Browsing by Subject "general surgery"

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    Open Access
    An evaluation of monitoring of respiratory physiological parameters in patients treated with non-invasive ventilation in the emergency department in Sligo University Hospital in Ireland
    (2021) Matalasi, Retselisitsoe Vincent; Hodkinson, Peter; Sweeney Michael
    Background: Acute respiratory failure is becoming a frequent phenomenon in the emergency department due to increasing life expectancy, and in the last two decades the number of presentations has more than doubled. Non-invasive ventilation has become the treatment modality of choice in selected patients, with a significant reduction of mortality in these cases. However, adequate monitoring of clinical and blood gas parameters is crucial to ensure treatment targets are met. Objective: This study aims to evaluate monitoring of respiratory physiological parameters in patients treated with non-invasive ventilation (NIV) in the ED in Sligo University Hospital. As a secondary objective, the study aims to evaluate how monitoring data influence treatment modification. Methodology: This was a retrospective chart review of 50 patients who presented to the ED in acute respiratory failure and were treated with non-invasive ventilation between September 2017 and March 2019. Results: A total of 50 charts were analysed, 62% female and 38% male. The average age for both genders was 76 years. Results showed that initial and ongoing monitoring of vital signs remained guideline compliant throughout the entire duration of NIV in the ED. All but one patient out of 50 had an initial blood gas analysis done prior to initiation of NIV treatment, while repeat blood gas analysis was inconsistent with 38% (n= 19) who did not have blood gas repeated. Conclusion: The study highlights the discrepancy between monitoring of vital signs and arterial blood gas during treatment of acute respiratory failure patients with non-invasive ventilation in the emergency department. A proforma may help bridge this gap to ensure a standardised care in order to improve treatment outcomes.
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    Assessing use of the South African triage scale in the Western Cape government emergency medical services system
    (2022) Mould-Millman, Carl Nee-Kofi; wallis, Lee A
    Introduction: A critical concept underpinning emergency medicine is triage. Triage is the systematic process of sorting patients based on acuity and/or resource need, with the goal of getting the right person to the right place at the right time to receive the right level of care. Triage influences a patient's clinical trajectory, hence impacts both patient outcomes and health system resource utilization. Therefore, the consequences of triage are arguably even more critical in two scenarios: first, early on in the patient's care, such as the prehospital setting; and second, care in resource-constrained health systems, such as in Africa. Prehospital emergency care, delivered by Emergency Medical Services (EMS) providers, represents one of the earliest opportunities for emergency triage of the undifferentiated patient. We conducted a series of projects to, first, understand the current global scientific context of prehospital triage and, next, to better understand how the South Africa Triage Scale (SATS) is used by Western Cape EMS providers for prehospital triage. Findings may help enhance the application of SATS for prehospital triage in the Western Cape. Additionally, findings could provide evidence to encourage the adoption, or rejection, of SATS triage by other EMS systems in resource-constrained settings, especially in Africa. Methods: This project consisted of three distinct objectives which were investigated as separate, but interconnected, studies. The first objective was answered using a secondary research method (a scoping review) designed to discover and appraise existing prehospital triage tools across the world in an effort to better contextualise the specific role filled, and value added, by SATS. The second and third objectives were answered using a quantitative and qualitative approach, respectively, to assess the validity and reliability of SATS among EMS providers, and to understand EMS providers' experiences and perspectives using SATS. We converged the quantitative and qualitative data in a mixed methods analysis. Main results: In the scoping review, we screened 1521 unique articles and completed a full review of 55 articles. We reported that the majority of publications on prehospital triage tools were focused on stroke triage (35%) and trauma triage (35%). There were 15 (27%) publications, corresponding to 11 unique tools, relevant to prehospital triage of undifferentiated patients - overall, the tools had modest triage performance characteristics in high-income settings. However, we found no publications relevant to prehospital triage with SATS in the 2009 