Four-year overall surgical mortality rate at Princess Marina Hospital, a tertiary hospital in Botswana.

Background: Improving surgical mortality rates is a global priority, as they measure the success of surgical care systems. There is no data on Botswana's overall surgical mortality rate. Therefore, this study set out to evaluate the overall mortality rate in a surgical department at Princess Marina Hospital, a tertiary hospital in Botswana. Method: This study is a single-center quantitative and retrospective study conducted in the surgical department at Princess Marina Hospital from August 2016 to December 2019. The Department of Surgery at Princess Marina Hospital keeps a prospectively updated database for quality assurance, which started in August 2016. The study received ethical approval. We included all patients older than 12 years admitted to the surgical department. Our adults surgical wards admit patients who are older than 12 years. This study collected all mortality data and determined the overall mortality rate as a percentage of surgical admissions. Results: We retrieved 4660 admissions. The mean age was 56 (standard deviation=20.1). 66% (3083/4660) were operated. Out of the 4660 admissions, 267 deaths were registered, giving an overall mortality rate of 6%. The overall postoperative mortality rate was 3.63%(112/3083), and the non-operatively managed patient mortality rate was 9.83% (155/1577). Overall, malignancies were the leading cause of death, at 49.1%(131/267), followed by trauma at 22.1% (59/267). Conclusions: The 4-year overall surgical mortality rate at Princess Marina Hospital was 6%. The mortality rate of the nonoperatively managed patients was more than twice as high as the postoperative mortality rate. Overall, malignancies were the leading cause of death, followed by trauma.

Surgical Simulation Training for Medical Students: Strategies and Implications in Botswana.

BACKGROUND: The role of simulation in teaching technical skills to medical students is not yet well defined. Strategies for its use may be especially relevant where teachers, time, and resources are limited, especially in low-middle-income countries. METHODS: Sixty-seven third-year and 67 fifth-year medical students at the University of Botswana were taught surgical skills by a trained peer medical student, a medical officer with no specialty training or a staff surgeon. Pre- and post-intervention performance of two basic tasks (simple interrupted suture (SIS) and laparoscopic peg transfer (LPT)) and one complex task (laparoscopic intracorporeal suture (LIS)) were assessed. Subjective measures of self-perceived performance, preparedness for internship, and interest in surgery were also measured. RESULTS: The simulation program decreased the time to complete the two basic tasks and improved the objective score for the complex task. Performance of the basic skills improved regardless of the seniority of the instructor while performance of the advanced skill improved more when taught by a staff surgeon. All students had similar improvements in their self-reported confidence to perform the skills, preparedness to assist in an operation and preparedness for internship, regardless of the seniority of their instructor. Students taught by a staff surgeon felt better prepared to assist in laparoscopic procedures. CONCLUSION: Simulation-based teaching of defined surgical skills can be effectively conducted by peers and near-peers. The implications are widespread and may be most relevant where time and resources are limited, and where experienced teachers are scarce.

Factors associated with adverse events after emergency laparotomy in Cape Town, South Africa: identifying opportunities for quality improvement.

BACKGROUND: Surgical outcomes research is limited in areas of the world with the greatest unmet surgical need and likely greatest variation in outcomes. Measurement alone may improve outcomes-the so-called Hawthorne effect. The purpose of this multicenter cohort study was to identify factors that are both feasible to collect and are associated with a major adverse event following a targeted procedure in Cape Town, South Africa. METHODS: A collaborative of four acute care surgical units was formed to develop a data set with minimal data burden describing outcomes after an emergency exploratory laparotomy during a 3-mo period (February-April 2015). Controlling for patient, problem, provider, procedure and process predictors, multivariate models were built to identify risk factors for a major adverse event and higher resource use after surgery in our collaborative. RESULTS: The outcomes of 450 exploratory laparotomies from the four participating hospitals were audited, 319 (70.9%) were for non-trauma and 131 (29.1%) were for trauma. The major adverse event rate was 15.7% (95% CI 12.6-19.4). In the multivariate analysis, factors associated with the primary outcome included age, American Society of Anesthesia score of greater than 2, bowel resection, preoperative CT scan, and a nontherapeutic laparotomy. A major adverse event was associated with all three outcomes assessing increased resource utilization. CONCLUSIONS: This study supports the comparative outcome assessment of a high-volume or high-risk procedure as a proxy for measuring the quality of care provided in a surgical collaborative. Such an exercise can identify opportunities for quality improvement.

