The utility of computed tomography at a district-level public hospital in Cape Town.

BACKGROUND:  Computed tomography (CT) has become an invaluable aid in medical diagnostic workup, and its global usage has been shown to be consistently increasing across all departments. While typically located in regional or central hospitals in South Africa, its recent introduction at the district level has many foreseeable benefits. We evaluated its utility at one of the first district hospitals in the Western Cape to obtain a CT suite. OBJECTIVES:  This study aimed to describe the type of CT scans ordered, the clinical indications, the prevalence of significant abnormal findings and the agreement between the clinical opinion and radiological diagnosis. METHODS:  A descriptive cross-sectional study was conducted over a 1-year period at Khayelitsha Hospital, an entry-level hospital just outside of Cape Town. RESULTS:  A total of 3242 CT scans were analysed. The mean age of patients was 46 years; 51.4% were males. A mean of 13 scans were performed per working day. The head and neck area were the most scanned region (n = 1841, 52.3%). Predominantly requested by the Emergency Centre (n = 1382, 42.6%), indications were mainly for general medical conditions workup (n = 2151, 66.4%). Most scans showed abnormalities (n = 2710, 83.6%), with 2115 (65.2%) considered relevant ('positive yield'). Clinical and CT diagnoses agreed in 1610 (49.7%) cases. CONCLUSION:  Computed tomography usage at the district level demonstrated positive yield rates comparable to that of tertiary centres. This implies an appropriate utilisation of the service with a potential decrease in the burden on the referral centre.Contribution: Computed tomography scanners at district-level facilities are appropriately utilised and can provide greater access to care while potentially decreasing the burden on referral centres.

Appropriateness and acceptability of continuous glucose monitoring in people with type 1 diabetes at rural first-level hospitals in Malawi: a qualitative study.

OBJECTIVES: The purpose of this qualitative study is to describe the acceptability and appropriateness of continuous glucose monitoring (CGM) in people living with type 1 diabetes (PLWT1D) at first-level (district) hospitals in Malawi. DESIGN: We conducted semistructured qualitative interviews among PLWT1D and healthcare providers participating in the study. Standardised interview guides elicited perspectives on the appropriateness and acceptability of CGM use for PLWT1D and their providers, and provider perspectives on the effectiveness of CGM use in Malawi. Data were coded using Dedoose software and analysed using a thematic approach. SETTING: First-level hospitals in Neno district, Malawi. PARTICIPANTS: Participants were part of a randomised controlled trial focused on CGM at first-level hospitals in Neno district, Malawi. Pretrial and post-trial interviews were conducted for participants in the CGM and usual care arms, and one set of interviews was conducted with providers. RESULTS: Eleven PLWT1D recruited for the CGM randomised controlled trial and five healthcare providers who provided care to participants with T1D were included. Nine PLWT1D were interviewed twice, two were interviewed once. Of the 11 participants with T1D, six were from the CGM arm and five were in usual care arm. Key themes emerged regarding the appropriateness and effectiveness of CGM use in lower resource setting. The four main themes were (a) patient provider relationship, (b) stigma and psychosocial support, (c) device usage and (d) clinical management. CONCLUSIONS: Participants and healthcare providers reported that CGM use was appropriate and acceptable in the study setting, although the need to support it with health education sessions was highlighted. This research supports the use of CGM as a component of personalised diabetes treatment for PLWT1D in resource constraint settings. TRIAL REGISTRATION NUMBER: PACTR202102832069874; Post-results.

Feasibility of continuous glucose monitoring in patients with type 1 diabetes at two district hospitals in Neno, Malawi: a randomised controlled trial.