to 2019 study period, and no triage tools were studied in low- or middle-income countries. In the quantitative study, we conducted cognitive paper-based SATS triage assessments of 102 EMS providers of all qualifications within the Western Cape Government EMS system. We found a high rate (29.5%) of under-triage and an acceptable rate (13.1 %) of over-triage. Providers' use of the Triage Early Warning Score (TEWS) and the clinical discriminators were often incorrect in 41.4% and 41.2% of cases, respectively. In the qualitative assessment, we completed three focus group discussions with 15 diverse and representative providers from the Western Cape Government EMS system, and we achieved thematic saturation. Four major themes emerged from the discussions: Limited implementation and variable use of SATS; Prehospital effectiveness of SATS; Limitations of the discriminator; and, Special EMS considerations limiting SATS. In general, participants felt SATS was fairly easy to use and an asset in their patient care, explaining that it aided them clinically and with hospital communication. Participants, however, noted that the clinical discriminators were often challenging to apply in the prehospital setting, and the TEWS often did not reflect the patient's true or changing prehospital acuity. The qualitative findings both corroborated and helped explain some of the key quantitative results, with both suggesting that many clinical discriminators are problematic for prehospital use and manually calculating TEWS is an error-prone process for Western Cape EMS providers. Conclusion: SATS is being successfully and innovatively used in the prehospital triage of undifferentiated patients in the Western Cape of South Africa. Researching prehospital SATS in South Africa fills a global scientific gap given we found no reports of prehospital triage tools from low- or middle-income countries. Western Cape EMS participants reported that SATS was generally helpful and relatively easy to use, but reported challenges using TEWS and the clinical discriminators. SATS had good inter-rater reliability, but poor validity. The under-triage rate of 30% was high and attributable to misuse of TEWS and clinical discriminators. The over-triage rate of 13% was acceptable and confirmed by experiences recounted by the EMS participants. Modest adaptations of SATS by expert stakeholders could improve its prehospital performance and utility in the Western Cape Province. SATS for prehospital triage likely has good applicability and utility in other resource-constrained systems, but further adaptation and testing are warranted.
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    Open Access
    Assessment of cataract blindness prevalence and factors associated with surgical coverage in Rwanda
    (2020) Owusu, Kyei Michael; Mathenge, Wanjiku; Geneau, Robert
    Background: The Rapid Assessment of Avoidable Blindness (RAAB) survey methodology is a cost-effective tool for assessing the burden of blindness and cataract surgical services in a population. This study analyses the 2015 Rwanda National RAAB data to ascertain whether there are gender differences in access to cataract surgical services and also assess whether there is an association between measured distances travelled to access cataract surgical services and the cataract surgical coverage (CSC) in the country. Methods: Secondary data non automated analysis was performed on the 2015 Rwanda RAAB data, which had a sample of 5,275 persons who underwent ophthalmic examinations as per RAAB protocols to elicit the prevalence and causes of blindness and answered a standard questionnaire on barriers to cataract surgery. Cataract blindness prevalence and cataract surgical coverage were estimated for males and females and assessed for significant differences. Distances from clustered patients' locations to the nearest eye surgical facility ere calculated using Google Maps and analyses performed to identify if a relationship exists between distances travelled and the CSC for the area. Results: The prevalence of bilateral cataract blindness for males was 0.4% (n=8; 95% CI=0.1-0.7) and females 0.5% (n=17; 95% CI=0.3-0.8) and the CSC for males and females were 69.2% and 68.5% respectively. The difference in CSC was not statistically significant. Females aged ≥70 years reported more barriers to cataract surgical services compared to men. At a VA <3/60 in the better eye, 1km increase in the distance to the nearest eye surgicalcentre was associated with a reduction in the CSC for the area of 4.8% (Linear regression: F (1,95) = 16.06, p = 0.0001, R-Squared = 0.1446, Adjusted R-Squared = 0.1356). Conclusions: Older women (≥70 years) were the most vulnerable to untreated cataract blindness in Rwanda and therefore special programs need to target them for cataract surgical services. Distance to surgical facilities with ophthalmologists is related to the cataract surgical coverage even in a small country like Rwanda.
