Mortality trends during the first three waves of the COVID-19 pandemic at an urban district hospital in South Africa: A retrospective comparative analysis

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) is the virus responsible for the COVID-19 (C19) pandemic. South Africa (SA) experienced multiple periods of increased transmission. Tertiary, regional and central hospitals were overwhelmed, resulting in low acceptance rates.

OBJECTIVES

To compare mortality trends of patients who died in hospital from SARS-CoV-2 infection during the first three waves of infection as defined by the National Institute of Communicable Diseases of South Africa.

METHODS

This was a retrospective cohort study at a district level hospital of 311 adults who died within the first three waves of COVID-19. The study analysed case and crude fatality rates, baseline characteristics, symptomatology, clinical presentation and management of patients.

RESULTS

Waves 1, 2 and 3 yielded case fatality rates of 14.5%, 27.6% and 6.3%, respectively, and crude fatality rates of 16.7%, 33.0% and 12.2%, respectively. Black Africans were less likely to die during the third wave (odds ratio (OR) 0.54; 95% confidence interval (CI) 0.31 - 0.94). Patients in the second wave had clinical frailty scores of <5 (OR 2.51; 95% CI 1.56 - 4.03). Obesity was most prevalent in the second wave (OR 1.87; 95% CI 1.01 - 3.46), and dyslipidaemia (OR 3.03; 95% CI 1.59 - 5.77) and ischaemic heart disease (OR 3.77; 95% CI .71 - 8.33) were most prevalent during the third wave. Severe ground glass appearance was most common during the second wave (OR 2.37; 95% CI 1.49 - 3.77). Renal impairment was most prevalent during the first wave (OR 3.28; 95% CI 1.59 - 6.77), and thrombo- embolic phenomena were less common during wave three (OR 0.12; 95% CI 0.02 - 0.91).

CONCLUSION

The Beta variant was the most virulent, with the highest case and crude fatality rates in wave 2.

Broad responses and attitudes to having music in surgery (the BRAHMS study) - a South African perspective

BACKGROUND

Music is played in operating theatres (OTs) throughout the world, though controversy around its use exists. While some clinicians may find background music favourable to the theatre mood and a way to augment surgical performance, there is concern raised over its distracting and noise-creating properties.

METHODS

In this prospective observational study, between August and December 2021, 110 surgeons and registrars in South Africa responded to a survey investigating the way they use music, and their perceptions and attitudes towards its effect on the OT environment.

RESULTS

In this cohort, 66% were male, 29% were consultants and the most common age range was 30-39 years old. Eighty per cent of respondents reported that music was played at least "sometimes", with 74% reporting that they enjoyed it. Easy Listening was the most played and preferred genre followed by Top 40/Billboard hits. Overwhelmingly, respondents reported that background music in the OT improved temperament, focus, mood, and performance, though over a quarter felt it worsened communication. Thirty-one per cent of respondents reported that the choice of music depended on the type of operation, and 70% would turn music down or off during crises. Those who enjoyed music in their spare time were significantly more likely to enjoy music in the OT and perceive it positively.

CONCLUSION

This study provides a window into the surgeons' use of and attitudes to intraoperative music in South Africa. While overall, music is viewed positively by this cohort, some concerns remain regarding communication and distractedness. Further interventional and qualitative studies would be useful.

Thirteen-year audit of the management of anorectal fistulae in a tertiary colorectal unit

BACKGROUND

Persistent anorectal fistulae are referred for assessment in the Durban Metropolitan area to the colorectal unit at the tertiary hospital. This audit aimed to report the assessment and management of these fistulae to benchmark the outcomes from these approaches at a South African tertiary colorectal unit.

METHODS

Retrospective analysis of prospectively collected data of patients with anorectal fistulae over a 13-year period at a tertiary referral centre. Data analysed included demographics, clinical presentation, comorbidity, management and outcome. Study outcomes measures were healing time and secondary outcome measures were complications of surgery.

RESULTS

One hundred and thirty-three patients (median age 44 and M:F ratio 2.8:1) with 206 fistulae were accrued. The initial assessment and diagnostic procedures included insertion of seton (126), fistulectomy (14), and fistulotomy (65). Definitive procedures included two-stage seton fistulotomy (43), ligation of the inter-sphincteric fistula tract (LIFT) procedure (39), modified Hanley procedure (17), and mucosal advancement flap (5). One patient had no surgery and nine did not undergo a definitive procedure. Additional procedures included anal sphincter reconstruction (2) and repair of rectovaginal fistula (2). Residual anal incontinence occurred in 13.5%. The failure rate was 6% and healing occurred in 94%. The median healing time was 8 months after the initial surgery and 4 months following the definitive procedure.

