Food-Based Interventions as Therapy for Inflammatory Bowel Disease: Important Steps in Diet Trial Design and Reporting of Outcomes.

Diet therapy for inflammatory bowel disease (IBD) is an international research priority but guidance for IBD-specific diet trial design is lacking. This review critically evaluates key elements of prospective IBD food-based intervention trials and identifies gaps. Electronic databases were searched for interventional IBD diet studies. Prospective primary studies/trials were included if used food-based dietary strategies. Forty studies/trials evaluating 29 food-based strategies as therapy for IBD were identified. Considerable heterogeneity in diets, trial design, and methodology exists. Thirty-one trials (78%) intended the diet to modulate inflammation but 14/31 (46%) did not have a primary endpoint measuring an objective change in inflammatory activity and 20/31 (65%) controlled for medication stability prior to application of diet at baseline. Higher-quality IBD diet trials used symptom-based assessment tools coupled with an objective evaluation of inflammatory activity. Dietary advice trials are the most common. One-third of trials developed and administered diet education without a dietitian. Evaluation and reporting on adherence to diet therapy occurred in <60% of trials. Failure to include or report on key elements of trial design reduced the interpretability and validity of the results. This is a considerable limitation to advancing scientific knowledge in this area. Diet therapy trials should adhere to similar rigorous quality standards used to develop other IBD therapies. Therefore, a set of practical recommendations was generated to provide the authors' perspective to help inform the future design of high-quality IBD diet trials.

High-quality inflammatory bowel disease (IBD) diet trials are lacking and existing trials are fraught with methodological flaws. This review is intended to assist clinician-researchers in the design and conduct of future food-based intervention trials to raise the quality of IBD diet research.

Is there an "optimal" diet for prevention of inflammatory bowel disease?

Nutritional epidemiological studies have evolved from a focus of single nutrients to diet patterns to capture the protective role of healthy diets on chronic disease development. Similarly, in inflammatory bowel disease (IBD), a healthy diet may be protective against its development in individuals with genetic susceptibility, but the definitions of the optimal diet pattern deserve further exploration. Hence, this review article presents evidence, mainly from prospective cohort studies, for the role of diet quality based on adherence to dietary guidelines, traditional and modern diet patterns in the prevention of IBD. Findings from a limited number of studies on diet quality suggest that high diet quality scores are associated with lower risk of developing Crohn's disease, but the data are inconsistent for ulcerative colitis (UC). There are signals that a Mediterranean diet pattern reduces the risk of Crohn's disease but, again, the data are inconsistent and further studies are much needed. Finally, the evidence is conflicting regarding the role of food additives, with difficulties in the assessment of their intake, namely non-nutritive sweeteners and emulsifiers, precluding accurate assessment of a relationship with IBD risk. In contrast, emerging evidence for a role of ultra-processed food in the development of Crohn's disease but not UC is identified. Given the potential influence of diet quality, a Mediterranean diet and ultra-processed food intake on the risk of Crohn's disease, assessment and implementation of dietary advice for these patients need to be tailored. The search for an optimal diet for UC remains elusive and further research for increasing the evidence in the area is greatly needed.

An analysis of referral patterns of traumatic brain injury at Groote Schuur Hospital Trauma Centre.

BACKGROUND: Traumatic brain injury (TBI) can result in significant morbidity and mortality if not diagnosed in a timely manner. Brain computed tomography (CT) is the diagnostic gold standard but is of limited availability in most South African public hospitals, resulting in transfer of TBI patients to tertiary hospitals. OBJECTIVE: To describe the referral patterns and outcomes of patients with TBI referred to Groote Schuur Hospital Trauma Centre. METHODS: This was a retrospective audit of all patients admitted to the Trauma Centre who had a brain CT scan for suspected TBI between 1 February 2022 and 31 March 2022. Demographic data (age, sex), mechanism of injury and Glasgow Coma Score were recorded. Referral pathways were determined, and final disposition of patients was recorded. RESULTS: A total of 522 patients had a brain CT for TBI. Of these, 314 (60.1%) were referred from other hospitals. CT scan was abnormal in 178 (34.1%) patients. Three hundred and two (58.6%) were discharged home within 24 hours. The mean time between referral and CT scan was 13 hours. CONCLUSION: More than half of patients referred for a CT scan were discharged from the Trauma Centre within 24 hours of admission, which indicates additional costs and inefficiencies in the health system. These data are useful to guide resource planning and allocation for district hospitals, since less expensive point-of-care modalities now exist to diagnose TBI, and which are useful in indicating the prognosis of patients.

