Auditing surgical service provision at a South African tertiary institution: Implications for the development of district services.

BACKGROUND: The optimal management of resources within South African state hospitals has been hampered by a paucity of data due to a lack of robust auditing information systems. This study reviews the use of a Hybrid Electronic Medical Record (HEMR) system to capture and aggregate data pertaining to the inpatient service demands on a South African tertiary surgical service. This dataset was used to analyse the appropriateness of tertiary surgical resource utilisation. METHOD: The HEMR system was implemented at Greys Hospital, in the city of Pietermaritzburg, Kwa-Zulu Natal, South Africa on 1 January 2013. Inpatient data pertaining to surgical admissions and operative interventions were captured prospectively. Following an 18-month study period, the data were extracted, aggregated and analysed. The district referral hospitals were mapped, and district surgical procedures performed within the tertiary center were identified and quantified. Results: 7314 patients were admitted and managed by the tertiary surgical service during the study period. The median patient age was 33 years (IQR 6.5-42.4 years). 59.7% were male and 40.3% were female. General, trauma and paediatric surgical admissions constituted 54.8%, 28.6% and 16.6% respectively. Emergency admissions constituted 62.4% and elective admissions 37.6%. Referral sources were captured for 6653 (91%) of the cohort. 4338 (65.2%) patients were referred from district hospitals. The district hospital (Northdale) closest to Greys Hospital was responsible for 1675 (25.2%) of surgical referrals. 4174 operative procedures were performed during the study period, 54.7% performed as an emergency, 34.1% electively and 11.2% semi-electively. The median waiting time for emergency operative intervention was 535 minutes (IQR 130-663). A total of 1272 (30.5%) operative procedures performed were assessed as district-level operations. The time intervals of 07:00-07:59 and 17:00-17:59 were identified as the time periods during which the least number of emergency procedures were performed in the operating theatres. CONCLUSION: The HEMR system enabled the Pietermaritzburg Metropolitan Department of Surgery to quantify the burden of surgical disease and map district referral patterns. Thirty percent of operative procedures performed were assessed as district-level operations. Potentially correctable deficits identified within the tertiary center were lengthy delays to emergency surgery and non-optimal theatre utilisation periods.

Self-Expanding Metal Stent (SEMS) insertion: Fluoroscopy versus pure endoscopic technique - A cost comparison.

Oesophageal cancer is a disease with significant morbidity and mortality, and in South Africa most patients present with advanced disease.1 Self-expanding metal stents (SEMS) are now widely used in the palliation of oesophageal cancer, and in most institutions SEMS are deployed under fluoroscopic guidance. In our institution, we use an exclusive endoscopic deployment technique which is comparable to the traditional fluoroscopic technique in terms of safety and efficacy.2-4 We undertook a study to compare the two techniques with respect to their time- and cost-effectiveness.

The morphology of the foetal sigmoid colon in the African population: a possible predisposition to sigmoid volvulus.

AIM: This study aimed to determine the morphological types of the foetal sigmoid colon and establish if the anatomical predisposition to sigmoid volvulus is present in Black African foetuses. Sigmoid volvulus affects Black Africans in our province more frequently than other ethnic groups, and males more than females. Its aetiology remains speculative, with factors being proposed that do not suggest the pathogenetic mechanisms or the gender bias. Previous anatomical studies have suggested that Black Africans have a predisposition to sigmoid volvulus due to an elongated sigmoid colon. We investigated whether this phenomenon occurred during foetal development. METHOD: Foetuses were donated from local hospitals. Population groups were defined as Black African and non-African. After dissection, the anatomy of the sigmoid colon was described according to level of origin, classic or elongated type and shape (broad or narrow). RESULTS: A total of 296 Black African foetuses and 37 non-African foetuses were donated. The sigmoid colon in the majority of foetuses in all gestational age groups had a low level of origin. An elongated colon was seen in 68% of Black African and 17% of non-African foetuses (P < 0.0001). Among Black Africans there was a higher proportion of elongated sigmoid colon among male (73%) than female foetuses (62%) (P = 0.044). In foetuses with an elongated sigmoid colon the broad shape was more common in females than males and the long-narrow shape was more common in males (P = 0.038). CONCLUSION: The elongated sigmoid colon seen in Black Africans is present in utero and occurs more frequently in Black African males. A narrow shape is more common in male foetuses and the broad shape is more common in female foetuses. These anatomical features may be the cause of the predisposition to sigmoid volvulus in Black African adults.

