, respiratory rate, and systolic blood pressure; in settings with pulse oximetry, oxygen saturation is included and, in settings without access, heart rate is included. The AFEM-CMS showed good discrimination: The model including pulse oximetry had a C-statistic of 0.775 (95% CI: 0.737-0.813) and the model excluding it had a C-statistic of 0.719 (95% CI: 0.678- 0.760). The tool was then validated against a second set of data from Sudan and found to once again have reasonable discriminatory power in identifying those at greatest risk of death from COVID-19: The model including pulse oximetry had a C-statistic of 0.732 (95% CI: 0.687-0.777) and the model excluding pulse oximetry had a C-statistic of 0.696 (0.645-0.747). Conclusions and relevance This dissertation establishes what is, to our knowledge, the first COVID-19 mortality prediction tool intentionally designed for frontline providers in LRS and validated in such a setting. The derivation and validation of the AFEM-CMS highlight the feasibility and potential impact of real-time development of clinical tools to improve patient care, even in times of surge in LRS. This study is just one of hundreds of efforts across all resource levels suggesting that rapid use of machine learning methodologies holds promise in improving responses to pandemics and other emergencies. It is our hope that, in future health crises, LRS-based clinicians and researchers can refer to these techniques to inform contextually and situationally appropriate clinical tools and reduce morbidity and mortality.
  • No Thumbnail Available
    Item
    Open Access
    Evaluating the role of a 99mTc-HYNIC-PSMA SPECT scan following a negative bone scan in men with prostate cancer: a single-centre, retrospective cohort study
    (2023) Oppel, Cleve; Lazarus, John
    Purpose: This study aimed to review the management of patients with high-risk and unfavourable intermediate-risk prostate cancer, who had a 99mTc-HYNIC-PSMA SPECT (technetium-99m hydrazine nicotinamide prostate-specific membrane antigen singlephoton emission computerised tomography) scan following a negative 99mTc-MDP (technetium-99m methylene diphosphonate) bone scan. Materials and methods: This study is a retrospective review of patients with high-risk and unfavourable intermediate-risk prostate cancer, who underwent a 99mTc-PSMA SPECT scan after a negative/equivocal bone scan between January 2018 and December 2020. Patients with a life expectancy of less than 10 years were excluded. Results: A total of 64 patients were investigated. The mean age was 63 years and the mean prostate-specific antigen (PSA) level was 40 ng/mL. The International Society of Urological Pathology (ISUP) scores were as follows: ISUP 1 in six patients, ISUP 2 in eight patients, ISUP 3 in 13 patients, and ISUP > 4 in 37 patients. A positive 99mTc-PSMA SPECT scan for disease metastases occurred in 20% of the patients who had a negative bone scan. Seven of the patients with a positive 99mTc-PSMA SPECT scan received a bilateral orchiectomy, while four patients received treatment with radical intent. Management of patients with both scans negative included external beam radiotherapy (EBRT) and androgen deprivation therapy (ADT) (n = 47), and radical prostatectomy with or without lymph node (LN) dissection (n = 4). A limiting factor was that not every patient underwent conventional cross-sectional imaging of the pelvis and prostate prior to intervention. Conclusion: A 99mTc-PSMA SPECT scan is a valuable diagnostic tool and was able to identify one in five men (20%) who are understaged by bone scan, allowing for their management plan to be tailored and sparing them morbid intervention.
  • Thumbnail Image
    Item
    Open Access
    Immunohistochemical identification of mismatch repair gene deficit and its clinico-pathologic significance in young patients with colorectal cancer
    (2005) Hameed, Muhammad Fayyaz; Goldberg, Paul A
    An immunohistochemical technique is used in this study to detect mismatch repair deficit in young patients with colorectal cancers. Ninety three patients who were 45 years of age or younger at the time of diagnosis of colorectal cancer were studied.