Stereotactic Magnetic Resonance-Guided Daily Adaptive SABR (SMART) for Localised Non-Metastatic Pancreatic Cancer: First Reported Clinical Outcomes From the UK.

AIMS: Prognosis of locally advanced pancreatic cancer (LAPC) remains poor with limited therapeutic options. Radiation therapy in pancreatic cancer has been restricted by the disease's proximity to radiosensitive organs at risk (OAR). However, stereotactic magnetic resonance-guided adaptive radiation therapy (SMART) has demonstrated promise in delivering ablative doses safely. We sought to report clinical outcomes from a UK-based Compassionate Access Programme that provided access to SMART to patients with LAPC. MATERIALS AND METHODS: This was a registry retrospective study conducted at a single centre with access to SMART. Patients with LAPC were treated with prescription dose of 40 Gy in 5 fractions. The planning objective was that 98% of PTV received ≥95% of the prescribed dose, prioritising duodenal, stomach and bowel UK SABR consortium constraints. Daily online adaptation was performed using magnetic resonance guidance and on-table re-optimisation. 0-3 months and > 3-month post-treatment-related toxicities, local progression-free survival, metastatic-free survival and overall survival were evaluated. RESULTS: 55 patients were treated with SMART at our institution from 2020 to 2022. Median follow-up from date of diagnosis was 17 months (range 5-37 months). Median age was 69.87% of patients underwent induction chemotherapy. 71% of patients reported 0-1 grade acute toxicity only. No grade >3 acute toxicity was reported. 5 patients (9%) reported a grade 3 toxicity (fatigue, nausea, abdominal pain, duodenal stricture). No grade >3 toxicity after 3 months was reported. 6 (10%) of patients had grade 3 toxicity (fatigue, nausea, abdominal pain, duodenal haemorrhage). Median local PFS post diagnosis was 17 months (95% CI 15.3-18.7). Median OS post diagnosis was 19 months (95% CI 15.9-22.1). One-year local control post SMART was 65%. CONCLUSION: This is the first UK-reported experience of MR-guided daily adaptive pancreatic SABR. SMART shows promise in delivering ablative doses with acceptable toxicity rates and good clinical outcomes.

Comparison of clinical data between the proximal femoral bionic nail (PFBN) and hip replacement for the treatment of femoral intertrochanteric fracture.

OBJECTIVE: The aim of this study was to compare the difference between proximal femoral bionic nail (PFBN) and hip replacement (HR) for femoral intertrochanteric fracture. MATERIALS AND METHODS: A retrospective analysis of the differences in operative time, length of stay, postoperative Harris score, and postoperative mortality between patients with femoral intertrochanteric fracture treated by PFBN and HR admitted to Jinzhai County People's Hospital from October 2020 to September 2022 was performed. RESULTS: A total of 56 patients with femoral intertrochanteric fracture, 26 with PFBN and 30 with HR, were included in the study. There were no differences in the length of surgery, pre- and post-operative hemoglobin, or post-operative Harris score at 3 months between the two groups. Compared to the HR group, the PFBN group had a lower total cost, shorter hospital stays, and lower mortality but a longer ambulation time, with a difference of 3.36 weeks. CONCLUSIONS: PFBN may be a promising new treatment for femoral intertrochanteric fracture.

[Prevalence of medicare antiviral drugs use and related factors in HIV-infected people in Ningbo].

Objective: To analyze the use of medicare antiviral drugs (ART) and related factors among HIV-infected people in Ningbo City. Methods: The retrospective data was collected related to infection and treatment of HIV-infected people in ART in Ningbo up to February 2023 through the National Infectious Disease Surveillance System. Binary logistic regression was used to analyze the factors related to medicare antiviral drug use in HIV-infected people. R 4.2.2 software was used for statistical analysis. Results: A total of 6 433 HIV-infected people with ART records were collected, among which 5 783 were in ART. The prevalence of medicare drugs use among people in ART was 24.8% (1 435/5 783, 95%CI: 23.7%-25.9%). Beilun District (8.7%, 43/497) and Fenghua District (5.7%, 14/247) had the lowest level in medicare drugs use. Among people in ART using medicare or out-of-pocket drugs, the prevalence of those who had at least one viral load test in the last year (84.9%, 1 352/1 593) was significantly lower than that of those using free drugs (91.4%, 3 829/4 190) (χ2=52.50, P<0.001). The results of multivariate logistic analysis showed that the factors influencing medicare drug use included low educational level (junior high school and below: aOR=0.24, 95%CI:0.17-0.34), farmer or worker (farmer: aOR=0.60, 95%CI: 0.39-0.91; worker: aOR=0.42, 95%CI: 0.27-0.64), low monthly income (<3 000 Yuan: aOR=0.29, 95%CI: 0.18-0.45), the longer interval time between diagnosis and treatment (≥21 days: aOR=0.47, 95%CI: 0.30-0.74). Conclusions: Significant regional differences on the prevalence of medicare antiviral drugs use in HIV-infected people exist in Ningbo City. Follow-up management program of patients should be improved to strengthen patient compliance to mobilize medicare drug promotion. Meanwhile, publicity of medicare drugs should be strengthened for farmers or workers with low education level and patients with delayed treatment.