A prospective evaluation of the predictive value of serum amylase levels in the assessment of patients with blunt abdominal trauma.

BACKGROUND: Less than ten percent of patients who sustain blunt abdominal trauma will suffer a significant intra-abdominal injury. Identifying these patients is difficult and this study reviews the results of routine serum amylase levels in a series of patients with blunt abdominal trauma. METHOD: All patients admitted, by the primary author from November 2010 to November 2012, with a diagnosis of blunt abdominal trauma were included. All these patients had a serum amylase level measurement performed on admission. RESULTS: One hundred and three patients were selected, with an age range from 3 to 68 years. There were 33 females and 70 males. Imaging was obtained in 47 patients (38 CT scans and 9 ultrasounds). Nine (19%) of the patients who were imaged required a laparotomy due to the radiological findings, and 38 (81%) of this sub group underwent successful conservative management. Eighteen patients had a laparotomy on clinical grounds. Intra-abdominal injuries were identified in 38 patients on imaging and/or at laparotomy. In five patients laparotomy did not reveal any injuries. The remaining 38 patients were admitted for serial abdominal observation. They were all discharged home and their symptoms resolved. The serum amylase level ranged from 34 U/L to 3 156 U/L, with a mean of 227 U/L (standard deviation 456 U/L). The levels were raised in 60 patients (58%) of whom 19 (32%) had a significant intra-abdominal injury. The serum amylase level was normal in 43 patients (42%), of whom 19 (44%) had a significant intra-abdominal injury. There were eight pancreatic injuries in the group (pancreatitis (1), pancreatic contusion (3), laceration (1), and transection (3). The serum amylase level was normal in two and mildly elevated in one of the patients with contusions (91, 92 and 129 U/L respectively), mildly elevated in the patient with pancreatitis (121 U/L), and significantly raised in the others (340 U/L with the pancreatic laceration; 3 156, 472, and 1 497 U/L in those with a transected pancreas). Four patients had a serum amylase level of greater than 1 000 U/L. Two of these had pancreatic injuries (3 156 and 1 497 U/L) and had hospital stays of six and sixteen days respectively. In the other two (3 042 and 1 454 U/L) no intra-abdominal injury was found.

Current trauma patterns in Pietermaritzburg.

BACKGROUND: The aim of this observational study was to audit the burden of trauma with which patients present at the three hospitals that comprise the Pietermaritzburg Metropolitan Complex, as well as their intensive care units (ICUs) and the government medico-legal mortuary. METHOD: A retrospective audit was conducted by assessing emergency department, critical care unit admission record books and medico-legal mortuary report files over a period of two years as well as reviewing patient demographics and the mechanism of trauma in patients. Data were manually entered into a data spreadsheet for the period 1 January 2010 to 31 December 2011. Recorded data included basic demographic information, mechanism of injury and the facility. Details of the injury precipitating the ICU admission and the length of stay were included in the ICU data. RESULTS: During the period 10 644 patients presented to the Pietermaritzburg Metropolitan Trauma Service as a result of trauma-related injuries. Of the 10 644 trauma patients seen, there were 3 688 assault-related injuries (35%), 3 715 motor vehicle accident (MVA)-related injuries (35%), 516 gunshot wound (GSW)-related injuries (5%) and 2 725 stabbings (26%). The trauma burden consisted predominantly of blunt trauma (70%), followed by penetrating trauma (30%). The majority of trauma patients were male (77%). Of the 10 644 trauma patients seen, 510 (5%) needed admission to an ICU. The composition of the group requiring ICU was assault (8%), MVAs (48%), GSWs (14%) and stabbings (30%). A total of 1 105 (10%) trauma victims died, 471 of whom survived long enough to be admitted to a medical facility. The mortuary group consisted of 56% incidents of blunt trauma and 44% of penetrating trauma. There were 153 (14%) assault-related deaths, 462 (42%) MVA-related deaths, 181 (17%) GSW-related deaths and 309 (28%) stabbing-related deaths. CONCLUSION: Although the rate of penetrating trauma remains high, it is being overtaken by blunt trauma. Almost half of this blunt trauma load is nonintentional. MVAs are expensive to treat, consume ICU resources and are associated with significant mortality. Injury-prevention strategies are a priority, and should address the high rate of MVAs and the high rate of interpersonal violence. The decline in GSW-related trauma is cause for cautious optimism.

