Doctoral Degrees (Surgery)
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Item Surgical site infections at a quaternary South African Hospital: epidemiology and impact on healthcare resources.(2021) Naidoo, Natasha.; Moodley, Yoshan.; Madiba, Thandinkosi Enos.ABSTRACT Background: Studies focused on the epidemiology of surgical site infection (SSI) and its impact on healthcare resource utilisation in resource-constrained African settings are rare. This information is important for two reasons: 1) It facilitates the development of setting-specific risk stratification tools for identifying patients who might benefit fro m additional preventative interventions, and 2) It can guide public health specialists’ decisions around resource and budget allocations to surgical units and the degree to which this can be optimised through SSI prevention. The research comprising this PhD thesis sought to address these gaps in the knowledge. Methodology: This research is comprised of five stand-alone analyses involving surgical patient dataobtained from a South African quaternary hospital. The data was collected through patient medical chart review, as well as accessing the hospital’s and service laboratory’s administrative systems. Study designs used in this research include cohort, trend analysis, geospatial analysis, case-control, and prognostic study designs. Results: The incidence of SSI in high-risk laparotomy patients was 16.6%. Risk factors for SSI in this group included infectious indication for surgery, preoperative non-steroidal anti-inflammatory use, preoperative hypoalbuminemia, Bogota bag use, and perioperative blood transfusion. A 10-year trend analysis of all surgeries performed at the hospital found no change in admissions for post-discharge SSI. Mortality in elderly SSI admissions declined. The geospatial analysis found that most postdischarge SSI admissions originated from urban areas. Analysis of the laparotomy dataset showed that SSI resulted in an additional 1.06 days of hospitalisation (additional cost of ZAR8900/ $1180), but only in patients who already had short hospital stays. While preoperative hypoalbuminemia demonstrates a similar prognostic performance to the more complex SENIC/NNIS risk stratification methods (Cstatistic 0.677 versus 0.652/0.634), preoperative serum sodium is unlikely to have the same prognostic utility. Conclusions: SSI is common among South African patients undergoing high-risk surgery. A settingspecific, multifactorial risk stratification tool might be of benefit in this population. Inpatient and postdischarge SSIs contribute to unnecessary healthcare utilisation a expenditure in this resource constrained setting. There is also great potential for certain routine preoperative laboratory tests to be used as simple, cost-effective SSI risk stratification tools in African settings. Isizinda: Ucwaningo lugxile ekwakhiwenisimo sendawo ehlinziwe yokutheleleka (SSI) nomthelela wakho wokusetshenziswa komthombo wokunakekela ngokokwelapha ezizindeni esivaleleke e-Afrika nokungavamile. Lolu lwazi lubalulekile ngezizathu ezimbili: 1) Kusebenzisa intuthuko yamathuluzi okuchaza ingcuphe egxile esizindeni esiqondile sokuhlonza iziguli ezingazuza emizamweni eyongeziwe yokuvimbela, nokuthi 2) ingahola izinqumo zongoti bezempilo yomphakathi ngomthombo nokwabiwa kwezimali kuya ezikhungweni zokuhlinzwa kanye nezinga lapho enganyuswa khona ngokuvimbela nge-SSI. Ucwaningo okusekelwe kuyo le PhD kuhloswe ngalo ukubhekana nalezi zikhala olwazini. Indlelakwenza: Lolu cwaningo lunohlaziyo oluyisihlanu oluzimele olufaka imininingo yesigulo esihlinziwe olutholakele esibhedlela esisezingeni lesine. Imininingo iqoqwe ngokubuyekeza ishathi lokwelapha lesiguli, kanjalo nokufinyelela ezinhlelweni zesibhedlela kanjalo nezinsiza zaselabhorethri. Uhlelosakhiwo locwaningo olusetshenziswe kulolu cwaningo lufaka ikhohothi, ukuhlaziya okwenziwa kuleso sikhathi, ukuhlaziya umumomhlaba, ukulawula ucwaningonto, nohlelosakhiwo locwaningo oluyinhlonzasifo. Imiphumela: Ukwenzeka kwe-SSI ezigulini ezisengcupheni yelapharathomi ingama-16.6%. Izizathu zengcuphe ze-SSI kuleli qembu elifakwe izinkomba zokutheleleka, isidambisikuvuvukala okunganasteroydi angesikhathi sokuhlinzwa. Ukuhlaziya okwenzeka eminyakeni eyi-10 kokuhlinza okwenziwa esibhedlela akutholanga shintsho ekungenisweni esibhedlela emva kokukhishwa. Ukufa kwabadala ekufakweni esibhedlela nge-SSI kusukela ezindaweni zasemadolobheni. Ukuhlaziya kwedathasethi yelapharothomi ikhombise ukuthi i-SSI inomphumela wezinsuku ezi-1.06 ezongeziwe zokulaliswa esibhedlela (izindleko ezongeziwe zama-ZAR8900/$1180), kodwa yiziguli esezike zahlala kafushane esibhedlela. Ngesikhathi i-hypoalbuminemia ngaphambi kokuhlinzwa ikhombisa ukusebenza kokuhlonzwa kwesifo ezindlelenikwenza zokuchaza ingcuphe eyinkimbi ye-SENIC/NNIS (istathistikhi i-C0677 uma siqhathaniswa ne-0.652/0.634), isiramu