The epidemiology and outcomes of prolonged trauma care (EpiC) study: methodology of a prospective multicenter observational study in the Western Cape of South Africa

Background
Deaths due to injuries exceed 4.4 million annually, with over 90% occurring in low-and middle-income countries. A key contributor to high trauma mortality is prolonged trauma-to-treatment time. Earlier receipt of medical care following an injury is critical to better patient outcomes. Trauma epidemiological studies can identify gaps and opportunities to help strengthen emergency care systems globally, especially in lower income countries, and among military personnel wounded in combat. This paper describes the methodology of the “Epidemiology and Outcomes of Prolonged Trauma Care (EpiC)” study, which aims to investigate how the delivery of resuscitative interventions and their timeliness impacts the morbidity and mortality outcomes of patients with critical injuries in South Africa.

Methods
The EpiC study is a prospective, multicenter cohort study that will be implemented over a 6-year period in the Western Cape, South Africa. Data collected will link pre- and in-hospital care with mortuary reports through standardized clinical chart abstraction and will provide longitudinal documentation of the patient’s clinical course after injury. The study will enroll an anticipated sample of 14,400 injured adults. Survival and regression analysis will be used to assess the effects of critical early resuscitative interventions (airway, breathing, circulatory, and neurologic) and trauma-to-treatment time on the primary 7-day mortality outcome and secondary mortality (24-h, 30-day) and morbidity outcomes (need for operative interventions, secondary infections, and organ failure).

Discussion
This study is the first effort in the Western Cape of South Africa to build a standardized, high-quality, multicenter epidemiologic trauma dataset that links pre- and in-hospital care with mortuary data. In high-income countries and the U.S. military, the introduction of trauma databases and registries has led to interventions that significantly reduce post-injury death and disability. The EpiC study will describe epidemiology trends over time, and it will enable assessments of how trauma care and system processes directly impact trauma outcomes to ultimately improve the overall emergency care system.

Trial Registration: Not applicable as this study is not a clinical trial.

Identification of risk factors for postoperative pulmonary complications in general surgery patients in a low-middle income country

Background
Postoperative pulmonary complications (PPCs) are an important cause of perioperative morbidity and mortality. Although risk factors for PPCs have been identified in high-income countries, less is known about PPCs and their risk factors in low- and middle-income countries, such as South Africa. This study examined the incidence of PPCs and their associated risk factors among general surgery patients in a public hospital in the province of KwaZulu-Natal, South Africa to inform future quality improvement initiatives to decrease PPCs in this clinical population.

Methods
A retrospective secondary analysis of adult patients with general surgery admissions from January 1, 2013 to December 31, 2017 was conducted using data from the health system’s Hybrid Electronic Medical Registry. The sample was comprised of 5352 general surgery hospitalizations. PPCs included pneumonia, atelectasis, acute respiratory distress syndrome, pulmonary edema, pulmonary embolism, prolonged ventilation, hemothorax, pneumothorax, and other respiratory morbidity which encompassed empyema, aspiration, pleural effusion, bronchopleural fistula, and lower respiratory tract infection. Risk factors examined were age, tobacco use, number and type of pre-existing comorbidities, emergency surgery, and number and type of surgeries. Bivariate and multivariable logistic regression models were conducted to identify risk factors for developing a PPC.

Results
The PPC rate was 7.8%. Of the 418 hospitalizations in which a patient developed a PPC, the most common type of PPC was pneumonia (52.4%) and the mortality rate related to the PPC was 11.7%. Significant risk factors for a PPC were increasing age, greater number of comorbidities, emergency surgery, greater number of general surgeries, and abdominal surgery.

Conclusions
PPCs are common in general surgery patients in low- and middle-income countries, with similar rates observed in high-income countries. These complications worsen patient outcomes and increase mortality. Quality improvement initiatives that employ resource-conscious methods are needed to reduce PPCs in low- and middle-income countries.