Review article: Current status and future directions of ingestible electronic devices in gastroenterology.

BACKGROUND: Advances in microelectronics have greatly expanded the capabilities and clinical potential of ingestible electronic devices. AIM: To provide an overview of the structure and potential impact of ingestible devices in development that are relevant to the gastrointestinal tract. METHODS: We performed a detailed literature search to inform this narrative review. RESULTS: Technical success of ingestible electronic devices relies on the ability to miniaturise the microelectronic circuits, sensors and components for interventional functions while being sufficiently powered to fulfil the intended function. These devices offer the advantages of being convenient and minimally invasive, with real-time assessment often possible and with minimal interference to normal physiology. Safety has not been a limitation, but defining and controlling device location in the gastrointestinal tract remains challenging. The success of capsule endoscopy has buoyed enthusiasm for the concepts, but few ingestible devices have reached clinical practice to date, partly due to the novelty of the information they provide and also due to the challenges of adding this novel technology to established clinical paradigms. Nonetheless, with ongoing technological advancement and as understanding of their potential impact emerges, acceptance of such technology will grow. These devices have the capacity to provide unique insight into gastrointestinal physiology and pathophysiology. Interventional functions, such as sampling of tissue or luminal contents and delivery of therapies, may further enhance their ability to sharpen gastroenterological diagnoses, monitoring and treatment. CONCLUSIONS: The development of miniaturised ingestible microelectronic-based devices offers exciting prospects for enhancing gastroenterological research and the delivery of personalised, point-of-care medicine.

Practical application of the Crohn's disease exclusion diet as therapy in an adult Australian population.

There is demand from patients and clinicians to use the Crohn's disease exclusion diet (CDED) with or without partial enteral nutrition (PEN). However, the therapeutic efficacy and nutritional adequacy of this therapy are rudimentary in an adult population. This review examines the evidence for the CDED in adults with active luminal Crohn's disease and aims to provide practical guidance on the use of the CDED in Australian adults. A working group of nine inflammatory bowel disease (IBD) dietitians of DECCAN (Dietitians Crohn's and Colitis Australian Network) and an IBD gastroenterologist was established. A literature review was undertaken to examine (1) clinical indications, (2) monitoring, (3) dietary adequacy, (4) guidance for remission phase, and (5) diet reintroduction after therapy. Each diet phase was compared with Australian reference ranges for food groups and micronutrients. CDED with PEN is nutritionally adequate for adults containing sufficient energy and protein and meeting > 80% of the recommended daily intake of key micronutrients. An optimal care pathway for the clinical use of the CDED in an adult population was developed with accompanying consensus statements, clinician toolkit, and patient education brochure. Recommendations for weaning from the CDED to the Australian dietary guidelines were developed. The CDED + PEN provides an alternate partial food-based therapy for remission induction of active luminal Crohn's disease in an adult population. The CDED + PEN should be prioritized over CDED alone and prescribed by a specialist IBD dietitian. DECCAN cautions against using the maintenance diet beyond 12 weeks until further evidence becomes available.

Developing a Pipeline of African Global Surgery Scholars.

Global surgery is developing as new discipline in many countries. Global surgery primarily aims to improve access to quality surgery in low-and-middle Income countries (LMICs). Thus, ensuring appropriate LMIC representation and leadership in global surgery research, projects, and innovations, is essential. There is a paucity of pathways for students and young clinicians in LMICs to attain training in and exposure to global surgery research and projects. If equity in global surgery leadership and scholarship is truly desired, steps need to be taken to ensure that more students and young clinicians in LMICs are exposed to global surgery as an academic discipline and are offered pathways to practice and leadership. This paper explores ways of ensuring this through increased exposure, increased training and increased funding.