yesodiyamu yangaphambi kokuhlinzwa okungenzeka ibe nenhlonzasifo efanayo. Iziphetho: I-SSI ivamile ezigulini zaseNingizimu Afrika ezisezingcupheni ezinkulu. Isizinda esiqondile, ithuluzi lokucacisa ingcuphe enezizathu eziningi zokuzuza eqoqwenibantu. Iziguli ezelashelwa esibhedlela nama-SSI emva kokukhishwa esibhedlela kufaka ukusetshenziswa kokunakekelwa ngokwezempilo nokusetshenziswa kulesi sizinda esincishelwe yimithombo. Kuphinde kube nokukwazi okusezingeni ngokwezivivinyo ezilungiswe ngaphambi kwesikhathi elabhorethri ukuba zisetshenziswe, njengamathuluzi alula, nashibhile okuchaza ingcuphe yama-SSI ezizindeni zase-Afrika.Item Revisiting the critical role of minimal invasive surgery (laparoscopy) in the management of trauma patients at a dedicated trauma unit at the Dr George Mukhari Academic Hospital, Pretoria, South Africa.(2018) Modise, Zacharia Koto.; Aldous, Colleen Michelle.; Madiba, Thandinkosi Enos.Background South Africa, as a low to middle income country (LMIC), is plagued by a quadruple burden on health-care, namely trauma; the human immuno-deficiency virus (HIV) with concomitant tuberculosis infection; maternal death; non-communicable diseases such as diabetes and hypertension. The impact of trauma on an already over-burdened public sector has been profound. Improving surgical outcomes is a global health priority according to the Lancet commission. One of the World Health Organization (WHO) mandates is to improve surgical care across the globe. In addressing this question, the WHO has suggested what is referred to as a list of Bellwether procedures. This is a list of important and common procedures that account for major mortalities in developing countries. The main goal of the list is to build proficiency and dexterity in these procedures so as to reduce mortality. This includes trauma laparotomy and other surgical procedures in emergencies. The traditional approach to managing trauma patients is premised on the well-established Advanced Trauma Life Support (ATLS) principles. This well documented approach has been shown to significantly improve health outcomes of trauma victims. Closely connected to this treatment pathway are surgical interventions that have also been shown to improve the health outcomes of trauma patients. At the heart of surgical intervention for abdominal trauma, is the tried and tested laparotomy. When one looks at this, from a health economics stand-point and a cost-effective platform, laparotomy has been shown to be cost-effective and life-saving. That said, laparotomy is not without major adverse outcomes; there has been significant morbidity and, in some cases, even mortality resulting from laparotomy reported by some investigators. Laparoscopy started in earnest during the 1980s with the first laparoscopic cholecystectomy described by Muhë from Germany and later popularised by Phillip Mourret of France. This was the start of a major surgical revolution that engulfed the whole surgical community. Laparoscopic cholecystectomy became the pivot around which this revolution evolved and gathered momentum. Indeed, there has been a sea-change of surgical procedures carried out laparoscopically since its evolution and rapid development of laparoscopic cholecystectomy. The benefits of laparoscopy and other minimally invasive procedures are well documented. Despite overwhelming evidence that supports the use of laparoscopy in surgery in general, there has been reluctance in the uptake of this procedure in trauma for a number of reasons; chief of which is the fear of missed injuries. This fear was fuelled by the publication by Ivatury and colleagues citing a high rate of missed small bowel injuries in trauma patients. Consequently, there was a large hiatus in the application of this technique in the management of trauma patients and, as expected, trauma has lagged behind in the uptake of laparoscopy and continues to do so today. A great deal has happened since the publication of the work by Ivatury and colleagues. The quality of laparoscopic cameras has improved significantly and more importantly, the average surgeon’s skills-set in laparoscopy has improved considerably. The rationale for my research was to look critically at our experience with laparoscopy, appraise the available data and see how this would impact on the tried and tested practice prevalent in the trauma arena, leading to a new paradigm being set in the laparoscopic management of trauma patients that are hemodynamically stable in the South African milieu. Aims The aim of this work was to critically evaluate the role and safety of laparoscopy in the management of stable trauma patients presenting at the dedicated trauma unit of the Dr George Mukhari Academic Hospital (DGMAH). Objectives We set out to investigate the role of laparoscopy in the following ways, in trauma scenarios: • laparoscopy as a diagnostic