Straight-to-test for the two-week-wait colorectal cancer pathway under the updated NICE guidelines reduces time to cancer diagnosis and treatment.

INTRODUCTION: The 2015 National Institute for Health and Care Excellence guidelines widened the referral criteria for the two-week-wait pathway for suspected lower gastrointestinal cancer. We implemented a straight-to-test protocol to accommodate the anticipated increase in referrals. We evaluated the impact of these changes for relevant pathway metrics and clinical outcomes using a retrospective cohort study with historic controls. MATERIALS AND METHODS: We analysed data from all patients referred to a teaching hospital via the two-week-wait pathway for suspected lower gastrointestinal cancer under the previous guidelines between 1 March and 31 August 2015 compared with the same period in 2016, when the updated guidelines and straight-to-test protocol had been implemented. RESULTS: In the 2015 cohort, there were 64 cancer diagnoses from 664 referrals (9.6% pick-up) compared with 58 cancer diagnoses from 954 referrals in the 2016 cohort (6.1% pick-up). Our straight-to-test protocol reduced the median time to cancer diagnosis by 12.5 days (P < 0.001) and reduced the median time to cancer treatment by 7.5 days (P < 0.05) An increased proportion of non-colorectal cancers were diagnosed in 2016 compared with 2015, (37.9% vs 17.2%, P < 0.05) and more adenomas were removed in 2016 compared with 2015 (377 vs 193). DISCUSSION AND CONCLUSION: Our straight-to-test protocol has resulted in a reduction in times to cancer diagnosis and cancer treatment, despite an increase in the number of referrals. The new referral criteria have considerable resource implications, but their implementation did not result in an increase in the total number of cancers diagnosed.

Investigating nystagmus in patients with traumatic brain injury: A systematic review (1996 - 2016).

BACKGROUND: Traumatic brain injury (TBI) is a health and socioeconomic concern worldwide. In patients with TBI, post-traumatic balance problems are often the result of damage to the vestibular system. Nystagmus is common in these patients, and can provide insight into the damage that has resulted from the trauma. OBJECTIVE: To present a systematic overview of published literature regarding nystagmus in patients with TBI. METHODS: Nine databases and platforms were searched during October 2016 for articles published between 1996 and 2016. Studies of any research design and published in English that focused on nystagmus in patients with TBI were considered for inclusion. A total of 110 articles were screened once duplicates had been removed, and 29 full-text articles were assessed. Eleven articles were included in the quality appraisal phase (using the McMaster tool), after which 10 articles were included in this review. RESULTS: This review describes nystagmus in 713 patients, and all articles reviewed described the type of assessment method that was used. However, the results lacked comprehensive data regarding the assessment, measurement and description of nystagmus in TBI patients, or the possible link and relationship between nystagmus and TBI. CONCLUSIONS: This systematic review indicated that: (i) there is a growing body of evidence that benign paroxysmal positional vertigo should be considered during the medical examination of all patients suffering from head trauma; (ii) all patients with TBI should undergo visual (eye movement) and vestibular examination; and (iii) future studies should include quantitative measurements of eye movements and nystagmus.

Non-invasive ventilation in children with upper airway obstruction.

OBJECTIVE: The aim of this paper is to highlight our experience with the use of non-invasive positive pressure ventilation (NIPPV) in children, neonates and pre-term infants with upper airway obstruction. METHODS: This was a retrospective review of our recent experience in using NIPPV for the management of upper airway obstruction in paediatric patients. RESULTS: NIPPV was successful in preventing tracheostomy in patients with significant laryngo-tracheomalacia as well as being used to optimise the timing of surgery in subglottic stenosis. Furthermore, it proved beneficial in stabilising the airway after aryepiglottoplasty and also had a role in the management of obstructive sleep apnoea. CONCLUSION: The use of NIPPV in children with upper airway obstruction can be a safe and effective alternative to invasive mechanical ventilation. NIPPV can potentially be beneficial in avoiding prolonged invasive ventilation, avoiding tracheostomy, stabilizing the airway after extubation or decannulation, and management of obstructive sleep apnoea.