Inspirational Women in Surgery: Professor Kokila Lakhoo, South Africa

“Imagine growing up in apartheid South Africa as a woman of color, wanting to do academic surgery.” This was the world in which Kokila Lakhoo began her surgical journey in pre-Mandela South Africa in the 1980’s during a time when the government was not supportive of the educational ambitions of black and brown communities. Now, as Professor of Pediatric Surgery at Oxford University, Prof Lakhoo remembers her own fight for social justice and remains one of the world’s strongest advocates for children and surgical health care providers in low-and-middle-income-countries (LMICs). She owes her early interest in medicine and social justice to her grandmother who was a community health care advocate in the hamlet (Bethal, South Africa) where there were no affordable facilities for people of color. She inculcated a strong sense of right and wrong in the young Kokila Lakhoo, who would go on to fight for the same rights for billions of people around the world as a global surgery advocate.

She completed medical school at the University of Natal in 1982 and discovered a burgeoning love for surgery as an intern. There was an immediate backlash to her nascent ambitions. She recalls, “Everybody thought I was mad… they would say ‘You have no chance… This is suicide… they won’t let you do it.” Professor Lakhoo remained resolute and pushed her case, without mentors, and with nothing but a quiet determination and her trademark resourcefulness to keep her going. This continued during her move to her first position at one of the segregated “apartheid hospitals.” She continued to face discouraging resistance to her career ambitions and was alone in her surgical aspirations. When against the odds, and contrary to expectations she fulfilled the academic criteria for admission by excelling in the part 1 exams, she again encountered resistance. During her first position as senior house officer in surgery at Baragwanath hospital (tertiary center for black and brown communities) there was a movement to reduce the number of doctors. She found herself in the line of fire. She was the only one in her cohort with the intent of becoming a surgeon and had passed part 1 of the surgical exams. It was then that her trademark tenacity shone through. She defied the insistence that she should give up her dreams and refused to leave the medical director’s office for 6 hours. She proclaimed “I’m not leaving–I want my job, because I have passed the exams and I want to be a surgeon, you have to give me the job.” Her insistence paid off when she was allowed to enter surgical training.

Her perseverance to educate herself did not stop. During her post-graduate studies, she traveled 35 km to attend lectures daily, attended extra surgical lectures at neighboring hospitals and pursued her PhD simultaneously with the grueling residency. “I did my experiments at night and weekends and took call in the morning.” After successfully completing her surgical training and PhD, she completed advanced training in pediatric surgery at Red Cross Children’s Hospital in Cape Town, South Africa, and then in Great Ormond Street in London. She completed her adult surgical training in 1989 and pediatric surgery in 1992. At the time of her completion of pediatric surgery training in 1992, she was the first qualified female pediatric surgeon and the first qualified female pediatric surgeon of color in South Africa.

Professor Lakhoo’s most impactful contribution to global health has been her role in developing pediatric surgery in Tanzania with little to no funding. She used her own funds and annual leave to help set the rudimentary building blocks of what would eventually become a longstanding partnership with Tanzanian surgeons [1]. She worked closely with the surgical team there to develop academic tools such as various aspects of scholarship and leadership. She also fostered clinical advances as well as career development alongside the local team [2, 3].

She is also a co-founder and past President of the Global Initiative in Children’s Surgery (GICS) and has been a strong advocate uplifting the voices of children and providers of surgery in LMICs [4]. She has led global efforts through the British Association of Pediatric Surgeons and provided leadership and support to the Pan-African Association of Pediatric Surgeons (PAPSA) and served as lead pediatric surgery external examiner for the College of Surgeons of East, Central, and Southern Africa (COSECSA) [5]. Professor Lakhoo believes the one of the most significant problems in the surgical community that needs to be addressed are the pervasive inequalities in the field with need for leadership, mentorship, role models, and advocacy.

In her spare time, she finds joy in making miniatures that she often gifts to her trainees.

Throughout her career, Professor Lakhoo has maintained a preserving outlook—“There are no failures in life, there are only setbacks. I hope more women and people from challenging backgrounds can be encouraged to take up surgical careers. Challenges in acknowledgement of the pioneering advances by women, especially those of color, still persist even up to now. The field still lacks sufficient workforce diversity in South Africa. I found I was able to have greater impact and career growth outside the country I trained and that remains the case for many other women globally as well.” She grounds herself in being able to separate her home (her husband and two children) and professional life, and she encourages trainees to strive for their dreams, never accept “no” and not be afraid to make mistakes along the way.