CONCLUSION

The fistula healing rate overall was 94% and was associated with an incontinence rate of 13.5%.

Experience and perceptions of laparoscopic appendectomy amongst surgical trainees in South Africa

BACKGROUND

TThis study is a survey amongst surgical trainees in South Africa (SA) designed to document their exposure to laparoscopic appendicectomy (LA) and their perceptions about the procedure and to identify possible barriers to its uptake.

METHODS

A structured survey was developed using a combination of quantitative and qualitative questions designed to determine the clinical exposure of surgical trainees to laparoscopic appendectomy and then probe possible factors limiting their access to the procedure. A questionnaire was created online, and a link was distributed to various surgical trainees in Southern Africa. A list of trainees was obtained from the Surgreg Training Association of South Africa (STA).

RESULTS

One hundred and thirty-two (47%) trainees completed the survey out of an estimated 280 general surgery registrars. Ninety-five (72%) were male and 37 (28%) were female respondents. Their median age was 31 years (25-36). There were 14 (11%) year-1 and 21 (16%) year-2, 32 (24%) year-3, 37 (28%) year-4 and 28 (21%) year-5 trainees. The breakdown according to region was area 1 (inland and central) 47 (36%), area 2 (western seaboard) 12 (9%) and area 3 (eastern seaboard) 73 (55%). Forty-three (33%) respondents experienced face-to-face teaching on how to perform a LA. Forty-two (32%) had exposure to laparoscopic simulators. Respondents reported a general lack of experience in performing this procedure. Sixty-nine (52%) had performed this procedure without a senior (i.e., solo) and 13 (10%) had only assisted a senior to perform this procedure. Seventy-four (56%) respondents felt confident performing a LA independently. One hundred and thirteen (86%) respondents expected to be taught this procedure. One hundred and five respondents (80%) were keen to learn to perform LA. One hundred and five respondents (80%) stated that they would be interested in attending an online course on LA. The respondents felt that the following were the significant barriers to performing LA: resource constraints 49 (37%) and time constraints 46 (35%). Thirty per cent of respondents (22) in area 3 reported a reluctance by seniors to teach the procedure.

CONCLUSION

There appears to be a lack of exposure to and confidence with LA amongst South African surgical trainees. This implies a deficiency in formal surgical training programmes. Addressing this deficiency will require innovative solutions.

Development of a competency-based clinical assessment instrument for exit level Oral Hygiene students at the University of Western Cape

Seminal to the process of a health sciences curriculum evaluation is the periodic review of clinical assessment instruments that measure competency. An assessment of quality is facilitated by using a well-structured, authentic and reliable instrument. This process rests on designing and measuring the instrument against a sound framework and validating it for scientific merit. This paper documents the pedagogy and the process taken in developing an improved formative competency-based assessment instrument for the final year students of the Bachelor of Oral Health program (BOH) at the University of the Western Cape (UWC).

Methods: A qualitative research study design employing the Nominal Group Technique (NGT) was used as a method for gaining small group consensus on the clinical assessment instrument for exit level Oral Hygiene (BOH3) students within the parameters of assessment principles. The key contributors to the instrument development process were the academic staff of the Department of Oral Hygiene, involved in clinical teaching and assessment of student competency.

Results: The domains of ethics and professionalism, patient assessment, diagnosis, treatment planning and implementation was identified as the core elements in the assessment. The principles of assessment, which include, alignment with outcomes, feedback, transparency and validity, were used to guide the instrument development. The assessment criteria were cross examined for alignment to the learning outcomes of the module and the program whilst formative feedback was foregrounded as a central feature to support student learning and progress monitoring. Transparency was obtained by providing students access to the instrument before and after the assessment including the written feedback on their performance. The instrument embodied a range of criteria to be assessed rather than on the awarding of a cumulative score. This allowed for the identification of the criteria or domain within which a student is struggling or excelling. Consensus on the instrument design was achieved using the NGT phases throughout the instrument development process including the weighting of the domains and grading. This level of engagement together with the application of scientifically sound assessment principles contributed to the validation of the instrument.