tool and how the risk of missed injuries should be addressed and minimized; • the role of laparoscopy in the management of thoraco-abdominal injuries, including right-sided injuries and also in patients with generalized peritonitis who are hemodynamically stable; • the appropriate access technique by a way of randomized controlled trial when offering these patients laparoscopy; • diagnostic accuracy of laparoscopy in trauma - how not to miss injuries; laparoscopic-assisted techniques as a strategy to address multiple injuries and therefore address gaps in skills-set and shorten the operative time of these trauma victims; • laparoscopic management of hemodynamically stable patients with blunt abdominal trauma; • the role of laparoscopy in the management of penetrating retroperitoneal injuries in hemodynamically stable patients. Methods The Trauma Unit of DGMAH has a prospectively collected database which was used to peruse the records of recruited participants for this work. Permission was sought from the Institutional Review Board of the Sefako Makgatho Health Sciences University (SMU) in accordance with the Helsinki Declaration that guides the conduct of biomedical research. Inclusion criteria were set for the various objectives of the study. We investigated the cohort of patients where laparoscopy was used within the setting of diagnosis of abdominal injuries and identified defined primary endpoints and outcomes. We also analysed the interventional strategies that were employed to achieve the desired end result. To begin with a laparoscope, the first step is safe access into the peritoneal cavity. A one-toone computer-generated randomized study was carried out comparing the traditional laparoscopic access to peritoneal cavity using Veress needle with the open Hasson technique. Unlike other studies, in this series we included patients who had had a previous laparotomy to address the question of safe abdominal access during laparoscopic procedures. We identified all major and minor complications as the primary outcome. We determined the outcomes of patients offered laparoscopic procedure in the following situations: thoraco-abdominal injuries where the primary focus was diaphragmatic injuries both on the left and right diaphragms. In this study we included patients with both peritonitis and right sided thoraco-abdominal injuries. We studied the outcomes of laparoscopy in the case of blunt trauma, penetrating retroperitoneal injuries. We also investigated the role of laparoscopy in the context of diagnosis and specifically identified factors that mitigate against missing injuries and suggested a management pathway to minimize the incidence of missed injuries. The overall primary outcome was all-cause mortality and complications. Findings Fifty (52%) patients were randomized to the closed Veress needle and 46 (48%) patients to the open Hasson technique. Six (6%) adverse events were recorded in the Veress needle arm (p=0.03). The Veress needle technique failed to establish pneumoperitoneum in three patients (6%), the port-site bleeding was observed in one (2%) and extraperitoneal insufflation in two (4%) patients. All patients with the adverse events had previous abdominal surgery. There were no adverse events in the open Hasson group. In the work on laparoscopy and how not to miss injuries, out of 250 patients managed with laparoscopy for penetrating abdominal trauma(PAT), 113(45%) underwent diagnostic laparoscopy (DL), of these 94(83%) of patients underwent stab wounds. The penetration of the peritoneal cavity or retroperitoneal cavity or peritoneal cavity was documented in 67(59%) of the patients. Organ evisceration was present in 21(19%) of patients. Multiple injuries were present in 22% of cases. The chest was most common associated injury. Two (1,8%) iatrogenic injuries were recorded. There was conversion rate of 1,7%(2/115). The mean length of hospital stay was 4 days. There were no missed injuries. Laparoscopic assisted approach (LAA)in multiple injuries is work aimed at addressing the problem of multiple injuries in laparoscopy. This work demonstrates the utility of laparoscopy in this setting. The procedure is to evaluate the effect LAA in multiple injuries. Over 2-year period 23 patients were managed with LAA and of these 13 were patients with stab wounds and 10 with gunshot wounds. Commonly performed procedure was repair of hollow viscus injury For thoracoabdominal injury, a total of 83 patients with thoracoabdomial injuries met the seletcion criteria. The injury sverity score (ISS) ranged from 8 to 24 with a median of 18. The incidence of diaphragmatic hernia was 54%. Majority (46,8%) had grade3 (2-10cm) laceration. Associated injuries encountered reqiring interventions we encountered in 28(62%). At least 93,3% of the patients wee treated exclusively with laparoscopy . the morbidity was encountrerd