Surgical training during the COVID-19 pandemic - a single institution's trainee survey.

BACKGROUND: Few studies have assessed the impact of COVID-19 on surgical training in low- and middle-income countries. The aim of this study was to survey the effect of the COVID-19 pandemic on postgraduate surgical training, research and registrar wellbeing in South Africa. METHODS: A cross-sectional study was conducted as an online survey from 5 October 2020 to 1 December 2020. The study population was registrars from all surgical disciplines at the Faculty of Medicine and Health Sciences of Stellenbosch University. The survey consisted of 26 multiple-choice and five open-ended qualitative questions on the impact of COVID-19 on physical and mental wellbeing, skills acquisition and postgraduate research. RESULTS: Of 98 surgical registrars, 35 (36%) responded. Twenty-three (65.7%) reported missed planned surgical rotations, 30 (85.7%) decreased surgical training time, and 22 (62.9%) reported a perceived decrease in training quality. Simulated skills training was only available to eight (22.9%) participants. Twenty-four (68.6%) experienced burnout and/or depression symptoms during the pandemic. Twenty-seven (77.1%) reported that postgraduate research was unaffected by the pandemic. CONCLUSION: During the COVID-19 pandemic, surgical trainees at this institution reported a decrease in the quality of surgical training and skills acquisition and a negative impact on their mental wellbeing.

Radiography students achieving competencies through structured interprofessional education.

INTRODUCTION: Interprofessional education (IPE) takes place when representatives of at least two professions work and learn together, about and from each other to provide optimal healthcare. For the successful implementation of an IPE programme, conceptualisation, planning, and operationalisation and coordination among the various professions is crucial, to assist students to obtain the desired competencies of such a programme. The purpose is to investigate if a structured IPE programme assisted radiography students to achieve competencies. METHODS: An online questionnaire was compiled from literature and completed by radiography students who participated in a structured, three-week-long IPE programme. The questionnaire was mainly quantitative (using a Likert scale), though it also consisted of qualitative elements (open-ended questions). A Fischer's Exact test was used to compare the responses of three different year groups. RESULTS: Feedback from the radiography students (n=63) indicated that they achieved this IPE programme's specific competencies: role clarification, interprofessional communication, teamwork, person-centered care and values and ethics. There was good correlation between the feedback from all three year groups. The feedback on the open-ended questions correlated with the quantitative feedback, though some students felt excluded, as there was little reference to their particular profession in the simulation session of the IPE programme. CONCLUSION: The results of the study indicate that radiography students achieved the prescribed competencies of a structured IPE programme. The results provide insight into ways to improve the IPE programme. A recommendation emanating from the results of this study is that, to improve the experience of all healthcare professions students, structured IPE programmes have to promote inclusive teaching and learning. IMPLICATIONS FOR PRACTICE: Radiography students that participate in a structured IPE programme develop competencies necessary for effective collaborative clinical practice.

Radon in groundwater baseline study prior to unconventional shale gas development and hydraulic fracturing in the Karoo Basin (South Africa).

The prospect of unconventional shale gas development in the semi-arid Karoo Basin (South Africa) has created the prerequisite to temporally characterise the natural radioactivity in associated groundwater which is solely depended on for drinking and agriculture purposes. Radon (222Rn) was the primary natural radionuclide of interest in this study; however, supplementary radium (226Ra and 228Ra) in-water measurements were also conducted. A total of 53 aquifers spanning three provinces were studied during three separate measurement campaigns from 2014 to 2016. The Karoo Basin's natural radon-in-water levels can be characterised by a minimum of 1 ±â€¯1 Bq/L (consistent with zero or below LLD), a maximum of 183 ±â€¯18 Bq/L and mean of 41 ±â€¯5 Bq/L. The mean radon-in-water levels for shallow aquifers were systematically higher (55 ±â€¯10 Bq/L) compared to deep (14 ±â€¯3 Bq/L) or mixed aquifers (20 ±â€¯6 Bq/L). Radon-in-water activity concentration fluctuations were predominantly observed from shallow aquifers compared to the generally steady levels of deep aquifers. A collective seasonal mean radon-in-water levels increase from the winter of 2014 (44 ±â€¯8 Bq/L) to winter of 2016 (61 ±â€¯16 Bq/L) was noticed which could be related to the extreme national drought experienced in 2015. Radium-in-water (228Ra and 226Ra) levels ranged from below detection level to a maximum of 0.008 Bq/L (226Ra) and 0.015 Bq/L (228Ra). The 228Ra/226Ra ratio was characterised by a minimum of 0.93, a maximum of 6.5 and a mean value of 3.3 ±â€¯1.3. Developing and improving baseline naturally occurring radionuclide groundwater databases is vital to study potential radiological environmental impacts attributed to industrial processes such as hydraulic fracturing or mining.