The burden of labour and delivery-related complications among pregnant women at Mokopane Hospital of Limpopo Province

The burden of labour and delivery-related complications are health problems that are life-threatening for the fetus and pregnant women. Mokopane hospital in Waterberg of Limpopo Province reports many maternal health complications. There has not been an investigation into the burden of delivery complications and therefore this study aims to investigate the burden of labour and delivery complication experienced by women giving birth at Mokopane hospital of Limpopo province. Purpose: of this study was to explore the burden of labour and delivery-related complications among pregnant women at Mokopane hospital of Limpopo province. Methods: A cross-sectional, retrospective descriptive study was conducted. The study followed a quantitative approach and the researcher completed a questionnaire using clinical records from all delivery files of mothers delivered at maternity between January 2017 to December 2019 Mokopane hospital. Findings: The major finding of this study was the majority of women were at a low risk of pregnancy (69%) followed by a high risk of pregnancy (24%). The study further revealed that (73.7%) of women at Mokopane hospital were delivered through the normal virginal procedure and (25.8%) delivered through Caesarean section. Moreover, about 86% of the mothers were normal after delivery whilst 14% were sick or had complications. Conclusion: This study, therefore, recommends that educational programs about labour and delivery-related complications and related programs should be prioritised for pregnant women. KEY CONCEPTS The burden: Is the intensity or severity of disease and its possible impact on daily life (Gidron 2013). In the context of this study, the burden will refer to the death and loss of health due to labour and delivery-related complications among pregnant women at Mokopane hospital of Limpopo Province. Labour: This is the process of rhythmic uterine contractions which results in cervical dilatation, a descent of the presenting part; and delivery of the fetus, placenta, and membrane. (Anthony & Van Der Spuy, 2002; Clark, Van de Velde, & Fernando, 2016). In the context of this study, labour will be defined as a physiologic process during which the fetus, membranes, umbilical cord, and placenta are expelled from the uterus. Delivery related complication: Is an acute condition arising from a direct cause of maternal death, such as antepartum or postpartum haemorrhage, obstructed labour, postpartum sepsis, a complication of abortion, pre-eclampsia or eclampsia, ectopic pregnancy and ruptured uterus, or indirect causes such as anaemia, malaria and tuberculosis. (WHO, 2018). In the context of this study, delivery related complications will include amongst others severe antenatal bleeding, Postpartum haemorrhage, nonconvulsive hypertensive disorder of pregnancy (pre-eclampsia), Eclampsia: preeclampsia plus convulsions, Convulsions, Prolonged labour, Premature rupture of the membranes, Retained placenta. Pregnant women: Is a woman who is in the period from conception to birth in which the egg is fertilised by a sperm and then implanted in the lining of the uterus then develops into the placenta and embryo, and later into a foetus (Martin, 2015). In the context of this study, a pregnant woman will be described as a woman who is carrying a developing embryo or fetus within her body.

Haemodynamic monitoring in patients undergoing high-risk surgery: a survey of current practice among anaesthesiologists at the University of the Witwatersrand

Background: Haemodynamic monitoring and optimisation in high-risk surgery patients improve postoperative outcomes. High-income countries (HICs) have reviewed their haemodynamic monitoring and management practices. There is, however, a paucity of literature in low- and middle-income countries (LMICs) in this regard. The aim of this study was to describe the current haemodynamic monitoring practice in high-risk surgery patients among anaesthesiologists at the University of the Witwatersrand.

Methods: A survey was conducted among anaesthesiologists at the University of the Witwatersrand using a convenience sampling method by means of an adapted questionnaire from previous research done on this topic.

Results: A total of 64 out of 76 questionnaires were analysed, attaining a response rate of 84%. Ninety-seven per cent of the respondents either provided or directly supervised anaesthesia for high-risk surgery patients. Ninety-seven per cent of them frequently monitored invasive arterial blood pressure (IABP), 68.8% monitored stroke volume variation (SVV) and 53% monitored cardiac output (CO). The most frequently optimised parameter was IABP (68.8%); while CO was optimised by only 39.1% of the respondents. The VigileoTM monitor was the most frequently used CO device (84.4%). The main reason for not monitoring CO was the use of dynamic parameters of fluid responsiveness as a surrogate for CO (57.8%). Seventy-five per cent of the respondents used SVV as a diagnostic indicator for volume expansion, but the haemodynamic effects of volume expansion were frequently assessed using change in heart rate (78.1%) and blood pressure (76.6%). Most of the respondents (98.4%) believed that their haemodynamic management practice could be improved.