OBJECTIVES: To assess the feasibility and change in clinical outcomes associated with continuous glucose monitoring (CGM) use among a rural population in Malawi living with type 1 diabetes. DESIGN: A 2:1 open randomised controlled feasibility trial. SETTING: Two Partners In Health-supported Ministry of Health-run first-level district hospitals in Neno, Malawi. PARTICIPANTS: 45 people living with type 1 diabetes (PLWT1D). INTERVENTIONS: Participants were randomly assigned to Dexcom G6 CGM (n=30) use or usual care (UC) (n=15) consisting of Safe-Accu glucose monitors and strips. Both arms received diabetes education. OUTCOMES: Primary outcomes included fidelity, appropriateness and severe adverse events. Secondary outcomes included change in haemoglobin A1c (HbA1c), acceptability, time in range (CGM arm only) SD of HbA1c and quality of life. RESULTS: Participants tolerated CGM well but were unable to change their own sensors which resulted in increased clinic visits in the CGM arm. Despite the hot climate, skin rashes were uncommon but cut-out tape overpatches were needed to secure the sensors in place. Participants in the CGM arm had greater numbers of dose adjustments and lifestyle change suggestions than those in the UC arm. Participants in the CGM arm wore their CGM on average 63.8% of the time. Participants in the UC arm brought logbooks to clinic 75% of the time. There were three hospitalisations all in the CGM arm, but none were related to the intervention. CONCLUSIONS: This is the first randomised controlled trial conducted on CGM in a rural region of a low-income country. CGM was feasible and appropriate among PLWT1D and providers, but inability of participants to change their own sensors is a challenge. TRIAL REGISTRATION NUMBER: PACTR202102832069874.

Ward-based in situ simulation: lessons learnt from a UK District General Hospital.

INTRODUCTION: In situ simulation (ISS) enables multiprofessional healthcare teams to train for real emergencies in their own working environment and identify latent patient safety threats. This study aimed to determine ISS impact on teamwork, technical skill performance, healthcare staff perception and latent error identification during simulated medical emergencies. MATERIALS AND METHODS: Unannounced ISS sessions (n=14, n=75 staff members) using a high-fidelity mannequin were conducted in medical, paediatric and rehabilitation wards at Stepping Hill Hospital (Stockport National Health Service Foundation Trust, UK). Each session encompassed a 15 min simulation followed by a 15 min faculty-led debrief. RESULTS: The clinical team score revealed low overall teamwork performances during simulated medical emergencies (mean±SEM: 4.3±0.5). Linear regression analysis revealed that overall communication (r=0.9, p<0.001), decision-making (r=0.77, p<0.001) and overall situational awareness (r=0.73, p=0.003) were the strongest statistically significant predictors of overall teamwork performance. Neither the number of attending healthcare professionals, their professional background, age, gender, degree of clinical experience, level of resuscitation training or previous simulation experience statistically significantly impacted on overall teamwork performance. ISS positively impacted on healthcare staff confidence and clinical training. Identified safety threats included unknown location of intraosseous kits, poor/absent airway management, incomplete A-E assessments, inability to activate the major haemorrhage protocol, unknown location/dose of epinephrine for anaphylaxis management, delayed administration of epinephrine and delayed/absence of attachment of pads to the defibrillator as well as absence of accessing ALS algorithms, poor chest compressions and passive behaviour during simulated cardiac arrests. CONCLUSION: Poor demonstration of technical/non-technical skills mandate regular ISS interventions for healthcare professionals of all levels. ISS positively impacts on staff confidence and training and drives identification of latent errors enabling improvements in workplace systems and resources.

Exploring disaster preparedness in an obstetric unit in a district hospital in the Western Cape Province.

BACKGROUND: Research on disaster preparedness in public hospitals is limited, and specialised units such as obstetric departments need to be even more prepared when rendering health care to vulnerable populations. Disasters can be natural, such as floods due to human interventions, sinkholes due to mining, or pandemic occurrences, such as the recent COVID-19 pandemic. Research on disaster preparedness is limited, and even more so in specialised units such as obstetrics and evacuating a ward of maternal and neonatal patients present unique challenges. Being prepared for any disaster is the only assurance of effective patient healthcare during a disaster. This study explored and described nurses' knowledge and attitudes regarding preparedness for a disaster in an obstetric unit in a public institution. The study aimed to make recommendations to improve disaster preparedness in an obstetric ward based on the nurses' knowledge and attitudes. METHODS: This study utilised an exploratory, descriptive qualitative design within a contextual approach. The data were acquired through individual interviews that were done using a semi-structured interview schedule. An observational walkabout was performed with the unit manager to validate interviewee responses. The study employed purposive sampling with a sample size of 17 nurses (N = 32, n = 17) and a response rate of 53%. The interviews were transcribed verbatim, and later, the data underwent analysis using theme analysis and a co-coder. RESULTS: The results indicate that the participants demonstrate an awareness of disaster terminology but need more assertiveness in executing the institutional disaster policy. The results illustrate that more frequent training, disaster rehearsals, and simulations should be implemented to improve disaster readiness. Strategies are recommended to enhance preparedness for a disaster in the obstetric unit. CONCLUSION: The study findings recommend more education and training opportunities that should be regularly instilled as a practice within the obstetric ward. More disaster drills and simulation exercises should be performed to ensure confidence in disaster preparedness. Obstetric staff of all levels should be involved with policymaking and disaster plan development.