Factors Contributing to Delays to Accessing Appendectomy in Low- and Middle-Income Countries: A Scoping Review.

BACKGROUND: Appendicitis is one of the most common emergency surgical conditions worldwide. Delays in accessing appendectomy can lead to complications. Evidence on these delays in low- and middle-income countries (LMICs) is lacking. The aim of this review was to identify and synthesise the available evidence on delays to accessing appendectomy in LMICs. METHODS: This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews framework. The delays and their interconnectivity in LMICs were synthesised and interpreted using the Three Delays framework. We reviewed Africa Wide EBSCOhost, PubMed-Medline, Scopus, Web of Science, African Journals Online (AJOL), and Bioline databases. RESULTS: Our search identified 21 893 studies, of which 78 were included in the final analysis. All of the studies were quantitative. Fifty per cent of the studies included all three types of delays. Delays in seeking care were influenced by a lack of awareness of appendicitis symptoms, and the use of self and alternative medication, which could be linked to delays in receiving care, and the barrier refusal of medical treatment due to fear. Financial concerns were a barrier observed throughout the care pathway. CONCLUSION: This review highlighted the need for additional studies on delays to accessing appendectomy in additional LMICs. Our review demonstrates that in LMICs, persons seeking appendectomy present late to health-care facilities due to several patient-related factors. After reaching a health-care facility, accessing appendectomy can further be delayed owing to a lack of adequate hospital resources.

Perceived dietary intolerances, habitual intake and diet quality of patients with an ileoanal pouch: Associations with pouch phenotype (and behaviour).

BACKGROUND AND AIMS: Ileoanal pouch patients frequently attribute pouch-related symptoms and pouchitis with diet. We aimed to assess perceived food intolerance and habitual dietary intake and their relationship with pouch indication, symptoms and current or history of pouchitis. METHODS: In this cross-sectional study, patients with an ileoanal pouch completed a dietary intolerance and a food frequency questionnaire, that specifically quantifies habitual intake of FODMAPs. Perceived dietary intolerance rates, nutrient intake and diet quality, and their differences based on pouch indication, symptom, and current or history of pouchitis were assessed. Associations between intolerances and intake, and between dietary intake with pouchitis risk were analysed using univariable and multivariable regression analysis. RESULTS: Of the 58 (10 FAP and 48 UC) patients with complete data, 81% of UC and 80% of FAP patients reported dietary intolerances. Overall diet quality was good. Differences in dietary intake were limited to a few food groups. Patients with a history of pouchitis had a lower intake of fruits (p = 0.03) and nuts (p = 0.004). Patients with current pouchitis had a lower intake of nuts (p = 0.02). On multivariable logistic regression, intake of dietary fibre was associated negatively [OR 0.68(95%CI:0.51-0.92)] and of non-digestible oligosaccharides positively with pouchitis history [OR 5.5(95% CI:1.04-29.1)]. CONCLUSIONS: In patients with an ileoanal pouch, perceived dietary intolerances are common but had minimal impact on nutritional adequacy and diet quality. Negative associations of the intakes of fruits, nuts and dietary fibre and positive association with non-digestible oligosaccharides with a history of pouchitis require further study to inform dietary recommendations.

Association between dietary factors, symptoms, and psychological factors in adults with dyspepsia: A cross-sectional study.

BACKGROUND: Evidence-based dietary management approaches for symptoms of dyspepsia are lacking. This study aimed to compare dietary factors, symptoms, quality of life (QOL) and salivary cortisol in dyspepsia participants and healthy controls. METHODS: A cross-sectional survey was completed by adults with dyspepsia (n = 121) meeting Rome IV criteria and healthy controls (n = 52). Outcome measures included self-reported questionnaires about dietary habits, triggers, restrictions, dietary management approaches, nutritional intake, psychological variables, QOL, gastrointestinal symptoms, and optional cortisol awakening response (CAR) via saliva samples. Data were analyzed using Chi-square or Mann-Whitney U. Cortisol awakening response data was analyzed using moderated regression controlling for age, gender and distress. KEY RESULTS: Fermentable carbohydrates (FODMAPs) (55%) were the most reported trigger in adults with dyspepsia. The dyspepsia group (88%) followed special diets more than controls (47%; p < 0.001), with a low FODMAP diet being most common (69%). The dyspepsia group consumed less fiber (p = 0.014), calcium (p = 0.015), and total FODMAPs (p < 0.001) than controls. There was a greater prevalence of comorbid anxiety (41%) and depression (31%) in dyspepsia compared to controls (15% and 12%, respectively, p < 0.001 and p = 0.006). The dyspepsia group had poorer QOL and greater gastrointestinal symptom severity than controls (p < 0.001). There was a negative association between anxiety and CAR (p = 0.001) in dyspepsia but not in controls. CONCLUSIONS & INFERENCES: Adults with dyspepsia follow special diets more than controls and perceive FODMAPs as a key dietary trigger. These findings highlight the importance of monitoring nutritional adequacy and QOL, and emphasize mechanisms of depleted stress response in dyspepsia, warranting further exploration.