The bird's-eye perspective: how do district health managers experience the impact of family physicians within the South African district health system? A qualitative study

Background: Health policy-makers in Africa are looking for local solutions to strengthen primary care teams. A South African national position paper (2015) described six aspirational roles of family physicians (FPs) working within the district health system. However, the actual contributions of FPs are unclear at present, and evidence is required as to how this cadre may be able to strengthen health systems.Methods: Using semi-structured interviews, this study sought to obtain the views of South African district health managers regarding the impact made by FPs within their districts on health system performance, clinical processes and health outcomes.Results: A number of benefits of FPs to the health system in South Africa were confirmed, including: their ability to enhance the functionality of the local health system by increasing access to a more comprehensive and coordinated health service, and by improving clinical services delivered through clinical care, capacitating the local health team and facilitating clinical governance activities.Conclusions: District managers confirmed the importance of all six roles of the FP and expressed both direct and indirect ways in which FPs contribute to strengthening health systems' performance and clinical outcomes. FPs were seen as important clinical leaders within the district healthcare team. Managers recognised the need to support newly appointed FPs to clarify their roles within the healthcare team and to mature across all their roles. This study supports the employment of FPs at scale within the South African district health system according to the national position paper on family medicine

Radon and Thoron In-air Occupational Exposure Study within Selected Wine Cellars of the Western Cape (South Africa) and Associated Annual Effective Doses.

This is the first known study of exposure of Rn (radon) and secondarily Rn (thoron) in-air activity concentrations assessed within nine selected wine cellars in four wine districts of the Western Cape (South Africa) and the associated annual occupational effective doses. E-PERM electret ion chambers (EIC) and RAD-7 α-detectors were used to perform these measurements. The radon in-air levels ranged from 12 ± 4 Bq m to 770 ± 40 Bq m within the nine selected wine cellars. Eight of the nine wine cellars (excluding results from cellar w-6) had a median radon in-air activity concentration of 48 ± 8 Bq m. Continuous thoron in-air activity concentration levels were also measured near an internal granite wall of the wine cellar w-6 (barrel room), where peak levels of up to 1,520 ± 190 Bq m and an average of 680 ± 30 Bq m were observed. The occupational annual effective dose due to radon and decay progeny exposure in-air within the selected wine cellars ranged from 0.08 ± 0.03 mSv to 4.9 ± 0.3 mSv with a median of 0.32 ± 0.04 mSv (Tmax = 2,000 h). The annual effective dose within the wine cellar (w-6) ranged up to a maximum of 2.5 ± 0.4 mSv (Tmax = 2000 h) due to exposure to thoron and decay progeny. In general, most of the wines cellars pose negligible associated health risk to personnel due to ionizing radiation exposure from the inhalation of radon and progeny. Under certain conditions (proximity and exposure time), caution should be exercised at wine cellar w-6 because of elevated thoron in-air levels.

Radon Levels Measured at a Touristic Thermal Spa Resort in Montagu (South Africa) and Associated Effective Doses.