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    Open Access
    Do anatomical contoured plates address scapula body, neck, and glenoid fractures and can these fractures be classified? – A multi-observer consensus study
    (2022) De Wet, Johannes Jacobus; Roche, Stephan
    Background: The surgical management of scapula body, neck and glenoid fractures remains a challenge. This study focusses on templating an available anatomical pre-contoured plating system using 3D printed scapulae to assess the ability of these plates to address the aforementioned fractures and to determine consensus on classifying scapula body, neck and glenoid fractures. Methods: We used a cohort of twenty-two 3D printed fractured scapulae prototypes and an available anatomical pre-contoured plating system to determine anatomical congruency and fit. Nine investigators templated the scapula fractures using four pre-contoured plates and the investigators classified the twenty-two fractured scapulae using the Ideberg and AO/OTA classification system. Results: Eleven out of twenty-two fractures were found to be fixable using the plates under study. The long lateral plate addressed 83.3% of fractures involving the lateral border, while the glenoid plate was unable to adequately address any glenoid fractures. We observed good to excellent (p ≤ 0.001) inter-observer reliability for three of the four plates. The inter-observer reliability was moderate (ICC = 0.74) for the AO/OTA classification and good (ICC = 0.88) for the Ideberg classification. Conclusion: We believe that the anatomical pre-contoured plating system does not address all the fracture patterns encountered in clinical practice and further development in plate design is required. Good to moderate interobserver reliability were observed using the Ideberg fracture classification for intra-articular fractures and the AO/OTA classification for extraarticular fractures involving the body.
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    Hard hitting facts on childhood head trauma: an epidemiological analysis
    (2019) Ferreira, Yolandi; van As, Arjan B; Figaji, Anthony; Dix-Peek, Stewart
    Background: According to the World Health Organization (WHO), Traumatic Brain Injury (TBI) will become the third largest cause of global disease by the year 2020. Despite its astonishing numbers, TBI remains a silent or even forgotten epidemic with significant paucity in epidemiological data. TBI in developing countries represents a disproportionate burden of disease and data are lacking regarding the unique demographics in South Africa to design and implement focused prevention programmes. A valuable tool to assess the severity of TBI is the use of Computer tomography (CT). CT also is the main imaging modality to provide rapid identification and information for the management of children with TBI. CT scanning utilises ionising radiation and as an imaging modality poses risk to the patient. In order to guide decision protocol/algorithm, various Clinical Decision Rules (CDRs) have been established in High Income Countries. These protocols, including the need for CT scan might differ in a Medium/Low Income setting. Methodology: This is a prospective, single centre cohort study. Data were collected over an 18-month period (1 August 2015 - 31 January 2017). Children under the age of 13 years (n=3007) presenting to RCWCH after sustaining a head injury were included. Various epidemiological data were collected. A Road Safety Questionnaire was also used to evaluate safety knowledge of health care workers. Three different CDRs were compared to the standard of practice in RCWCH. A final analysis of demographics, mechanism of injury, radiology outcome, safety analysis and evaluation of a comparison of local protocol compared to the other CDRs was performed using descriptive statistics. Results: The mean age of paediatric patients presenting after a head injury was 4.6 years. There was a significant male predominance (66%) and almost two thirds of all children were of pre-school age. Falls (53%; n=1601) represented the most common mechanism of injury across all age groups, followed by road traffic related injuries (RTI) (29%; n=864), struck by or against an object (9%; n=279) and injuries as a result of interpersonal violence (8%; n=230). Within the subset of RTI (n=864) only 6 passengers were appropriately restrained, with 142 unrestrained and 56 passengers transported on the back of a goods vehicle. In the under 3-yearold age group, only 1 patient was appropriately transported in a car seat, with 51 unrestrained and 6 transported on the back of a goods vehicle. Pedestrian related injuries were by far the largest group of RTI (70%) with 50% of these under the age of 5 years. Intentional injuries inflicted by an adult were most common (34%) in the pre-verbal (under 2 years old) group. Interpersonal violence among minors (assault with a brick or stone) constituted 52% of intentional injuries. Eight firearm related injuries were recorded. Appliances and iron gates that were not correctly installed were additional causes of injury. CT scans were obtained according to the RCWCH protocol in 59% of cases and 34% showed an abnormal result. The sensitivity (98%) and specificity (93%) while using the standard of practice protocol was better than the 3 CDRs developed in High Income Countries. Analysing our Road Safety Questionnaire there appears great room for improvement regarding awareness of road safety guidelines and legislation. Conclusion: The performance of the current RCWCH CT scan protocol appears appropriate in our setting although there is some room for improvement using the strengths of the other CDRs. Valuable insight regarding the epidemiology of TBI in our setting has been highlighted. Of specific importance is the large proportion of very young children at risk of injury by all mechanisms of injury, particularly pedestrian-related injuries, unrestrained passengers and interpersonal violence among minors. Important gaps in knowledge about current recommendations for road safety were identified by the questionnaire. As long as these issues are not appropriately addressed through enhanced injury prevention programmes, children will continue to carry the heavy burden of TBI morbidity and mortality.