Surgical experience obtained by urology registrars : changes in the volume and spectrum of operative procedures: 1975 - 2002

Objective: To analyze changes in the operative experience of Urology registrars at Tygerberg Hospital; an academic training hospital attached to the University of Stellenbosch; South Africa. Materials and Methods: Computerized analysis of 32;703 operating room cases (60;096 procedures) performed or assisted by 30 registrars in the period January 1975 to December 2002. Results: The average total number of procedures/registrar decreased by 32(from 1752 to 1163) for those who started training in the period 1990-99 compared with 1975-90 (p=0.0005); largely due to a 35reduction in bed numbers and theatre time resulting from budgetary restrictions. Comparison of the period 1994-2002 with 1976-84 showed a 4-fold increase in percutaneous nephrolithotomy; radical prostatectomy and inguinal herniotomy; with a moderate (50) increase in bladder rupture repair (54); circumcision (89); orchidopexy (105); insertion of peritoneal dialysis catheter (274); laparotomy (54) and surgical debridement (215). There was a 50decrease in nephrectomy (57); renal exploration for trauma (75); open kidney stone surgery (87); pyeloplasty (44); reimplantation of the ureter (60); ureterolithotomy (66); suprapubic cysto-tomy (71); transurethral resection of the prostate (54); open prostatectomy (90); urethral dilatation (78); internal urethrotomy (54); urethroplasty (72); varicocelectomy (62); and creation of arteriovenous fistula for dialysis (58). Conclusions: There have been substantial changes in the spectrum of surgical procedures performed or assisted by Urology registrars in the period 1975 to 2002. The significant decrease in the total number of procedures per registrar in the past decade is a reason for concern; although it remains unknown what the minimum number of any given urological procedure should be in order to ensure adequate operative training

Organ donation: attitude and knowledge of nurses in South Africa.

Various factors influence the process of organ donation. As a result, there is a shortage of organs for transplant. Poor communication and cooperation between transplant coordinators and intensive care nursing staff can lead to the non-referral of potential organ donors, which is detrimental to the process. The purpose of this research was to ascertain the attitude and knowledge of the transplant coordinators and intensive care nursing staff that work in intensive care units during organ donation. Contextual descriptive research was carried out by compiling literature-based questionnaires, one each for the transplant coordinators and intensive care nursing staff, and then analysing responses. The indications are that problem areas exist between the role players in the organ transplant process. Guidelines were drawn up for the improvement of communication and cooperation between them in order to promote organ donation.

Early diagnosis of prostate cancer in the Western Cape.