Radon activity concentrations (in water and in air) were measured at 13 selected locations at the Avalon Springs thermal spa resort in Montagu (Western Cape, South Africa) to estimate the associated effective dose received by employees and visitors. A RAD-7 detector (DURRIDGE), based on alpha spectrometry, and electret detectors (E-PERM®Radelec) were used for these radon measurements. The primary source of radon was natural thermal waters from the hot spring, which were pumped to various locations on the resort, and consequently a range of radon in-water analyses were performed. Radon in-water activity concentration as a function of time (short term and long term measurements) and spatial distributions (different bathing pools, etc.) were studied. The mean radon in-water activity concentrations were found to be 205 ± 6 Bq L (source), 112 ± 5 Bq L (outdoor pool) and 79 ± 4 Bq L (indoor pool). Radon in-air activity concentrations were found to range between 33 ± 4 Bq m (at the outside bar) to 523 ± 26 Bq m (building enclosing the hot spring's source). The most significant potential radiation exposure identified is that due to inhalation of air rich in radon and its progeny by the resort employees. The annual occupational effective dose due to the inhalation of radon progeny ranges from 0.16 ± 0.01 mSv to 0.40 ± 0.02 mSv. For the water samples collected, the Ra in-water activity concentrations from samples collected were below the lower detection limit (~0.7 Bq L) of the γ-ray detector system used. No significant radiological health risk can be associated with radon and progeny from the hot spring at the Avalon Springs resort.

High average power Q-switched 1314-nm two-crystal Nd:YLF laser.

A 1314 nm two-crystal Nd:YLF laser was designed and operated in both CW and actively Q-switched modes. Maximum CW output of 26.5 W resulted from 125 W of combined incident pump power. Active Q-switching was obtained by inserting a Brewster-cut acousto optic modulator. This setup delivered an average power of 18.6 W, with a maximum of 5.6 mJ energy per pulse with a pulse duration of 36 ns at a pulse repetition frequency of 500 Hz.

High average power 1314 nm Nd:YLF laser, passively Q-switched with V:YAG.

A 1314 nm Nd:YLF laser was designed and operated both CW and passively Q-switched. Maximum CW output of 10.4 W resulted from 45.2 W of incident pump power. Passive Q-switching was obtained by inserting a V:YAG saturable absorber in the cavity. The oscillator delivered a maximum of 825 µJ energy per pulse, with a pulse duration of 135 ns at a pulse repetition frequency of 6.3 kHz, effectively delivering 5.2 W of average power.

Overcoming the learning curve in hand-assisted laparoscopic live donor nephrectomy - a study in the animal model.

The demand for kidneys in South Africa is staggering. Only 38% of the kidney transplants done in 2008 were from related living donors. Laparoscopic living donor nephrectomy has been shown to have the advantages of decreased postoperative pain, better cosmesis and a quicker return to work when compared with the open technique. With limited surgical expertise, a realistic model was needed to overcome the learning curve. Methods. A total of 21 nephrectomies were performed on 12 pigs. The transperitoneal hand-assisted laparoscopic technique was used. Results. The median operative time was 75 minutes and the median warm ischaemic time 88 seconds. Three cases were aborted owing to major vascular injuries. Discussion. The advent of laparoscopic techniques has been associated with an increase in morbidity and complications in donor and recipient during the initial learning curve. We found that with our porcine model, 21 nephrectomies were adequate in overcoming the learning curve. After 15 nephrectomies no complications were noted.

Anatomical considerations of the anterior approach for central venous catheter placement.