SAFE USE OF INTRA-OPERATIVE TOURNIQUETS IN A DISTRICT HOSPITAL IN THE UK-AN AUDIT STUDY IN ORTHOPAEDIC THEATRES AND REVIEW OF CURRENT LITERATURE.

The use of tourniquet is common in orthopaedic surgeries as it reduces blood loss, enhances visualization of the operating field, and leads to quicker procedures. However, the use of tourniquet has certain risks which can be avoided by following guidelines like British Orthopaedic Association Standards for Trauma (BOAST) guidelines for safe use of tourniquet. This audit study was done in a District general hospital to check the compliance of two trauma theatres with BOAST guidelines. The audit found that there was poor documentation of tourniquet details in the operation notes (10%). Regarding tourniquet time and pressure, the compliance in the two theatres was 95 % & 97.5 %. The recommendations of this audit were to use a template to improve documentation of tourniquet details in the operation notes and training of theatre staff on BOAST guidelines for safe use of tourniquet.

Medical interns' training in family medicine at a district hospital and primary health care clinics in Middelburg, Mpumalanga.

Training of medical interns at the Middelburg district hospital has been introduced as part of the mandatory 6 months' rotation in Family Medicine department since 2021. This report provides an overview of what has been attained in 2021 and 2022. It covers various aspects of the activities medical interns have been exposed to in the Middelburg hospital and the surrounding primary health care clinics.Contribution: Sharing experiences of family medicine training for medical interns in district hospitals is essential because the 6 months' rotation is new for most family physician trainers, especially those in small hospitals and primary health care clinics. Taking into account the paucity of evidence on the topic, the report brings current information that supports that training medical interns in district hospitals and primary health care clinics prepares them to be comfortable and competent clinicians for the generalist work during the community service year ahead.

Improving healthcare delivery at a district hospital through teaching interns - A short report.

Every district in Malawi has at least two doctors managing the social and healthcare needs of the local population. The medical doctors at the district are involved in administrative work and have minimal time for clinical practice. As such in most district hospitals, clinical officers (COs) form the backbone of patient care provision. These are cadres that have a 3-year training in clinical medicine; they work side by side with medical assistants (MAs) and nurses. Apart from the Ministry of Health (MoH) workforce, the Department of Family Medicine (FM) of Kamuzu University of Health Sciences (KUHeS) has its main district site at Mangochi. Family physicians and residents from FM department assist in provision of mentorship and teaching to other cadres. Work-based learning requires various strategies and approaches. The experience reported here involves deliberate mentorship and support to enhance the learning of other cadres. Family medicine residents learn through the active participation in these sessions to become future consultants and leaders in primary health care.

Lived experiences of women with spontaneous abortion at a district hospital, South Africa.

BACKGROUND:  Spontaneous abortions occur in 12.5% of pregnancies and have a significant impact on the well-being of women. Dissatisfaction with health services is well-documented, but no studies have been conducted in district health services of the Western Cape. The aim was to explore the lived experiences of women presenting with spontaneous abortions to the emergency department at Helderberg Hospital. METHODS:  A descriptive phenomenological qualitative study used criterion-based purposive sampling to identify suitable participants. Data were collected through semi-structured individual interviews. Atlas-ti (version 22) software assisted with data analysis using the framework method. RESULTS:  A total of nine participants were interviewed. There were four main themes: a supportive environment, staff attitudes and behaviour, the impact of time, and sharing of information. The comfort, cleanliness and privacy of the environment were important. COVID-19 had also impacted on this. Showing interest, demonstrating empathy and being nonjudgemental were important, as well as the waiting time for definitive treatment and the time needed to assimilate and accept the diagnosis. In addition, the ability to give relevant information, explain the diagnosis and help patients share in decision-making were key issues. CONCLUSION:  This study highlighted the need for a more person-centred approach and managers should focus on changes to organisational culture through training and clinical governance activities. Attention should be paid to the physical environment, availability of patient information materials and sequential coordination of care with primary care services.Contribution: This study identifies issues that can improve person-centredness and women's satisfaction with care for spontaneous abortion.