in 7(16%) of the patients. The commonest was cloteed hemothorax Clavian Dindo (ii)b , but only one patient required decortication.There was one procedure related mortality. In laparoscopy management of retropritoneal injuries in hemodynamically stable patients, of 284 with PAT 56 had involvement of the retroperitoneum. Stab wounds accounted accounted for 62,5% of the patients . the mean ISS score was 7,4(4-20). Amongst the the retroperitoneal injuries the colon (27%) was the most commonly injured hollow viscus followed bt the duodenum (5%). The kidney (5%) and pancrease(4%) were the commonly injured solid organs. The conversion rate was 19,6% and this was mainly due to active bleeding. Significantly more patients were with GSW had their procedures converted to open laparotomy(38% vs 9%). Therapeutic laparoscopy wa sperformed in 36% of the pateints. The were no recorded missed injuries. Five (9%) patients developed Clavien-Dindo grade 3 complications , three were managed with reoperation, one with drainage and one with endovascular technique In laparoscopy for blunt trauma, a chalenging endeavour- Thirty-five stable patients underwent laparoscopy. The mean Injury Severity score was 12 (4-38). Therapeutic laparoscopy was performed in 15 (56%) and diagnostic in 12 (44%) patients. Eight (23%) patients were converted to therapeutic laparotomy. Intraoperative bleeding, complex injuries, visualization problem and equipment failure necessitated conversion. Three (30%) patients with negative CT scan had therapeutic laparoscopy for mesenteric injuries. There were no missed injuries. The mean length of hospital stay was 11 days in both groups. This series of studies shows that laparoscopy in all the stated objectives was safe and feasible. Multiple laparoscopic interventions in the different trauma scenarios have demonstrated the safety of laparoscopy in haemodynamically stable trauma patients. Contrary to the suggestion by other investigators, that laparoscopy is contraindicated in retroperitoneal injuries, the current study in retroperitoneal trauma has shown that it was safe and accurate in this cohort of patients. Therapeutic laparoscopy was feasible in 36% of the patients and the conversion rate was 19%. Importantly there were no missed injuries or mortality when managing penetrating trauma patients with retroperitoneal injuries. Therapeutic laparoscopy was feasible in thoraco-abdominal injuries and these patients were successfully managed, including those with generalized peritonitis. The study of thoracoabdominal injuries, including those with peritonitis, also included patients with injuries to the right side of the abdomen, as well as individuals with generalized peritonitis. We were able to offer therapeutic and diagnostic laparoscopy to this cohort of patient. Conclusions In conclusion, laparoscopy is feasible and safe in hemodynamically stable trauma patients in the context of thoraco-abdominal injuries, blunt abdominal trauma, in the presence of peritonitis as well as in laparoscopic-assisted setting, both as a strategy to reduce the incidence of nonremedial laparotomies as well as a diagnostic tool.Item Upper limb sympathectomy in current surgical practice.(2002) Singh, Bhugwan.; Robbs, John Vivian.Abstract available in PDF.Item Developing a multi-faceted approach to improving and uplifting trauma care in the periphery.(2013) Clarke, Damian Luiz.; Thomson, Sandie Rutherford.Introduction Rural trauma care in South Africa is under resourced and the quality of rural trauma care appears to be uneven. This project aimed to assess the quality of rural trauma care in Sisonke Health District and to develop targeted quality improvement programmes to improve it. Methodology A strategic planning methodology consisting of a situational analysis, planning synthesis and implementation was used in the project and was integrated with a health system’s model of inputs, process and outcome to provide a structured overview of the whole process. A number of academic constructs from fields outside of health care were used to analyse the quality of care and to develop targeted quality improvement programmes. Results The table below summarises the results of this project by placing each of the published papers in this thesis into the integrated grid. The various tools that were adopted to assist with the project included error theory and quality metrics for trauma and acute surgery. These are also situated within the grid. Analysis of the inputs of rural trauma care revealed that there were major deficits in terms of the human resources available to manage the large burden of trauma seen in rural hospitals. Analysis of the process revealed deficits in the transfer process and the quality of documentation and observation of trauma patients in our system. Analysis of the outcomes revealed a high incidence of error associated with