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.

Surgical training and capacity development in the South African internship programme.

Medical practitioners in South Africa manage a quadruple burden of disease. Junior doctors, who contribute significantly to the health workforce, must complete 2 years of internship training and 1 year of community service work in state health facilities after graduation to register as an independent medical practitioner. The aim of this article is to give a critical appraisal of the current national internship programme and why it was implemented, and outline suggestions for future changes. There is a compelling need to train competent, confident doctors while ensuring that the requirements and demands of our health system remain a central concern.

Impact of COVID-19 on breast cancer diagnostic and surgical services at a South African academic hospital.

BACKGROUND: The purpose of the study was to describe the impact of the COVID-19 pandemic on diagnostic and surgical breast cancer services at Groote Schuur Hospital (GSH) and affiliated hospitals. METHODS: All patients, newly diagnosed, awaiting surgery, and listed for neoadjuvant chemotherapy (NACT) by the breast surgical service from 23 March - 23 June 2020 were included. A historic control was used where appropriate consisting of patients presenting in the same period in 2019. Clinic attendance records and surgical waiting lists were used to identify patients in the three months and data were extracted from hospital records including hospital admission records and surgical operative notes. RESULTS: The number of patients who presented with a new breast symptom to the diagnostic breast clinic decreased from 1 094 in 2019 to 299 in 2020, representing a 72.6% decrease. Telemedicine use as a function of the total follow-ups increased from 53% (n = 1 350) in 2019 to 75% (n = 735) in 2020. The overall number of new breast cancers diagnosed decreased from 146 in 2019 to 79 in 2020, but the proportion of patients seen with a new breast symptom who were diagnosed with breast cancer increased from 13% (n = 1 094) in 2019 to 26% (n = 299) in 2020. Eighteen per cent (n = 105) fewer breast cancer surgeries were performed in 2020 compared to 2019, with immediate breast reconstructive procedures representing the largest decrease of 40%. CONCLUSION: The impact of COVID-19 on breast cancer services has been both at the diagnostic level and in delays to surgery. A new online referral system improved referral efficacy translating to more cancers being diagnosed as a function of total referrals. The drop in absolute numbers of cancer diagnoses, however, represents an unmet health need. An expansion of our telemedicine service mitigated COVID risk in the outpatient setting. The greatest impact on our treatment decisions was seen in the cohort of patients placed on neo-adjuvant endocrine therapy (NET). We saw a global decrease in breast surgeries performed, with the greatest decrease being in reconstructions.

Establishing a South African national framework for COVID-19 surgical prioritisation.

BACKGROUND: Since the start of the COVID-19 pandemic, surgical operations have been drastically reduced in South Africa (SA). Guidelines on surgical prioritisation during COVID-19 have been published, but are specific to high-income countries. There is a pressing need for context-specific guidelines and a validated tool for prioritising surgical cases during the COVID-19 pandemic. In March 2020, the South African National Surgical Obstetric Anaesthesia Plan Task Team was asked by the National Department of Health to establish a national framework for COVID-19 surgical prioritisation. OBJECTIVES: To develop a national framework for COVID-19 surgical prioritisation, including a set of recommendations and a risk calculatorfor operative care. METHODS: The surgical prioritisation framework was developed in three stages: (i) a literature review of international, national and local recommendations on COVID-19 and surgical care was conducted; (ii) a set of recommendations was drawn up based on the available literature and through consensus of the COVID-19 Task Team; and (iii) a COVID-19 surgical risk calculator was developed and evaluated. RESULTS: A total of 30 documents were identified from which recommendations around prioritisation of surgical care were used to draw up six recommendations for preoperative COVID-19 screening and testing as well as the use of appropriate personal protective equipment. Ninety-nine perioperative practitioners from eight SA provinces evaluated the COVID-19 surgical risk calculator, which had high acceptability and a high level of concordance (81%) with current clinical practice. CONCLUSIONS: This national framework on COVID-19 surgical prioritisation can help hospital teams make ethical, equitable and personalised decisions whether to proceed with or delay surgical operations during this unprecedented epidemic.

Towards high-quality peri-operative care: a global perspective.

Article 25 of the United Nations' Universal Declaration of Human Rights enshrines the right to health and well-being for every individual. However, universal access to high-quality healthcare remains the purview of a handful of wealthy nations. This is no more apparent than in peri-operative care, where an estimated five billion individuals lack access to safe, affordable and timely surgical care. Delivery of surgery and anaesthesia in low-resource environments presents unique challenges that, when unaddressed, result in limited access to low-quality care. Current peri-operative research and clinical guidance often fail to acknowledge these system-level deficits and therefore have limited applicability in low-resource settings. In this manuscript, the authors priority-set the need for equitable access to high-quality peri-operative care and analyse the system-level contributors to excess peri-operative mortality rates, a key marker of quality of care. To provide examples of how research and investment may close the equity gap, a modified Delphi method was adopted to curate and appraise interventions which may, with subsequent research and evaluation, begin to address the barriers to high-quality peri-operative care in low- and middle-income countries.