Cost analysis for initiating an integrated package of essential non-communicable disease interventions (PEN-Plus) in Kondoa District Hospital, Tanzania: a time-driven activity-based costing (TDABC) study protocol.

INTRODUCTION: Non-communicable diseases (NCDs) constitute approximately 74% of global mortality, with 77% of these deaths occurring in low-income and middle-income countries. Tanzania exemplifies this situation, as the percentage of total disability-adjusted life years attributed to NCDs has doubled over the past 30 years, from 18% to 36%. To mitigate the escalating burden of severe NCDs, the Tanzanian government, in collaboration with local and international partners, seeks to extend the integrated package of essential interventions for severe NCDs (PEN-Plus) to district-level facilities, thereby improving accessibility. This study aims to estimate the cost of initiating PEN-Plus for rheumatic heart disease, sickle cell disease and type 1 diabetes at Kondoa district hospital in Tanzania. METHODS AND ANALYSIS: We will employ time-driven activity-based costing (TDABC) to quantify the capacity cost rates (CCR), and capital and recurrent costs associated with the implementation of PEN-Plus. Data on resource consumption will be collected through direct observations and interviews with nurses, the medical officer in charge and the heads of laboratory and pharmacy units/departments. Data on contact times for targeted NCDs will be collected by observing a sample of patients as they move through the care delivery pathway. Data cleaning and analysis will be done using Microsoft Excel. ETHICS AND DISSEMINATION: Ethical approval to conduct the study has been waived by the Norwegian Regional Ethics Committee and was granted by the Tanzanian National Health Research Ethics Committee NIMR/HQ/R.8a/Vol.IX/4475. A written informed consent will be provided to the study participants. This protocol has been disseminated in the Bergen Centre for Ethics and Priority Setting International Symposium, Norway and the 11th Muhimbili University of Health and Allied Sciences Scientific Conference, Tanzania in 2023. The findings will be published in peer-reviewed journals for use by the academic community, researchers and health practitioners.

[The financial activity of district hospitals of the Irkutsk general-governorship in the end of XIX century].

The article presents results of the study of archive sources and reference publications. The unknown facts of subsidization of district hospitals of the Irkutsk general-governorship, items and amount of current and supernumerary expenses and sources of financial allocations are revealed. The scope of financial accountability made up by directors and hospital supervisors, office and council of hospitals as well care of charge of patients is impressive. The concrete data concerning food allowance of employees and servants of civilian hospitals and provision of clothing and salaries is presented. The prices of bread, forage and goods permit to evaluate income level of physicians working in the Eastern Siberia. The role of the Department of Public Charity in financing of civil hospitals of the Irkutsk general-governorship in last third of the XIX century is revealed. The article uses terminology corresponding to analyzed time period.

Trends in immunological markers of transfusion transmissible infections among blood donors in Mamfe District Hospital, Southwest Cameroon.

BACKGROUND: Blood transfusion is associated with exposure to blood Transfusion Transmissible Infection (TTIs). The threat posed by the blood-borne pathogens is disproportionately distributed in different healthcare facilities in Cameroon. Thus, there is a need for continuous surveillance of TTIs in the country. This study aimed to assess the screening procedure for blood transfusion and determine the trend in immunological markers of TTIs among blood donors at the Mamfe District Hospital. METHODS: A prospective descriptive, cross-sectional and analytical study was conducted at Mamfe District Hospital from March to May 2022. A total of 165 blood donors were recruited by the consecutive sampling method. Donors were screened using both Rapid diagnostic tests,T. pallidum haemagglutination test and indirect enzyme-linked immunosorbent assay (ELISA) for the detection of TTIs. Data generated was entered into an Excel spreadsheet and analysed using the statistical software R, version 4.2.0. Statistical analysis included descriptive statistics of percentages, means ± standard deviation, and student t-test was used to compare both diagnostic techniques, and was considered significant when p < 0.05. RESULTS: A hundred and sixty-five donors were enrolled in the study with a male preponderance giving a male-female sex ratio of 22.5 and a mean age of 32.23 ± 8.60 years. The majority (75.2%) of the donors were of the O-positive blood type, repeat donors (69.1%) and were mainly family replacement and paid donors as against the voluntary blood donors (39.4% and 37.0% vs. 23.6% respectively). overall TTIs prevalence was 18.78% (31/165) (), with HBsAg being the most predominant marker at 12.12% (20/165) followed by Treponema pallidum, HCV and HIV antibodies at 4.85 (8/165), 1.21%(2/165), 0.60% (1/165) respectively. Except for the HBV, The prevalence of TTIs was higher when using a single RDT than the ELISA test, and the difference was significant (p < 0.05). CONCLUSION: Bloodborne pathogens remain a major menace to safe blood transfusion practice in Mamfe district hospital and their detection could be easily missed if the RDT method alone is used for donor screening. Therefore, the donor screening protocol in Mamfe District Hospital should systematically incorporate a confirmation diagnostic test such as ELISA.

