South Africa's COVID-19 Tracing Database: Risks and rewards of which doctors should be aware.

In response to the COVID-19 pandemic, South Africa (SA) has established a Tracing Database, collecting both aggregated and individualised mobility and locational data on COVID-19 cases and their contacts. There are compelling public health reasons for this development, since the database has the potential to assist with policy formulation and with contact tracing. While potentially demonstrating the rapid facilitation through technology of an important public service, the Tracing Database does, however, infringe immediately upon constitutional rights to privacy and heightens the implications of ethical choices facing medical professionals. The medical community should be aware of this surveillance innovation and the risks and rewards it raises. To deal with some of these risks, including the potential for temporary rights- infringing measures to become permanent, there are significant safeguards designed into the Tracing Database, including a strict duration requirement and reporting to a designated judge. African states including SA should monitor this form of contact tracing closely, and also encourage knowledge-sharing among cross-sectoral interventions such as the Tracing Database in responding to the COVID-19 pandemic.

Pandemics, professionalism and the duty of care: Concerns from the coalface.

It is likely that the SARS-CoV-2 pandemic will affect a large part of the world's population and will last for several years. Many critical ethical issues have arisen in the healthcare context. While response from healthcare professionals to participating in the care of patients in the era of COVID-19 has generally been positive, there have also been disturbing experiences on the ground. The practice of medicine is a social contract with humanity. Challenges have arisen because the patient is both a victim and a vector of the coronavirus. All humans should have a natural instinct to care for those in need. Ethically and legally, healthcare professionals cannot be expected to assume a significant and unreasonable risk of harm. While fear is understandable, altruism and interest in serving the sick exemplify the value of solidarity. Social harms like stigmatisation and discrimination can occur. Concerns have been raised regarding protection of privacy and respect for rights of infected individuals. In the era of COVID-19, fear, misinformation and a detachment from one's calling put professionalism strongly to the test.

Suture material use and procurement: an audit of a public hospital surgical system in Gauteng, South Africa.

BACKGROUND: Surgical systems are integral to successful, safe and cost effective clinical practice and must balance surgical demands on consumable items and their costs. Suture material is a key consumable resource, and was evaluated in an audit of consumable use and cost as well as the procurement systems within the South African Gauteng public health care sector. AIMS: To determine suture use and cost in the four commonest general surgical procedures - abdominal wall closure, mastectomy, appendicectomy and inguinal hernia repair - in three academic Gauteng hospitals. Performance and availability were evaluated as a secondary aim in suture material use. METHOD: A prospective observational study. Suture use was documented by the surgeon at the time of the procedure and qualitative investigation at relevant hospital departments determined suture material procurement and expenditure. RESULTS: The surgeons in three facilities documented consistent material type and average number of units used; however, in some cases there was a lack of availability of appropriate material and breakage of generic material intraoperatively. There is no consistent and consolidated electronic record-keeping of suture stock and cost in all three hospitals, therefore cost of suture material used was not obtainable. CONCLUSION: Clinical deficiencies in availability and quality of material may have adverse implications for patient health, healthcare costs and budgets through procedure-related complications and should be investigated. There is a lack of communication between the financial management, procurement officers, hospital and theatre stores and theatre staff. It is suggested that clinical protocols and system-based strategies be put in place to manage surgical consumables.

Lessons learned from the endovascular management of blunt thoracic aortic injuries: A single-centre experience.

BACKGROUND: Blunt thoracic aortic injuries (BTAIs) remain a leading cause of death after blunt trauma. In severe injuries, thoracic endovascular aortic repair (TEVAR) has provided a less invasive alternative to conventional open repair. OBJECTIVE: To report the TEVAR-related complications and uncertainties in patients who presented with traumatic pseudoaneurysms (grade III BTAI). METHODS: From April 2004 to February 2012, 55 patients (42 male, mean age 34.7 years) with severe BTAI were treated with stent grafts. Computed tomography (CT) was used to diagnose the injuries, and follow-up scans were planned at 6 and 12 months. We report the complications and the technical uncertainties related to the procedure. RESULTS: Successful sealing of the injury sites was achieved in all patients, either with a thoracic stent graft (53/55) or infrarenal aortic aneurysm extender cuffs (2/55). During hospitalisation, 13 patients died after TEVAR (mean 14 days). Procedure-related complications included left common carotid artery coverage (1/55), ischaemic left leg (1/55) and graft collapse (1/55). The procedurerelated uncertainties included excessive graft oversizing (15/55), poor graft apposition to the inner curve of the aorta (19/55) and left subclavian artery coverage (24/55). CONCLUSION: Stent grafts appear safe and effective in treating pseudoaneurysms caused by BTAI. However, they are likely to be associated with long-term complications and monitoring strategies of >30 years may be necessary.