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    Is psoas muscle area as determined by cross-sectional measurement an accurate predictor of peri-operative outcomes in adenocarcinoma of the upper gastrointestinal tract?
    (2022) Divey, Mark; Chinnery, Galya; Jonas, Eduard
    Background Radiologically measured psoas muscle area has been associated with poorer surgical outcomes. Our hypothesis is that patients with gastric cancer and lower psoas muscle area have poorer short-term surgical outcomes. Methods Individuals with gastric cancer were assessed and total psoas muscle area (TPA) in mm2 was measured at the level of the third lumbar vertebra on staging CT, using Phillips IntelloSpace PACS Enterprise version 4.4.553.50. The psoas muscle area was normalised for height (TPA mm2 /m2 ), creating the psoas muscle index (PMI). All individuals proceeding to surgery were compared in terms of PMI with correlation to short-term complications (Accordion), length of stay and mortality. In addition, PMI and tumour staging was evaluated. Results One hundred and seventy-seven individuals (115 males, 62 females, mean age of 60.8 ± 0.9) were evaluated of which sixty-eight underwent surgery (56 resections, 12 palliative bypasses). The surgical complication rate was 40% (27/68), major complications being Accordion 3 or higher at a rate of 16% (11/68) and mortality rate of 10% (7/68). The average length of stay was 10 ± 0.7 days. There was no statistically significant difference in PMI for males or females in respect to all complications, major complications, length of stay or mortality. PMI and tumour staging did not correlate. Males with gastric outlet obstruction had a statistically significant lower PMI (p <0.03) Conclusions Although low psoas muscle area has been shown to correlate with poorer surgical outcomes, we did not show this is our population undergoing surgery for gastric cancer.
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    Pathways, through opportunity, towards social inclusion: a multiple case study of young womxn in marginalising contexts in post-apartheid South Africa
    (2024) Peters, Liesl; Galvaan, Roshan; Soudien, Crain
    Background Post-apartheid South Africa promised a born-free generation, but young people are not always able to participate in ways that allow them to live freely. Race, class and gender continue to be designated markers of particular life trajectories as young people operate from historically oppressed race, class and gender positions. Young womxn from and in such marginalising contexts experience an array of challenges that place them at risk of an experience of waithood and social exclusion. Various iterations of South African youth policies have suggested that certain kinds of opportunities could play a pivotal role in contributing to more prosperous futures for young people. Previous research concurs. However, the solutions offered through these policies have not resulted in an experience of different futures for young womxn at risk of social exclusion. An exploration of relevant literature on key concepts and related studies in occupational science, and other aligned disciplines, revealed the fragmented and static understanding that existed at the inception of this study about opportunity as a phenomenon that contributes to just and equitable outcomes. As such, critical and socially transformative occupational therapy and occupational science, as the broad grounds for the scholarly work presented in this thesis, have not contributed sizeable solutions to the problems of exclusion facing young people in South Africa. Notwithstanding, young womxn from and in marginalising contexts are capable of agency, demonstrating a responsiveness to social conditions that defies a victory of structure in 1 conclusively predetermining their experiences of everyday life. Examples exist of young womxn who have opened and walked their own pathways towards social inclusion. The need to learn from and with these young womxn was the focus of this research study. The aim of this study was therefore: To explore and describe how young womxn from and in marginalising contexts move towards experiences of social inclusion, through opportunity, in post-apartheid South Africa. Methods A merged theoretical perspective, including decoloniality as a form of critical social theory and the theory of structuration, oriented the understanding of the praxis of living for young womxn from and in marginalising contexts in South Africa. Such a perspective was central for apprehending the relational aspects of agency and