A closer look at burn injuries and epilepsy in a developing world burn service.

BACKGROUND: Burn injuries in South Africa result in significant morbidity and mortality, and specific vulnerable groups of patients are at increased risk of sustaining a burn injury. Epileptic patients are one such vulnerable group. The spectrum of burn injuries sustained by epileptic patients in a South African township and the pattern of injury, mechanism and outcome were reviewed in this study. METHOD: A retrospective review of all epileptic patients admitted to the burn service of Edendale Hospital was undertaken for the period July 2011 to June 2013. RESULTS: One hundred and ninety-seven adult patients were admitted with burns over this period. There were 39 epileptic patients in this cohort, of whom 26 were female. The average age of the patients was 36 years (a range of 21-40 years). The majority of patients sustained a small total body surface area burn. The most common mechanism of burn was from a fire or flames, followed by hot water scalding. Coal or wood fires were the predominant energy source used for heating and cooking at home. CONCLUSION: Epileptics comprise a significant proportion of patients who sustain a burn injury. Typically, they sustain burns during a seizure. These are mostly caused by open flames in the South African environment, and are deep. They tend to be confined to the upper torso, upper limbs and hands. Injury prevention programmes should target epileptics as a vulnerable group.

Prostate Cancer at a regional hospital in South Africa: we are only seeing the tip of the iceberg.

OBJECTIVES: The objectives were to document the presentation of prostate cancer in the Zulu population of KwaZulu-Natal in South Africa, to identify this as a high-risk population, and to determine the potential for under-diagnosis in this population. METHOD: All histopathology results confirming prostatic adenocarcinoma from biopsies preformed at Edendale hospital from 01/11/2012 to 30/04/2014 were collected. A total of 81 participants were enrolled, and a review of their outpatient records was performed. Patient presentation was analysed, younger patients were compared to older patients, and observed incidence was compared to expected incidence. RESULTS: The majority of patients (66%, 95% confidence interval [CI]:54-76%) presented with radiographic evidence of metastatic disease or PSA greater than 100 ng/ml. The median PSA level at presentation was 154 ng/ml (Interquartile range [IQR] = 39-448). Clinically staged T4 disease was present in 44% of patients and only 10% of patients presented with PSA detected disease. Poorly differentiated tumours (Gleason grades 8, 9 and 10) were found in 43% of patients. Only 81 out of a maximum potential of 625 incident prostate cancer cases were diagnosed. CONCLUSION: Black South African men from a predominantly rural Zulu population present late and with advanced and aggressive disease. We are missing the opportunity for remission in most patients in this high risk population group. The establishment of a National Prostate Cancer Registry and further research into a prostate cancer screening programme may be beneficial to this community.

A pilot study of women's experiences after being offered late termination of pregnancy for severe fetal anomaly.

OBJECTIVE: We investigated the attitudes and experiences of women pregnant with an anomalous fetus after being offered late termination of pregnancy (LTOP) before and after delivery or TOP. METHODS: This was a pre- and post-intervention structured interview questionnaire-based study. Pregnant women with severe fetal abnormalities (lethal and nonlethal) diagnosed after 24 weeks gestation were recruited. All were managed according to standard protocol. Interviews were conducted by the researcher over a 3 months period (August-October 2010). Experiences, demographic profile, and sociocultural characteristics were compared between the groups that accepted and declined LTOP. RESULTS: Fifteen pregnant women with severe fetal anomalies were enrolled. Around 5 (33.3%) requested termination, and 10 (66.6%) continued the pregnancy. Those who continued their pregnancies were significantly younger (mean age 25 years, range 20-32 years) than those who requested termination (mean age 31 years, range 22-35 years) (P < 0.05). Mean parity was one (range 0-3) in the patients who continued the pregnancy, and 2 (1-3) in those who terminated it. Partners and immediate family members influenced decision making. All women reported a positive experience of the treatment protocol. CONCLUSION: The decision to continue or terminate a pregnancy for severe fetal abnormalities diagnosed after viability is complex and variable. Younger primigravidas were more likely to continue with the pregnancy in the hope that the baby would be born normal. Good support from partners and family, after delivery, was associated with less regret about the decision that had been made.

Understanding the burden and outcome of trauma care drives a new trauma systems model.

