Surgical skills deficiencies and needs of rural general practitioners in South Africa.

BACKGROUND: At present, much of the global surgical workforce consists of non-specialist physicians (general practitioners (GPs)) whose only formal surgical training was in medical school as an undergraduate. However, there is widespread concern that GPs do not have the skills necessary to deliver essential surgical care in a rural setting. This requires that a specific training programme be developed to train rural GPs in essential surgical skills for rural settings. OBJECTIVES: To perform a critical analysis to determine essential surgical skills required by GPs in rural South Africa, with the intention of developing the content of an accredited continuing professional development (CPD) learning programme to address needs identified. METHODS: This was a descriptive study in which a desk-top review analysis and a questionnaire survey were used to obtain both qualitative and quantitative data on essential skills required for rural surgical practice. RESULTS: Of 300 GPs, 102 (34.0%) completed the questionnaire. Some of the skills listed as essential for rural surgical practice were removal of foreign objects not in the visual axis (90.0%), packing of epistaxis (93.0%), haematoma drainage (78.3%) and wound debridement and suturing (96.0%). The study also identified the outcomes and essential content of a proposed CPD programme to provide GPs in the rural setting with the required surgical skills. CONCLUSIONS: Enhancing skills of GPs in essential surgical techniques and procedures through an accredited CPD short learning programme will ensure that adequate and comprehensive essential surgical care is provided to people living in rural communities.

The acute AIDS abdomen--a prospective clinical and pathological study.

OBJECTIVES: Patients with AIDS who present with an acute abdomen pose a new challenge to surgeons. The purpose of this study was to determine the nature and outcome of intra-abdominal catastrophes in AIDS patients. METHODS: A prospective clinical study was conducted on HIV-positive patients who presented with an acute abdomen. RESULTS: Thirteen patients were included. Average age was 36 years. Seven patients presented with advanced AIDS. In 10 the ileo-caecal region was affected by a chronic inflammatory process resulting in ulceration and necrosis. Intestinal tuberculosis was found in 7 patients. Despite optimal treatment more than half the study group died in hospital. CONCLUSION: The 'acute AIDS abdomen' proved to be different in nature and prognosis than has been described previously. Intestinal tuberculosis can reasonably be suspected. Operative mortality is unacceptably high. Other treatment options are being investigated.

Risk of asbestosis in crocidolite and amosite mines in South Africa.

X-rays of all while and mixed-race men employed in crocidolite and amosite mines and mills were read independently by three experienced readers according to the ILO U/C classification. Abnormality was regarded as present if reported by two or more readers. Parenchymal abnormality, defined as the presence of small irregular opacities of profusion 1/0 or greater, was found in 7.3% of the workers. Pleural thickening was found in 4.5% of the workers, costophrenic angle obliteration in 3.2%, and pleural calcification in 1.7%. The prevalences of both pleural and parenchymal abnormality were strongly related to the duration of exposure to asbestos at work. The overall prevalence of abnormality increase from 4.0% in men with exposure for 1 year or less to 47.9% in men with more than 15 years of exposure. After taking into account the effects of age and duration of asbestos exposure, the prevalence of pleural abnormality was not predicted by fiber concentration. However, white men working with amosite tended to develop a higher prevalence of pleural abnormality than did those working with crocidolite. Compared to whites, men of mixed race, who only work with crocidolite, had a high prevalence of pleural abnormality in each exposure duration category. In contrast to pleural abnormality, the prevalence of parenchymal abnormality, after taking into account the effects of age and duration of exposure, was significantly predicted by fiber concentration but not by race or asbestos type. Our results suggest that parenchymal abnormality in workers in South African asbestos mines could be largely prevented by reducing exposure to fibers visible under the light microscope. However, this may not be the case for pleural abnormality.

An evaluation of differences in prognosis, recurrence patterns and receptor status between invasive lobular and other invasive carcinomas of the breast.

One-hundred-and-seventy-one patients with invasive lobular carcinomas have been matched with 342 patients with non-lobular invasive carcinomas for lymph node stage, tumour differentiation and patient age on a one to two basis. The two groups were investigated for differences in prognostic factors, survival, disease-free interval, metastatic patterns, receptor status, response to endocrine therapy after distant metastases and bilateral cancer rates. Patients with lobular carcinomas survived significantly longer than patients with carcinomas of no specific type, particularly in survival from the time of diagnosis of distant metastases; lobular carcinomas more often responded to endocrine treatment for systemic disease. Lobular cancers had a significantly higher rate of local recurrence, particularly after treatment by excision and breast irradiation. No differences were found between the two groups with respect to regional or distant recurrence rates, distant organ involvement patterns, distant metastatic free intervals and receptor status. Bilateral cancer was more frequent in patients with lobular carcinoma.