rural trauma care and poor outcomes for a number of conditions such as burns. Synthesis and Implementation involved the development of a number of strategies and a review of their efficacy. These included a surgical outreach programme, restructured morbidity and mortality meetings, error-awareness training and the use of tick-box clerking sheets. The impact of these various programmes was mixed. The surgical outreach programme was successful at delivering surgical care in the districts but less successful at transferring surgical skills to rural staff. The morbidity and mortality meetings, and the errorawareness training changed the culture of the institution and increased the understanding of the danger of error. The tick-box initiative revealed how difficult it is to change human behaviour. A number of audits have suggested that there is a general improvement in the quality of care. This has resulted in improved outcomes for the management of penetrating abdominal trauma and burns care. Conclusion Rural trauma care has many deficits and these translate into poor outcomes. Addressing these deficits is difficult and requires a multi -faceted approach. Undertaking quality improvement programmes in an ad hoc manner may be counter-productive and using a structured systematic approach may allow planners to contextualise their interventions. Currently trying to increase the inputs and resources available for rural trauma care is difficult and most of the intervention should aim at refining and improving the process of care. A number of projects have emerged from this thesis.Item The spectrum, outcomes and costs of acute appendicitis at Edendale Hospital and its related catchment areas.(2014) Kong, Victor.; Aldous, Colleen Michelle.; Clarke, Damian Luiz.Abstract available in PDF file.Item A trauma system for KwaZulu-Natal : local development for local need.(2014) Hardcastle, Timothy Craig.; Thomson, Sandie Rutherford.; Muckart, David James Jackson.Introduction: The need for Trauma Care in South Africa is without question one of the four major health issues facing the country and indeed the African continent today. First-world developed systems focus on the care of trauma from prevention to rehabilitation, yet in Africa the issue of access to even resuscitation is often the challenge faced by communities in poverty. The philosophical concepts which underpin the main thrust of the thesis are summarised as the introductory chapter. “The 11 P’s of an Afrocentric trauma system for South Africa” and “Guideline for the assessment of trauma centres for South Africa” were the result of this literature review. “Trauma care in South Africa: From humble beginnings to an afrocentric outreach” examines the history of trauma care in South Africa and the current desire to be relevant to the greater African Continent, highlighting the realities of practicing trauma care in this country. Local development is essential with regionally specific injury profiles, especially in a country like South Africa with very high trauma rates when compared to the rest of the world. Aim: This PhD submission aims to review the practical problems and the ethical issues facing trauma in South Africa. This submission examines the current burden of disease of live-injured patients entering the existing informal system in KwaZulu-Natal, both at a prehospital and in-hospital level of care. This submission also examines the current facilities and transfer processes within the government hospital sector, including specifically the utilization of the Level 1 Trauma Centre at Albert Luthuli Central Hospital. The submission aims to provide a solid provincial dataset on which to design a proposal for a practical system of trauma care across the province, and that may be potentially exportable to the rest of the country, and to Africa. Methods: This PhD proposal provides the evidence for the achievement of the stated aims through the submission of linked papers published in peer-reviewed medical journals relevant to the field of study covering an overview of the literature, examination of the ethical challenges in trauma facing South Africa, and the need for trauma systems. The current prehospital and hospital disease burden is examined and facility structure and staff skill-sets reviewed. A review of utilisation of and need for a major trauma centre is undertaken. Finally the thesis proposes an appropriate regionalised trauma system, emphasising the need for more such facilities across the province. The methods were described in the approved protocol and these are presented in the overview chapters. Results: The three papers that form the thrust of the scientific contribution of this work were all published in July 2013 in World Journal of Surgery and are as follows: 1. The Prehospital Burden of Disease due to Trauma in KwaZulu-Natal: The Need for Afrocentric Trauma Systems. 