Background. Non-cardiac surgical morbidity and mortality is a major global public health burden. Sub-Saharan African perioperative outcome data are scarce. South Africa (SA) faces a unique public health challenge, engulfed as it is by four simultaneous epidemics: (i) poverty-related diseases; (ii) non-communicable diseases; (iii) HIV and related diseases; and (iv) injury and violence. Understanding the effects of these epidemics on perioperative outcomes may provide an important perspective on the surgical health of the country.
Objectives. To investigate the perioperative mortality and need for critical care admission in patients undergoing inpatient non-cardiac surgery in SA.
Methods. A 7-day national, multicentre, prospective, observational cohort study of all patients ≥16 years of age undergoing inpatient non-cardiac surgery between 19 and 26 May 2014 at 50 public sector, government-funded hospitals in SA.
Results. The study included 3 927/4 021 eligible patients (97.7%) recruited, with 45/50 hospitals (90.0%) submitting data that described all eligible patients. Crude in-hospital mortality was 123/3 927 (3.1%; 95% confidence interval (CI) 2.6 - 3.7). The rate of postoperative admission to critical care units was 255/3 927 (6.5%; 95% CI 5.7 - 7.3), with 43.5% of admissions being unplanned. Of the surgical procedures 2 120/3 915 (54.2%) were urgent or emergency ones, with a population-attributable risk for mortality of 25.5% (95% CI 5.1 - 55.8) and a risk of admission to critical care of 23.7% (95% CI 4.7 - 51.4).
Conclusions. Most patients in SA's public sector hospitals undergo urgent and emergency surgery, which is strongly associated with mortality and unplanned critical care admissions. Non-communicable diseases have a larger proportional contribution to mortality than infections and injuries. However, the most common comorbidity, HIV infection, was not associated with in-hospital mortality. The study was registered on ClinicalTrials.gov (NCT02141867).
Background. Acute β-blockade has been associated with poor perioperative outcomes in non-cardiac surgery patients, probably as a result of β-blocker-induced haemodynamic instability during the perioperative period, which has been shown to be more severe in hypertensive patients.
Objective. To determine the impact of acute preoperative β-blockade on the incidence of perioperative cardiovascular morbidity and all-cause mortality in hypertensive South African (SA) patients who underwent vascular surgery at a tertiary hospital.
Methods. We conducted two separate case-control analyses to determine the impact of acute preoperative β-blockade on the incidence of major adverse cardiovascular events (MACEs, a composite outcome of a perioperative troponin-I leak or all-cause mortality) and perioperative troponin-I leak alone. Case and control groups were compared using χ2, Fisher's exact, McNemar's or Student's t-tests, where applicable. Binary logistic regression was used to determine whether acute preoperative β-blocker use was an independent predictor of perioperative MACEs/troponin-I leak in hypertensive SA vascular surgery patients.
Results. We found acute preoperative β-blockade to be an independent predictor of perioperative MACEs (odds ratio (OR) 3.496; 95% confidence interval (CI) 1.948 - 6.273; p< 0.001) and troponin-I leak (OR 5.962; 95% CI 3.085 - 11.52; p< 0.001) in hypertensive SA vascular surgery patients.
Conclusions. Our findings suggest that acute preoperative β-blockade is associated with an increased risk of perioperative cardiac morbidity and all-cause mortality in hypertensive SA vascular surgery patients.
Background. Over time, most patients with Crohn's disease (CD) develop strictures or fistulas, resulting in hospitalisations and surgery. Timely therapy with immunomodulators and biologicals may alter this natural history, but carries a significant risk of side-effects.
Objective. To identify factors to predict poor-outcome severe CD at diagnosis, and thus patients who would benefit most from early, aggressive medical therapies.
Methods. CD patients (n=101) with uncomplicated non-stricturing, non-penetrating disease at diagnosis, and with follow-up >5 years, were retrospectively analysed using a predefined definition of severe CD (SCD) over the disease course. Clinical, demographic, laboratory and histological factors at diagnosis associated with SCD and poor outcome were evaluated by univariate and multivariate analysis.
Results. Overall 33.7% of the cohort developed SCD, and on multivariate Cox proportional hazard analysis the presence of granulomas on endoscopic biopsy at diagnosis was independently associated with development of SCD (hazard ratio (HR) 2.3; 95% confidence interval (CI) 1.15 - 4.64; p=0.02). Simple perianal disease was also associated with this outcome (HR 2.49; 95% CI 1.14 - 5.41; p=0.02). The presence of these variables had a specificity of 99% and a positive predictive value of 88%.
Conclusion. At diagnosis, factors predictive of SCD in our referral centre were the presence of endoscopic biopsy granulomas and perianal disease. Patients with these risk factors should be considered for early, aggressive medical therapy, as benefit will probably outweigh risk. To our knowledge, this is the first study to show that endoscopic biopsy granulomas in patients with uncomplicated (non-stricturing, nonpenetrating) CD predict the subsequent development of SCD.
Background. There is currently no evidence in the South African (SA) literature to suggest how long patients with clinically suspected prostate cancer (an elevated prostate-specific antigen level or abnormal findings on digital rectal examination) wait to have a prostate biopsy.
Objectives. To improve the overall efficiency of the prostate biopsy service offered at St Aidan's Regional Hospital, Durban, SA, by quantifying the burden of disease and waiting times and to identify potential delays in management outcomes, thereby helping to alleviate patient anxiety during the stressful period of investigation.
Methods. We did a retrospective folder review of patients who underwent trans-rectal prostate biopsy at St Aidan's Hospital, where the vast majority of prostate biopsies in the KwaZulu-Natal state healthcare sector are performed, from January to June 2013. The Statistical Package for Social Sciences was used for data analysis.
