Mortality trends during the first three waves of the COVID-19 pandemic at an urban district hospital in South Africa: A retrospective comparative analysis.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) is the virus responsible for the COVID-19 (C19) pandemic. South Africa (SA) experienced multiple periods of increased transmission. Tertiary, regional and central hospitals were overwhelmed, resulting in low acceptance rates. OBJECTIVES: To compare mortality trends of patients who died in hospital from SARS-CoV-2 infection during the first three waves of infection as defined by the National Institute of Communicable Diseases of South Africa. METHODS: This was a retrospective cohort study at a district level hospital of 311 adults who died within the first three waves of COVID-19. The study analysed case and crude fatality rates, baseline characteristics, symptomatology, clinical presentation and management of patients. RESULTS: Waves 1, 2 and 3 yielded case fatality rates of 14.5%, 27.6% and 6.3%, respectively, and crude fatality rates of 16.7%, 33.0% and 12.2%, respectively. Black Africans were less likely to die during the third wave (odds ratio (OR) 0.54; 95% confidence interval (CI) 0.31 - 0.94). Patients in the second wave had clinical frailty scores of <5 (OR 2.51; 95% CI 1.56 - 4.03). Obesity was most prevalent in the second wave (OR 1.87; 95% CI 1.01 - 3.46), and dyslipidaemia (OR 3.03; 95% CI 1.59 - 5.77) and ischaemic heart disease (OR 3.77; 95% CI .71 - 8.33) were most prevalent during the third wave. Severe ground glass appearance was most common during the second wave (OR 2.37; 95% CI 1.49 - 3.77). Renal impairment was most prevalent during the first wave (OR 3.28; 95% CI 1.59 - 6.77), and thrombo- embolic phenomena were less common during wave three (OR 0.12; 95% CI 0.02 - 0.91). CONCLUSION: The Beta variant was the most virulent, with the highest case and crude fatality rates in wave 2.

Broad responses and attitudes to having music in surgery (the BRAHMS study) - a South African perspective.

BACKGROUND: Music is played in operating theatres (OTs) throughout the world, though controversy around its use exists. While some clinicians may find background music favourable to the theatre mood and a way to augment surgical performance, there is concern raised over its distracting and noise-creating properties. METHODS: In this prospective observational study, between August and December 2021, 110 surgeons and registrars in South Africa responded to a survey investigating the way they use music, and their perceptions and attitudes towards its effect on the OT environment. RESULTS: In this cohort, 66% were male, 29% were consultants and the most common age range was 30-39 years old. Eighty per cent of respondents reported that music was played at least "sometimes", with 74% reporting that they enjoyed it. Easy Listening was the most played and preferred genre followed by Top 40/Billboard hits. Overwhelmingly, respondents reported that background music in the OT improved temperament, focus, mood, and performance, though over a quarter felt it worsened communication. Thirty-one per cent of respondents reported that the choice of music depended on the type of operation, and 70% would turn music down or off during crises. Those who enjoyed music in their spare time were significantly more likely to enjoy music in the OT and perceive it positively. CONCLUSION: This study provides a window into the surgeons' use of and attitudes to intraoperative music in South Africa. While overall, music is viewed positively by this cohort, some concerns remain regarding communication and distractedness. Further interventional and qualitative studies would be useful.

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%.

Experience and perceptions of laparoscopic appendectomy amongst surgical trainees in South Africa.