Antibiotic use and resistance patterns at Rumphi District Hospital in Malawi: a cross-sectional study.

BACKGROUND: Overuse of antibiotics is a key driver of antimicrobial resistance (AMR) world-wide. Malawi continues to report rising cases of AMR among both in-patients and out-patients. We investigated antibiotic use and resistance patterns among patients with suspected first line antibiotic treatment failure at Rumphi District Hospital, Malawi. METHODS: We used a cross-sectional study design in which records of patients data on culture and antimicrobial sensitivity tests were extracted, alongside treatment history from 2019 to March, 2023, retrospectively. We also included findings for point prevalence survey (PPS) conducted within four hospital wards in June, 2022 by a well-trained multi-disciplinary team from within the hospital. The data was analyzed for antibiotic use, characterization of pathogens and their susceptibility patterns using Microsoft excel and STATA-14 software. RESULTS: A total of 85 patients' data records were reviewed on antibiotics resistance pattern in which 54 (63.5%) were females. Patient antibiotic history captured indicated Metronidazole (23%), Gentamycin (20%) and Doxycycline (23%) as the most frequently used antibiotics among clients referred for microbiological investigations. Among locally available antibiotics with over 50% sensitivity were Chloramphenicol (61%), ciprofloxacin (55%), and ceftriaxone (54%). Penicillins were among antibiotics with highest resistance: ampicillin (100%), amoxyclav (90%), Piperacilin-tazobactam (63%). The majority of patients came from STI clinic and presented with genital discharges 44% (n = 39). Over 80% of the isolated N. gonorrhoeae exhibited a reduced susceptibility to gentamycin. Prevalence of Methicillin resistant staphylococcus Aureus (MRSA) was 46% and were mostly isolated from wound pus. Among 80 data records of the patients reviewed during PPS, Ceftriaxone (54.3%) and Metronidazole (23.3%) emerged as the most frequently used antibiotics in the wards which were prescribed empirically without a microbiological indication. CONCLUSION: In this study setting, we observed high use of watch antibiotics along with problem of multi-drug resistant infections in patients experiencing clinical failure in a variety of clinical syndromes. The findings underline the need to revamp diagnostic microbiology to increase the uptake of antimicrobial susceptibility testing to guide specific prescriptions of broad-spectrum antibiotics in the watch list.

Comparison of early surgical outcomes of robotic and laparoscopic colorectal cancer resection reported by a busy district general hospital in England.

Robotic platforms provide a stable tool with high-definition views and improved ergonomics compared to laparoscopic approaches. The aim of this retrospective study was to compare the intra- and short-term postoperative results of oncological resections performed robotically (RCR) and laparoscopically (LCR) at a single centre. Between February 2020 and October 2022, retrospective data on RCR were compared to LCR undertaken during the same period. Parameters compared include total operative time, length of stay (LOS), re-admission rates, 30-day morbidity. 100 RCR and 112 LCR satisfied inclusion criteria. There was no difference between the two group's demographic and tumour characteristics. Overall, median operative time was shorter in LCR group [200 vs. 247.5 min, p < 0.005], but this advantage was not observed with pelvic and muti-quadrant resections. There was no difference in the rate of conversion [5(5%) vs. 5(4.5%), p > 0.95]. With respect to perioperative outcomes, there was no difference in the overall morbidity, or mortality between RCR and LCR, in particular requirement for blood transfusion [3(3%) vs. 5(4.5%), p 0.72], prolonged ileus [9(9%) vs. 15(13.2%), p 0.38], surgical site infections [5(4%) vs. 5(4.4%), p > 0.95], anastomotic leak [7(7%) vs. 5(4.4%), p 0.55], and re-operation rate [9(9%) vs. 7(6.3%), p 0.6]. RCR had shorter LOS by one night, but this did not reach statistical significance. No difference was observed in completeness of resection but there was a statically significant increase in lymph node harvest in the robotic series. Robotic approach to oncological colorectal resections is safe, with comparable intra- and peri-operative morbidity and mortality to laparoscopic surgery.