2. An Assessment of the Hospital Disease Burden and the Facilities for the In-hospital Care of Trauma in KwaZulu-Natal,South Africa. 3. Utilisation of a Level 1 Trauma Centre in KwaZulu-Natal: Appropriateness of Referral Determines Trauma Patient Access All three studies received BREC approval (BE011/010). The essential methodology, findings and conclusions derived from these three papers are outlined here: Paper 1: Methods: Using a convenience data set all Emergency Medical Service (EMS) call data for the months of March and September 2010 were reviewed for the three main EMS providers in KZN. Data were extrapolated to annual data and placed in the context of population, ambulance service, and facility. The data were then mapped for area distribution and prehospital workload relative to the entire province. Questionnaire-based assessments of knowledge and deficiencies of the current system were completed by senior officers of the provincial system as part of the analysis of the current system. Results: The total annual call burden for trauma ranges between 94,840 and 101,420, or around 11.6 trauma calls per thousand of the population per year. Almost 70 % of calls were either for interpersonal intentional violence or vehicular collisions. Only 0.25 % of calls involved aeromedical resources. Some 80 % of patients were considered to be moderately to seriously injured, yet only 41 % of the patients were transported to a suitable level of care immediately, with many going to inappropriate lower level care facilities. Many rural calls are not attended within the time norms accepted nationally. Deficiencies noted by the questionnaire survey are the general lack of a bypass mechanism and the feeling among staff that most EMS bases do not have a bypass option or feel part of a system of care, despite large numbers of staff having been recently trained in triage and Conclusions: The prehospital trauma burden in KZN is significant and consumes vital resources and gridlocks facilities. A prehospital trauma system that is financially sustainable and meets the needs of the trauma burden is proposed to enable Afrocentric emergency care planning for low and middle income regions. Paper 2: Methods: Hospital administrators in KZN were requested to submit trauma caseloads for the months of March and September 2010. Caseloads were reviewed to determine the trauma load for the province per category using two extrapolation methods to determine the predicted range of annual incidence of trauma, intentional versus non-intentional trauma ratios and population-related incidence of trauma. The results were GIS mapped to demonstrate variations across districts. Hospital data were obtained from assessments of structure, process, and personnel undertaken prior to a major sporting event. These were compared to the ideal facilities required for accreditation of trauma care facilities of the Trauma Society of South Africa and other established documents. Results: Data were obtained from 36 of the 47 public hospitals in KZN that manage acute emergency cases. The predicted annual trauma incidence in KZN ranges from 124,000 to 125,000, or 12.9 per 1,000 population. This would imply a national public hospital trauma load on the order of at least 750,000 cases per year. Most hospitals are required to treat trauma; however, within KZN many hospitals do not have adequate personnel, medical equipment, or structural integrity to be formally accredited as trauma care facilities in terms of existing criteria. Conclusions: There is a significant trauma load that consumes vital emergency center resources. Most hospitals will need extensive upgrading to provide appropriate care for trauma. An inclusive trauma system needs to be formalized and funded, especially in light of the planned National Health Insurance for South Africa. Paper 3: Methods: An audit was performed of the referral proformas used in the unit to record admission decisions and of the computerised trauma database. The audit examined referral source (scene vs. interhospital), regional distribution, and final decision regarding admission of the injured patients. The study was approved by the UKZN Ethics Committee (BE207/09 and 011/010). Results: Of the 1,212 external consults, 540 were accepted for admission while the rest were not accepted for various reasons. These included 206 cases where no bed was available, 233 did not meet admission criteria (minor injury or futile situation), and 115 were for subspecialty management of a single-system injury. Finally, 115 were initially refused pending stabilisation for transfer at a regional facility. Twenty-six percent of the cases were referrals from the scene, with an acceptance rate of 96 %. Most patients (59 %) were from the local eThekwini region. Conclusion: Major multiorgan system trauma remains a significant public health burden in