Three months in a high-volume tertiary orthopaedic trauma unit: What is a registrar worth?

BACKGROUND: South Africa has a high burden of traumatic injuries that is predominantly managed in the public healthcare system, despite the relative disparity in human resources between the public and private sectors. Because of budget and theatre time constraints, the trauma waiting list often exceeds 50 - 60 patients who need urgent and emergent surgery in high-volume orthopaedic trauma centres. This situation is exacerbated by other surgical disciplines using orthopaedic theatre time for life-threatening injuries because of lack of own theatre availability. One of the proposed solutions to this problem is outsourcing of some of the cases to private medical facilities. OBJECTIVES: To establish the volume of work done by an orthopaedic registrar during a 3-month trauma rotation, and to calculate the implant and theatre costs, as well as compare the salary of a registrar with the theoretical private surgeon fees for procedures performed by the registrar in the 3-month period. METHODS: In a retrospective study, the surgical logbook of a single registrar during a 3-month rotation, from 14 January to 14 April 2019, was reviewed. Surgeon fees were calculated for these procedures, according to current medical aid rates, without additional modifier codes being added. RESULTS: During the 3-month study period, a total of 157 surgical procedures was performed, ranging from total hip arthroplasty to debridement of septic hands. Surgeon fees amounted to ZAR186 565.10 per month ‒ double the gross salary of a registrar. Total implant costs amounted to ZAR1 272 667. Theatre costs were ZAR1 301 976 for the 3-month period. CONCLUSIONS: Although this analysis was conducted over a short period, it highlights the significant amount of trauma work done by a single individual at a high-volume tertiary orthopaedic trauma unit. With increasing budget constraints, pressure on theatre time and a growing population, cost-effective expansion of resources is needed. From this study, it appears that increasing capacity in the state sector could be cheaper than private outsourcing, although a more in-depth analysis needs to be conducted.

A prospective observational study of preoperative natriuretic peptide testing in adult non-cardiac surgical patients in hospitals in Western Cape Province, South Africa.

BACKGROUND: International guidelines recommend risk stratification to identify high-risk non-cardiac surgical patients. It is also recommended that all patients aged ≥45 years with significant cardiovascular disease should have preoperative natriuretic peptide (NP) testing. Abnormal preoperative B-type NPs have a strong association with postoperative cardiac complications. In South African hospitals, it is not known how many patients with significant cardiovascular disease scheduled for intermediate- to high-risk surgery will have raised NPs. OBJECTIVES: To determine the prevalence of abnormal (raised) NPs in non-cardiac surgical patients with cardiac clinical risk factors. A secondary objective was to develop a model to identify surgical patients who may benefit from preoperative NP screening. METHODS: The inclusion criteria were patients aged ≥45 years presenting for elective, non-obstetric, intermediate- to high-risk non-cardiac surgery with at least one of the following cardiovascular risk factors: a history of ischaemic heart disease or peripheral vascular disease (coronary equivalent); a history of stroke or transient ischaemic attack; a history of congestive cardiac failure; diabetes mellitus currently on an oral hypoglycaemic agent or insulin; and serum creatinine level >175 µmol/L (>2.0 mg/dL). Blood samples for N-terminal-prohormone B-type NP (NT-proBNP) were collected before induction of anaesthesia. The preoperative prognostic threshold for abnormal (raised) NT-proBNP was ≥300 pg/mL. A generalised linear mixed model was used to determine the association between the risk factors and an abnormal NT-proBNP level. RESULTS: Of 172 patients, 63 (37%) had an elevated preoperative NT-proBNP level. The comorbidities independently associated with elevated preoperative NT-proBNP were coronary artery disease or peripheral vascular disease, congestive cardiac failure, and a creatinine level >175 µmol/L CONCLUSIONS: We strongly recommend that non-cardiac surgical patients aged ≥45 years undergoing intermediate- or high-risk noncardiac surgery with a history of coronary artery disease/peripheral vascular disease, congestive cardiac failure or elevated creatinine have preoperative NP testing as part of risk stratification.

Pregnancy outcome in patients with pregestational and gestational diabetes attending Groote Schuur Hospital, Cape Town, South Africa.