Exposure to key surgical procedures during specialist general surgical training in South Africa.

BACKGROUND: The logged experience of specialist general surgical trainees has made it possible to analyse their surgical procedural exposure. METHOD: Logbooks submitted and meeting the minimum requirements for the six final examinations for the fellowship of the College of Surgeons of the CMSA between August 2010 and March 2013 were selected. Consolidated surgical procedural experience was analysed according to procedural category, extent of supervision, procedure complexity and university at which the trainee performed the procedures. RESULTS: The 95 logbooks entered into the study recorded 144 499 procedures, 60.6% of which were unsupervised, 18.5% supervised and 20.9% assisting another surgeon. Major and minor procedures made up 40.4% and 54.6%, respectively, with the remaining 5% categorised as 'other'. A breakdown of procedural exposure per category, including the main contributing or key procedure for each category, is presented. CONCLUSION: Large numbers of procedures are logged by trainees during their surgical training. Inter-university and trainee key procedural exposure in SA differ to a small degree but are striking in some categories. Exposure to key procedures is insufficient in some categories. We are currently unable to assess the quality of training and quality of surgical skills from such logbooks. A standardised electronic logbook will facilitate future analyses of trainee procedural exposure, but other tools will be required to assess the quality of surgical skills training.

A mismatch between aortic pulse pressure and pulse wave velocity predicts advanced peripheral arterial disease.

OBJECTIVES: To determine whether increases in central aortic pulse pressure (PPc), but decreases in carotid-femoral pulse wave velocity (PWV) predict the presence of advanced peripheral arterial disease (PAD). METHODS: Applanation tonometry and vascular ultrasound were employed to assess carotid-femoral PWV, PPc, and carotid intima media thickness (IMT) in 136 patients of African ancestry with chronic critical lower limb ischaemia (CLI) and in 1,030 randomly selected healthy adults of African ancestry, 194 of whom were age- and sex matched (controls). RESULTS: With adjustments for confounders, compared with age- and sex-matched controls, participants with CLI had an increased carotid IMT (p = .0001) and PPc (p < .0001), but a markedly reduced PWV (m/second) (CLI = 5.7 ± 3.7, controls = 8.6 ± 3.4, p < .0001). PWV was correlated with PPc in controls (r = .52, p < .0001), but not in CLI (r = -.06). A PPc/PWV mismatch index showed increased values in participants with CLI over the full adult age range assessed. With carotid IMT, PPc, or aortic augmentation index in the same regression model, an increase in the PPc/PWV mismatch index was independently associated with CLI (p < .0001) and a PPc/PWV value upper 95% confidence interval in the community sample predicted CLI (odds ratio = 32 [6-169], p < .0001). PPc/PWV predicted CLI with a similar level of performance and accuracy and a greater specificity (98%) than that of IMT (82%). CONCLUSION: In CLI, while PPc increases, carotid-femoral PWV is markedly reduced. A PPc/PWV mismatch may be a new risk marker for advanced PAD.

Vascular surgical education in a medium-income country.

Medium income country such as South Africa face a dilemma on the need to offer high quality vascular surgical care in a resource constrained environment, where the vast majority of population has inadequate access to even the most basic health care provision. At the same time with rapid development in technology there is also the need to provide high technological treatment to a small population that can afford high cost therapy. This apparent dichotomy in health care provides a challenge and the solution is for all role players in the health care provision to find a solution which will suite the population at large.

HIV and venous thrombotic events.

HIV has been widely recognised as a prothrombotic condition, with the first case reports having appeared more than 20 years ago. However, surprisingly little evidence is available regarding the mechanisms by which this disease leads to thrombosis. There is little doubt that the relationship is both multifactorial and complex. This review aims to look at the available data and provide a concise summary of the present level of knowledge.