BACKGROUND: TThis study is a survey amongst surgical trainees in South Africa (SA) designed to document their exposure to laparoscopic appendicectomy (LA) and their perceptions about the procedure and to identify possible barriers to its uptake. METHODS: A structured survey was developed using a combination of quantitative and qualitative questions designed to determine the clinical exposure of surgical trainees to laparoscopic appendectomy and then probe possible factors limiting their access to the procedure. A questionnaire was created online, and a link was distributed to various surgical trainees in Southern Africa. A list of trainees was obtained from the Surgreg Training Association of South Africa (STA). RESULTS: One hundred and thirty-two (47%) trainees completed the survey out of an estimated 280 general surgery registrars. Ninety-five (72%) were male and 37 (28%) were female respondents. Their median age was 31 years (25-36). There were 14 (11%) year-1 and 21 (16%) year-2, 32 (24%) year-3, 37 (28%) year-4 and 28 (21%) year-5 trainees. The breakdown according to region was area 1 (inland and central) 47 (36%), area 2 (western seaboard) 12 (9%) and area 3 (eastern seaboard) 73 (55%). Forty-three (33%) respondents experienced face-to-face teaching on how to perform a LA. Forty-two (32%) had exposure to laparoscopic simulators. Respondents reported a general lack of experience in performing this procedure. Sixty-nine (52%) had performed this procedure without a senior (i.e., solo) and 13 (10%) had only assisted a senior to perform this procedure. Seventy-four (56%) respondents felt confident performing a LA independently. One hundred and thirteen (86%) respondents expected to be taught this procedure. One hundred and five respondents (80%) were keen to learn to perform LA. One hundred and five respondents (80%) stated that they would be interested in attending an online course on LA. The respondents felt that the following were the significant barriers to performing LA: resource constraints 49 (37%) and time constraints 46 (35%). Thirty per cent of respondents (22) in area 3 reported a reluctance by seniors to teach the procedure. CONCLUSION: There appears to be a lack of exposure to and confidence with LA amongst South African surgical trainees. This implies a deficiency in formal surgical training programmes. Addressing this deficiency will require innovative solutions.

Development of a competency-based clinical assessment instrument for exit level Oral Hygiene students at the University of Western Cape.

Seminal to the process of a health sciences curriculum evaluation is the periodic review of clinical assessment instruments that measure competency. An assessment of quality is facilitated by using a well-structured, authentic and reliable instrument. This process rests on designing and measuring the instrument against a sound framework and validating it for scientific merit. This paper documents the pedagogy and the process taken in developing an improved formative competency-based assessment instrument for the final year students of the Bachelor of Oral Health program (BOH) at the University of the Western Cape (UWC). METHODS: A qualitative research study design employing the Nominal Group Technique (NGT) was used as a method for gaining small group consensus on the clinical assessment instrument for exit level Oral Hygiene (BOH3) students within the parameters of assessment principles. The key contributors to the instrument development process were the academic staff of the Department of Oral Hygiene, involved in clinical teaching and assessment of student competency. RESULTS: The domains of ethics and professionalism, patient assessment, diagnosis, treatment planning and implementation was identified as the core elements in the assessment. The principles of assessment, which include, alignment with outcomes, feedback, transparency and validity, were used to guide the instrument development. The assessment criteria were cross examined for alignment to the learning outcomes of the module and the program whilst formative feedback was foregrounded as a central feature to support student learning and progress monitoring. Transparency was obtained by providing students access to the instrument before and after the assessment including the written feedback on their performance. The instrument embodied a range of criteria to be assessed rather than on the awarding of a cumulative score. This allowed for the identification of the criteria or domain within which a student is struggling or excelling. Consensus on the instrument design was achieved using the NGT phases throughout the instrument development process including the weighting of the domains and grading. This level of engagement together with the application of scientifically sound assessment principles contributed to the validation of the instrument. CONCLUSION: The development of a competency-based assessment instrument was the result of a structured, collaborative and scientifically engaged process framed around specific assessment principles. The process culminated in the development of a formative competency-based clinical assessment instrument that was fit for purpose in the Bachelor of Oral Health program.The Nominal Group Technique served to be a valuable approach for small group consensus in developing the instrument. It served to promote individual perspectives and to generate debate and group discussion between academics that were proficient in clinical teaching and, finally to facilitate group consensus on the instrument structure and system for administration.

Artificial intelligence in healthcare: Proposals for policy development in South Africa.

Despite the tremendous promise offered by artificial intelligence (AI) for healthcare in South Africa, existing policy frameworks are inadequate for encouraging innovation in this field. Practical, concrete and solution-driven policy recommendations are needed to encourage the creation and use of AI systems. This article considers five distinct problematic issues which call for policy development: (i) outdated legislation; (ii) data and algorithmic bias; (iii) the impact on the healthcare workforce; (iv) the imposition of liability dilemma; and (v) a lack of innovation and development of AI systems for healthcare in South Africa. The adoption of a national policy framework that addresses these issues directly is imperative to ensure the uptake of AI development and deployment for healthcare in a safe, responsible and regulated manner.

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.