BACKGROUND: The Pietermaritzburg Metropolitan Trauma Service (PMTS) attempts to provide care for a whole city and hence is referred to as a service rather than a center. As part of a multifaceted quality improvement program, the PMTS has developed and implemented a robust electronic surgical registry (ESR). This review of the first year's data from the ESR forms part of a situational analysis to assess the burden of trauma managed by the service and the quality of care delivered within the constraints of the available resources. METHODS: Formal ethical approval was obtained prior to design and development of this study, and appropriate commercial software was sourced. The exercise of data capture was integrated into the process of service delivery and was accomplished at the endpoint of patient care. 12 months after implementation of the registry, the data were extracted and audited. RESULTS: A total of 2,733 patients were admitted over the 12 month study period. The average patient age was 28.3 years. There were 2,255 (82.5 %) male patients and 478 (17.5 %) female patients. The average monthly admission rate was 228 patients, with a peak of 354 admissions over the December period. The mean injury severity score (ISS) was 12 [interquartile range (IQR) 6.7-23.2]. A quarter (24.8 %) of all new emergency admissions had an ISS > 15. The average duration of stay for patients was 5.12 days (IQR 2.3-13.2 days). Some 2,432 (92.1 %) patients survived, and 208 (7.9 %) died. A total of 333 (13 %) patients required admission to either the intensive care unit (ICU) or the high dependency unit. From the city mortuary data a further 362 deaths were identified. These included 290 deaths that occurred on scene and 72 that occurred within Pietermaritzburg hospitals other than Greys and Edendale. The total trauma-related mortality for the entire city in 2012 was 570 (51 % on-scene deaths and 49 % in-hospital deaths). Blunt trauma accounted for 62 % of deaths. CONCLUSIONS: The PMTS treats a significant volume and spectrum of trauma. Despite significant resource limitations, we have managed to implement a functional and sustainable trauma service across multiple hospitals. We believe the major resource deficits limiting our service could be ameliorated by the development of an additional trauma facility, adequately equipped with dedicated trauma operating slates and trauma ICU beds. The adoption of our current model of trauma care came out of a need to work within our resource constraints, and it differs from the traditional model. Within the aforementioned limits, our data suggest that this model of delivering care is feasible, practical, and successful. Considering the universal burden of trauma and the all-too-common imbalance between resource demand and supply among many health-care institutions, it is our hope that this report will contribute to the ongoing academic debate around the topic of optimal systems of providing global trauma care.

Development, implementation, and evaluation of a hybrid electronic medical record system specifically designed for a developing world surgical service.

BACKGROUND: The Pietermaritzburg Metropolitan Trauma Service previously successfully constructed and implemented an electronic surgical registry (ESR). This study reports on our attempts to expand and develop this concept into a multi-functional hybrid electronic medical record (HEMR) system for use in a tertiary level surgical service. This HEMR system was designed to incorporate the function and benefits of an ESR, an electronic medical record (EMR) system, and a clinical decision support system (CDSS). METHODS: Formal ethical approval to maintain the HEMR system was obtained. Appropriate software was sourced to develop the project. The data model was designed as a relational database. Following the design and construction process, the HEMR file was launched on a secure server. This provided the benefits of access security and automated backups. A systematic training program was implemented for client training. The exercise of data capture was integrated into the process of clinical workflow, taking place at multiple points in time. Data were captured at the times of admission, operative intervention, endoscopic intervention, adverse events (morbidity), and the end of patient care (discharge, transfer, or death). RESULTS: A quarterly audit was performed 3 months after implementation of the HEMR system. The data were extracted and audited to assess their quality. A total of 1,114 patient entries were captured in the system. Compliance rates were in the order of 87-100 %, and client satisfaction rates were high. CONCLUSIONS: It is possible to construct and implement a unique, simple, cost-effective HEMR system in a developing world surgical service. This information system is unique in that it combines the discrete functions of an EMR system with an ESR and a CDSS. We identified a number of potential limitations and developed interventions to ameliorate them. This HEMR system provides the necessary platform for ongoing quality improvement programs and clinical research.

Understanding the reasons for delay to definitive surgical care of patients with acute appendicitis in rural South Africa.