Surgeons and HIV: South African attitudes.

OBJECTIVES: The HIV status of surgeons, in the context of the informed consent obtained from their patients, is a contentious matter. We surveyed the views of practising surgeons in South Africa regarding aspects of HIV and its impact on surgeons. DESIGN: A cross-sectional survey of surgeons who were members of the Association of Surgeons of South Africa, regarding their attitudes to the preceding issues. RESULTS: The salient findings included the view that a patient-centered approach requiring HIV status disclosure to patients would be discriminatory to surgeons and provide no clear benefit to patients, and that HIV-positive surgeons should determine their own scope of practice. CONCLUSION: Patient-centered approaches and restrictive policies, related to this issue, do not accord with clinician sentiment. In the absence of comparable local or international data, this study provides clinicians' views with implications for the development of locally relevant policies and guidelines.

Trauma and emergency surgery: South African model.

South Africa is a low- to middle-income country with huge disparities in income, and a legacy of a disadvantaged majority. During the last 30 years, many of the advantaged minority found greener pastures and emigrated to first-world countries. We are left with a desperate shortage of specialists (including surgeons), particularly in the public sector. The need is especially acute in secondary and rural hospitals. A career in general surgery has become less attractive because of issues of lifestyle, remuneration, and the expanding requirements of the first-world part of our population.Worldwide, South African surgeons are recognized as hardworking and capable, with a broad repertoire-because that is the way they are trained. They are backed by a relatively small group of subspecialists, and all categories of specialists are burdened by a heavy workload. Continuing surgical education is mandatory but poorly enforced.Trauma surgery and intensive care form a substantial proportion of postgraduate training and general surgical practice. In isolation, these fields cannot sustain the needs and demands for the operative skills of a general surgeon. Trauma surgeons would have to find operative general surgical work to maintain their operative skills (and credibility).Because of the large gaps in service delivery to our population, and the shortage of general surgeons, particularly in secondary centers, there is at present limited space for a discipline of emergency surgery. The primary need for our population is access to well-trained generalists, backed by a small cadre of subspecialists.

Proximal suture line support in open abdominal aortic aneurysm repair: a comparative study.

OBJECTIVES: The aim of this study was to determine whether the collar graft (standard dacron graft with a customized flexible collar attached to the proximal rim) decreased anastomotic bleeding and the overall clamp time. DESIGN: Prospective randomised single center study. METHODS: Between November 2003 and January 2006, 21 patients were treated with a collar graft and 19 with a standard dacron graft. Routine endoaneurysmorraphy was used. Only infra-renal aneurysms between 5.5cm and 6.5cm were included. Aneurysms were diagnosed by CT scans. The total number of bleeding points, the total clamp time, and the number of teflon felt pledgets, was determined. RESULTS: The total number of bleeding points; the number of aortic re-clamps and total clamp time (minutes) per patient were all significantly lower in the collar graft group (1.2 versus 2, p<0.04; 0.5 versus 2.0, p<0.001; 13.6 versus 20.1, p<0.003 respectively). The number of teflon felt pledgets and new sutures used was significantly lower in the collar graft group (p<0.001 and p<0.003 respectively). CONCLUSION: The collar graft resulted in fewer anastomotic bleeding points and a shorter clamp time.

HIV-positive status among surgeons - an ethical dilemma.

HIV/AIDS is a manageable disease with a reasonable expectation that affected individuals might be able to experience both reduced mortality and morbidity. Within the socio-political context of the illness there has been a very strong emphasis on human rights issues, especially in relation to discrimination, which has seemingly been influenced more by emotion than science. This article explores and addresses the potential risk of an HIV-positive surgeon transmitting the virus to a patient. We argue that the Centers for Disease Control (CDC) and Health Professions Council of South Africa (HPCSA) guidelines are too restrictive, especially against a background of limited transmission risk, and hence that these guidelines could be more harmful than beneficial to our health systems.

General surgery in crisis--the critical shortage.