An approach to acute pulmonary embolism in the primary emergency care environment

Pulmonary embolism (PE) is a common emergency presenting among high risk patients. It is important to have a structured approach to clinical assessment, diagnosis and management of this potentially life-threatening emergency. Clinical and management pathways have improved over the last 10 years as clear guidelines have emerged. Newer diagnostic modalities have become available and will hopefully improve the pick-up rate of PE and reduce the morbidity and mortality. High level evidence presented by the American Society of Haematology and the European Society of Cardiology forms the basis for this review

Oral anticoagulants and atrial fibrillation: A South African perspective.

This review evaluates the current literature on available oral anticoagulants and atrial fibrillation with specific relevance to the South African (SA) public healthcare sector, focusing on the pharmacology and monitoring of anticoagulants, current guidelines, initiation of treatment and risk stratification, effectiveness of treatment, cost-effectiveness and specific costing implications. The direct-acting oral anticoagulants (DOACs) are superior to warfarin, with dabigatran being the preferred treatment option in patients with non-valvular atrial fibrillation (NVAF). Warfarin is still the preferred anticoagulant in patients with renal failure and prosthetic heart valves and is still the most cost-effective anticoagulant in the SA public sector setting. There is a growing body of evidence that demonstrates the advantages of DOACs over warfarin in NVAF. Warfarin will remain the anticoagulant of choice until cheaper generic DOACs become available.

An evaluation of warfarin use at an urban district-level hospital in KwaZulu-Natal Province, South Africa.

BACKGROUND: Warfarin is a commonly prescribed drug that needs to be monitored regularly. OBJECTIVES: To evaluate the quality of care of patients on warfarin and to determine the cost-effectiveness of this drug in a South African district hospital setting. METHODS: Quality of care was assessed through a structured patient interview, and cost-effectiveness of warfarin was determined by retrospective review of all costs over a 6-month period. RESULTS: A total of 110 participants from the dedicated warfarin clinic at Wentworth Hospital, Durban, were enrolled over a 1-month period. The median cost of all warfarin-related expenditure was ZAR295.05 per patient per month (pppm) (interquartile range (IQR) 283.42 - 333.17), with a mean (standard error of the mean (SEM)) cost of ZAR394.90 (53.03). The median cost for patients with non-valvular atrial fibrillation was ZAR294.40 pppm (IQR 283.85 - 345.10) and the mean (SEM) cost was ZAR430.54 (116.14), compared with an estimated cost of ZAR545.96 and ZAR673.85 per month for rivaroxaban and dabigatran tablets, respectively. Of the participants interviewed (N=110), 69.1% agreed or strongly agreed that monthly international normalised ratio monitoring frustrated them, 74.5% agreed or strongly agreed that they sometimes wished that they did not have to take warfarin, and 84.5% would be willing to pay for a drug that required less frequent blood tests and clinic visits. CONCLUSIONS: Warfarin still appears to be the most cost-effective drug in our setting, but it significantly affects patients' quality of life. We suggest a prospective head-to-head trial to compare both cost-effectiveness and quality of life of patients on warfarin and the new oral anticoagulants at a district hospital facility.

Wound infection secondary to snakebite.