Carcinoma of the head of the pancreas. Morbidity and mortality of surgical procedures.

This retrospective study analyses the peri-operative morbidity and mortality of 165 patients presenting with carcinoma of the head of the pancreas over a 5-year period. Patients clinically fit for surgery (84%) were subdivided into three main groups, namely: group I (6%) underwent pancreaticoduodenal resection; group II (42%) had locoregionally advanced disease; and group III (36%) with metastatic disease. The latter group was subdivided into groups IIIa (22%) without ascites and IIIb (14%) with ascites. In the palliative groups (II and III), 61% underwent operative biliary drainage procedures, 33% a combined biliary drainage and a duodenal bypass procedure and 5% a duodenal bypass only. Obstructive jaundice recurred in 3% of cases after operative biliary drainage. Only 7% of patients required a duodenal bypass during follow-up. The mortality rates after surgery were 22% following pancreaticoduodenectomy (group I), 1.5% for the palliative procedures in group II, but 17% in group IIIa patients with metastatic disease without ascites and 83% when ascites was present (group IIIb). This study demonstrates that patients with ascites, although clinically fit for surgery, had a prohibitively high operative mortality rate and represented a subgroup of patients better treated by non-operative methods. Surgical drainage of the biliary system in all other cases had acceptably low morbidity and mortality rates. A prophylactic duodenal bypass is not mandatory.

The role of mammography to evaluate palpable breast tumours.

Mammography is the best screening tool at present available to detect early breast cancer in asymptomatic women. Its diagnostic ability to clarify the true nature of a palpable tumour in symptomatic breast disease remains controversial. To investigate this, case records of 115 women over 35 years, who presented clinically with a palpable and solid breast tumour over a 5 1/2-year period at Universitas Hospital, Bloemfontein, were retrospectively reviewed. All women were pre-operatively evaluated by clinical examination, mammography and fine-needle aspiration cytology and all patients subsequently underwent open surgical biopsy. Results of this triple diagnostic regimen were correlated to the final histopathological diagnosis. No differences in diagnostic accuracy could be found between mammography and either clinical or cytological diagnosis alone. Combining the clinical finding with that of either mammography or cytology significantly improved the diagnostic ability of both. Malignant disease diagnosed by cytology alone negated the additional diagnostic role of mammography in this context. However, to enable confirmation of a benign tumour, mammography proved to be an essential addition to clinical and cytological evaluation. Mammography correctly detected multicentricity in 7% of malignant tumours, proving it to be essential before breast-conserving surgery could be carried out for malignant tumours.

Pre-operative evaluation of palpable breast tumours.

The diagnostic accuracy of clinical examination, mammography and fine-needle aspiration cytology in identifying malignancy was retrospectively assessed in 207 women with palpable breast masses undergoing breast biopsy for histological examination. Clinical examination was more sensitive (96%) than mammography (81%) or cytology (69%). Cytological examination was totally specific for malignancy. The combined evaluation of clinical examination, mammography and cytological examination revealed a 100% diagnostic accuracy for concordant triplet results. Where discordant triplet results were recorded, 75% of tumours were malignant. Biopsy and frozen section are thus recommended if the 'triplet' provides conflicting results. Preliminary biopsy and frozen section may be unnecessary when the diagnostic triplet unequivocally demonstrates malignancy, or when cytological examination reliably reveals the presence of malignancy. Where the components of the triplet all point to benignity, the patient may be confidently followed up without the necessity of biopsy. The adoption of these guidelines may safely reduce the number of open breast biopsies by about 50-60%.

An estimate of the rate at which crocidolite asbestos fibres are cleared from the lung.

The cumulative fibre exposure of 36 deceased persons who had been employed on crocidolite asbestos mines of the NW Cape was compared with their lung burden determined by fibre count by optical microscope. Allowance for the period which lapsed between date of last exposure and death revealed a lung clearance rate amounting to a half-life of about 6 years.

[Factors which may mask a possible safe threshold for asbestos fibre]. / Faktore wat'n moontlike veilige grenskonsentrasie van asbesvesels kan verbloem.