BACKGROUND: The burden of diabetes mellitus (DM) has increased dramatically worldwide. The association between poorly controlled DM and poor pregnancy outcomes has been well described. OBJECTIVES: To describe the pregnancy outcomes of patients with pregestational and gestational DM attending Groote Schuur Hospital, Cape Town, South Africa. METHODS: A retrospective audit was undertaken of all women with pregestational and gestational DM (GDM) who attended Groote Schuur Hospital obstetric care from 1 September 2010 to 31 August 2011. Information routinely collected at booking and during the rest of pregnancy was entered onto a data abstraction form. Patients diagnosed with GDM were further subdivided into two groups, GDM and impaired glucose tolerance (IGT), depending on the oral glucose tolerance test results. RESULTS: A total of 725 diabetic pregnancies were managed: 35 women had type 1 DM (T1DM), 194 had type 2 DM (T2DM), 192 had GDM and 304 had IGT. The median glycated haemoglobin (HbA1c) value at booking was highest for T1DM, followed by T2DM and lastly GDM. Overall, 10.7% of women had pre-existing hypertension and 9.8% developed pre-eclampsia (PET). The preterm delivery rate (before 38 weeks) was 68.8% for women with T1DM, 38.7% for those with T2DM, 34.9% for those with GDM and 22.4% for those with IGT. The caesarean section rate exceeded 50% in all groups. The overall perinatal mortality rate was 2.5% (25/1 000 births) for the study population, with T1DM and T2DM contributing most deaths (6.4% and 4.2%). The overall rate of congenital malformations was 2.4% (n=18 cases), but the rate was 5.7% for patients with T1DM and 4.6% for those with T2DM. CONCLUSION: The audit demonstrated outcomes similar to those in the developed world, with major congenital malformations, unexplained stillbirths and PET accounting for the majority of perinatal deaths. Stricter control with the aim of achieving lower or normal HbA1c levels before conception may be the only intervention that could bring about change.

Primary health care nurses implement and evaluate a community outreach approach to health care in the South African agricultural sector.

BACKGROUND: Early detection and effective case management of tuberculosis (TB) among a high-risk group of materially poor farm workers in an area of the Cape Winelands, South Africa, presents special challenges to the health community, where resource constraints lead to service reduction. In order to address this problem, local nurses established a collaborative partnership between permanent farm workers and their families, their employers, selected non-governmental organizations and the public health sector. In consultation with stakeholders, they developed an intervention primarily focusing on having peer selected trained lay health workers (LHWs) on farms, mentored and managed by nurses. PURPOSE: To describe the complex process of implementation and evaluation of the LHW project, and provide a summary of a number of discrete studies evaluating the effectiveness, cost implications, and the perceptions and experiences of key stakeholders of the intervention. METHODS: Quantitative and qualitative research methods conducted within the context of a pragmatic unblinded community cluster randomized control trial were used. Emphasis was placed on an iterative participatory interaction between the researchers and key stakeholders. RESULTS: The intervention contributed to significantly better successful treatment completion rates among adult new smear-positive TB cases. The process implemented proved cost-effective and was pivotal in initiating a community-based social development programme. CONCLUSIONS: The use of peer-selected LHWs within a wider programme of integrated care designed to merge technical biomedical approaches to disease management with more holistic social development activities, appears essential to meet the complex health needs in conjunction with public health of the rural poor.

Assessment of point and non-point pollution associated with the power generation sector in South Africa.

Access to water and water availability remains a key factor in ensuring the sustainability of development in Southern Africa. The need for guidelines to improve management of this valuable resource, and to regulate pollutant discharge, is therefore of national interest. A new and growing threat to our natural water resources is non-point source (NPS) pollution. The important distinction between point pollution and NPS pollution is that the latter is difficult to identify and the entry point of contamination to resources is diffuse and not limited to a single location. NPS pollution associated with power generation includes, but is not limited to, atmospheric deposition resulting from emissions (air and water), leachate from coal storage piles and runoff from impervious areas which are covered with dust fallout from coal and ash handling operations. Emissions of primary concern are sulfur, nitrogen and mercury.

Ear to the ground: listening to farm dwellers talk about the experience of becoming lay health workers.