BACKGROUND: Acute appendicitis in rural South Africa is associated with significant morbidity due to prolonged delays before definitive surgical care. OBJECTIVE: This audit aimed to quantify the delay in our healthcare system. METHODS: From September 2010 to September 2012, all patients with confirmed acute appendicitis were interviewed and asked about the onset of symptoms and subsequent events in the disease process. Events before and after contact with the healthcare system were referred to as the pre-hospital or behavioural domain and the in-hospital or assessment domain, respectively. RESULTS: Of the 500 patients, 350 (70.0%) experienced a delay of>48 hours from onset of symptoms to definitive surgical care. The mean time before treatment for this group was 5 days (range 3 - 7), while the mean for the group without delay was 1.6 days (range 1 - 2) (p<0.0001). Of 463 delays, 291 were in the behavioural domain and 172 in the assessment domain; 178 patients (50.9%) experienced delay in the behavioural domain only, 59 (16.9%) in the assessment domain only, and 113 (32.2%) in both domains. The mean ambulance transport time from the district hospital to the regional hospital was 4.9 hours. CONCLUSION: There are barriers that prevent patients with acute appendicitis from accessing care. There are also prolonged delays within the system once care has been accessed. Both these sources of delay need to be addressed by quality improvement programmes.

An audit of trauma-related mortality in a provincial capital in South Africa.

BACKGROUND: It has been shown repeatedly that hospital-based mortality data do not capture the actual mortality rate in South Africa, as many corpses are taken directly to the state mortuary. METHOD: A retrospective audit was conducted by reviewing all mortuary reports for the period 1 January 2010 - 31 December 2011. The data recorded included demographics, mechanism of trauma, and cause and site of death. RESULTS: A total of 1 105 trauma victims died. There were 930 males (84.2%) and 175 females (15.8%), of whom 615 were victims of blunt trauma (55.7%) and 490 victims of penetrating trauma (44.3%). The scenes of death were: on scene 584 (52.9%), Edendale Hospital 259 (23.4%), Grey's Hospital 144 (13.0%), Northdale Hospital 68 (6.2%), and 'other' 50 (4.5%). The 'other' group comprised nine deaths at primary healthcare clinics and 41 at private hospitals in Pietermaritzburg. Of deaths related to blunt trauma, 153 (24.9%) were secondary to assault and 462 (75.1%) to a road traffic collision. Of the victims of penetrating trauma, 81 (36.9%) had sustained gunshot wounds and 309 (63.1%) stab wounds. The three leading causes of trauma-related deaths were head injuries (32.6%), polytrauma (29.7%) and chest injuries (27.4%). CONCLUSION: Pietermaritzburg has both a high rate of trauma-related mortality and an immature trauma system, resulting in a significant number of preventable deaths.

Developing a clinical model to predict the need for relaparotomy in severe intra-abdominal sepsis secondary to complicated appendicitis.

BACKGROUND: Complex intra-abdominal sepsis secondary to acute appendicitis is common in South Africa, and management frequently involves relaparotomy. The decision to perform relaparotomy is often difficult, and this study aimed to develop a clinical model to aid the decision-making process. METHOD: The study was conducted from January 2008 to December 2012 at Edendale Hospital, Pietermaritzburg. All patients with intraoperatively confirmed acute appendicitis and all patients in this group who subsequently underwent relaparotomy were included. The clinical course, intraoperative findings and outcome of all patients were recorded until discharge (or death). Using a combination of preoperative and intraoperative parameters, a clinical model was developed to predict the need for relaparotomy. RESULTS: Of the total of 1 000 patients identified, 54.1% were males. The median age for all patients was 21 years. Of 406 relaparotomies, 227 (55.9%) were planned and 179 (44.1%) on demand (expectant treatment). In the relaparotomy group, 367 patients (90.4%) had positive findings. Logistic regression analysis showed that the following four factors accurately predicted the need for subsequent relaparotomy: patients referred from any rural centre, duration of illness >5 days, heart rate >120 bpm, and perforation associated with generalised intraabdominal sepsis. Th is model had a predictive value of >90%. CONCLUSION: We have constructed a model that uses clinical data available at initial laparotomy to predict the need for subsequent relaparotomy in patients with complicated acute appendicitis. It is hoped that this model can be integrated into routine clinical practice, but further study is first needed to validate this model.

Association between chronic pancreatitis and pancreatic cancer at a central hospital in KwaZulu-Natal, South Africa.