Conclusion: The development of a competency-based assessment instrument was the result of a structured, collaborative and scientifically engaged process framed around specific assessment principles. The process culminated in the development of a formative competency-based clinical assessment instrument that was fit for purpose in the Bachelor of Oral Health program.

The Nominal Group Technique served to be a valuable approach for small group consensus in developing the instrument. It served to promote individual perspectives and to generate debate and group discussion between academics that were proficient in clinical teaching and, finally to facilitate group consensus on the instrument structure and system for administration.

Artificial intelligence in healthcare: Proposals for policy development in South Africa

Despite the tremendous promise offered by artificial intelligence (AI) for healthcare in South Africa, existing policy frameworks are inadequate for encouraging innovation in this field. Practical, concrete and solution-driven policy recommendations are needed to encourage the creation and use of AI systems. This article considers five distinct problematic issues which call for policy development: (i) outdated legislation; (ii) data and algorithmic bias; (iii) the impact on the healthcare workforce; (iv) the imposition of liability dilemma; and (v) a lack of innovation and development of AI systems for healthcare in South Africa. The adoption of a national policy framework that addresses these issues directly is imperative to ensure the uptake of AI development and deployment for healthcare in a safe, responsible and regulated manner.

A fourteen-year audit of surgery for inflammatory bowel disease at a tertiary colorectal unit

BACKGROUND

In South Africa, inflammatory bowel disease (IBD) is increasing in frequency. The purpose of the study was to document our experience with the surgical management of patients with IBD and describe the cohort undergoing surgical management of IBD in a KwaZulu-Natal province tertiary state sector hospital.

METHODS

Retrospective analysis of a database of patients undergoing surgery for IBD. Demographics, site and disease duration, surgical indications, management and outcome were analysed.

RESULTS

Of 397 patients with IBD, 136 had Crohn's disease (CD) (African 13, Indian 78, Coloured 10 and White 35) and 261 had ulcerative colitis (UC) (African 67, Indian 158, Coloured 9 and White 27). Eighty-six of 136 patients with CD required surgical referral. Ileo-colonic CD was most common and non-stricturing/non-penetrating disease behaviour predominated. Seventy-four patients with CD underwent 76 abdominal surgical procedures with in-hospital mortality of 3.5% and a morbidity of 20.9%. Twenty patients required anorectal fistula procedures. Recurrence occurred in nine patients (10.5%) and malignant transformation was seen in three patients (2.2%). One hundred and sixty-three of the 261 patients with UC had pancolitis. Failed medical management was the most common indication for surgical referral. Fiftyone patients with UC had surgery, (age 44.5 [IQR 27-56] years). Forty-five patients underwent 63 abdominal surgical procedures with an overall mortality of 17.7% and a morbidity of 39.2%. Colorectal cancer was seen in 10 patients (3.8%). Laparoscopic procedures were undertaken in eight CD patients (10.8%) and 29 UC patients (39%). The median hospital stay was 7 days for both open and laparoscopic resection.

CONCLUSION

IBD is not uncommon in African patients, with UC being more frequent than CD. Postoperative mortality and potential for malignant transformation are higher for UC.

A fourteen-year audit of surgery for inflammatory bowel disease at a tertiary colorectal unit

ABSTRACT BACKGROUND: In South Africa, inflammatory bowel disease (IBD) is increasing in frequency. The purpose of the study was to document our experience with the surgical management of patients with IBD and describe the cohort undergoing surgical management of IBD in a KwaZulu-Natal province tertiary state sector hospital METHODS: Retrospective analysis of a database of patients undergoing surgery for IBD. Demographics, site and disease duration, surgical indications, management and outcome were analysed RESULTS: Of 397 patients with IBD, 136 had Crohn's disease (Cd) (African 13, Indian 78, Coloured 10 and White 35) and 261 had ulcerative colitis (UC) (African 67, Indian 158, Coloured 9 and White 27). Eighty-six of 136 patients with CD required surgical referral. Ileo-colonic CD was most common and non-stricturing/non-penetrating disease behaviour predominated. Seventy-four patients with CD underwent 76 abdominal surgical procedures with in-hospital mortality of 3.5% and a morbidity of 20.9%. Twenty patients required anorectal fistula procedures. Recurrence occurred in nine patients (10.5%) and malignant transformation was seen in three patients (2.2%). One hundred and sixty-three of the 261 patients with UC had pancolitis. Failed medical management was the most common indication for surgical referral. Fifty-one patients with UC had surgery, (age 44.5 [IQR 27-56] years). Forty-five patients underwent 63 abdominal surgical procedures with an overall mortality of 17.7% and a morbidity of 39.2%. Colorectal cancer was seen in 10 patients (3.8%). Laparoscopic procedures were undertaken in eight CD patients (10.8%) and 29 UC patients (39%). The median hospital stay was 7 days for both open and laparoscopic resection CONCLUSION: IBD is not uncommon in African patients, with UC being more frequent than CD. Postoperative mortality and potential for malignant transformation are higher for UC Keywords: inflammatory bowel disease, Crohn's disease, ulcerative colitis, surgical management