INTRODUCTION: General surgery is facing a serious crisis. There has been a significant decline in the number of applicants for registrar posts and an inability to attract and retain general surgical specialists in the state sector. The Association of Surgeons of South Africa (ASSA) undertook this study to determine the extent and cause of the problem. METHODS: The study involved a combination of desk research and structured interviews. In addition, the Health Professions Council of South Africa (HPCSA) database was reviewed and compared with the South African Medical Association (SAMA) and ASSA databases. The medical schools provided information about student numbers and demographics, and the National Department of Health pro vided information about the status of medical practitioner and specialist posts in the state sector. RESULTS: Overall, 26.1% of the specialist posts were vacant. The situation was particularly critical in Mpumalanga and the Eastern Cape, where 84% and 58% of the specialist posts were vacant. Using a predictive model, a conservative estimate of the need for general surgeons was found to be at least 50 per year. Currently the eight medical schools graduate about 25 general surgeons per year. The changing demographics of medical students may be partly responsible for the decline in registrar applicants. CONCLUSION: The findings from this study have revealed that the shortage of general surgeons in the state sector has reached critical levels.

General surgery in crisis--comparatively low levels of remuneration.

INTRODUCTION: Several factors, including comparatively low remuneration, may be responsible for the decline in applicants to general surgery. In this study, the levels of remuneration of general surgeons in the state sector were compared with other professionals in the state sector and general surgeons overseas. METHODS: The study involved a combination of desk research and structured interviews. The Paterson system of job evaluation was used to compare general surgeons with other professionals. The levels of remuneration of general surgeons in the state sector were compared with those of other professionals. RESULTS: There was a significant difference in the levels of remuneration between state-employed medical practitioners and other professional positions such as legal professionals, municipal managers and airline pilots. At senior levels (senior specialist) the remuneration was only +/- 55% of that paid to the selected comparator group. There was also a significant differential between the remuneration of state-employed general surgeons and their overseas counterparts. CONCLUSION: Levels of remuneration of state-employed medical practitioners continue to lag behind other professionals.

General surgery in crisis--factors that impact on a career in general surgery.

INTRODUCTION: The Association of Surgeons of South Africa (ASSA), because of a concern about the decline in the number of applicants for registrar posts, undertook this study into the various factors that may influence the choice of surgery as career option. METHODS: The study involved a combination of desk research and structured interviews with heads of departments, specialists, and registrars in general surgery. RESULTS: The reasons for choosing general surgery as a career included the immediately visible results of a surgeon's efforts and the practical and intellectual challenge of the specialty. General surgery continued to enjoy a high status in society. The greater focus on primary health care has affected facilities at tertiary and secondary institutions. General surgeons worked excessively long hours, which was associated with increased levels of stress and placed severe strains on family life. All respondents felt that their levels of remuneration were 'poor' in relation to other disciplines and professions. CONCLUSION: In this study we identified various factors that impacted either positively or negatively on the choice of general surgery as a career option.

Foam-sclerotherapy, surgery, sclerotherapy, and combined treatment for varicose veins: a 10-year, prospective, randomized, controlled, trial (VEDICO trial).

The study compared, by a prospective, randomized method, 6 treatment options: A: Sclerotherapy; B: High-dose sclerotherapy; C: Multiple ligations; D: Stab avulsion; E: Foam-sclerotherapy; F: Surgery (ligation) followed by sclerotherapy. Results were analyzed 10 years after inclusion and initial treatment. Endpoints of the study were variations in ambulatory venous pressure (AVP), refilling time (RT), presence of duplex-reflux, and number of recurrent or new incompetent venous sites. The number of patients, limbs, and treated venous segments were comparable in the 6 treatment groups, also comparable for age and sex distribution. The occurrence of new varicose veins at 5 years varied from 34% for group F (surgery + sclero) and ligation (C) to 44% for the foam + sclero group (E) and 48% for group A (dose 1 sclero). At 10 years the occurrence of new veins varied from 37% in F to 56% in A. At inclusion AVP was comparable in the different groups. At 10 years the decrease in AVP and the increase in RT (indicating decrease in reflux), was generally comparable in the different groups. Also at 10 years the number of new points of major incompetence was comparable in all treatment groups. These results indicate that, when correctly performed, all treatments may be similarly effective. "Standard," low-dose sclerotherapy appears to be less effective than high-dose sclero and foam-sclerotherapy which may obtain, in selected subjects, results comparable to surgery.