BACKGROUND: Snakebites can produce severe local and systemic septic complications as well as being associated with significant overall morbidity and even mortality. OBJECTIVE: A prospective audit was undertaken to determine the bacterial causation of wound infection secondary to snakebite, and attempt to quantify the burden of disease. METHODS: The audit was undertaken at Ngwelezane Hospital, which provides both regional and tertiary services for north-eastern KwaZulu-Natal Province, South Africa, over a 4-month period. Records of patients who required surgical debridement for extensive skin and soft-tissue necrosis were analysed. At the time of debridement, tissue samples of necrotic or infected tissue were sent for bacteriological analysis as standard of care. Microbiology results were analysed. RESULTS: A total of 164 patients were admitted to hospital for management of snakebite, of whom 57 required surgical debridement and 42 were included in the final microbiological analysis. Children were found to be the most frequent victims of snakebite; 57.8% of patients in this study were aged ≤10 years and 73.7% ≤15 years. Culture showed a single organism in 32/42 cases, two organisms in 8 and no growth in 2. Eight different types of organisms were cultured, five of them more than once. Thirty-five specimens (83.3%) grew Gram-negative Enterobacteriaceae, the most frequent being Morganella morganii and Proteus species. Thirteen specimens (31.0%) grew Enterococcus faecalis. Gram-negative Enterobacteriaceae showed 31.4% sensitivity to ampicillin, 40.0% sensitivity to amoxicillin plus clavulanic acid, 34.3% sensitivity to cefuroxime, 97.1% sensitivity to ceftriaxone, and 100% sensitivity to ciprofloxacin, gentamicin and amikacin. E. faecalis was 92.3% sensitive to amoxicillin, 92.3% sensitive to amoxicillin plus clavulanic acid, 100% sensitive to ciprofloxacin, 92.3% resistant to erythromycin and 100% resistant to ceftriaxone. CONCLUSION: Children are particularly vulnerable to snakebite, and the consequences can be devastating. While the majority of patients in this study were shown to have secondary bacterial infection, debridement and subsequent wound management is considered the mainstay of treatment. Common organisms are Enterobacteriaceae and enterococci. There appears to be a role for antibiotics in the management of these patients. A good antibiotic policy is strongly advocated.

The impact of a modified World Health Organization surgical safety checklist on maternal outcomes in a South African setting: A stratified cluster-randomised controlled trial.

BACKGROUND: In South Africa (SA), the Saving Mothers Reports have shown an alarming increase in deaths during or after caesarean delivery. OBJECTIVE: To improve maternal surgical safety in KwaZulu-Natal Province, SA, by implementing the modified World Health Organization surgical safety checklist for maternity care (MSSCL) in maternity operating theatres. METHODS: The study was a stratified cluster-randomised controlled trial conducted from March to November 2013. Study sites were 18 hospitals offering maternal surgical services in the public health sector. Patients requiring maternal surgical intervention at the study sites were included. Pre-intervention surgical outcomes were assessed. Training of healthcare personnel took place over 1 month, after which the MSSCL was implemented. Post-intervention surgical outcomes were assessed and compared with the pre-intervention findings and the control arm. The main outcome measure was the mean incidence rate ratios (IRRs) of adverse incidents associated with surgery. RESULTS: Significant improvements in the adverse incident rate per 1 000 procedures occurred with combined outcomes (IRR 0.805, 95% confidence interval (CI) 0.706 - 0.917), postoperative sepsis (IRR 0.619, 95% CI 0.451 - 0.849), referral to higher levels of care (IRR 1.409, 95% CI 1.066 - 1.862) and unscheduled return to the operating theatre (IRR 0.719, 95% CI 0.574 - 0.899) in the intervention arm. Subgroup analysis based on the quality of implementation demonstrated greater reductions in maternal mortality in hospitals that were good implementers of the MSSCL. CONCLUSIONS: Incorporation of the MSSCL into routine surgical practice has now been recommended for all public sector hospitals in SA, and emphasis should be placed on improving the quality of implementation.

The impact of a modified World Health Organization surgical safety checklist on maternal outcomes in a South African setting: A stratified cluster-randomised controlled trial

Background. In South Africa (SA), the Saving Mothers Reports have shown an alarming increase in deaths during or after caesarean delivery.Objective. To improve maternal surgical safety in KwaZulu-Natal Province, SA, by implementing the modified World Health Organization surgical safety checklist for maternity care (MSSCL) in maternity operating theatres.Methods. The study was a stratified cluster-randomised controlled trial conducted from March to November 2013. Study sites were 18 hospitals offering maternal surgical services in the public health sector. Patients requiring maternal surgical intervention at the study sites were included. Pre-intervention surgical outcomes were assessed. Training of healthcare personnel took place over 1 month, after which the MSSCL was implemented. Post-intervention surgical outcomes were assessed and compared with the pre-intervention findings and the control arm. The main outcome measure was the mean incidence rate ratios (IRRs) of adverse incidents associated with surgery.Results. Significant improvements in the adverse incident rate per 1 000 procedures occurred with combined outcomes (IRR 0.805, 95% confidence interval (CI) 0.706 - 0.917), postoperative sepsis (IRR 0.619, 95% CI 0.451 - 0.849), referral to higher levels of care (IRR 1.409, 95% CI 1.066 - 1.862) and unscheduled return to the operating theatre (IRR 0.719, 95% CI 0.574 - 0.899) in the intervention arm. Subgroup analysis based on the quality of implementation demonstrated greater reductions in maternal mortality in hospitals that were good implementers of the MSSCL.Conclusions. Incorporation of the MSSCL into routine surgical practice has now been recommended for all public sector hospitals in SA, and emphasis should be placed on improving the quality of implementation

Human papillomavirus (HPV) vaccination of adolescents in the South African private health sector: Lessons from the HPV demonstration project in KwaZulu-Natal.