Conclusion: Anaesthesiologists at the University of the Witwatersrand frequently monitored and optimised IABP rather than CO in high-risk surgery patients. The respondents used dynamic parameters of fluid responsiveness as a surrogate for CO monitoring and as an indicator for volume expansion. Most of the respondents believed that their current haemodynamic management practice in this setting could be improved.

An analysis of overweight and obesity in South Africa: the case of women of childbearing age

This thesis used nationally representative data from the 2008 – 2017 National Income Dynamics Study, 1998 and 2016 South African Demographic and Health Surveys and 2005/06 and 2010/11 Income and Expenditure Surveys to examine prevalence, socioeconomic inequality, and determinants of overweight and obesity among non-pregnant women of childbearing age (15 to 49 years) (WCBA) in South Africa over time. It also assessed socioeconomic inequality in the intergenerational transmission of overweight and obesity from mothers to their offsprings among 10,735 mother-offspring pairs and decomposed socioeconomic inequality in household ultra-processed food (UPF) product spending in samples of 16,209 households in 2005/06 and 17,217 households in 2010/11. Overweight and obesity in WCBA in South Africa increased between 1998 and 2017 with factors including increased age, self-identifying with the Black African population group, higher educational attainment, residing in an urban area, and wealth contributing to the rise. Smoking had a protective effect on being overweight and obese. Overweight and obesity were also increasingly prevalent among wealthier than poorer WCBA in South Africa between 1998 and 2016. It was found that UPF expenditure increased between 2005/6 and 2010/11, accounting for a substantial share of poorer households’ expenditures than their wealthier counterparts over time. Although factors explaining socioeconomic inequality in the intergenerational transmission of overweight and obesity differed by offspring sex, intergenerational overweight and obesity occur more frequently among wealthier mother-offspring pairs than their poorer counterparts. Key factors explaining inequalities in intergenerational overweight and obesity include the mother’s socioeconomic status, education and exercise habits. This study improves the empirical understanding of the burgeoning overweight and obesity challenges among women, especially in South Africa, who are likely to transmit them to their offspring. Policy to address these issues should not only be about health services but also focus on the social determinants of health inequalities.

Community-based adult hearing care provided by community healthcare workers using mHealth technologies

Background
The rising prevalence of hearing loss is a global health concern. Professional hearing services are largely absent within low- and middle-income countries where appropriate skills are lacking. Task-shifting to community healthcare workers (CHWs) supported by mHealth technologies is an important strategy to address the problem.

Objective
To evaluate the feasibility of a community-based rehabilitation model providing hearing aids to adults in low-income communities using CHWs supported by mHealth technologies.

Method
Between September 2020 and October 2021, hearing aid assessments and fittings were implemented for adults aged 18 and above in two low-income communities in the Western Cape, South Africa, using trained CHWs. A quantitative approach with illustrative open-ended questions was utilised to measure and analyse hearing aid outcomes. Data were collected through initial face-to-face interviews, telephone interviews, and face-to-face visits post-fitting. Responses to open-ended questions were analysed using inductive thematic analysis. The International Outcome Inventory – Hearing Aids questionnaire determined standardised hearing aid outcomes.

Results
Of the 152 adults in the community who self-reported hearing difficulties, 148 were successfully tested by CHWs during home visits. Most had normal hearing (39.9%), 24.3% had bilateral sensorineural hearing loss, 20.9% had suspected conductive hearing loss, and 14.9% had unilateral hearing loss, of which 5.4% had suspected conductive loss. Forty adults met the inclusion criteria to be fitted with hearing aids. Nineteen of these were fitted bilaterally. Positive hearing aid outcomes and minimal device handling challenges were reported 45 days post-fitting and were maintained at six months. The majority (73.7%) of participants fitted were still making use of their hearing aids at the six-month follow-up.

Conclusions
Implementing a hearing healthcare service-delivery model facilitated by CHWs in low-income communities is feasible. mHealth technologies used by CHWs can support scalable service-delivery models with the potential for improved access and affordability in low-income settings.