KwaZulu-Natal. A Level 1 Trauma Service is used appropriately in most circumstances. However, the additional need for more hospital facilities that provide such services across the whole province to enable effective geographical coverage for those trauma patients requiring such specialised trauma care is essential. After evaluation of the submitted papers a summative chapter is provided as to how they provide a framework to design a Trauma System relevant to KZN, South Africa and potentially Africa. Overall Conclusions: In the developed world trauma systems have been shown to substantially reduce mortality and morbidity after major and moderate trauma. Few such systems and centres of excellence exist within the developing world scenario. The solutions offered by such systems may not be entirely relevant to the African scenario. A trauma system relevant to KwaZulu-Natal, South Africa and the African continent is essential to reduce the huge mortality burden in low to middle income regions, where trauma is a major source of reduced life-years. The results of the studies presented here are valuable in providing insight to the needs and potential solutions to the challenges faced in our environment. A plea is therefore made for pilot implementation at provincial level. This will involve further research into the feasibility of introduction and how such an introduction could be audited and refined for broader adoption in South Africa and the African continent.Item The histopathological characteristics of the skin in congenital idiopathic clubfoot.(2012) Rasool, Mahomed Noor.; Govender, Shunmugam.; Ramdial, Pratistadevi K.Purpose: To highlight the histopathological characteristics of the skin in congenital clubfoot and correlate the clinical findings in clubfoot with the changes in the dermal layers. Materials and methods: One hundred skin specimens, from 77 infants (6 to 12 months), were studied between 2004 and 2008. Using the Pirani scoring system, the clinical severity was recorded. The mobility of the skin and the correctability of the medial ray were assessed clinically. A skin specimen (1cm x 1mm) was taken from the medial side of the foot at surgery following failed plaster treatment. The layers were studied under light microscopy. The thickness of the dermis and the histopathological features of clubfoot skin were compared with 10 normal skin specimens. Results: The dermis of clubfoot skin showed significant fibrosis with thick bundles of collagen fibres (P = .001) on Haematoxylin and Eosin staining (H&E). The dermal thickness ranged between 1.0mm and 5.2mm in clubfoot skin, compared with controls (0.64-1.28mm). Fibrosis extended into the subcutis in a septolobular fashion in 95% of the cases. Significant atrophy of eccrine glands was seen in 98% (P = .001). Hair follicles were absent in 78%. The elastic fibres of clubfoot skin, stained with Elastic van Gieson staining (EVG), showed hypertrophy in varying degrees in all skin specimens. They were fragmented, with loss of their parallel arrangement. There was no significant inflammatory reaction in the dermis. The Pirani score was significantly increased (mean 7.8). Discussion: Fibrosis and thickening of the dermis were the most significant histopathological features of the clubfoot skin. The elastic fibres were also abnormal. There was atrophy of the skin appendages due to the fibrosis. There was a strong correlation between the Pirani score and the severity of the deformity(P 0.016). The cases with poor outcome had a higher score than those with a satisfactory outcome.Lack of a significant inflammatory reaction suggests that neither the serial manipulations of the foot, nor the repeated plaster cast changes, were responsible for the dermal fibrosis, which is probably present from birth and contributes to the deformity.Item An inter-racial study into the pattern and prevalence of atherosclerotic peripheral vascular disease in the University-based vascular surgical service in Durban.(1996) Maharaj, Rabindranath Ramsuk.; Robbs, John Vivian.This study investigates the clinical and major risk factor profiles in Whites, Indians and Blacks with atherosclerotic peripheral vascular disease at the Vascular Service in Durban; and compares them to that for coronary artery disease in the same race groups. The clinical profile for chronic peripheral vascular disease was established in a retrospective study of 2175 patients seen at the Vascular Service during 1981-1986. Atherosclerosis was confirmed in 1974 patients (92,3%) on the basis of clinical, doppler, angiographic and histological evidence. The disease predominantly affected the aorta and distal peripheral vessels. Extracranial cerebrovascular disease occurred less commonly in Blacks than in Whites and Indians. Occlusive disease was the most common pathological type in all race groups. Aneurysmal disease occurred