In South Africa (SA), >4,000 women die annually of cervical cancer, a disease caused by the human papillomavirus (HPV). Infections caused by certain genotypes of HPV increase the risk of cervical cancer. HIV-infected women in particular are more likely to have persistent HPV infection, with higher-risk genotypes. In SA, two vaccines (HPV quadrivalent (types 6, 11, 16, and 18) vaccine, recombinant (Gardasil) and HPV bivalent (types 16 and 18) vaccine, recombinant (Cervarix)) are currently registered for the prevention of HPV-related disease. In the past, there have been significant challenges to achieving high coverage and uptake of vaccination­contributory factors include cost and lack of awareness. An HPV demonstration project among schoolgirls in rural KwaZulu-Natal showed that high vaccine uptake is achievable. In 2014, the National Department of Health launched the national HPV vaccination programme among female learners attending public schools. Awareness of HPV vaccination among healthcare providers, education of parents, teachers and learners, and avoidance of missed opportunities for vaccination are vital to the success of the programme. Primary healthcare practitioners may play an important role in cervical cancer prevention by identifying and offering vaccination to girls who miss the opportunity to be vaccinated at school. HPV vaccination should be considered as one arm of a comprehensive programme of cervical cancer prevention and control.

Laparoscopic splenectomy for immune thrombocytopenic purpura.

BACKGROUND: Laparoscopic splenectomy has become the preferred method of splenectomy for refractory immune thrombocytopenic purpura (ITP). We present our experience with the introduction of laparoscopic splenectomy for ITP. METHODS: Over a 2-year period, retrospective and prospective data were collected on all patients undergoing laparoscopic splenectomy for ITP at our institution. We analysed demographic data, peri-operative courses, platelet count responses and complications. RESULTS: Twenty laparoscopic splenectomies were performed. There were 2 conversions to an open procedure. The average operating time was 100 minutes (range 30 - 170 minutes), and mean blood loss was 106 ml (range 50 - 200 ml). There were no deaths or major complications. The mean follow-up period was 7 months. Ninety-five per cent of patients had a complete or partial response to splenectomy. CONCLUSION: Laparoscopic splenectomy can be introduced safely with an acceptable conversion rate, and is an effective treatment for ITP on short-term follow-up.

Intestinal inflammatory myofibroblastic tumour.

BACKGROUND: Inflammatory myofibroblastic tumours (IMFTs) are rare tumours characterised by nosologic, histogenetic and aetiopathogenetic controversy and variable clinicopathological features. We report our experience with intestinal-IMFTs (I-IMFTs) that have been reported mainly as single case reports to date. METHODS: Five patients with I-IMFTs, identified between 2005 and 2008, formed the study cohort. The clinicopathological features were obtained from departmental and hospital records. RESULTS: The median patient age was 13 years. While 4 patients presented with symptoms and signs of intestinal obstruction, one IMFT was an incidental finding at laparotomy for trauma. Three I-IMFTs were located in the small bowel and 2 in the colon. Complete resection with end-to-end anastomoses was performed. The gross morphology included 1 polypoid myxoid tumour that served as a lead point for an intussusception, 3 multinodular whorled masses and 1 firm circumferential, infiltrative tumour. Microscopically, all tumours had typical features of IMFT with variable expression of ALK-1, a low proliferation index and tumour-free resection margins. All patients had an uneventful recovery. One patient was lost to further follow-up. Four patients were well, without local recurrence or metastases at 6 months to 3 years. CONCLUSIONS: Surgery with tumour-free resection margins is the gold standard of care of adult and paediatric I-IMFTs. Heightened recognition of I-IMFT, albeit rare, as a cause of intestinal obstruction, including intussusception, is necessary for pre-operative suspicion of I-IMFT.