Central venous catheterization (CVC) entails the catheterization of the superior vena cava via either the subclavian or the internal jugular vein (IJV). This study looked at the frequency in which a needle was inserted into the IJV using the anterior CVC approach, which entails inserting the needle into the apex of Sedillot's triangle, formed by the sternal and clavicular heads of sternocleidomastoid (SCM). The ipsilateral distances from the apex of Sedillot's triangle to the superior aspect of the sternoclavicular joint and the diameter of the IJV were also measured. A needle was inserted into the apex of Sedillot's triangle in 36 adult cadavers with mean age of 62 +/- 19 years (mean +/- SD), mean height of 1.6 +/- 0.18 m, and a mean weight of 55 +/- 16 kg. Subsequent dissections of this area revealed the relation of the needle to the IJV. Results indicate that on the right, the needle was inserted into the IJV in 97.14% of the cases. On the left, the needle entered the IJV in 78.79% of the cases. From the sternoclavicular joint, the apex of Sedillot's triangle was found to be 40.87 +/- 1.62 mm and 38.73 +/- 6.34 mm on the right and left, respectively. The IJV diameter was 17.29 +/- 1.07 mm on the right and 15.30 +/- 0.25 mm on the left. We conclude that the anterior CVC approach is an anatomically accurate technique. It is furthermore important to realize that when performing any invasive procedure, a sound anatomical knowledge of the region is extremely important, as complications are often due to lack of understanding or misunderstanding of the relevant anatomy.

Emergence of a pneumococcal clone with cephalosporin resistance and penicillin susceptibility.

We report two South African serotype 6B pneumococcal isolates with cephalosporin resistance, yet with susceptibility to penicillin. DNA fingerprinting revealed that they were clonal in origin. pbp 2X and 1A genes showed major alterations typical of cephalosporin-resistant pneumococci. The pbp 2B gene was completely unaltered, explaining the penicillin susceptibility of the isolates.

Development of early melanocytic lesions in transgenic mice predisposed to melanoma.

We have previously described a line of transgenic mice (TG3) that spontaneously develops heritable malignant melanoma. Histological analysis of these animals during the first postnatal month is described here. In the TG3 line, the number of melanocytes is increased at all anatomical sites to which neural-crest-derived melanocytes normally migrate. Clonal expansion and morphological changes of these melanocytes can be detected as early as postnatal day (PND) 15. By PND 30, cells morphologically indistinguishable from the tumor cells of adult transgenic mice were detected in the ear, eye lid and perianal region. These cells are believed to be the precursors of the primary tumors in adult mice. The stepwise development of melanoma in the TG3 line is similar to the stepwise development of melanoma in humans.

Hyperparathyroidism and chronic pancreatitis.

Hyperparathyroidism is a rare cause of pancreatitis. The nature of the relationship between the two entities is not well defined, i.e. is it casual or causal? We describe 2 patients with chronic pancreatitis and hyperparathyroidism who presented with epigastric pain and were initially treated unsuccessfully by surgical drainage of the pancreatic ducts. In 1 case the hyperparathyroidism was only recognised after the pancreatic surgery. In both the symptoms of chronic pancreatitis responded well to parathyroidectomy. We believe that our cases add support to a causal relationship between pancreatitis and hyperparathyroidism. Whatever the true relationship, management of these patients should initially be directed at the hyperparathyroidism, followed by appropriate treatment of the pancreatitis.

Cryptococcal meningitis in an HIV negative patient with systemic sarcoidosis.

A case of Cryptococcus neoformans meningitis is described in an HIV negative patient with undiagnosed systemic sarcoidosis. The patient presented with signs of meningitis together with generalised lymphadenopathy and hepatosplenomegaly. Cryptococcal meningitis was diagnosed on lumbar puncture. She was treated with intravenous amphotericin B but died within two weeks of admission. Necropsy revealed lesions in the lungs, liver, spleen, lymph nodes, small intestine, and bone marrow consistent with sarcoidosis. Microscopically the lesions contained non-caseating epithelioid cell granulomas typical of sarcoidosis. No Schaumann or Hamazaki-Wesenberg bodies were identified. Cryptococcus neoformans meningitis is generally associated with immunosuppressive disorders. As T cell abnormalities have been described in sarcoidosis, this could have been a case of opportunistic infection. Although rare, sarcoidosis merits consideration in patients with cryptococcal disease in the absence of HIV infection.

Development of heritable melanoma in transgenic mice.