BACKGROUND: Early stage prostate cancer does not cause symptoms, and even metastatic disease may exist for years without causing symptoms or signs. Whereas early stage prostate cancer can be cured with radical prostatectomy or radiotherapy, the prognosis of patients with locally advanced or metastatic cancer is significantly poorer. OBJECTIVES: In view of the high incidence of advanced and therefore incurable prostate cancer seen at the oncology clinic of the Department of Urology, Tygerberg Hospital, we started a prostate clinic with the aim of detecting early stage prostate cancer which is potentially curable. A secondary objective was to investigate the question whether there is a higher incidence of prostate cancer among black African men. PATIENTS AND METHODS: Men aged 50-70 years were invited by means of media communications (newspaper and radio) to attend our prostate clinic for a free physical examination, including a digital rectal examination (DRE) and serum prostate specific antigen (PSA) assay. If the DRE was clinically suspicious of malignancy and/or the serum PSA was > 4 ng/ml, the patient was appropriately counselled and referred for transrectal ultrasound (TRUS)-guided sextant prostate biopsy. RESULTS: In the period June 1997-September 1999 a total of 1,056 men attended the prostate clinic. Biopsies were indicated in 160 cases, and were obtained in 114 (71.3%, i.e. 10.8% of the entire cohort). Prostate cancer was detected on first biopsy in 3.5% of the entire group of men (in 35.9% of those with a clinically abnormal DRE, in 41.3% of those with a serum PSA > 4 ng/ml and in 88.6% of those with an abnormal DRE and serum PSA > 4 ng/ml. In the 37 men with prostate cancer, the clinical tumour stage was T1-2 in 83.8% and T3-4 in 16.2%. In the group of patients with clinical stage T1-2 tumours, the treatment was watchful waiting in 62.5% of cases, radiotherapy in 20.8% and radical prostatectomy in 16.7%. Analysis of the data according to race showed that in the group of 47 black men there was a higher percentage of clinically abnormal DRE, PSA > 4.0 ng/ml and biopsies showing malignancy, and a higher overall prostate cancer detection rate (8.5%). CONCLUSIONS: Our prostate cancer detection rate of 3.5% is slightly lower than that reported in larger studies (4.7%), which may be due to the fact that prostate biopsy was performed in only 71% of those who had an indication for biopsy. In the men diagnosed with clinically localised prostate cancer, potentially curative treatment was given in only 37.5% of cases. This compares unfavourably with the historical cohort of men seen at our oncology clinic, where 53% received potentially curative treatment, and a large European study where potentially curative treatment was given in 89% of cases. Our finding that black men had a higher percentage of clinically abnormal DRE, PSA > 4.0 ng/ml and biopsies showing malignancy and a higher overall detection rate of prostate cancer should be interpreted with caution, since black men comprised only 4.5% of our overall study cohort.

Serum prostate-specific antigen as surrogate for the histological diagnosis of prostate cancer.

INTRODUCTION: To determine whether there is a cut-off value of serum prostate-specific antigen (PSA) which can be used confidently to make the diagnosis of prostate cancer, thereby obviating the need for biopsy. PATIENTS AND METHODS: During the period October 1991 to March 1998 the Department of Chemical Pathology at Tygerberg Hospital performed a total of 6,733 serum PSA assays on 3,960 patients. The histopathological and clinical diagnoses of these patients were obtained from records in the departments of Anatomical Pathology, Urological Oncology and Radiation Oncology. The serum PSA levels were correlated with the histopathology reports, using different PSA cut-off values ranging from 5 to 500 ng/ml, to calculate the sensitivity, specificity, and positive and negative predictive values of each cut-off value of PSA in predicting the presence of prostate cancer. RESULTS: In total, 3,837 (57%) of the 6,733 serum PSA assays were < or = 4 ng/ml, 1,045 (15.5%) of the assays were > or = 50 ng/ml, and 798 (11.9%) were > or = 100 ng/ml. Of the total of 3,960 individual patients, 531 (13.4%) had a serum PSA > or = 50 ng/ml and 423 (10.7%) had a PSA > or = 100 ng/ml. A serum PSA of > or = 30 ng/ml had a positive predictive value (PPV) of 90% at a specificity of 87% and sensitivity of 78%, while a PSA > or = 60 ng/ml had a PPV of 98% at a specificity of 98% and sensitivity of 65% for the presence of prostate cancer. The PPV reached 99% at a PSA > or = 100 ng/ml and 100% at a PSA > or = 500 ng/ml, with a specificity of 99% and 100%, but sensitivity of only 53% and 19%, respectively. CONCLUSIONS: A serum PSA > or = 60 ng/ml has a PPV of 98% for the presence of adenocarcinoma of the prostate, and may be used as a surrogate for histological diagnosis where facilities for obtaining prostatic biopsies are not readily available, thus decreasing costs and patient morbidity.

The development of a microcomputer system for poisons information retrieval.

The Poisons Information Centre at the Red Cross War Memorial Children's Hospital in Cape Town makes use of a microcomputer for information retrieval. An outline is given of the data base design and the manner in which data were collected and collated. User operation of the system is described and its effect on the efficiency of the service noted.