Predicting gallstone pancreatitis in HIV infected patients.

BACKGROUND: Human immunodeficiency virus (HIV) infection, low cluster of differentiation (CD)4 counts and antiretroviral therapy can cause cholestasis and raised transaminases. In acute pancreatitis, this may render biochemical predictors of a gallstone aetiology inaccurate. METHODS: In a prospective observational study, acute pancreatitis was diagnosed by standard criteria. Cholecystolithiasis and bile duct diameter were diagnosed by ultrasound. Cholestasis was defined as two of the following: bilirubin ≥ 21 umol/l, γ glutamyl transferase ≥ 78 U/l, alkaline phosphatase ≥ 121 U/l. Cholangitis was defined as cholestasis and any two sepsis criteria: (temperature > 38˚C, WCC > 12.6 ×109/L, pulse > 90 beats/min). Cholangitis, cholestasis, and bile duct diameter greater that 1 cm were indications for endoscopic retrograde cholangiopancreatography (ERCP). These parameters' ability to predict gallstone pancreatitis (GSP) and choledocholithiasis were compared in HIV+ve and HIV-ve patients. RESULTS: Sixty-two (26%) of 216 patients had GSP. Twenty four were HIV+ve patients. More HIV+ve patients had cholestasis (p = 0.059) and ERCP (p = 0.004). In HIV+ve patients alanine aminotransferase (ALT) > 100 U/L, gamma glutamyl transferase (GGT) > 2 upper limit of normal and cholestasis had a negative predictive value of 92%, 96.7% and 95.2% respectively. In HIV-ve patients, negative predictive value (NPV) was 84%, 83.8% and 84.6% respectively. Bile duct stones were demonstrated at ERCP in 6 (25%) and 3 (8%) of HIV+ve and HIV-ve patients respectively (p = 0.077). Five of 14 ERCP patients had no bile duct stones. HIV+ve and HIV-ve groups had two deaths each. CONCLUSION: Absence at presentation of the abnormal parameters analysed were good predictors of a non-gallstone aetiology particularly in HIV+ve patients. Prior, magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) would reduce the number of non-therapeutic ERCPs.

The clinicopathological spectrum and treatment outcomes in metastatic colorectal cancer in the KwaZulu-Natal province of South Africa.

BACKGROUND: In high-income countries (HICs) 17-20% of colorectal cancer (CRC) patients have metastatic CRC (mCRC) at the time of diagnosis, of which 10-25% are or become resectable, and a further 4-11% of patients will develop metachronous metastases. The study aimed to establish the prevalence and pattern of metastatic CRC to document treatment outcomes in KwaZulu-Natal (KZN), and to compare results to international norms. METHODS: The study population comprised patients with mCRC presenting between 2000 and 2019. Demographics, primary tumour site, spectrum of metastatic disease and resection rate were assessed. RESULTS: MCRC occurred in 33% of the CRC patient population. Eight hundred and thirty-six patients had metastatic disease, comprising Africans (325, 38.8%), Indians (312, 37.3%), Coloureds (37, 4.4%) and Whites (161, 19.2%). Six hundred and fifty-four patients (79%) had synchronous metastases and 182 patients had metachronous metastases (21%). Single organ metastases occurred in 596 patients (71.2%) (M1A) and multiple organ metastasis occurred in 240 patients (28.7%) (M1B). Metastases occurred in the liver (613), lung (240) and peritoneum (85). Fifty-two patients (6.2%) underwent resection of their metastases. CONCLUSION: The prevalence of stage IV CRC in our setting is at the upper limit of international norms. mCRC occurred in 33%, with similar proportions in all races. Resection rate for metastases is low.

A South African central hospital's experience with malignant colorectal obstruction.

BACKGROUND: The spectrum and outcome of colorectal cancer (CRC) presenting with obstruction is not well studied in low- to middle-income countries (LMIC) and could have implications for health policy. This study aimed to address this deficit in an LMIC setting. METHODS: A retrospective analysis was conducted of patients with large bowel obstruction, during the period 2000-2019 from the prospective Inkosi Albert Luthuli Central Hospital (IALCH) CRC registry data. Data analysed included the site of CRC, tumour differentiation, management of patients with obstructive CRC, resection margins post resection, oncological management and reasons for failure to receive oncological therapy. Patient follow-up and recurrence were recorded. RESULTS: Malignant obstruction from CRC occurred in 510 patients (20% of the CRC registry). Median age at presentation was 57 years (IQR 48-67). One hundred and seventy-six (34.5%) and 135 (26.5%) had stage III and IV disease respectively. Moderately differentiated cancer was seen in 335 (65.6%). Management was resection (370; 72.5%), diverting colostomy (123; 24.1%) and stent insertion (55; 10.8%). Twenty-one patients (5.7%) had positive resection margins. Recurrence occurred in 34 patients (6.7%), all of whom had initially undergone resection, giving a recurrence rate of 9.8% in those receiving surgery. Median disease-free interval for patients developing recurrence was 21 months (IQR 12-32). CONCLUSION: One in five patients with CRC presented with obstruction. These patients were younger than in high incomecountry (HIC) series. Over 70% underwent resection. Stomas were used twice as frequently as stents to relieve the obstruction, a finding that is the reverse of that in HICs.