Lymphoepithelial lesions of the parotid gland in the HIV era--a South African experience.

OBJECTIVE: Historically, lymphoepithelial lesions (LELs) have been a peripheral indication for surgery on the parotid gland, accounting for less than 1% of all parotidectomies undertaken. In the HIV era the profile of parotidectomy has changed, with LEL becoming a common indication for parotidectomy, prompting a review of our current experience. DESIGN: A retrospective study was undertaken between January 1998 and December 2005. Setting. Surgical services at King Edward VIII Hospital, Durban. SUBJECTS: All patients presenting with parotidomegaly. RESULTS: One hundred and sixty-two patients with parotidomegaly were evaluated; 53 (32.7%) had LEL lesions. A total of 151 parotidectomies (including 42 parotidectomies undertaken for LEL lesions) were performed in 147 patients. Radiotherapy was offered to 11 patients with LEL lesions. Complications following parotidectomy for LEL included facial nerve palsy (N=3), seroma formation (N=5) and facial artery false aneurysm (N=1). Three patients required re-parotidectomy for recurrent LEL parotidomegaly. In the patients who underwent radiotherapy, there was a satisfactory outcome; 2 patients who received 4 Gy radiation per sitting developed mild skin discolouration of the treated area. CONCLUSION: Although surgical management of LEL parotidomegaly may provide a satisfactory result, this approach is technically challenging and is associated with complications and recurrences. For these reasons, the non-operative approach employing radiotherapy should be considered.

Changes in Neutrophil Count; Creatine Kinases and Muscle Soreness after Repeated Bouts of Downhill Running

OBJECTIVE. A primary objective was to examine circulating neutrophil count after repeated bouts of downhill running. An additional aim was to determine creatine kinase (CK)levels during the initial 12 hours; after repeated DHRs. DESIGN. Eleven healthy; untrained Caucasian males performed 2 x 60 min bouts of DHR (-13.5); spaced 14 days apart; at a speed equal to 75VO2max on a level grade. Blood was collected before; after; and every hour for 12 hours; and every 24 hours for 6 days. Absolute neutrophil count; CK; and delayed-onset muscle soreness (DOMS) were assessed. Result were analysed using repeated measures ANOVA (p0.05) with appropriate post hoc tests. RESULT. There were no significant differences in neutrophil count (p

Assessing the impact of renal impairment on outcome after arterial intervention: a prospective review of 1,559 patients.

AIM: To investigate the impact of pre and peri-operative renal impairment on outcome, and the need for renal replacement therapy, in a multicenter study of patients undergoing a variety of surgical and radiological arterial procedures. METHODS: A six month prospective multi-centre study of 1,559 consecutive patients undergoing arterial interventions was performed. The primary outcome measures were the development of renal impairment, 30 day mortality and the need for renal replacement therapy. CRI was defined as an admission serum Creatinine>125 micromol/l. ARI was defined as a rise in serum Creatinine of >50% above pre-operative levels, excluding patients in whom the post operative level remained <125 micromol/l. A multivariate logistic regression model was constructed to identify independent risk factors for the development of ARI and mortality. RESULTS: There was a significantly increased 30 day mortality in those patients who developed ARI (29/90 - 32%) or who had CRI (43/269 - 16%) when compared with those whose creatinine remained normal throughout (44/1200 - 4%) (p<0.0001 - Chi-square test). One thousand two hundred and ninety patients had normal pre operative renal function and 269 patients had CRI. Seven percent (90/1290) of the patients with normal pre-operative creatinine developed ARI. Operation type, emergency presentation, and chronic renal impairment were independent predictors of both acute renal impairment (p<0.01) and mortality (p<0.001). Sixteen patients (1%) required temporary haemofiltration (in 9 patients this developed in the context of multiple organ failure) with only 1 requiring long term support. Eleven of these patients died (30 day mortality 69%). CONCLUSIONS: Renal failure following arterial intervention is associated with significant mortality. Renal replacement therapy is necessary mainly in the setting of multiple organ failure on intensive care units with few patients surviving to require long term renal replacement therapy. The identification of the 'at risk' patient is most strongly associated with age, raised preoperative creatinine, emergency procedures and thoraco-abdominal aneurysm.