Early detection and treatment of clubfoot in a rural setting in South Africa

Clubfoot is one of the most common musculoskeletal congenital disorders and annually affects around 174 000 babies worldwide. Untreated clubfoot leads to significant permanent impairment and problems with ambulation, thus presenting a potential public health dilemma. Clubfoot can however be corrected with a non-surgical method referred to as the Ponseti method. This gives a child normal, pain free mobility and the potential to grow up as a productive member of society. Treatment for clubfoot needs to be implemented as soon as possible after birth of the child to produce the best results and avoid possible relapse of the clubfoot. Diagnosis and treatment of clubfoot starting at, or later than three months of age, is regarded as late detection and treatment. The purpose of this study was to determine the healthcare-seeking behaviour of guardians of children with clubfoot at or after the age of three months to promote early detection and treatment. A qualitative study was conducted to explore the reasons for seeking healthcare at Ponseti clinics for children that were three months or older; and to describe the challenges that the guardians experienced in seeking healthcare for their children. Data collection was done through semi-structured interviews at two public sector hospitals in KwaZulu Natal Province. Two major themes emerged from the study, namely discovering the clubfoot deformity, and the challenges guardians experienced in seeking healthcare for their children with clubfoot. There is a lack of knowledge about clubfoot resulting in late detection and initiation of treatment; and that clubfoot is a treatable condition which can result in the child leading a normal life if treated with the Ponseti method. Participants attending antenatal care were not informed by health practitioners of clubfoot being a potential birth defect. In some cases, guardians approached health practitioners early, but were referred late to a Ponseti clinic. Guardians in the study experienced several challenges when seeking healthcare for their children, including financial, transport and family responsibility challenges. They described having a child with clubfoot as an emotionally taxing journey. Recommendations are made for education, practice, policy, and research. An information brochure was designed to promote early detection and treatment of clubfoot.

Troubleshooting obstetric spinal anaesthesia at district hospital level

Obstetric spinal anaesthesia is routinely used in South African district hospitals for caesarean sections, providing better maternal and neonatal outcomes than general anaesthesia in appropriate patients. However, practitioners providing anaesthesia in this context are usually generalists who practise anaesthesia infrequently and may be unfamiliar with dealing with complications of spinal anaesthesia or with conversion from spinal to general anaesthesia. This is compounded by challenges with infrastructure, shortages of equipment and sundries and a lack of context-sensitive guidelines and support from specialised anaesthetic services for district hospitals. This continuous professional development (CPD) article aims to provide guidance with respect to several key areas related to obstetric spinal anaesthesia, and to address common concerns and queries. We stress that good clinical practice is essential to avoid predictable, common complications, and hence a thorough preoperative preparation is essential. We further discuss clinical indications for preoperative blood testing, spinal needle choice, the use of isobaric bupivacaine, spinal hypotension, failed or partial spinal block and pain during the caesarean section. Where possible, relevant local and international guidelines are referenced for further reading and guidance, and a link to a presentation of this topic is provided.

Burn Admissions Across Low- and Middle-income Countries: A Repeated Cross-sectional Survey

Burn injuries have decreased markedly in high-income countries while the incidence of burns remains high in Low- and Middle-Income Countries (LMICs) where more than 90% of burns are thought to occur. However, the cause of burns in LMIC is poorly documented. The aim was to document the causes of severe burns and the changes over time. A cross-sectional survey was completed for 2014 and 2019 in eight burn centers across Africa, Asia, and Latin America: Cairo, Nairobi, Ibadan, Johannesburg, Dhaka, Kathmandu, Sao Paulo, and Guadalajara. The information summarised included demographics of burn patients, location, cause, and outcomes of burns. In total, 15,344 patients were admitted across all centers, 37% of burns were women and 36% of burns were children. Burns occurred mostly in household settings (43–79%). In Dhaka and Kathmandu, occupational burns were also common (32 and 43%, respectively). Hot liquid and flame burns were most common while electric burns were also common in Dhaka and Sao Paulo. The type of flame burns varies by center and year, in Dhaka, 77% resulted from solid fuel in 2014 while 74% of burns resulted from Liquefied Petroleum Gas in 2019. In Nairobi, a large proportion (32%) of burns were intentional self-harm or assault. The average length of stay in hospitals decreased from 2014 to 2019. The percentage of deaths ranged from 5% to 24%. Our data provide important information on the causes of severe burns which can provide guidance in how to approach the development of burn injury prevention programs in LMIC.