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%.

Quantifying the relationship of HIV infection with clinicopathological spectrum and outcome among patients with colorectal cancer in a South African population.

Introduction: Literature is limited on HIV and colorectal cancer (CRC) in sub-Saharan Africa despite it being the epicentre of the HIV epidemic. Purpose: To compare clinicopathological features and outcome of CRC in HIV-negative and HIV-positive patients. Methods: Retrospective analysis of a prospective CRC database. Demographic details, HIV status, anatomical site, disease stage, treatment and follow-up were documented. Results: Of 715 patients with CRC, 145 and 570 tested positive and negative respectively for HIV. Median age was 45 (IQR 36-53 and 57 (IQR 45-66) years among HIV-positive and HIV-negative patients respectively (p<0.0001). Tumour differentiation differed between the two groups (p=0.003) but staging was not different (p=0.6). Surgical resection rate was 52% for HIV-positive patients versus 59% for HIV-negative patients (p=0.07). Median follow-up was 9 (IQR 2-20.5) months for HIV-positive patients and 12 (IQR 6-29) months for HIV-negative patients (p=0.154). Recurrence rate was 14.7% among HIV positive patients and 6.8% in HIV negative patients (p=0.089). Conclusion: When compared with HIV-negative patients, HIV-positive patients with CRC presented at a younger age and tended to have lower surgical resection rates. There was no difference between the two groups with CRC in terms of anatomical sub-site distribution, disease staging and recurrence rates.

A South Africa tertiary centre experience with redo mitral valve replacement.

BACKGROUND: Severe cardiac failure from mechanical mitral valve thrombosis due to poor warfarin control is a major cause of emergency redo mitral valve replacement (MVR) in South Africa. This study aimed to review the outcomes of redo MVR in patients presenting with mitral valve failure to a tertiary South African centre. METHODS: Retrospective chart review of patients undergoing redo MVR over a 10-year period (2005-2014). Patient demographics, aetiology of valve dysfunction, preoperative clinical assessment and outcomes were analysed. RESULTS: Sixty-four patients had 80 mitral valve procedures. The M:F ratio was 1:2.8 and the median age was 18 (IQR 14-28.5) and 25 (IQR 18-40) at initial surgery and at redo surgery, respectively. Median interval between original and redo MVRs was 47.5 (IQR 7.5-124) months. Rheumatic valve disease was the original pathology in 58 patients (90.6%). Fifty-two patients underwent a single redo MVR and 12 patients had multiple redo MVRs. Fifty-eight (72.5%) were emergency redo procedures. Prosthetic valve thrombosis was present in 73.8%. Ten patients (15.6%) developed postoperative complications. The median hospital stay and ICU stay were 19 (IQR 12-27.5) days and 4 (IQR 3-7) days, respectively. Two patients died in the postoperative period (3.1%). The mean patient follow-up was 42 months. Three patients died during follow-up. CONCLUSION: The majority of redo MVR procedures were undertaken as an emergency with valve thrombosis being the most common aetiology. The mortality rate was 3.1% and postoperative complication rate was 15.6%.

Engaging surgeons among clinician-scientists.

Since completion of the Human Genome Project at the turn of the century, there have been significant advances in genomic technologies together with genomics research. At the same time, the gap between biomedical discovery and clinical application has narrowed through translational medicine, so establishing the era of personalised medicine. In bridging these two disciplines, the clinician-scientist has become an integral part of modern practice. Surgeons and surgical diseases have been less represented than physicians and medical conditions among clinician-scientists and research. Here, we explore the possible reasons for this and propose strategies for moving forward. Discovery-driven personalised medicine is both the present and the future of clinical patient care worldwide, and South Africa is uniquely placed to build capacity for biomedical discovery in Africa. Diverse engagement across clinical disciplines, including surgery, is necessary in order to integrate modern medicine into a developing-world contextualised perspective.