structure in young womxn's lives, and how these played out in a context heavily shaped by apartheid and coloniality. The phenomenon explored in this study was defined as the movement of young womxn towards an experience of social inclusion, through opportunities. A qualitative, multiple case study design was applied, drawing on narrative inquiry as a key approach. Using purposive sampling and guided by selection advisors, three young womxn from different communities in the Western Cape Province of South Africa - who believed they were experiencing a more prosperous life that they likened to an experience of social inclusion - were selected to participate in the study. These womxn were willing to offer up their life histories as individual cases that we could explore and learn from. An array of data sources and data generation methods were used to construct each individual case narrative, utilising multiple perspectives. These included life history interviews, in-depth interviews and focus groups with people who were part of each young womxn's life, document analysis and observation. Participants also introduced artifacts which complimented and developed the understanding of their life trajectories. A narrative analytic approach supported the interpretive process to develop within-case inferences about the phenomenon, as it had manifested within the unique circumstances of each case. Following this, a cross-case analysis was conducted to develop an explanation of 2 the phenomenon. Trustworthiness was assured through a range of methods, the most important of which included multiple triangulation approaches, reflexive journaling, and a process of member checking that ensured the veracity of the individual case narratives. Further, data was generated over a prolonged period. These methods provided the foundation for a credible cross-case analysis. The study received ethical approval from the Faculty of Health Sciences Human Research Ethics Committee at the University of Cape Town. Strategies that ensured the ethical conduct of the study were applied throughout, with minimal risk to participants. Of central importance was the maintenance of confidentiality, since intricate and in-depth details were part of participants' life histories. This risk was mitigated by changing minor details that did not adversely affect the credibility of the data and protected the anonymity of participants. All participants expressed the benefits associated with having been able to share their experiences through the data generation processes in the study. Findings and Discussion The analytic process led to the development of an overarching intuition, comprised of a set of inferences, that illustrated that the way young womxn from and in marginalising contexts move towards social inclusion, through opportunity, is through the process of making-a-life. Making-a-life was understood as a uniquely crafted political praxis that is given impetus through a meshwork of lifelines, co-creating the likelihood of young womxn reaching towards social inclusion. Theorising this notion generated the key thesis in this study: that making-a-life is an ontogenetic praxis of correspondences that is routed within the meshwork. Making-a-life improvises with opportunities as possibilities-in-the-making, that must cohere within the context of young womxns' everyday lives to contribute valuably to this praxis. The cumulative result is the evolution of transgressive and generative agencies that operationalise a different social positioning for young womxn from and in marginalising contexts, making it possible to subvert the intentions of the modern/colonial post-apartheid context. Taking up these insights within the disciplines of occupational science and occupational therapy will require us to think relationally about agency, structure, opportunity and 3 occupation in ways that are acentred from the individual. The idea of making-a-life calls for a more explicit grasp of the relational and co-creational flows of doing over time. Conclusion and Implications The conceptualisation of pathways towards social inclusion, as acentred from young womxn as individuals, offers a new way to think about the focal point in youth interventions and policy options. This creates a space to reorient our practices towards understanding how to protect the integrity of the meshwork and create the coherence between opportunities and young womxn's everyday lives. Such actions/approaches have the potential to generate new vistas for the social inclusion of young womxn from and in marginalising contexts.