Five factors are identified which could mask a possible threshold for asbestos fibre as a cause of asbestosis: (i) the definition of asbestosis; (ii) the influence of dust other than asbestos fibre; (iii) the underestimation of the true exposure to fibres; (iv) the non-allowance for random error in the determination of disease; and (v) the overestimation of early (high) exposures coupled with the underestimation of later (low) exposures. The manner in which each of these factors may tend to mask the existence of a threshold is dealt with. It is concluded that one or more of the factors could have been responsible for some of the unsuccessful past attempts to demonstrate a safe concentration for asbestos fibre. It is recommended that in future, exposure-response studies should take these factors into account.

Asbestos-related radiological changes in residents of South African amphibole asbestos mining fields and the fibre counts to which they may have been exposed.

Radiological abnormalities consistent with the results of inhalation of asbestos dust were found in nonoccupationally, environmentally exposed people on South African amphibole mining fields. Dust concentrations in the general atmosphere of the residential areas in the mining fields are reported.

Dust exposure and pneumoconiosis in a South African pottery. 1. Study objectives and dust exposure.

Dust exposure and pneumoconiosis were investigated in a South African pottery that manufactured wall tiles and bathroom fittings. This paper describes the objectives of the investigation and presents dust measurement data. x Ray diffraction showed that the clays used by the pottery had a high quartz content (range 58%-23%, mean 38%). Exposure to respirable dust was measured for 43 workers and was highest (6.6 mg/m3) in a bathroom fitting fettler. Quartz concentrations in excess of 0.1 mg/m3 were found in all sections of the manufacturing process from slip production to biscuit firing and sorting. The proportion of quartz in the respirable dust of these sections was 24% to 33%. This is higher than is usually reported in English potteries. Four hundred and six (80%) of the 509 workers employed at the pottery were potentially at risk of occupational lung disease. The finding of large numbers of pottery workers exposed to unacceptable dust concentrations is not surprising as poor dust control was found in all six wall tile and sanitary ware factories surveyed by the National Centre for Occupational Health between 1973 and 1989. Dust related occupational disease can be expected in potters for many years to come.

Estimating the quartz exposure of South African gold miners.

The possibility that dust and silica exposure estimates in epidemiological studies of South African gold miners have been underestimated has been postulated for some years. These exposure estimates were obtained by converting particle number concentrations measured with konimeters and thermal precipitators to respirable mass concentrations, primarily on theoretical considerations. A detailed review of the methodology has revealed that the theoretically based dust and silica estimates were probably underestimated. In the absence of systematic side-by-side thermal precipitator and modern respirable mass measurements in the South African gold mines, the true relationship between the respirable mass concentrations and the theoretically derived concentrations cannot be known. However, with many uncertainties, we estimate that the quartz exposures of South African miners derived from past theoretically based conversions from particle number to respirable mass underestimate the actual quartz exposures by a factor of about 2.

Paget's disease of the breast.

Twenty patients with histologically proven Paget's disease of the breast are reviewed. They represent an incidence of 1.06% of all breast carcinomas seen over a 12-year period in the Bloemfontein academic hospitals. All cases had ductal carcinoma. Clinically, 20% presented with a mass only, 20% with nipple disease only and 60% with both lesions. More patients with a mass compared with patients with only nipple disease had positive axillary lymph nodes--68.7% v. 25%. Cumulative 5-year survival rates showed a 100% survival rate for patients with only nipple disease, and an 83% survival rate for stage I and II disease. All the patients with stage III and IV disease died within the 4-year follow-up period. Nipple (skin) involvement per se did not worsen the prognosis of patients presenting with both a mass and nipple disease. The main predictors of prognosis were tumour size and lymph node involvement. It is suggested that patients presenting with nipple involvement only and/or small T1 lesions close to the nipple could be treated with wide local excision and axillary dissection in discontinuity followed by radiotherapy to the rest of the breast.

Evidence for an amphibole asbestos threshold exposure for asbestosis assessed by autopsy in South African asbestos miners.

In an attempt to determine whether there exists a threshold asbestos dose below which asbestosis does not occur, data on 807 men who had worked on amphibole asbestos mines and undergone autopsy were analysed. When exposure was expressed as fibre-years no asbestosis was found at autopsy when exposure was up to 2 fibre-years, even after 31-45 years of residence time. In the group exposed to greater than 2-5 fibre-years asbestosis was found. When exposure was expressed as average fibre concentration asbestosis occurred below 2 fibres per ml (f ml-1) and the prevalence increased with residence time. In conclusion, if a threshold dose for asbestosis does exist it is at approximately 2 fibre-years if off-shift exposure is ignored.