Towards the quantification of perioperative cardiovascular risk in the African context: A sub-analysis of the South African Surgical Outcomes Study and the African Surgical Outcomes Study.

BACKGROUND: The burden of cardiovascular disease in patients requiring non-cardiac surgery in Africa is not known. These patients are at increased risk for postoperative cardiovascular complications. OBJECTIVES: In this sub-study, to use data on comorbidities and surgical outcomes from two large observational studies, the South African Surgical Outcomes Study (SASOS) and the African Surgical Outcomes Study (ASOS), to investigate the prevalence of cardiovascular disease in elective surgical patients and the risk of postoperative cardiovascular complications in this population. METHODS: SASOS and ASOS were both prospective, observational cohort studies that collected data over 1 week in each participating centre. The primary outcome was in-hospital postoperative complications, which included prespecified and defined cardiovascular complications. We defined the cardiovascular disease burden of patients aged ≥45 years presenting for surgery (main objective), determined the relative risk of developing postoperative cardiovascular complications (secondary objective) and assessed the utility of the Revised Cardiac Risk Index (RCRI) for preoperative cardiovascular risk stratification of elective, non-cardiac surgical patients in Africa (third objective). RESULTS: The primary outcome analysis of 3 045 patients showed that patients with major cardiac complications were significantly older, with a higher prevalence of hypertension, coronary artery disease or congestive cardiac failure, and had undergone major surgery. In-hospital mortality for the cohort was 1.2%. CONCLUSIONS: The substantial burden of cardiovascular disease in patients presenting for non-cardiac surgery in Africa is shown in the principal findings of this study. The RCRI has moderate discrimination for major cardiac complications and major adverse cardiac events in African patients undergoing non-cardiac surgery.

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.

Clinicopathological spectrum of small bowel obstruction and management outcomes in adults - experience at a regional academic hospital complex.

BACKGROUND: Delay in operative management of small bowel obstruction (SBO) results in increased morbidity and mortality. The objective was to evaluate clinical presentation and treatment outcome of SBO. METHOD: Prospective cohort study between 2013-2014. Adult patients presenting with SBO were included. Demographics, clinical details, investigations, operative findings, in-hospital progress and outcomes were documented. RESULTS: There were 156 patients (median age 37 [IQR 27-54 years]) with early (44) and delayed (112) presentation. M:F ratio was 1.4:1. Common causes of obstruction were adhesions (94; 60.3%) and hernias (31; 19.9%). Non-operative management was feasible in 59 patients (37.3%) with a success rate of 71.2%. Nonviable bowel was present in 45.1% (early 31%, delayed 50%; p = 0.078). Sixty-one patients (54%) underwent bowel resection; nine patients (20.5%) in the early presentation group and 52 (46.4%) in the delayed group (p = 0.003). Thirty-one patients needed ICU admission (early 5, delayed 26; p = 0.091). The delayed group had longer ICU stay (p = 0.018) and longer hospital stay (p < 0.001). There were more complications (p = 0.084) and re-laparotomies (p = 0.156) in the delayed group. Eight patients died (5.1%). CONCLUSION: The main causes of SBO were adhesions and hernias. Late presentation was associated with higher resection rate, higher critical care admission and longer hospital stay.

Diabetes and lower extremity amputation - rehabilitation pathways and outcomes at a regional hospital.

BACKGROUND: Lower extremity amputations (LEAs) are most frequently due to diabetes mellitus (DM), a disease on the rise. The objective of this study was to determine the prevalence and aetiology of LEAs at Addington Hospital from 2013 to 2017 and to explore the physiotherapy referral practices and outcomes. METHODS: Retrospective study carried out at Addington Hospital, Durban. Patients who underwent LEAs were filtered from theatre registers and the hospital Meditech database. Data collected included patients' demographic profile, diabetic status, level of amputation, limb orientation, physiotherapy referral status, and rehabilitation outcomes. Physiotherapy files were scanned for the attendance of referred patients. Study endpoints were prevalence, diabetes status, referral status, compliance and rehabilitation outcomes. RESULTS: From 2013 to 2017, 1 028 LEAs in 843 patients were identified with single amputations (697) and multiple amputations (146). The median age was 61 (IQR 52-68) years, and the M:F ratio was 1.3:1. A total of 574 (68.1%) patients had DM. Seven hundred and thirty-eight (71.8%) amputations were as a result of DM. The level of amputations was below-knee (479; 46.6%), toectomy (236; 23%), above-knee (196; 19%) and trans-metatarsal (117; 11.4%). Only 148 patients (17.6%) were referred for physiotherapy, of which 91 (61.5%) attended. Mobility in those who attended rehabilitation was with a walking frame (51; 56%), crutches (29; 31.9%), prosthesis and crutches (7; 7.7%), and wheelchair-bound (4; 4.4%). CONCLUSION: Over half the amputations were associated with DM, which was also a risk factor for multiple amputations. Although referral and attendance for physiotherapy were very poor, mobility in those who attended was excellent, indicating a dire need to improve hospital referral pathways.