Transfer of genetic material into recipient cells by transfection has been used successfully to isolate genes responsible for particular phenotypic traits. By using this strategy, DNA fragments were isolated that when transfected into appropriate uncommitted cells will commit the recipient cells to undergo adipocyte differentiation. Transgenic mice were generated with one of the active DNA clones, Clone B. The transgenic mice were expected to display an adipocyte-related phenotype; however, the animals developed melanin containing tumors at a young age. Insertion of Clone B into the mouse DNA probably interrupted a gene(s) that is involved in the regulation of cell growth, specifically regulation of cell growth in melanin-producing cells. Histopathologic analysis of these mice showed dark spots on the ear lobes of the animals as early as 10-12 d of age. By 3 mo, in addition to the ear lobes, pigmented tumors could be observed in other organs. A significant number of these transgenic mice died within 1 y of age. The melanomas developed spontaneously in these animals in the absence of any known chemical carcinogen or ultraviolet radiation. This line of mice provides a way of identifying genes involved in regulation of cell growth control and differentiation. These mice also serve as a model system to investigate the molecular, genetic, and phenotypic characterization and development of melanomas.

The value of Swan-Ganz catheterization and volume loading in preventing renal failure in patients undergoing abdominal aneurysmectomy.

A prospective analysis of 61 patients undergoing abdominal aneurysmectomy is presented. When compared with 87 historical controls we have shown that the incidence of hypotensive episodes (31 out of 62 patients in the original study compared with 13 out of 44 patients in the prospective analysis) is significantly reduced when fluid balance is monitored invasively using the pulmonary artery wedge pressure and keeping it at 10 mm H2O (p less than 0.03). Renal dysfunction, defined as a significant drop in urine output and a doubling of the serum creatinine, occurred in only 10% of patients compared with 33% in the controls (p less than 0.001). The decreased prevalence of renal failure accounts for the reduction in mortality noted (p less than 0.01). There were 27 deaths (31%) amongst the patients in the earlier study compared with 9 (15%) in the prospective analysis. The pathogenetic mechanisms responsible for the development of renal failure following surgical manipulation of the abdominal aorta are reviewed.

Lymphocoeles in renal homograft recipients.

UNLABELLED: Seven lymphocoeles have complicated 158 cadaver and 18 related live donor transplants performed over six years. The purpose of this study is to review the clinical, diagnostic and therapeutic problems encountered with lymphocoeles at this centre. Presentation was insidious, delayed (50 days post-op), and manifested by one or more of the following: palpable rectal or supra-pubic mass; unilateral leg oedema; recurrent urine infections with radiographic evidence of obstruction; filling defect in bladder on routine IVP. Possible pathogenetic factors: transplants performed on side of functioning Scribner shunts (6/7 cases); severe rejection episodes with graft lymphatic leak (1/7 cases). Differentiation from urinomas, haematomas, perinephric abscesses or other causes of obstructive uropathy were facilitated by: needle aspiration; IVP and cystogram, serial ultrasound sonography. Lymphangiography was not used. Treatment was conservative in three, repeated aspirations were performed in two and formal drainage procedures were required in three patients. Repeated cyst aspirations resulted in serious infections in both patients. Marsupialisation into the peritoneal cavity failed in one. CONCLUSIONS: 1) The graft should be anastomosed on side opposite a functioning shunt. 2) Lymphocoeles have an occult presentation and should be actively sought for as they may produce urinary obstruction. 3) Serial ultrasound is an excellent method of diagnosis and follow-up. 4) Unless urinary obstruction is present management should be conservative as spontaneous resolution may occur. 5) Ideal surgical management is problematical. Repeated needle aspirations should be approached with caution. Lymphocoeles are an uncommon but well documented complication of renal transplantation (Schweizer et al, 1972; Koehler et al, 1972; Christiansen et al, 1974; Rashid et al, 1974). They represent definite hazards and can either directly or indirectly contribute to morbidity or even mortality in the post-transplant patient. They must be differentiated from other pelvic masses such as urinomas, haematomas and perinephric abscesses as they all require different modes of treatment. As a rule, the diagnosis of one from another is straightforward, but as certain clinical features are shared, differentiation can on occasions be more difficult. In order to clarify some of these problems and outline a mode of therapy, a study was carried out in patients who have presented with lymphocoeles in our unit.