BACKGROUND: The frequency of histological chronic pancreatitis (CP) evidence in the resident pancreas of resected periampullary cancers (PACs) has never been studied in Africa. This study aims to describe the spectrum of pathology and outcomes of pancreatic surgeries and address this deficit from a South African central hospital cohort. METHODS: A retrospective audit of patients undergoing pancreatic surgery at Inkosi Albert Luthuli Central Hospital (IALCH) between 2003 and 2023 was conducted. The patient demographics, human immunodeficiency virus (HIV) status, histological subtypes, type and extent of surgery, and 30-day and overall mortality were captured from medical records. The presence of CP in the resident pancreas of patients resected for pancreatic and PAC was obtained from the pathology reports. RESULTS: Of the cohort, 72% were Africans, presenting at an earlier average age than other races. Surgery was performed on 126 (107 for cancer, 19 for CP) patients. Of these, 77 were pancreaticoduodenectomy (PD), of which 34 were for pancreatic ductal adenocarcinoma (PDAC). The prevalence of CP in the resident pancreas was 29.9%, and 55.9% in PDAC. Age was the only factor significantly associated with 30-day mortality, as well as long-term survival amongst patients with pancreatic and PAC. The overall median survival for patients with PAC was seven months; 11 patients are alive. CONCLUSION: In a predominantly African cohort undergoing pancreatic surgery, PDAC presents at a younger age. The high perioperative mortality and low overall survival (OS) in the setting of high CP prevalence in the resident pancreas requires further investigation of its role in the aetiopathogenesis and prognosis in PDAC.

Patterns of injury seen in road crash victims in a South African trauma centre.

BACKGROUND: Road traffic crashes (RTCs) account for a significant burden of disease in South Africa. This prospective study reviews basic demographic and outcome data of patients who sustained an RTC-related injury and analyses the common patterns of injury associated with specific mechanisms of injury. METHOD: We reviewed all patients seen at a single regional hospital (Edendale Hospital, Pietermaritzburg, KwaZulu-Natal) with injuries sustained in RTCs over a 10-week period. State mortuary data were gathered on all RTC-related fatalities over the same period. RESULTS: Three hundred and five patients were seen at the hospital over the 10-week period. The average transfer time to hospital was 9.2 hours (range 1 - 17 hours) One hundred patients were admitted and the rest were discharged home from the emergency department. Of the admitted cohort, 59 were motor vehicle occupants (MVC group) and 41 were pedestrians (PVC group). PVC patients commonly had lower limb, head, radio-ulnar and clavicular injuries, while MVC patients commonly had neck and intra-abdominal injuries. Thirty-seven patients had multiple injuries. The in-hospital mortality rate was 5.6%, but the overall mortality rate was 10.0%, as 15 patients died at the scene. CONCLUSIONS: Patterns of injury differ according to the mechanism of injury. Pedestrians impact against various parts of the vehicle and the ground and so sustain injuries to their arms and legs. Occupants of vehicles impact against the dashboard and steering wheel and are more likely to sustain torso injuries. The low number of severe injuries and multiple injuries and the relatively low inpatient mortality rate are a consequence of the triage effect of long delays in transfer. More severely injured patients are more likely to die at the scene.

A review of key terminology and definitions used for birth defects globally.

Birth defects, also known as congenital disorders, are a significant health issue impacting at least five million births annually worldwide. For policymakers to mount a relevant healthcare response to care for those affected, the burden of disease of these conditions must be quantified. Estimates of the contribution of birth defects to under-5 child mortality and morbidity are generated by several groups globally. These estimates often differ, causing confusion for policymakers. While some differences may be attributed to the data sources and methods used, much is due to a lack of clarity in the terminology used for the group of disorders classed as "congenital". This study aimed to gain insight into the diversity of terms and definitions for birth defects, including those used routinely by relevant international/national organisations and in the peer-reviewed literature. This two-part study included (1) scoping review of peer-reviewed literature to identify terms and definitions in use for birth defects and (2) review of key websites and grey literature to identify terms and definitions used. The results of this study indicate a wide variety of terms being used, often interchangeably and undefined, in peer-reviewed publications, on institutional websites and related literature. This suggests a lack of clarity related to terminology and sets the scene for further discussion, recommending that the community of practice working on birth defects comes to a consensus on standard terminology and definitions for global uptake and implementation. Such standardisation will facilitate a common understanding of the burden of these disorders globally, regionally and within countries so that action can be taken to support affected children and their families.

Development and internal validation of the survival time risk score in patients treated for oesophageal cancer with palliative intent in South Africa.