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    The burden of firearm injuries at two district level emergency centres in Cape Town, South Africa: a descriptive analysis
    (2022) Bush, Luke Anthony; Evans, Katya; Hendrikse, Clint; Van Koningsbruggen, Candice
    Introduction Firearm injuries account for an increasingly significant portion of violence related trauma experienced in South Africa. The related burden on district level emergency care, surgical and inpatient services is poorly described. This research aims to provide epidemiological and health service data on patients sustaining firearm injuries presenting at Mitchells Plain Hospital and Heideveld Emergency Centre. The research also assesses the association of the Triage Early Warning Score with anatomical location of injury, the need for surgical intervention and mortality. A geographical analysis of incident location with respect to home address has also been undertaken. Methods All patients who presented to these emergency centres with a firearm injury over a 12-month period (1 Jan 2019 – 31 Dec 2019) were eligible for inclusion in a retrospective chart review. Results Seven-hundred-and-seventy-six firearm injuries were analysed with those injured having a mean age of 27 years and 91% of those injured being male. Sixty-seven percent of patients self-presented and there were 18 deaths in the emergency centre and a further 23 as an inpatient. The Triage Early Warning Score and Shock Index both showed statistical significance when comparing those not surviving to hospital discharge against those that did survive (p<0.01). Discussion Firearm injuries represented 5.7% of all trauma seen at these two facilities and likely form a higher proportion of the injury profile than at other district services in the City of Cape Town. Although a significant number of those injured are transferred out to tertiary centres that are better capacitated to manage these injuries, many remain at district level for their care. Conclusion Firearm injuries, the immediate surgical needs of those injured and the long-term consequence of those injuries pose a significant burden on limited healthcare resources. Multi-sectoral action, supported by evidence-based primary and secondary preventative strategies, is required to reduce this intentional injury burden, and mitigate the effects.
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    The effectiveness and safety of micropulse transscleral cyclodiode photocoagulation therapy in glaucoma patients at Groote Schuur Hospital, Cape Town, South Africa
    (2023) Manyeruke, Stephen; Du Toit, N; Tinley, C
    Aim To determine the efficacy and safety of micropulse transscleral cyclodiode photocoagulation laser (MP-TSCPC), in terms of intraocular pressure (IOP) reduction, in refractory glaucoma eyes and in blind glaucomatous eyes that were not on antiglaucoma medications. Method 28 consecutive patients were prospectively recruited. Iridex G6 micropulse laser with its P3 probe was used. Baseline variables, including IOP, number of glaucoma medications and visual acuity (VA)were assessed. Success was set at a minimum of 20% reduction in baseline IOP, or a pressure drop to below 21mmHg at 6 months. Results Twenty-eight eyes of 15 female and 13 male glaucoma patients were enrolled. The mean baseline IOP was 40±11mmHg and the mean post laser pressures were 23±10mmHg at 1 week, 25±11mmHg at 4 weeks, 32±12mmHg at 12 weeks and 27±13mmHg at 24 months, representing a percentage drop of 40%, 35%, 30% and 35%, respectively. There was a reduction of one anti glaucoma agent in 11 (39%) patients. The overall success rate of MP-TSCPC was 71% with no serious complications noted. Conclusion In this small cohort of patients, micropulse transscleral laser cyclophotocoagulation was safe and effective in reducing IOP in glaucoma patients, with a success rate of 71%. Further studies are required to verify this finding.
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    The functional and cosmetic outcome of the ventral slit procedure for congenital megaprepuce
    (2022) Tasker, David Beaumont; Howlett, Justin; Rode, Heinz
    Background: Congenital Megaprepuce is a urological condition characterized by a megapreputial reservoir with a long redundant inner prepuce. The condition has been linked to urinary tract infections, lower urinary tract symptoms, and ballooning of the penis during voiding. An impeded urinary stream and resultant ballooning is associated with discomfort and causes parental anxiety due to the unusual appearance of phallus. Surgical correction should improve functionality, but cosmesis is also important. This study took place in a community in which traditional circumcision remains an essential rite of passage. Therefore, early surgical correction of congenital megaprepuce was complicated by the unique requirement that patients remain uncircumcised. Methodology: Here we investigated the functional and cosmetic outcomes of the ventral slit procedure, an uncomplicated technique used to restore urinary flow which, importantly, preserves the foreskin. Parents of 18 paediatric patients were interviewed post-operatively regarding phallic appearance and functionality following surgery. Results: Overall, the ventral slit procedure successfully restored flow, prevented ballooning and alleviated discomfort during voiding in all patients. Parents interviewed were highly satisfied with surgical outcomes, as assessed by the Pediatric Penile Perception score. Conclusion: The ventral slit procedure was found to be a culturally acceptable and simple surgical solution to congenital megaprepuce.