Anal squamous cell carcinoma in KwaZulu-Natal Province, South Africa, with special reference to the influence of HIV infection on clinical presentation and management outcome.

BACKGROUND: Anal carcinoma is rare. Clinicopathological features influencing outcome have not been determined in HIV-negative and HIV-positive patients in South Africa. OBJECTIVES: To compare presentation and treatment tolerance among HIV-positive and negative patients. METHODS: This study was a retrospective analysis of prospectively collected data on patients with squamous cell carcinoma of the anus. Patients with known HIV status were extracted from the anal cancer database and analysed. Data analysed included demographics, clinical features, stage, pathology and treatment outcome. RESULTS: There were 268 patients with anal squamous cell carcinoma (n=135 HIV-positive and n=33 negative). The median age was 39 years and 53 years for HIV-positive and negative patients, respectively, the male/female ratio was 1:2.7 and 1:1.8 for the two groups, and the ratio of anal margin to canal distribution was 1.3:1 and 1:1. Disease stage was similar, with minor differences. The resection rate was 17% in HIV-positive patients and 9% in those who were HIV-negative. Half the patients in both groups were eligible for definitive therapy, and side-effects of oncotherapy occurred with similar frequency in both groups. The recurrence rate was 7% in both groups and the disease-free interval was similar. Overall survival was longer for HIV-negative patients (p=0.0240). CONCLUSIONS: The prevalence of anal squamous cell carcinoma is much higher in individuals with HIV infection than in those who are HIV-negative. HIV-positive patients present at a younger age and with locally advanced disease that responds less well to standard treatment, and their survival is poorer.

Admissions for post-discharge surgical site infection at a quaternary South African public sector hospital.

BACKGROUND: Reports of post-discharge admissions for surgical site infection (SSI) in African settings are lacking. This information could assist with allocating resources within hospitals, as well as developing targeted interventions aimed at reducing post-discharge SSI. The primary objective of this study was to determine trends in admissions for post-discharge SSI at a South African quaternary/teaching hospital. The secondary objective was to determine trends in mortality rates for these admissions. METHODS: This was a retrospective review of adult admissions for post-discharge SSI at a quaternary/teaching South African hospital between 2006 and 2015. Admissions for post-discharge SSI were identified using the hospital administrative database and appropriate International Classification of Disease, 10th Revision codes. Mortality was determined from the discharge disposition for each admission. Data were analysed with simple regression and trend line statistics. The geospatial distribution of post-discharge SSI, based on the residential postal codes recorded on the hospital administrative database for each admission, was determined using the Power Map® software program. RESULTS: There was no change in admissions for post-discharge SSI over the study period (p = 0.17). Mortality in elderly admissions declined during the study period (p = 0.03). Most admissions for post-discharge SSIs originated from urban areas. CONCLUSION: Despite the implementation of universal SSI prevention methods, admissions for post-discharge SSI remained consistent during the study period. Urban areas appeared to be more.

General attitudes toward research: a pilot survey of HIV-positive surgical patients.

BACKGROUND: The general attitude of HIV-positive surgical patients toward research has not been described, and it is uncertain whether interventions aimed at improving general attitudes toward research are required in this group. The aim of this pilot survey was to address the aforementioned paucity in the literature. METHOD: This was a prospective survey of 39 HIV-positive surgical patients. The 7-item Research Attitudes Questionnaire (RAQ) and a demographic characteristics questionnaire were administered to each study participant. Likert responses for the RAQ were converted into numeric values, and cumulative research attitude scores were computed for each study participant. A descriptive analysis of study participant responses to the RAQ was performed. Statistical associations between demographic characteristics and cumulative research attitude scores were also assessed. RESULTS: Depending on the RAQ item, between 74.3% and 95.9% of study participants responded positively toward research. Negative responses ranged between 0.0% and 10.3%, while neutral responses to RAQ items ranged between 2.6% and 23.1%. Female study participants had lower median research attitudes scores when compared with their male counterparts (p = 0.014). CONCLUSION: In general, study participants expressed a positive attitude toward research. The proportion of neutral responses for some RAQ items suggests there are certain aspects of research which require clarification to prospective research participants. Efforts should be made to improve female HIV-positive surgical patients' overall attitude toward research.