Mastering your Fellowship

The series, “Mastering your Fellowship”, provides examples of the question format encountered in the written and clinical examinations, Final Part A of the FCFP(SA) examination. The series is aimed at helping family medicine registrars prepare for this examination. Model answers are available online.

Mastering your Fellowship

The series, “Mastering your Fellowship”, provides examples of the question format encountered in the written and clinical examinations, Final Part A of the FCFP(SA) examination. The series is aimed at helping family medicine registrars prepare for this examination. Model answers are available online.

Mastering your Fellowship

The series, “Mastering your Fellowship”, provides examples of the question format encountered in the FCFP(SA) examination. The series aims to help family medicine registrars and their supervisors prepare for this examination. Model answers are available online.

Mastering your Fellowship

The series, “Mastering your Fellowship”, provides examples of the question format encountered in the FCFP(SA) examination. The series aims to help family medicine registrars and their supervisors prepare for this examination. Model answers are available online.

An approach to acute pulmonary embolism in the primary emergency care environment

Pulmonary embolism (PE) is a common emergency presenting among high risk patients. It is important to have a structured approach to clinical assessment, diagnosis and management of this potentially life-threatening emergency. Clinical and management pathways have improved over the last 10 years as clear guidelines have emerged. Newer diagnostic modalities have become available and will hopefully improve the pick-up rate of PE and reduce the morbidity and mortality. High level evidence presented by the American Society of Haematology and the European Society of Cardiology forms the basis for this review.

Mastering your Fellowship, Vol 58, No 1 (2016)

The series, “Mastering your Fellowship”, provides examples of the question format encountered in the written examination, Part A of the FCFP(SA) examination. The series aims to help Family Medicine registrars prepare for this examination. Model answers are available online.

Intestinal inflammatory myofibroblastic tumour

BACKGROUND

Inflammatory myofibroblastic tumours (IMFTs) are rare tumours characterised by nosologic, histogenetic and aetiopathogenetic controversy and variable clinicopathological features. We report our experience with intestinal-IMFTs (I-IMFTs) that have been reported mainly as single case reports to date.

METHODS

Five patients with I-IMFTs, identified between 2005 and 2008, formed the study cohort. The clinicopathological features were obtained from departmental and hospital records.

RESULTS

The median patient age was 13 years. While 4 patients presented with symptoms and signs of intestinal obstruction, one IMFT was an incidental finding at laparotomy for trauma. Three I-IMFTs were located in the small bowel and 2 in the colon. Complete resection with end-to-end anastomoses was performed. The gross morphology included 1 polypoid myxoid tumour that served as a lead point for an intussusception, 3 multinodular whorled masses and 1 firm circumferential, infiltrative tumour. Microscopically, all tumours had typical features of IMFT with variable expression of ALK-1, a low proliferation index and tumour-free resection margins. All patients had an uneventful recovery. One patient was lost to further follow-up. Four patients were well, without local recurrence or metastases at 6 months to 3 years.

CONCLUSIONS

Surgery with tumour-free resection margins is the gold standard of care of adult and paediatric I-IMFTs. Heightened recognition of I-IMFT, albeit rare, as a cause of intestinal obstruction, including intussusception, is necessary for pre-operative suspicion of I-IMFT.

Lymphoepithelial lesions of the parotid gland in the HIV era--a South African experience

OBJECTIVE

Historically, lymphoepithelial lesions (LELs) have been a peripheral indication for surgery on the parotid gland, accounting for less than 1% of all parotidectomies undertaken. In the HIV era the profile of parotidectomy has changed, with LEL becoming a common indication for parotidectomy, prompting a review of our current experience.

DESIGN

A retrospective study was undertaken between January 1998 and December 2005. Setting. Surgical services at King Edward VIII Hospital, Durban.

SUBJECTS

All patients presenting with parotidomegaly.