BACKGROUND: Most patients who present to South African state hospitals with advanced stage oesophageal squamous cell cancer (OSCC) disease receive palliative treatment. This study aimed to assess the factors that influence survival in patients with OSCC who received palliative management and to develop a prognostic score to aid clinicians in decisionmaking. METHODS: Analysis of a prospectively collected database assessed factors influencing survival of patients diagnosed with OSCC receiving palliative treatment. Factors assessed included patient demographics, clinical and laboratory data and tumour factors. A multivariable logistic regression model was used to assess for significant factors associated with survival time and a prognostic score was developed and internally validated based on these factors. RESULTS: There were 384 patients with a male-to-female ratio of 1.3:1. The median survival of the cohort was 3.7 months. Factors that influenced survival on multivariate analysis included area of residence (aOR 1.82, 95% CI 1.02-3.24), performance status (aOR 2.56, 95% CI 1.50-4.35), body mass index (aOR 1.87, 95% CI 1.14-3.06) and serum albumin (aOR 3.06, 95% CI 1.46-6.42). The final prognostic score contained three of the four independent variables based on the regression coefficient for each variable. After internal validation, the risk score maintained fair discrimination and good calibration. CONCLUSION: The prognostic scoring system based on patient performance status, body mass index and serum albumin, if validated on an independent cohort, would allow more objective decisions on whether to stage or not prior to embarking on palliative treatment, streamlining care and improving quality of life.

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.

Validation and effect on diabetes control of glycated haemoglobin (HbA1c) point-of-care testing.

BACKGROUND: Optimal control of diabetes mellitus (DM) remains daunting globally. Point-of-care testing (POCT) for glycated haemoglobin (HbA1c) enables the clinician to make immediate management decisions and thereby improve DM control and complications. Better control is increasingly being striven for in developing countries where availability of POCT devices is limited. METHODS: Every alternate patient who visited the diabetes clinic at Edendale Hospital, Durban, South Africa, between 1 June 2017 and 31 August 2017 was invited to participate in the study. These patients made up the POCT group, with the remainder making up the control laboratory group. The POCT group had Quo-Test HbA1c POCT done at the clinic visit and their treatment was adjusted based on the HbA1c reading, while the control group received standard treatment. The two groups of patients were reviewed at 3 months to identify differences in diabetes control between them. RESULTS: Data from 266 patients were analysed (135 in the POCT group v. 131 in the control group). There was no significant difference between the price of the POCT and laboratory HbA1c tests (p=0.823). The POCT and laboratory HbA1c values showed good correlation at baseline (r=0.995; p<0.001). The two groups of patients were evenly matched in respect of most demographic and clinical variables. Patients in the POCT group showed a significant improvement in mean (standard deviation) glycaemic control between baseline and 3 months (9.61 (2.46) v. 8.98 (2.15); p<0.043). No improvement was noted in the control group (9.58 (2.49) v. 9.43 (2.15); p=0.823). CONCLUSIONS: The Quo-Test HbA1c POCT had good correlation with standard laboratory methods in respect of both glycaemic control and price. Patients who had POCT at baseline showed a significant improvement in glycaemic control at 3 months. HbA1c POCT in the setting of a multifaceted approach to diabetes care has been shown to have definite benefits.

Oesophageal cancer in Area 2 of Kwazulu-Natal: predictors of late presentation.

BACKGROUND: There are limited prospective data sets on clinical characteristics, stage of presentation and treatment of patients with Oesophageal Squamous Cell Carcinoma (OSCC) in South Africa. This study aimed to assess the frequency and severity of clinical characteristics associated with late presentation of patients with OSCC presenting to a cancer referral centre in KwaZulu-Natal, South Africa. METHODS: A prospective consecutive series of patients presenting with confirmed OSCC treated at Greys Hospital in 2016/2017 were enrolled. Data collected included: age, gender, home language, referral centre, clinical and laboratory characteristics: dysphagia score, Eastern Cooperative Oncology Group (ECOG) performance status, body mass index (BMI), serum albumin, tumour pathology and treatment administered. RESULTS: One hundred patients were analysed. Ninety four percent spoke isiZulu. The mean age was 61 with a male to female ratio of 1.5:1 Ninety percent had palliative treatment as their overall assessment precluded curative treatment. Five patients underwent curative treatment. The age standardised incidence (ASR) was 25.2 per 100 000. The factors associated with late presentation and their frequency were: advanced dysphagia grade (