[Prevalence and influencing factors of human soil-transmitted nematode infections in Ningbo City from 2016 to 2021].

OBJECTIVE: To investigate the prevalence and influencing factors of soil-transmitted nematode infections in Ningbo City from 2016 to 2021, so as to provide insights into the development of targeted control measures against soil-transmitted nematodiasis. METHODS: Permanent residents at ages of 3 years and older were sampled in Ningbo City using a multi-stage sampling method each year during the period from 2016 to 2021. Soil-transmitted nematode eggs were detected in stool samples using a modified Kato-Katz thick smear method (two slides for each stool sample), and Enterobius vermicularis eggs were additionally identified among children at ages of 3 to 12 years using the adhesive cellophane-tape perianal swab method. The time- and regions-specific prevalence of soil-transmitted nematode infections was calculated, and the factors affecting hookworm infections were identified using a multivariate logistic regression model. RESULTS: A total of 11 573 person-times were detected for soil-transmitted nematode infections in Ningbo City from 2016 to 2021, and 296 egg-positives were detected, with a mean prevalence rate of 2.56% [95% confidential interval (CI): (2.28%, 2.87%)]. Hookworm was the predominant species of soil-transmitted nematode among egg-positives in Ningbo City (98.31%, 291/296), and there was a significant difference in the prevalence of hook-worm infections among years (χ2 = 190.27, P < 0.01). The highest prevalence of hook-worm infections was observed in Ninghai County (4.06%), and there was a region-specific prevalence rate of hookworm infection in Ningbo City (χ2 = 148.43, P < 0.01). Multivariate logistic regression analysis showed that elderly residents at ages of over 60 years [odds ratio (OR)= 1.94, 95% CI: (1.07, 3.54), P < 0.05], males [OR = 2.19, 95% CI: (1.72, 2.80), P < 0.01], farmers [OR = 6.94, 95% CI: (3.37, 14.29), P < 0.01] and residents with a low education level [illiteracy or semi-illiterate: OR = 3.82, 95% CI: (1.56, 9.35), P < 0.05; primary school: OR = 2.70, 95% CI: (1.11, 6.59), P < 0.05] were at a higher risk for hookworm infections. CONCLUSIONS: The overall prevalence of soil-transmitted nematode infections was low among residents in Ningbo City from 2016 to 2021. The surveillance and health education for human hookworm disease remain to be reinforced among male farmers with a low education level at ages of over 60 years in Ninghai County.

Detection of changes in regional colonic fermentation in response to supplementing a low FODMAP diet with dietary fibres by hydrogen concentrations, but not by luminal pH.

BACKGROUND: Carbohydrate fermentation plays a pivotal role in maintaining colonic health with excessive proximal and deficient distal fermentation being detrimental. AIMS: To utilise telemetric gas- and pH-sensing capsule technologies for defining patterns of regional fermentation following dietary manipulations, alongside conventional techniques of measuring fermentation. METHODS: In a double-blind crossover trial, 20 patients with irritable bowel syndrome were fed low FODMAP diets that included no extra fibre (total fibre content 24 g/day), or additional poorly fermented fibre, alone (33 g/day) or with fermentable fibre (45 g/day) for 2 weeks. Plasma and faecal biochemistry, luminal profiles defined by tandem gas- and pH-sensing capsules, and faecal microbiota were assessed. RESULTS: Plasma short-chain fatty acid (SCFA) concentrations (µmol/L) were median (IQR) 121 (100-222) with fibre combination compared with 66 (44-120) with poorly fermented fibre alone (p = 0.028) and 74 (55-125) control (p = 0.069), but no differences in faecal content were observed. Luminal hydrogen concentrations (%), but not pH, were higher in distal colon (mean 4.9 [95% CI: 2.2-7.5]) with fibre combination compared with 1.8 (0.8-2.8) with poorly fermented fibre alone (p = 0.003) and 1.9 (0.7-3.1) control (p = 0.003). Relative abundances of saccharolytic fermentative bacteria were generally higher in association with supplementation with the fibre combination. CONCLUSIONS: A modest increase in fermentable plus poorly fermented fibres had minor effects on faecal measures of fermentation, despite increases in plasma SCFA and abundance of fermentative bacteria, but the gas-sensing capsule, not pH-sensing capsule, detected the anticipated propagation of fermentation distally in the colon. The gas-sensing capsule technology provides unique insights into localisation of colonic fermentation. TRIAL REGISTRATION: ACTRN12619000691145.