mainly in the aorta with peripheral aneurysms being most common in Blacks. The disease manifested in Blacks at an . earlier age and more aggressively than in Whites and Indians. The risk factor profile for atherosclerotic peripheral vascular disease was established in a prospective study of 302 male patients consisting of 100 Whites, 97 Indians and 105 Blacks on the basis of historical, clinical and haematological data. The sample was randomly selected, and not strictly representative of the clinical pattern in the retrospective study. All patients were confirmed to have atherosclerosis on the basis of the previously mentioned criteria. Smoking was the single most common risk factor in all race groups. Hypertension occurred more commonly in Whites and Indians than in Blacks, while diabetes was commonest in Indians. Insulin resistance did not occur in Blacks, but was possibly present in Whites and Indians. Total cholesterol, LDL cholesterol and triglycerides were raised in Whites and Indians, but not in Blacks. HDL cholesterol was reduced in all 3 race groups. These findings suggest that contrary to the established view, atherosclerotic peripheral vascular disease is an established entity in Blacks seen at the Vascular Service in Durban without a concomitant increase in coronary and extracranial cerebrovascular disease. In Whites and Indians atherosclerosis occurred in all of the vascular beds. This could support the contention that in a socially developing society atherosclerosis affects the aorta and distal peripheral vessels before the coronary vascular bed. Since this occurs in the presence of normal levels of total cholesterol, LDL cholesterol and triglycerides, it does not support the contention that hypercholesterolaemic states are essential for atherosclerotic lesions to develop. On this basis it is postulated that with social transition there is a differential atherosclerotic involvement of the vascular beds due to a differential vascular susceptibility. Smoking is an important socio-environmental risk factor, while at the biochemical level a reduced HDL cholesterol and not a raised total cholesterol, LDL cholesterol or triglyceride could trigger the 'lipid pathway' in atherogenesis. It is further postulated that the differential vascular susceptibility does not exist in a fully developed society once lipid aberrations include a raised total cholesterol, LDL cholesterol and triglycerides. Insulin resistance/hyperinsulinaemia may play a role in the evolution of the disease within the coronary vascular bed.Item An anatomical exploration into the variable patterns of the venous vasculature of the human kidney.(1993) Satyapal, Kapil Sewsaran.; Haffejee, A. A.; Robbs, John Vivian.In clinical anatomy, the renal venous system is relatively understudied compared to the arterial system. This investigation aims to clarify and update the variable patterns of the renal venous vasculature using cadaveric human (adult and foetal) and Chacma baboon (Papio ursinus) kidneys and to reflect on its clinical application, particularly in surgery and radiology. The study employed gross anatomical dissection and detailed morphometric and statistical analyses on resin cast and plastinated kidneys harvested from 211 adult, 20 foetal and 10 baboon cadavers. Radiological techniques were used to study intrarenal flow, renal veins and collateral pathways and renal vein valves. The gross anatomical description of the renal veins and its relations were confirmed and updated. Additional renal veins were observed much more frequently on the right side (31 %) than previously documented (15.4%). A practical classification system for the renal veins based on the number of primary tributaries, additional renal veins and anomalies is proposed. Detailed morphometric analyses of the various parameters of the renal veins corroborated and augmented previous anatomical studies. Contrary to standard anatomical textbooks, it was noted that the left renal vein is 2.5 times the length of its counterpart and that there are variable levels of entry of the renal veins into the IVC. Justification for the distal segment of the left renal vein to be termed the surgical trunk, and the proximal segment to be the homologue of the right renal vein is presented. Radiological investigations demonstrated a non-segmental and non-lobar intrarenal venous architecture, an absence of renal vein valves and extensive venous collaterals centering on the left renal vein. These collateral channels, present in the foetus, and persisting in the adult, may be operative and of clinical significance in pathological states. No sex differences and no race differences of note were recorded in this study. The Chacma baboon displayed similar intra-renal venous anatomy. The applied clinical anatomy of these findings with particular regard to renal surgery and uro-radiology is emphasised.