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    ‘The rates of pre-hospital over-triage and the reasons behind them in a Cape Town setting'
    (2021) McAlpine, David; Hodkinson, Peter; Fleming, Julian
    Introduction: Inappropriate dispatch of urgent ambulances by call centre personnel causes an unnecessary drain on existing resources. How often these urgent dispatches are inappropriate has not been evaluated in any lower middle income countries, nor have factors been assessed that contribute to these decisions. Problem: The study aims to establish rates of pre-hospital over-triage in Cape Town, South Africa and to assess the call centre factors around these decision-making processes. Methods: This was a retrospective study examining a single calendar month of all urgent ("lights and sirens") ambulance dispatches made from a large public sector ambulance call centre in Cape Town. On-scene, the ambulance field crew assessed these patients using the South African Triage Score (SATS) and these assessments were correlated with the prioritization of these dispatches by the call centre to determine which patients were 'over-triaged' by the call-taker. Contributory factors were also analysed and included time of day, nature of presenting complaint; and call-taker training and experience - all of which may have affected rates of over-triage. Results: In the course of one month in 2017, 4169 urgent calls were assessed: of these 2701 were over-triaged (58.48%). Over-triage was similar between day (58.02%) and night (59.11%). The most regularly over-triaged complaint was obstetric & gynaecological (84.87%) followed by motor vehicle accidents (65.70%); the lowest rate was for cardiac call-outs (47.12%). We reviewed the 38 highest workload call-takers, and found subtle, but non-statistically significant, trends towards higher over-triage rates with higher levels of training (ILS 62.16%, no medical training 59.42%; p=0.67), more years as a call-taker (< 2 years 59.32%, > 5 years 60.23%; p=0.93) and more years working in the field (0 years 59.36%, > 5 years 63.66%; p=0.31). Conclusion: Rates of pre-hospital over-triage in Cape Town are marginally lower than those described internationally. The nature of the complaint had a strong impact on these rates, notably trauma and gynaecological issues. More experienced call-takers may tend to over-triage more frequently, however the small sample size made these findings uncertain. These findings do however suggest the potential for improvement for better efficiency without compromising patient safety.
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    The role of serial lactate and liver enzyme dynamics in predicting post hepatectomy liver failure
    (2022) Soldati, Vuyolwethu Sonwabile; Bernon, Marc; Jonas, Eduard
    Background: Post-hepatectomy liver failure (PHLF) is an important cause of morbidity and mortality following liver resection. Current prognostic models only allow for the detection of PHLF on post-operative day 5. Earlier detection and intervention may improve outcomes. To date, no studies have evaluated serial post-operative lactate and liver function tests (LFT) to predict PHLF. Aim: This study evaluated the prognostic utility of serial lactate concentrations and LFTs to predict PHLF following hepatectomy. Methods: All major liver resections (≥ 3 Couinaud segments) undertaken at Groote Schuur Hospital and UCT Private Academic Hospital from May 2018 to April 2021 were included. Lactate levels were measured 4-hourly for the first 24 hours post hepatectomy and daily LFTs for the first 5 days. Associations between baseline patient characteristics and lactate dynamics in PHLF as well as the predictive value of lactate, INR and bilirubin were determined. Results: Forty-seven patients, mean age 56.5 (±13.2) years, of whom 24 were males were assessed. Five (10.6%) patients had PHLF and were older (67.4 ± 12.2) and were predominantly men (80%)...