Increasing access to pediatric surgical care: Assessing district hospital readiness in rural Rwanda.

Introduction/Background: Safe and quality surgery is crucial for child health. In Rwanda, district hospitals serve as primary entry points for pediatric patients needing surgical care. This paper reports on the organizational readiness and facility capacity to provide pediatric surgery in three district hospitals in rural Rwanda. Methods: We administered the Children's Surgical Assessment Tool (CSAT), adapted for a Rwandan district hospital, to assess facility readiness across 5 domains (infrastructure, workforce, service delivery, financing, and training) at three Partners in Health supported district hospitals (Kirehe, Rwinkwavu, and Butaro District Hospitals). We used the Safe Surgery Organizational Readiness Tool (SSORT) to measure perceived individual and team readiness to implement surgical quality improvement interventions across 14 domains. Results: None of the facilities had a dedicated pediatric surgeon, and the most common barriers to pediatric surgery were lack of surgeon (68%), lack of physician anesthesiologists (19%), and inadequate infrastructure (17%). There were gaps in operating and recovery room infrastructure, and information management for pediatric outpatients and referrals. In SSORT interviews (n=47), the highest barriers to increasing pediatric surgery capacity were facility capacity (mean score=2.6 out of 5), psychological safety (median score=3.0 out of 5), and resistance to change (mean score=1.5 out of 5 with 5=no resistance). Conclusions: This study highlights challenges in providing safe and high-quality surgical care to pediatric patients in three rural district hospitals in Rwanda. It underscores the need for targeted interventions to address facility and organizational barriers prior to implementing interventions to expand pediatric surgical capacity.

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.

The effect of hypoxic ischemic encephalopathy towards multi-organ complications and its early outcome at a Malaysian district hospital.

INTRODUCTION: Hypoxic ischemic encephalopathy (HIE) is a clinically defined syndrome of disturbed neurologic function in the newborn with evidence of perinatal asphyxia. Stages of HIE are categorised into mild, moderate or severe based on the Sarnat classification. Neurological dysfunction constitutes a part of the wide spectrum of hypoxic ischemic insult as affected infants can have co-existing multi-organ dysfunction which further contributes to morbidities and mortality. This study aims to determine the relationship between the severity of HIE with multi-organ complications and early clinical outcomes. MATERIALS AND METHODS: All neonates who were admitted to the NICU at Hospital Sultan Abdul Halim between January 2018 to December 2022, who fulfilled the inclusion criteria were included. Demographic data, clinical course and investigation results were retrospectively obtained from the medical records. RESULTS: From a total of 90 infants (n = 90) who fulfilled our inclusion criteria, 31 (34%) were mild, 31 (34%) were moderate and 28 (31%) were severe HIE. The mean maternal age was 27 years. Common antenatal issues include diabetes mellitus (37.8%) and anaemia (22.2%). The Apgar scores at 1 and 5 minutes, initial resuscitation requiring intubation, chest compression and adrenaline were associated with higher severity of HIE (p < 0.05). Coagulation dysfunction was the most common complication (79.7%), followed by respiratory dysfunction (33.3%), cardiac dysfunction (28.9%), renal dysfunction (16.1%), haematological dysfunction (15.6%) and hepatic dysfunction (12%). Respiratory and haematological dysfunctions were significantly associated with higher mortality (p < 0.05). There was a significant longer hospital stay (p = 0.023), longer duration of ventilation (p < 0.001) and increase in frequency of seizures (p < 0.001) when comparing moderate and severe HIE patients to mild HIE patients. With increasing severity of HIE, there was also statistically significant higher mortality (p < 0.001). CONCLUSIONS: There is a significant relationship between multiorgan dysfunction, the severity of HIE and mortality. Early anticipation of multi-organ injury is crucial for optimal early management which would reduce the mortality and improve the neurological outcome of the patients.

Total femoral spanning for distal femur "fragility" fractures utilising nail-plate fixation "short-term experience of a district general hospital".

