Malignant and pre-malignant oesophageal pathology in a South African teaching hospital

Background: South Africa (SA) has one of the highest global incidences of squamous cell carcinoma of the oesophagus (SCC). A decreasing incidence of oesophageal SCC in SA has been suggested. The study aimed to assess whether the incidence of these malignant histopathological subtypes has changed in this setting. Methods: A retrospective review of histopathological reports on pre-malignant and malignant oesophageal lesions over three time periods (TP), namely: 2003­4 (TP1), 2008­9 (TP2) and 2013­14 (TP3) was carried out at Inkosi Albert Luthuli Central Hospital, Durban, South Africa.Results: A total of 1341 specimen reports were retrieved. TP1-3 consisted of 514 (39.3%), 320 (24.5%) and 474 (36.2%) patients respectively. Six hundred and forty-nine patients were male (48.3%), 642 were female (47.8%) and 50 were not specified. i.e. a sex ratio of 1.01:1. The mean age was 60.8 (± 11.8). There were 1197 Black patients (91.5%), 66 Asian (5.1%), 25 White (1.9%), 9 mixed ancestry (0.7%), and 11 of unknown race (0.8%). SCC was the most common cancer 1098 (89.1%) followed by adenocarcinoma (AC) 69 (5.6%). The ratio of SCC to AC remained fairly consistent over the total time period. Seventy-four oesophageal resections were performed with a yearly average resection rate of only 5.6%.Conclusions: SCC is still the most prevalent oesophageal cancer (OC) without an increase in the ratio of AC to SCC. The diagnosis of squamous cell dysplasia is concordant with previously cited rates. Barrett's oesophagitis remains uncommon. Resection rates for OC are low but similar to other South African referring centers

Independent and interactive effects of HIV infection, clinical stage and other comorbidities on survival of children treated for severely malnourished in rural South Africa: A retrospective multi-cohort study

Background. There is still limited to no evidence on the independent and interactive effects of HIV infection, disease stage, baseline disease severity and other important comorbidities on mortality risk among young children treated for severe acute malnutrition (SAM) in South Africa (SA, using the World Health Organization (WHO) recommended treatment modality. Objectives. To determine baseline clinical characteristics among children with SAM and assess whether HIV infection, disease stage, critical illness at baseline and other comorbidities independently and interactively contributed to excess mortality in this sample. Methods. We followed up children aged 6 - 60 months, who were admitted with and treated for SAM at two rural hospitals in SA, and retrospectively reviewed their treatment records to abstract data on their baseline clinical characteristics and treatment outcomes. In total, 454 children were included in the study. Descriptive statistical tests were used to summarise patients' clinical characteristics. Kaplan-Meier failure curves were created for key characteristics and compared statistically using log-rank tests. Univariate and multivariate Cox regression was used to estimate independent and interactive effects. Results. The combined case fatality rate was 24.4%. HIV infection, clinical disease stage, the presence of lower respiratory tract infection, marasmus and disease severity at baseline were all independently associated with excess mortality. The critical stage for higher risk of death was when cases were admitted at WHO stage III. The interactions of two or three of these characteristics were associated with increased risk of death when compared with having none, with HIV infection and critical illness showing the greatest risk (hazard ratio 22, p<0.001). Conclusion. The high HIV prevalence rate in the study setting and the resultant treatment outcomes support the notion that the WHO treatment guidelines should be revised to ensure that mechanisms for effective treatment of HIV comorbidity in SAM are in place. However, a much more rigorous study is warranted to verify this conclusion

The spectrum and outcome of surgical sepsis in Pietermaritzburg, South Africa

Background. Sepsis is a leading cause of morbidity and mortality worldwide, and the incidence appears to be increasing. In the resource-limited environment in low- and middle-income countries, the management of surgical sepsis (SS) continues to represent a significant portion of the workload for most general surgeons.Objective. To describe the spectrum of SS seen at a busy emergency department, and categorise the outcomes.Methods. The Pietermaritzburg Metropolitan Trauma Service (PMTS) and Pietermaritzburg Metropolitan Surgical Service (PMSS) in KwaZulu-Natal Province, South Africa (SA), maintain a prospective electronic registry. All patients with features of sepsis among emergency general surgical patients >15 years of age admitted to the PMSS over the period January 2012 - January 2015 were identified. From this cohort, all patients with sepsis that required surgical source control or who had a documented surgical source of sepsis (i.e. had SS) were selected for analysis.Results. Of a total of 6 020 adult surgical patients on the database, a cohort of 1 240 acute surgical patients with features of sepsis were identified, and 675 with SS were then analysed further. Of the 675 patients, 49.2% were male, and the mean age was 46 years (standard deviation (SD) 19); 47.0% presented to the PMSS directly from within the metropolitan area, while the remaining 53.0% were referred from hospitals outside the area. Physiological parameters (mean values) on presentation were as follows: systolic blood pressure 123 mmHg (standard deviation (SD) 23), respiratory rate 22 breaths/min (SD 5.2), heart rate 107 bpm (SD 19), temperature 37°C (SD 2) and white cell count 20 × 109/L (SD 8). Of the patients, 21.6% were known to be HIV-positive, 13.5% (91/675) were negative and 64.9% were of unknown status; 57.6% had intra-abdominal sepsis, 26.1% diabetes-related limb sepsis and the remaining 16.3% soft-tissue infections; 17.5% required intensive care unit admission, with a mean length of stay of 4 days (SD 4), and 30.7% developed complications. In this last group (n=207), a total of 313 morbidities were identified. The overall mortality rate was 12.7% (86/675). The mortality rate for intra-abdominal sepsis was 13.1%, for diabetic foot sepsis 14.2% and for necrotising fasciitis 27.3%.Conclusions. The spectrum of SS in SA is different to that seen in the developed world. Intra-abdominal sepsis is the most common SS and is overwhelmingly caused by acute appendicitis. Diabetic foot infection is a major cause of SS, reflecting the increasing burden of non-communicable chronic diseases in SA