Plasma homocysteine is elevated in COPD patients and is related to COPD severity.

BACKGROUND: Although recent studies have found that total plasma homocysteine (tHCY) and chronic obstructive pulmonary disease (COPD) are both risk factors for cardiac disease, there have been few studies of plasma homocysteine levels in COPD patients. We tested the hypothesis that total plasma homocysteine (tHCY) would be elevated in patients diagnosed with COPD compared with controls. METHODS: We studied 29 COPD outpatients and 25 asymptomatic subjects (controls) over age 55 years with measurement of forced expiratory volume in one second (FEV1), forced vital capacity (FVC), St. Georges Respiratory Questionnaire (SGRQ) score, tHCY and serum C-reactive protein (sCRP). RESULTS: There was no difference between controls vs. COPD patients in mean age or gender but mean (SD) FEV1 was 2.25 (0.77) vs. 1.43 (0.60) L; FEV1 per cent predicted 76.1 (17.2) vs. 49.1 (16.3) p < 0.001 in both cases. Median (IQR) tHCY was 8.22 (6.63, 9.55) in controls vs. 10.96 (7.56, 13.60) micromol/l for COPD, p = 0.006 and sCRP 0.89 (0.47, 2.55) vs. 2.05 (0.86, 6.19) mg/l, p = 0.023. tHCY(log) was also higher in (r, p) smokers (0.448, 0.001), patients with low FEV1 per cent (-0.397, 0.003), males (0.475, < 0.001), but high SGRQ Total score (0.289, 0.034), and high sCRP (0.316, 0.038). tHCY(log) was independently related to (regression coefficient, p) sCRP(log) (0.087, 0.024), male gender (0.345, < 0.001) and presence of COPD (0.194, 0.031). Median (IQR) tHCY GOLD Stage I and II 8.05 (7.28, 11.04), GOLD Stage III and IV: 11.83 (9.30, 18.30); p = 0.023. CONCLUSIONS: Plasma homocysteine is significantly elevated in COPD patients relative to age and sex-matched controls and is related to serum CRP and COPD severity.

Plasma homocysteine is elevated in COPD patients and is related to COPD severity.

BACKGROUND: Although recent studies have found that total plasma homocysteine (tHCY) and chronic obstructive pulmonary disease (COPD) are both risk factors for cardiac disease, there have been few studies of plasma homocysteine levels in COPD patients. We tested the hypothesis that total plasma homocysteine (tHCY) would be elevated in patients diagnosed with COPD compared with controls. METHODS: We studied 29 COPD outpatients and 25 asymptomatic subjects (controls) over age 55 years with measurement of forced expiratory volume in one second (FEV1), forced vital capacity (FVC), St. Georges Respiratory Questionnaire (SGRQ) score, tHCY and serum C-reactive protein (sCRP). RESULTS: There was no difference between controls vs. COPD patients in mean age or gender but mean (SD) FEV1 was 2.25 (0.77) vs. 1.43 (0.60) L; FEV1% predicted 76.1 (17.2) vs. 49.1 (16.3) p < 0.001 in both cases. Median (IQR) tHCY was 8.22 (6.63, 9.55) in controls vs. 10.96 (7.56, 13.60) micromol/l for COPD, p = 0.006 and sCRP 0.89 (0.47, 2.55) vs. 2.05 (0.86, 6.19) mg/l, p = 0.023. tHCY(log) was also higher in (r, p) smokers (0.448, 0.001), patients with low FEV1% (-0.397, 0.003), males (0.475, < 0.001), but high SGRQ Total score (0.289, 0.034), and high sCRP (0.316, 0.038). tHCY(log) was independently related to (regression coefficient, p) sCRP(log) (0.087, 0.024), male gender (0.345, < 0.001) and presence of COPD (0.194, 0.031). Median (IQR) tHCY GOLD Stage I and II 8.05 (7.28, 11.04), GOLD Stage III and IV: 11.83 (9.30, 18.30); p = 0.023. CONCLUSIONS: Plasma homocysteine is significantly elevated in COPD patients relative to age and sex-matched controls and is related to serum CRP and COPD severity.