'Real' epidemiology of varicose veins and chronic venous diseases: the San Valentino Vascular Screening Project.

The aim of this study was to evaluate the prevalence and incidence of venous diseases and the role of concomitant/risk factors for varicose veins (VV) or chronic venous insufficiency (CVI). The study was based in San Valentino in Central Italy and was a real whole-population study. The study included 30,000 subjects in eight villages/towns evaluated with clinical assessment and duplex scanning. The global prevalence of VV was 7%; for CVI, the prevalence was 0.86% with 0.48% of ulcers. Incidence (new cases per year) was 0.22% for VV and 0.18% for CVI; 34% of patients with venous disease had never been seen or evaluated. The distribution of VV and CVI in comparison with duplex-detected incompetence (DI) indicates that 12% of subjects had only VV (no DI), 2% had DI but no VV, 7.5% had DI associated with VV, 2% apparent CVI without DI, 3% DI only (without CVI), and 1.6% both CVI and DI. VV associated with DI are rapidly progressive and CVI associated with DI often progresses to ulceration (22% in 6 years). VV without significant DI (3%) and venous dilatation without DI tend to remain at the same stage without progression for a lengthy time. New cases per year appear to have a greater increase in the working population (particularly CVI) possibly as a consequence of trauma during the working period. In older age (>80 years), the incidence of CVI tends to decrease. Ulcers increase in number with age. Only 22% of ulcers can be defined as venous (due to venous hypertension, increased ambulatory venous pressure, shorter refilling time, obstruction and DI). Medical advice for VV or CVI is requested in 164 subjects of 1,000 in the population. In 39 of 1,000, there is a problem but no medical advice is requested and in only 61 of 1,000, the venous problem is real. In VV in 78% of limbs, there is only reflux, in 8% only obstruction, and in 14% both. In CVI, 58% of limbs have reflux, 23% obstruction, and 19% both. In conclusion, VV and CVI are more common with increasing age. The increase with age is linear. There was no important difference between males and females. These results are the basis for future real, whole population studies to evaluate VV and CVI.

Modification of the echogenicity of femoral plaques after treatment with total triterpenic fraction of Centella asiatica: a prospective, randomized, placebo-controlled trial.

The aim of this study was to evaluate whether TTFCA (total triterpenic fraction of Centella asiatica), was effective, by modulating collagen production, in a period of 12 months, increasing the echogenicity of echolucent plaques at the femoral bifurcation. Hypoechoic atherosclerotic plaques have been found to be associated with an increased evidence of cerebrovascular events. In this type of plaques stromal composition is limited as the collagen component is generally very low; the plaque composition is mainly due to lipid accumulation or thrombosis. The aim of this study was the evaluation of echogenicity of hyperechoic plaques and how it could be modified by a drug acting on the modulation of collagen synthesis. Antiplatelet agents were used in all patients; cholesterol-lowering agents were used in 34% of patients in the treatment group and in 36% in the placebo group. TTFCA was used at the dose of 60 mg thrice daily (oral tablets). Of the 60 included subjects 26 completed the study in the treatment group and 24 in the placebo group. At inclusion the average GSM in the treatment group was 14 (SD 3) and 14.3 (SD 3) in controls. At 12 months GSM was increased up to 22.8 (SD 4) in the treatment group and it was 15 (SD 3) in controls. Considering texture no significant changes were observed in controls while a qualitative increase in homogenicity was observed in the TTFCA group. Plaque size measured at the beginning and at the end of the study showed a median increase in size, in controls (23%; range 0%-44%); it was unchanged in the TTFCA group (variation 7%; 4%-26%). In conclusion in the treatment group plaques increased in echogenicity and in homogenicity; size and stenosis remained unchanged. Modulating the scarring process within echolucent plaques (low echogenicity, high echolucency, with a very low collagen/stromal component), possibly by collagen modulation, makes plaques more stable. This has been achieved and documented in the present study by an increase in the gray-scale median (plaques become more echogenic, more 'white'). The variation in GSM is generally associated with a lower risk of wall thrombosis, rupture and embolization. These observations indicate a positive action of TTFCA on the stabilization of hypoechoic, low-density femoral plaques.