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

Implementation and outcome evaluation of the medical education partnership initiative biostatistical reasoning workshops for faculty and postgraduate students at the university of kwazulu-natal; durban; south africa

Background. There is a shortage of biostatistics expertise at the University of KwaZulu-Natal (UKZN); Durban; South Africa and in the African region. This constrains the ability to carry out high-quality health research in the region.Objectives. To quantitatively and qualitatively evaluate a programme designed to improve the conceptual and critical understanding of bio statistical concepts of UKZN health researchers.Methods. A 40-hour workshop in biostatistical reasoning was conducted annually between 2012 and 2015. The workshops were structured around interpretation and critical assessment of nine articles from the medical literature; with a mix of in-class sessions and small group discussions. Quantitative evaluation of the knowledge gained from the workshops was carried out using a pre- and post-workshop quiz; and qualitative evaluation of the workshop process was done using a mid-workshop questionnaire and focus group discussions.Results. For each year that the workshop was conducted; post-workshop quiz scores were significantly higher than pre-workshop scores. When quiz assessments from all 4 years of training were combined; the pretest median score was 55% (interquartile range (IQR) 40 - 62%) and the post-test median score was 68% (IQR 62 - 76%); with p0.0001 for the overall comparison of pre- v. post-scores. There was a general consensus among participants that the workshop improved their reasoning skills in biostatistics. Participants also recognised the value of the workshop in building biostatical capacity at UKZN. Conclusion. The workshops were well received and improved the critical and conceptual understanding of the participants. This education mode offers the opportunity for health researchers to advance their knowledge in settings where there are few professional biostatistician collaborators

Elevated International Normalised Ratios Correlate with Severity of Injury and Outcome

Background. Haemorrhagic shock is the leading cause of preventable early deaths from trauma. Acute coagulopathy on admission to a trauma unit is associated with worse outcomes. The relationship of haemorrhage to early mortality remains consistent regardless of mechanism of injury. Haemorrhage and haemorrhagic shock are increasingly amenable to interventions that result in reductions in morbidity and mortality.Objectives. To assess the prevalence of coagulopathy in patients admitted to the level 1 trauma unit at Inkosi Albert Luthuli Central Hospital; Durban; South Africa; and correlate it with in-hospital mortality.Methods. A retrospective analysis of the first 1 000 patients admitted to the trauma unit during the years 2007 - 2011 was performed. The admission international normalised ratios (INRs) were correlated with Injury Severity Scores (ISSs) and in-hospital mortality. A multivariable Poisson model with robust standard errors was used to assess the relationship between coagulopathy and mortality after adjustment for the confounding influence of age and gender. The data were analysed using the R statistics program. Results.Of the 1 000 patients; 752 were male. There were 261 admissions directly from the scene and 739 inter-hospital transfers (non scene). The mean INRs among survivors for all; scene and non-scene patients were 1.33; 1.30 and 1.34; respectively; and those among non-survivors 1.92; 2.01 and 1.88; respectively (p0.001). The overall prevalence of coagulopathy was 48.7%; 46.9% in scene patients and 49.2% in non-scene patients. The mortality rate of scene patients with abnormal INR levels was 41.1% (adjusted relative risk (aRR) 3.59; 95% confidence interval (CI) 2.11 - 6.44; p0.001) v. 25.1% for non-scene patients (aRR 1.67; 95% CI 1.15 - 2.05; p

The Costs of Delivering Human Papillomavirus Vaccination to Grade 4 Learners in KwaZulu-Natal; South Africa

BACKGROUND:The national human papillomavirus (HPV) vaccination roll-out in South Africa provides two doses of Cervarix to all female Grade 4 learners in state schools. This study estimated the costs of vaccinating all learners in KwaZulu-Natal Province (females or males and females) using either the two- or three-dose strategies for both the bivalent and quadrivalent vaccines.OBJECTIVE:To determine costs of the HPV vaccination programme in KwaZulu-Natal.METHODS:Costs were determined adapting World Health Organization vaccination costing guidelines. RESULTS:The 2014 current cost of delivering three doses of Gardasil was ZAR510 per learner. The projected cost of delivering Cervarix to female learners at two or three doses over the period 2014 - 2018; adjusted for inflation; was ZAR172 717 342 and ZAR250 048 426; respectively. Similarly; the cost for Gardasil at these doses was ZAR197 482 200 and ZAR287 194 361; respectively. For male and female learners the cost for Cervarix over this period at two or three doses was ZAR337 101 132 and ZAR540 150 713; respectively. Similarly; the cost for Gardasil at these doses was ZAR426 597 971 and ZAR620 392 784; respectively. Accounting for population variation for females over 5 years; the cost of two doses of Cervarix ranged from ZAR168 888 677 to ZAR 176 545 977 at the lower and upper 95% confidence intervals (CIs); respectively. For three doses the cost ranged from ZAR244 505 544 to ZAR255 591 263 at the lower and upper 95% CIs; respectively. Similarly; the cost for two doses of Gardasil ranged from ZAR193 104 566 to ZAR201 859 798. For three doses the cost ranged from ZAR280 828 057 to ZAR293 560 614. CONCLUSION:This study gives decision makers a basis for structured planning and cost apportionment to ensure effective roll-out of the HPV vaccination programme