Results. One hundred and six patients (mean age 67.6 years, 69.8% black Africans) underwent biopsy during the 6-month study period; 49.1% were found to have adenocarcinoma, and of the 80.1% of these who had a bone scan, 73.8% had skeletal metastases (p=0.1379). The median period of time from referral to biopsy was 55 days, from referral to first follow-up date (when the diagnosis is given and treatment options discussed or instituted) 100 days, and from biopsy to first follow-up date (i.e. waiting period to retrieve histological diagnosis) 36 days.
Conclusion. Despite the late presentation of prostate cancer in KZN, patients are waiting an average of 3 months from initial referral for a prostate biopsy to institution of definitive management.
Background. Inappropriate preoperative blood testing can negatively contribute to healthcare costs.
Objective. To determine the extent and cost implications of inappropriate preoperative blood testing in adult patients booked for orthopaedic, general or trauma surgical procedures at a regional hospital in KwaZulu-Natal Province, South Africa (SA).
Methods. We undertook a retrospective observational study using routine clinical data collected from eligible patient charts. The appropriateness of preoperative blood tests was evaluated against locally published guidelines on testing for elective and non-elective surgery. The cost of the relevant blood tests was determined using the National Health Laboratory Service 2014 State Pricing List.
Results. A total of 320 eligible patient charts were reviewed over a 4-week period. Preoperative blood testing was performed in 318 patients. There was poor compliance with current departmental guidelines, with an estimated over-expenditure of ZAR81 019. Non-compliance was particularly prevalent in younger patients, patients graded as American Society of Anesthesiologists 1 and 2, and low-risk surgery groups.
Conclusion. Inappropriate preoperative blood testing is common in our hospital, particularly in low-risk patients. This is associated with an increase in healthcare costs, and highlights the need for SA doctors to become more cost-conscious in their approach to blood testing practices.
Background. Intensive care unit (ICU) beds are scarce resources in low- and middle-income countries. Currently there is little literature that quantifies the extent of the demand placed on these resources or examines their allocation.
Objectives. To analyse the number and nature of referrals to ICUs in the Pietermaritzburg metropolitan area, South Africa, over a 1-year period, to observe the triage process involved in selecting patients for admission.
Methods. A retrospective review of the patients referred to ICUs at Grey's and Edendale hospitals, Pietermaritzburg, was performed over a year. The spectrum of patients was evaluated with respect to various demographics, and the current triage process was observed.
Results. The Pietermaritzburg Metropolitan Critical Care service (PMCCS) received 2 081 patient referrals, 53.4% (1 111/2 081) of males and 46.6% (970/2 081) of females, with a mean patient age of 32 years. The majority of referrals were of surgical patients (39.3%, 818/2 081), followed by medical (18.9%, 393/2 081), trauma (18.6%, 387/2 081) and obstetrics and gynaecology (11.7%, 244/2 081). The chief indications for referral were the need for cardiovascular and respiratory support. Of these referrals, 72.0% (1 499/2 081) were accepted and planned for admission and 28.0% (582/2 081) were refused ICU care. Of the patients accepted, 60.7% (910/1 499) experienced delays prior to admission and 37.4% (561/1 499) were never physically admitted to the units.
Conclusions. The PMCCS receives a far greater number of patient referrals than it is able to accommodate, necessitating triage. Patient demographics reflect a young patient population referred with chiefly surgical pathology needing physiological support.
Background. Present limitations in primary and secondary prevention of diabetic retinopathy mean that many patients with diabetes present with advanced retinal complications, often requiring surgery (vitrectomy).
Objectives. To determine the outcomes of vitrectomy for advanced diabetic retinopathy and to examine context-specific risk factors that may influence outcomes and decisions affecting resource allocation.
Methods. This was a retrospective cohort study of 124 vitrectomies with up to 6 months' follow-up.
Results. Visual acuity was 6/60 or worse in the better eye in 23.4% of patients at presentation. The mean visual acuity of the listed eye was2/60. The fellow eye was considered inoperable in 20.2% of cases. Visual function declined significantly in 26.2% of patients while awaiting surgery. The average waiting time until surgery was 2.9 months (range 1 day - 9 months). Epiretinal membranes were present in 93.6% of cases, and posterior iatrogenic breaks occurred in 49.2%. Silicone oil was used in 24.2%. Visual acuity improved in 54.9%, was unchanged in 30.1%, and worsened in 14.0% of cases at 6 months. Patients with poorer vision at surgery were more likely to improve (odds ratio 2.15; p=0.048). Factors associated with a worse visual outcome were increased age at surgery (p=0.042) and posterior iatrogenic retinal breaks (p=0.007). Renal dysfunction was not associated with worse visual outcomes.
Conclusion. Vitrectomy improved or stabilised vision in 85.0% of cases, although outcomes were unpredictable. A long waiting time to surgery contributed to patient morbidity. The presence of renal dysfunction did not predict poorer visual outcomes.
It has been four years since I wrote an editorial in the SAMJ relating to the problems of trauma in South Africa (SA). I was more optimistic, naïve perhaps, and looking for meaningful change. In the face of the daily carnage from road accidents and interpersonal violence, I asked, 'is 2011 the year we will stand up and do something?' - apparently not. We continue to face the same onslaught, the same 1 200 deaths on our roads each month, and the same number of violent attacks of one man (it is usually men) on another human being. Trauma is an epidemic and, as with any other epidemic, demands policy intervention, preventive measures and provision of care.
Approach to blunt abdominal trauma
Approach to penetrating chest trauma (central chest wall)
Approach to penetrating chest trauma (lateral chest wall)
Approach to penetrating neck trauma
Approach to penetrating limb trauma
Approach to frank haematuria in trauma (bladder and renal injuries)
Approach to frank haematuria in trauma (urethral injuries)
Approach to head injury