The impact of a decentralised orthopaedic service on tertiary referrals in Cape Town, South Africa.

BACKGROUND: In South Africa (SA), district hospitals (DHs) have limited capacity to manage the high burden of traumatic injuries. Scaling up decentralised orthopaedic care could strengthen trauma systems and improve timely access to essential and emergency surgical care (EESC). Khayelitsha township in Cape Town, SA, has the highest trauma burden in the Cape Metro East health district. OBJECTIVES: The primary objective of this study was to describe the impact of Khayelitsha District Hospital (KDH) on acute orthopaedic services in the health district, with a focus on the volume and type of orthopaedic services provided without tertiary referral. METHODS: This retrospective analysis described acute orthopaedic cases from Khayelitsha and their management between 1 January 2018 and 31 December 2019. Orthopaedic resources and the proportion of cases referred to the tertiary hospital by all DHs in the Cape Metro East health district are described. RESULTS: In 2018 - 2019, KDH performed 2 040 orthopaedic operations, of which 91.3% were urgent or emergencies. KDH had the most orthopaedic resources and the lowest referral ratio (0.18) compared with other DHs (0.92 - 1.35). In Khayelitsha, 2 402 acute orthopaedic cases presented to community health clinics. Trauma (86.1%) was the most common mechanism of injury for acute orthopaedic referrals. Of clinic cases, 2 229 (92.8%) were referred to KDH and 173 (7.2%) directly to the tertiary hospital. The most common reason for direct tertiary referral was condition related (n=157; 90.8%). CONCLUSION: This study outlines a successful example of a decentralised orthopaedic surgical service that increased EESC accessibility and alleviated the high burden of tertiary referrals compared with other DHs with fewer resources. Further research on the barriers to scaling up orthopaedic DH capacity in SA is needed to improve equitable access to surgical care.

The impact of a decentralised orthopaedic service on tertiary referrals in Cape Town, South Africa.

BACKGROUND: In South Africa (SA), district hospitals (DHs) have limited capacity to manage the high burden of traumatic injuries. Scaling-up decentralised orthopaedic care could strengthen trauma systems and improve timely access to essential and emergency surgical care (EESC). Khayelitsha township in Cape Town, SA has the highest trauma burden of the Cape Metro East health district.   Objectives. The primary objectives of this study were to describe the impact of the Khayelitsha District Hospital (KDH) on acute orthopaedic services for the health district with a focus on the volume and type of orthopaedic services provided without tertiary referral.  Methods. This retrospective analysis described acute orthopaedic cases and their management from Khayelitsha township between 1 January 2018 to 31 December 2019. Orthopaedic resources and the proportion of cases referred to the tertiary hospital by all DHs in the Cape Metro East health district were described.  Results. In 2018-2019, KDH performed 2040 orthopaedic operations of which 91.3% were urgent or emergencies. KDH had the most orthopaedic resources and the lowest referral ratio (0.18) compared to other DHs (0.92-1.35). In the Khayelitsha township, 2402 acute orthopaedic cases presented to community health clinics. Trauma (86.1%) was the most common mechanism for acute orthopaedic referrals. 2229 (92.8%) clinic cases were referred to KDH and 173 (7.2%) directly to the tertiary hospital. The most common reason for direct tertiary referral was condition related (n=157, 90.8%).   Conclusions. This study outlines a successful example of a decentralised orthopaedic surgical service that increased EESC accessibility and alleviated the high burden of tertiary referrals compared to other DHs with fewer resources. Further research on the barriers to scaling-up orthopaedic DH capacity in SA is needed to improve equitable access to surgical care.