Preoperative anaemia and clinical outcomes in the South African Surgical Outcomes Study.

BACKGROUND: In high-income countries, preoperative anaemia has been associated with poor postoperative outcomes. To date, no large study has investigated this association in South Africa (SA). The demographics of SA surgical patients differ from those of surgical patients in the European and Northern American settings from which the preoperative anaemia data were derived. These associations between preoperative anaemia and postoperative outcomes are therefore not necessarily transferable to SA surgical patients. OBJECTIVES: The primary objective was to determine the association between preoperative anaemia and in-hospital mortality in SA adult non-cardiac, non-obstetric patients. The secondary objectives were to describe the association between preoperative anaemia and (i) critical care admission and (ii) length of hospital stay, and the prevalence of preoperative anaemia in adult SA surgical patients. METHODS: We performed a secondary analysis of the South African Surgical Outcomes Study (SASOS), a large prospective observational study of patients undergoing inpatient non-cardiac, non-obstetric surgery at 50 hospitals across SA over a 1-week period. To determine whether preoperative anaemia is independently associated with mortality or admission to critical care following surgery, we conducted a multivariate logistic regression analysis that included all the independent predictors of mortality and admission to critical care identified in the original SASOS model. RESULTS: The prevalence of preoperative anaemia was 1 727/3 610 (47.8%). Preoperative anaemia was independently associated with in-hospital mortality (odds ratio (OR) 1.657, 95% confidence interval (CI) 1.055 - 2.602; p=0.028) and admission to critical care (OR 1.487, 95% CI 1.081 - 2.046; p=0.015). CONCLUSIONS: Almost 50% of patients undergoing surgery at government-funded hospitals in SA had preoperative anaemia, which was independently associated with postoperative mortality and critical care admission. These numbers indicate a significant perioperative risk, with a clear need for quality improvement programmes that may improve surgical outcomes. Long waiting lists for elective surgery allow time for assessment and correction of anaemia preoperatively. With a high proportion of patients presenting for urgent or emergency surgery, perioperative clinicians in all specialties should educate themselves in the principles of patient blood management.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications.

BACKGROUND: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. METHODS: ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery. RESULTS: The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784. CONCLUSIONS: This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance. CLINICAL TRIAL REGISTRATION: NCT03044899.

Does the reporting of gastro-intestinal endoscopy meet the minimal terminology standard at King Edward VIII Hospital?

BACKGROUND: The Minimal Standard Terminology (MST) was developed to standardise endoscopic reporting. This study is aimed at assessing current reporting at a tertiary hospital and whether it meets this Minimal Standard Terminology. METHOD: This was a retrospective observational study of upper endoscopy reports between January and December 2014. The data extracted were compared to the current reporting standard listed in the MST. To assess and grade the quality of reporting we developed a Gastrointestinal Reporting Score, which incorporates MST variables in addition to demographic details, indication for endoscopy, report legibility, sedation and the use of classification systems to describe pathology. Variables were classified as blank, partially complete or complete and assigned a score of 1-3. The reports were graded according to their overall score for all variables (Max 40) into Grade A (> 36), B (28-36) and C (< 28). RESULTS: There were 100 patients of which 58 were female. Thirty-seven per cent were from the 60-75 year age group. Fiftyfour endoscopies were performed by trainee specialists. Junior and senior consultants performed 36 and 9 upper endoscopies respectively. Indications for upper endoscopy were stated in 51 reports. The use of pre-procedural sedation was not stated in 51 reports. Four reports were illegible; one was conducted by a junior consultant, two by a fourth year trainee specialist and one by an unknown endoscopist whose name was illegible. Common classification systems for oesophagitis, gastropathy features, ulcer characteristics, and ulcer location are not routinely used. Based on the Gastrointestinal Reporting Score there were no Grade A reports, 16 Grade B and 84 Grade C reports. CONCLUSION: The MST is not routinely utilised in our setting and reports are incomplete. There is a need for optimal upper endoscopic reporting, incorporating the MST guidelines.

Serum alcohol levels correlate with injury severity and resource utilization.