Ranking ninth in the world for its contribution to the global burden of tuberculosis (TB), South Africa continues to battle the disease. Within the framework of the World Health Organisation's Directly Observed Treatment Short Course (DOTS) strategy, attempts have been made to utilize lay health workers (LHWs) as TB treatment supporters. Previous research has highlighted the benefits and difficulties associated with such an approach, but little attention has been paid to the perceptions of LHWs themselves. A randomised control trial of a LHW intervention in TB treatment in the farming areas of the Western Cape, South Africa has shown a 19% improvement in TB treatment outcomes. This paper describes the experiences of those LHWs drawing on data collected through focus groups with incumbents. The data has shown that once trained, respondents were engaged in a wide range of activities, well beyond simple health care. In the majority LHWs were women. Becoming LHWs opened up their worlds, creating opportunities they would otherwise not have had. But while doing so, it also added extra responsibilities and stresses, which were not easy to manage. Respondents sustained themselves through support from each other, the intervention team, their employers and contact with the public health system. The question this study raises is given the obvious need for LHWs, how can they be motivated to participate in primary health care in such a way that maximises their access to resources while minimising their experience of the role as burdensome?

Retrospective determination of HIV-1 status by a PCR method on paraffin wax embedded sections.

AIM: To develop a simple but reliable polymerase chain reaction (PCR) method to determine the HIV-1 status of patients on formalin fixed, paraffin wax embedded lymph node tissue. METHODS: Fifty lymph node specimens, 20 from HIV-1 seropositive and 30 from HIV-1 seronegative patients, were analysed. Lymph nodes with a variety of disease conditions were included in the study. Tissue sections were treated with a DNA extraction buffer containing proteinase K and the crude cell lysate was used in PCR analysis. Nested primers were used to amplify HIV-1 DNA sequences coding for gag, pol and env proteins. PCR products were demonstrated by polyacrylamide gel electrophoresis. Results were then compared with HIV-1 serology of the patients from whom the tissue was obtained. RESULTS: The PCR method yielded a specificity of 100%, a sensitivity of 95%, a positive predictive value of 100%, and a negative predictive value of 97% when compared with HIV-1 serology. The kappa statistic (0.958) showed an excellent agreement between the PCR method and serology. Furthermore, HIV-1 DNA was demonstrated in lymph node tissue from a serologically unconfirmed acquired immunodeficiency syndrome case necropsied in 1982. CONCLUSION: This PCR method is a simple and reliable means of retrospectively determining the HIV-1 status of patients using formalin fixed, paraffin wax embedded lymph node tissue.

Influence of freezing method on thaw drip and protein loss of low-voltage electrically stimulated and non-stimulated sheeps' muscle.

South African Mutton Merino wethers (n = 32) were slaughtered, yielding carcasses with a mean weight of 22·18 ± 2·11 kg. Sixteen carcasses were electrically stimulated (ES) (21 V, 60 Hz, 120 s) immediately and all carcasses were chilled at room temperature (16°C) for 3 h and then overnight at 4°C, 95% RH. Both left and right Mm. longissimus lumborum et thoracis were excised and cut into six portions (77 g ± 7·8 g), each placed separately in a polyethylene bag and randomly allocated to five freezing treatments. These were: (1) cryogenic, -65°C; (2) cryogenic, -90°C; (3) walk-in-freezer, -21°C; (4) blast freezer, -21°C; (5) domestic freezer, -25°C. The respective freezing rates were 4·4, 6·4, 0·55, 0·35 and 0·51 cm h(-1) to -2·2°C at core depth of 1 cm below the surface. Samples were frozen to core temperatures of -20°C, removed and placed in a storage freezer (-20°C) for 48 h and 2·5 months. Samples were then suspended in perforated bags in a chiller (4°C) to thaw, and drip was collected in outer bags over the periods 0-24, 24-48, 48-72 and 72-96 h and expressed as g (100 g)(-1). Freezing methods had significant (P < 0·01) influences on drip loss in both ES and NES samples. Following storage for 48 h post-freezing at -20°C, total drip (g (100 g)(-1)) over 96 h of both ES and NES samples for the five freezing treatments were respectively: (1) 7·61 and 4·61; (2) 7·35 and 3·29; (3) 9·44 and 4·68; (4) 9·07 and 5·43; (5) 10·58 and 5·15. Following storage for 2·5 months, the total ES and NES drip were respectively, (1) 11·25 and 9·38; (2) 10·36 and 9·15; (3) 13·72 and 12·65; (4) 13·70 and 12·26; (5) 11·92 and 11·29. Total protein in the drip did not differ between freezing treatments. Differences between ES and NES samples did occur in the 48 h storage group. It is concluded that cryogenic freezing results in less thaw drip than the vapour compression systems. This advantage of cryogenic freezing disappears if meat is stored for long periods at -20°C. Electrical stimulation increases the drip loss in samples frozen for 48 h, but the differences are not significant after 2·5 months frozen storage. Protein losses parallel the drip.