  • No Thumbnail Available
    Item
    Open Access
    Impact of nighttime versus daytime emergency surgery on the outcome of necrotising enterocolitis
    (2023) Mbonisweni, Akhona; Arnold, Marion
    Background Necrotising enterocolitis (NEC) is the most common neonatal gastrointestinal surgical emergency, with a high mortality. We hypothesised that nighttime (NT) surgery was associated with higher mortality, intra-operative adverse events (AE) and post operative complications. Objectives To determine differences in mortality, intra operative AE and post operative complications between NT and DT surgery for NEC. Methods Patients with NEC (n=96) who needed surgical intervention (2015 - 2019) were retrospectively reviewed at a free-standing tertiary paediatric hospital. Differences in mortality, intraoperative AE, post operative surgical complications and length of intensive care unit stay were assessed for NT versus daytime (DT) surgery. Results Thirty-three patients (34.4%) were operated during NT. Demographics of the two groups were similar for gestational age, birth weight, sex, and age at operation. NT patients required increased inotropic support pre-operatively (p=.013) and had shorter time from diagnosis to surgical intervention (p<.001). Other preoperative characteristics (SNAPPE II score, haemoglobin, platelet count, C-reactive protein, and serum sodium) showed no statistically significant differences. Duration of anaesthesia and operative time were shorter at NT (p=.01 and p=.002 respectively). Red blood cell transfusion rates were higher at NT (p=.03). “Damage control” surgery was more common at NT (p=.01) and associated with 25% 30-day mortality compared to 33% for other patients (p=.03). Other operative characteristics and intraoperative AE were similar. Thirty-day mortality and enterostomy complications were higher for NT surgery (p=.02 and p=.013), while overall mortality and incidence of other post-operative surgical complications were not significantly different between groups. Longer duration of surgery collerated with increased risk of mortality for both DT and NT surgery (p=.009 and p=.023 respectively). Conclusion Patients operated at night required more inotropes and red cell transfusion, and had an increased 30-day mortality and post-operative enterostomy complications. The incidence of intraoperative AE and other post operative complications were similar between groups. A damage control mindset was more prevalent at NT and may reduce mortality. The time of day for surgery for NEC depends on acuity of disease and local resources. NT surgery was found to be as safe as DT surgery in our institution. Further research on damage control surgery outcomes and reduction of stoma complications is needed.
  • Thumbnail Image
    Item
    Open Access
    Logistical factors associated with adverse outcomes following emergency surgery in an acute care surgical unit
    (2021) Nel, Daniel Benjamin; Klopper, Juan H
    Purpose The Acute Care Surgical Unit at Groote Schuur Hospital was established in 2010 and is the first of its kind in Africa. The aim of this study was to describe the outcomes of emergency surgical cases, as well as determine the logistical factors associated with adverse outcomes following surgery within the unit. Methods This study was a retrospective audit which reviewed the folders of adult patients who underwent an emergency surgical procedure from July 2016 to July 2017. The primary outcome was a major adverse event (AE) which was defined by a Clavien-Dindo score of 3-5. A number of logistical factors related to patient admission and operation were evaluated for association with outcomes. Results A total of 271 patients were included with an mean age of 47 years, with 48% females and 52% males. A major AE was recorded for 13% of patients. The following factors were found to be predictive of a major AE: referral from outside the hospital, urgent booking colour code, reoperation and consultant most senior surgeon present during procedure. Patient admission/surgery performed outside of normal working hours, being booked for surgery on admission, as well as delay to surgery beyond colour code were not associated with a major AE. Conclusion Apart from traditional clinical parameters, factors related to perioperative logistics may contribute to the risk of a major AE after emergency surgery and should be considered for inclusion in more comprehensive predictive models for adverse outcomes within an acute care surgery unit.
  • No Thumbnail Available
    Item
    Open Access
    Misdiagnosis of Appendicitis in Women in a Resource Limited Setting: Lessons from South Africa
    (2023) Kariem, Nazmie; Chu, Kathryn
    Introduction: Acute appendicitis (AA) is a common surgical emergency. In low and middleincome countries, the diagnosis is often made clinically due to the lack of access to specialised imaging. Misdiagnosis in females is common, given the potential broad differential diagnosis. The rate of misdiagnosis varies between countries, but there is a paucity of data in the developing world. The aim and objectives of this study were to describe the routine workup of females with suspected AA at a South African government hospital and to determine factors associated with the misdiagnosis of AA. Methods: A retrospective review of all females older than 12 years operated on by general surgeons with a suspected diagnosis of AA over a 2-year period was reviewed. Data including age, gender, presenting complaints and physical findings, laboratory and radiological results, pre and post-operative diagnoses were extracted and analysed using descriptive and inferential statistics. Results: A total of 180 females were included and 48 (26.7%) of them were misdiagnosed with AA. Of these 48 that were misdiagnosed, 22 (46%) had pelvic inflammatory disease (PID), 15 (31%) had a normal appendix, 10 (21%) had ovarian cysts and (2%) had endometriosis. Gynaecologic bimanual examination was performed in 123 (68.3%) patients. Twelve (6.7%) patients had a CT scan and 16 (8.9%) had an abdominal ultrasound. In the multivariate model, the absence of nausea, vomiting and anorexia (odds ratio (OR)=2.43; p=0.023), the presence of cervical excitation tenderness (CET) (OR: 4.32; p=0.009) and adnexal tenderness (OR=3.06; p=0.021) were significantly associated with a diagnosis other than appendicitis. These factors remained significant in the multivariate model after adjusting for relevant covariates. Conclusion: More than 25 % of females referred to general surgeons with suspected AA were misdiagnosed. Since imaging is not accessible at most resource-limited settings, it is imperative to conduct a gynaecologic examination on every female since adnexal and cervical tenderness were associated with PID and not AA.