Causes of maternal death at Natalspruit Hospital, Johannesburg, South Africa.

BACKGROUND: Despite increased resources to reduce maternal deaths, South Africa (SA) has an unacceptably high maternal mortality rate (MMR). OBJECTIVES: To determine the causes of maternal deaths at Natalspruit Hospital, Johannesburg, SA. METHODS: A 2-year retrospective audit of case records was done All maternal deaths from January 2013 to December 2014 were included. RESULTS: There were 20 676 live births and 79 deaths, with a MMR of 382.08/100 000. Forty-four women (56%) were HIV-positive, 14 (21%) died of obstetric haemorrhage and 12 (15%) had hypertensive disorders of pregnancy. Thirty women (38%) had not attended an antenatal clinic. More women died between 16h00 and 08h00 than between 08h00 and 16h00. Most women (88%) had at least one avoidable factor. CONCLUSIONS: Natalspruit Hospital has a high MMR. The majority of deaths were HIV-related. There was a high number of women who were unbooked. Most deaths occurred after normal working hours.

Why women bleed and how they are saved: a cross-sectional study of caesarean section near-miss morbidity.

BACKGROUND: Maternal deaths from 'bleeding during and after caesarean section' (BDACS) have increased in South Africa, and have now become the largest sub-cause of deaths from obstetric haemorrhage. The aim of this study was to describe risk factors and causes of near-miss related to BDACS and interventions used to arrest haemorrhage and treat its effects. METHODS: Cross-sectional prospective study in 13 urban public hospitals in South Africa, from July to December 2014. RESULTS: There were 93 cases of near-miss related and 7 maternal deaths related to BDACS. The near-miss rate was 2.1/1000 live births, and the case fatality rate was 3.5/10 000 caesarean sections. Associated near-miss risk factors were previous caesarean section in 60% of multiparas, pre-operative anaemia (55%), abruptio placentae (20%) and placenta praevia and/or accreta (20%). Atonic uterus (43%) was the most frequent anatomical cause of bleeding for near-miss, followed by surgical trauma (29%). The median duration of the operations resulting in near-miss was 90 min, with 81% noted as difficult by the surgeon. Interventions in cases of near-miss included second-look laparotomy (46%), hysterectomy (41%), B-Lynch brace suture (9%), intensive care unit admission (32%) and red cell transfusion ≥3 units (21%). CONCLUSION: Cases from maternal near-miss from BDACS were frequently associated with pre-operative risk factors. Extensive life-saving interventions were required during and after the operations. An important factor in initiating the sequence of interventions is the realisation by the surgeon that the caesarean section is difficult, so that the progression from uneventful operation to near-miss to death can be arrested.

National Priorities for Perioperative Research in South Africa

BACKGROUND:Perioperative research is currently unco-ordinated in South Africa (SA); with no clear research agenda.OBJECTIVE:To determine the top ten national research priorities for perioperative research in SA.METHODS:A Delphi technique was used to establish consensus on the top ten research priorities.RESULTS:The top ten research priorities were as follows: (i) establishment of a national database of (a) critical care outcomes; and (b) critical care resources; (ii) a randomised controlled trial of preoperative B-type natriuretic peptide-guided medical therapy to decrease major adverse cardiac events following non-cardiac surgery; (iii) a national prospective observational study of the outcomes associated with paediatric surgical cases; (iv) a national observational study of maternal and fetal outcomes following operative delivery in SA; (v) a stepped-wedge trial of an enhanced recovery after surgery programme for (a) surgery; (b) obstetrics; (c) emergency surgery; and (d) trauma surgery; (vi) a stepped-wedge trial of a surgical safety checklist on patient outcomes in SA; (vii) a prospective observational study of perioperative outcomes after surgery in district general hospitals in SA; (viii) short-course interventions to improve anaesthetic skills in rural doctors; (ix) studies of the efficacy of simulation training to improve (a) patient outcomes; (b) team dynamics; and (c) leadership; and (x) development and validation of a risk stratification tool for SA surgery based on the South African Surgical Outcomes Study (SASOS) data.CONCLUSIONS:These research priorities provide the structure for an intermediate-term research agenda