PURPOSE: Our primary objective was to investigate the time to radiological union following linked nail-plate fixation of distal femur "fragility" fractures. Secondary objectives were to evaluate all-cause reoperations, 90-day mortality, rate of blood transfusion and the impact on quality of life. METHODS: In this retrospective study of all adults (≥ 65 years) with native or periprosthetic distal femur fragility fractures, underwent a linked nail-plate fixation, data were retrieved on fracture classifications, clinical frailty score, blood transfusion, length of hospital stay, 90-day mortality, time to radiological union, overall complication rates and EuroQoL-5D. RESULTS: In total, 18 out of 23 patients completed sequential follow-up. Radiological union was observed in 14 patients (median 143 days; range 42-414). Three patients underwent reoperations. There were no implant failures or a subsequent periprosthetic fractures. Ninety-day mortality was 17.4%. Eighteen patients required blood transfusion. The QoL was significantly lower after index surgery (0.875 vs. 0.684; p < 0.01). CONCLUSION: Based on our observation, with short-term follow-up, the linked nail-plate yields optimal stability to allow immediate weight bearing, in a cohort with moderate frailty. It is reproducible, with variable radiological union rates. The concept of "total femoral spanning" reduces the risk of subsequent periprosthetic fractures. The additional intervention has increased the rates of allogenic blood transfusion. There is significant impact on overall QoL, with almost 50% being more dependent in self-care.

The economic and resource burden of e-scooter-related orthopaedic injuries: A district general hospital's experience.

PURPOSE: Electric scooters (e-scooters) are an increasingly popular method of transportation worldwide. However, there are concerns regarding their safety, specifically with regards to orthopaedic injuries. We aimed to investigate the overall burden and financial impact on orthopaedic services as a result of e-scooter-related orthopaedic injuries. METHODS: We retrospectively identified all e-scooter-related injuries requiring orthopaedic admission or surgical intervention in a large District General Hospital in England over a 16-month period between September 2020 and December 2021. Injuries sustained, surgical management, inpatient stay and resources used were calculated. RESULTS: Seventy-nine patients presented with orthopaedic injuries as a result of e-scooter transportation with a mean age of 30.1 years (SD 11.6), of which 62 were males and 17 were females. A total of 86 individual orthopaedic injuries were sustained, with fractures being the most common type of injury. Of these, 23 patients required 28 individual surgical procedures. The combined theatre and recovery time of these procedures was 5500 min, while isolated operating time was 2088 min. The total cost of theatre running time for these patients was estimated at £77,000. A total of 17 patients required hospital admission under Trauma and Orthopaedics, which accounted for total combined stay of 99 days with a mean length of stay of 5.8 days. CONCLUSION: While there are potential environmental benefits to e-scooters, we demonstrate the risks of injury associated with their use and the associated increased burden to the healthcare system through additional emergency attendances, frequent outpatient clinic appointments, surgical procedures, and hospital inpatient admissions.

Identifying avoidable causes of perinatal deaths in a district hospital in Lesotho.

BACKGROUND:  Certain determinants can be associated with avoidable perinatal deaths, and audits are needed to establish what these determinants are, and what can be done to prevent such deaths. OBJECTIVES:  The study aimed at identifying and describing determinants associated with avoidable perinatal deaths at a district hospital in Lesotho and strategies to curb their occurrence. METHOD:  A retrospective descriptive study was conducted using 142 anonymised obstetric records from January 2018 to December 2020. A data collection tool was adopted from the Perinatal Problem Identification Programme. In this tool, avoidable determinants are referred to as 'factors' or 'problems'. RESULTS:  A concerning number of perinatal deaths were secondary to avoidable patient factors, namely a delay in seeking medical care, inappropriate responses to antepartum haemorrhage, and inadequate responses to poor foetal movements. Medical personnel factors are also worth observing, namely incorrect use of partograph, insufficient notes to comment on avoidable factors and 'other' medical personnel problems. Ranking highest among administrative problems were the unavailability of intensive care unit beds and ventilators and inadequate resuscitation equipment. Administrative problems accounted for more perinatal deaths than the patient-related factors and medical personnel factors. CONCLUSION:  There is an urgent need for periodic audits, health education for patients, staff competency and the necessary equipment to resuscitate neonates.Contribution: Avoidable determinants associated with perinatal deaths in a district hospital in Lesotho could be identified. This information provides an understanding of what can be done to limit avoidable perinatal deaths.