RESULTS

One hundred and sixty-two patients with parotidomegaly were evaluated; 53 (32.7%) had LEL lesions. A total of 151 parotidectomies (including 42 parotidectomies undertaken for LEL lesions) were performed in 147 patients. Radiotherapy was offered to 11 patients with LEL lesions. Complications following parotidectomy for LEL included facial nerve palsy (N=3), seroma formation (N=5) and facial artery false aneurysm (N=1). Three patients required re-parotidectomy for recurrent LEL parotidomegaly. In the patients who underwent radiotherapy, there was a satisfactory outcome; 2 patients who received 4 Gy radiation per sitting developed mild skin discolouration of the treated area.

CONCLUSION

Although surgical management of LEL parotidomegaly may provide a satisfactory result, this approach is technically challenging and is associated with complications and recurrences. For these reasons, the non-operative approach employing radiotherapy should be considered.

Changes in neutrophil count, creatine kinases and muscle soreness after repeated bouts of downhill running

Objective. A primary objective was to examine circulating neutrophil count after repeated bouts of downhill running. An additional aim was to determine creatine kinase (CK) levels during the initial 12 hours, after repeated DHRs. Design. Eleven healthy, untrained Caucasian males performed 2 x 60 min bouts of DHR (-13.5%), spaced 14 days apart, at a speed equal to 75% VO2max on a level grade. Blood was collected before, after, and every hour for 12 hours, and every 24 hours for 6 days. Absolute neutrophil count, CK, and delayed-onset muscle soreness (DOMS) were assessed. Results were analysed using repeated measures ANOVA (p

Inferior lumbar triangle hernia: case report

A patient with a spontaneously acquired hernia along the inferior lumbar triangle commonly referred to as lumbar triangle of Petit is presented. This was confirmed on CT scan and successfully treated surgically. A review of the literature relevant to this condition is presented. It is likely that with advances in imaging techniques and a wider clinical usage of these investigative modalities there will be further recognition of this uncommon condition.

The pathogenesis of membranoproliferative glomerulonephritis in KwaZulu-Natal, South Africa is unrelated to hepatitis C virus infection

Idiopathic membranoproliferative glomerulonephritis (MPGN) is a well-defined clinicopathological entity with a poor prognosis, with 50% of patients progressing to end stage renal disease (ESRD) within 10 years. It was reported in about 36% of adult Black patients with nephrotic syndrome in our center previously [Seedat et al. 1988]. Hepatitis C virus (HCV) infection has been shown to be associated with cryoglobulinemic as well as non-cryoglobulinemic (or idiopathic glomerulonephritis). The aim of this study was to determine whether an association exists between HCV infection and idiopathic MPGN in a population with a relatively high prevalence of MPGN. We studied adult patients referred with glomerular disease over a two-year period, 104 patients had primary glomerulonephritis. All 23 (22%) patients with idiopathic MPGN were enrolled, as well as 32 age-matched patients presenting with other primary glomerular diseases. We examined serum from all 55 patients for evidence of HCV antibodies and HCV RNA. None of the 55 patients showed evidence of HCV infection. Chronic renal failure was present in 82.6% of the patients with idiopathic MPGN and it was advanced in 52,2%, who either were dialysis-requiring at presentation or progressed to ESRD soon thereafter; 30.4% had moderate chronic renal failure, while only 17.4% had normal renal function. HCV infection is not associated with idiopathic MPGN in our patients. Idiopathic MPGN remains an idiopathic disease, possibly with a poor prognosis in our population.

Cardiac responses to mild hypoxic hypercapnia in newborn babies: no effect of sleep position

OBJECTIVE

To evaluate whether cardiac responses to a level of hypoxic hypercapnia that may be observed in rebreathing studies are altered with infant sleep position.

METHODOLOGY

Eighteen healthy term infants (< 5-days-old) were studied. Heart rate (HR) and HR variability were monitored during air breathing and during 3 min exposure to a mixture of 15% O2/3% CO2 in both the prone and supine positions. Power spectral analysis of HR was performed.

RESULTS

Heart rate was the only measured variable to be significantly changed in response to 15% O2/3% CO2. Hypoxic hypercapnia elicited no significant responses in power spectral HR variables. There was no effect of sleeping position on any of the measured variables.

CONCLUSIONS

There are no significant differences in cardiac responses to mild hypoxic hypercapnia between sleep positions and power spectral indices of the autonomic control of HR are not altered by sleep position in newborn babies.