BACKGROUND: Alcohol consumption leads to violence and poor judgement. The resultant trauma is the leading cause of emergency department visits. In South Africa, alcohol-related emergency visits can be as high as 57%. The purpose of this prospective study was to establish the prevalence of positive blood alcohol and Blood Alcohol Concentration (BAC) at a tertiary trauma unit in Durban, and to correlate it with injury severity, length of hospital stay and resource utilization. METHOD: A total of 100 patients from King Edward trauma unit were analysed prospectively during the period December 2014 to February 2015. The BAC was correlated with Injury Severity Score (ISS), mechanism of injury, length of stay, and in-hospital mortality. Pearson chi-square test, Wilcoxon rank sum and student t-test were used for statistical analysis. RESULTS: Eighty-eight patients were male. The mean age was 30 ± 9.3 years. Forty-seven patients tested positive for blood alcohol, of whom 81% were above the legal limit for professional drivers. The mean BAC among the alcohol positive patients was 0.146 g/dL. Positive blood alcohol was associated with significantly higher ISS scores (p = 0.0004). Injuries due to interpersonal violence were seen in 83 patients of whom 42 (51%) had positive blood alcohol. Hospital stay for alcohol positive patients was significantly longer compared to alcohol negative patients (p < 0.001). CONCLUSION: The prevalence of blood alcohol in the trauma population is high. Positive blood alcohol is associated with high ISS and longer hospital stays.

Does gender impact on female doctors'experiences in the training and practice of surgery? A single centre study.

BACKGROUND: Surgery has been identified as a male-dominated specialty in South Africa and abroad. This study explored how female registrars perceived the impact of gender on their training and practice of surgery. METHOD: A self-administered questionnaire was used to explore whether females perceived any benefits to training in a male-dominated specialty, their choice of mentors and the challenges that they encountered during surgical training. RESULTS: Thirty-two female registrars participated in the study. The respondents were mainly South African (91%) and enrolled in seven surgical specialties. Twenty-seven (84%) respondents were satisfied with their training and skills development. Twenty-four (75%) respondents had a mentor from the department. Seventeen (53%) respondents perceived having received differential treatment due to their gender and 25 (78.2%) thought that the gender of their mentor did not impact on the quality of the guidance received in surgery. Challenges included physical threats to female respondents from patients and disrespect, emotional threats and defaming statements from male registrars. Additional challenges included time-constraints for family and academic work, poor work-life balance and being treated differently due to their gender. Seventeen (53%) respondents would consider teaching in the Department of Surgery. CONCLUSION: Generally, females had positive perceptions of their training in Surgery. They expressed concern about finding and maintaining a work-life balance. The gender of their mentor did not impact on the quality of the training but 'bullying' from male peers and selected supervisors occurred. Respondents will continue to recommend the specialty as a satisfying career to young female students.

What is the diagnostic yield of colonoscopy in patients with a referral diagnosis of constipation in South Africa?

BACKGROUND: Constipation is a common problem for referral to surgical and colorectal units. Its association with colorectal cancer is controversial. Some authors have found an increased incidence while others have not. The aim of this study is to investigate the incidence of colorectal cancer (CRC) and other significant colonoscopic pathologies in patients undergoing colonoscopy for constipation. METHOD: All colonoscopy reports for constipation were retrieved from our database from January 2011 to 30 June 2014. Data extracted included demographics, colonoscopic findings and adequacy of bowel preparation. Exclusion criteria included patients with other symptoms known to be associated with colonic neoplasia such as lower GIT bleeding, loss of weight, patients with associated anaemia, those with abnormalities on imaging, patients with personal or family history of colorectal cancers or colorectal polyps and patients with inflammatory bowel disease. The primary outcome was the presence of neoplasia at colonoscopy and the secondary outcomes were other colonoscopy findings. RESULTS: A total of 985 colonoscopies were performed from January 2011 to June 2014 of which 144 were done for a referral diagnosis of constipation. Eighty eight (61.1%) were female. Their mean age was 58.6 + 13.8 years (range 19-95 years). There were 61 (42.4%) African patients, 38 (26.4%) White, 33 (22.9%) Asians and 12 (8.3%) Coloured patients. Eighty seven (60.4%) patients had a normal colonoscopy, 20 (13.9%) diverticular disease, 14 (9.7%) polyps of which 6 (4.2%) were neoplastic, and 9 (6.3%) had colorectal cancer. CONCLUSION: Constipation is associated with CRC. The presence of constipation should be a criterion for colonoscopy regardless of age or any other associated clinical features.