The physical impact of long bone fractures on adults in KwaZulu-Natal

Background: Limb fractures are increasingly common in low-income and middle-income countries due to an increase in motor vehicle and other accidents. Fractures may often lead to physical impairment that affects an individual’s ability to carry out tasks.

Objectives: To assess the physical impact of long bone fractures on adults in KwaZulu-Natal.

Method: A standardised questionnaire pertaining to activities at home and leisure was used to establish patient-reported outcomes at nine public hospitals. English-speaking and isiZulu-speaking participants who had sustained a single long bone fracture in the preceding 4 to 12 weeks at the time of data collection were included. The following activities were evaluated: walking, running, exercising, driving, performing household chores, writing, answering telephones, texting on a cell phone, bathing, using crockery and preparing meals.

Results: A total of 821 participants completed the questionnaire. Ninety-three per cent had closed long bone fractures and 69 per cent were lower limb fractures. Fifty-seven per cent of the fractures were caused by a fall. Female participants (p = 0.19) with lower limb fractures were more likely to have greater difficulty in performing tasks and participants 60 years of age and older (p = 0.001) were significantly more likely to have difficulty performing tasks.

Conclusion: These findings illustrate the daily limitations in patients’ everyday activities at home, leisure and in activities such as driving.

Clinical implications: This study highlights the difficulty that some individuals, particularly women and individuals 60 years of age and older, face in performing daily tasks after experiencing a long bone fracture.

Caesarean section rates in South Africa: A case study of the health systems challenges for the proposed National Health Insurance

Broader policy research and debate on the issues related to the planning of National Health Insurance (NHI) in South Africa (SA) need to be complemented by case studies to examine and understand the issues that will have to be dealt with at micro and macro levels. The objective of this article is to use caesarean section (CS) as a case study to examine the health systems challenges that NHI would need to address in order to ensure sustainability. The specific objectives are to: (i) provide an overview of the key clinical considerations related to CS; (ii) assess the CS rates in the SA public and private sectors; and (iii) use a health systems framework to examine the drivers of the differences between the public and private sectors and to identify the challenges that the proposed NHI would need to address on the road to implementation.

Results from the first audit of an intensive care unit in Botswana

BACKGROUND: Botswana is an economically stable middle-income country with a developing health system and a large HIV and infectious disease burden. Princess Marina Hospital (PMH) is the largest referral and teaching hospital with a mixed eight-bed intensive care unit (ICU
OBJECTIVES: To conduct an audit of PMH ICU in order to investigate major admission categories and quantify morbidity and mortality figures using a validated scoring system for quality improvement, education and planning purposes
METHODS: PMH medical records and laboratory data were accessed to record demographics, referral patterns, diagnoses, HIV status, Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scores and mortality rates
RESULTS: A total of 182 patients >14 years of age were enrolled over a 12-month period from April 2017 – March 2018. Patient’s mean age was 42.9 years, males represented 56.6% of the study population and surgical conditions accounted for 46% of diagnostic categories. Sixty percent of the patients were HIV-negative and 12% had no HIV status recorded. The mean APACHE II score was 25 and the mean length of stay in ICU was 10.3 days. Higher APACHE II scores were associated with higher mortality regardless of HIV status. The overall mortality was 42.8% and there was no difference in mortality rates in ICU or at 30 days between HIV-positive and HIV-negative ICU patient groups
CONCLUSIONS: The PMH ICU population is young with a high mean APACHE II score, significant surgical and HIV burdens and a high mortality rate. PMH ICU has significant logistical challenges making comparison with international ICUs challenging, and further research is warranted

The EQ-5D-3L administered by text message compared to the paper version for hard-to-reach populations in a rural South African trauma setting: a measurement equivalence study

Introduction
Administering patient-reported outcome measures (PROMs) by text message may improve response rate in hard-to-reach populations. This study explored cultural acceptability of PROMs and compared measurement equivalence of the EQ-5D-3L administered on paper and by text message in a rural South African setting.

Materials and methods
Participants with upper or lower limb orthopaedic pathology were recruited. The EQ-5D was administered first on paper and then by text message after 24 h and 7 days. Differences in mean scores for paper and text message versions of the EQ-5D were evaluated. Test–retest reliability between text message versions was evaluated using Intraclass Correlation Coefficients (ICCs).

Results
147 participants completed a paper EQ-5D. Response rates were 67% at 24 h and 58% at 7 days. There were no differences in means between paper and text message responses for the EQ-5D Index (p = 0.95) or EQ-5D VAS (p = 0.26). There was acceptable agreement between the paper and 24-h text message EQ-5D Index (0.84; 95% Confidence Interval (CI) 0.78–0.89) and EQ-5D VAS (0.73; 95% CI 0.64–0.82) and acceptable agreement between the 24-h and 7-day text message EQ-Index (0.72; CI 0.62–0.82) and EQ-VAS (0.72; CI 0.62–0.82). Non-responder traits were increasing age, Xhosa as first language and lower educational levels.

Conclusions
Text messaging is equivalent to paper-based measurement of EQ-5D in this setting and is thus a viable tool for responders. Non-responders had similar socioeconomic characteristics and attrition rates to traditional modes of administration. The EQ-5D by text message offers potential clinical and research uses in hard-to-reach populations.

A geospatial analysis of two-hour surgical access to district hospitals in South Africa

Background
In a robust health care system, at least 80% of a country’s population should be able to access a district hospital that provides surgical care within 2 hours. The objective was to identify the proportion of the population living within 2 hours of a district hospital with surgical capacity in South Africa.

Methods
All government hospitals in the country were identified. Surgical district hospitals were defined as district hospitals with a surgical provider, a functional operating theatre, and the provision of at least one caesarean section annually. The proportion of the population within two-hour access was estimated using service area methods.

Results
Ninety-eight percent of the population had two-hour access to any government hospital in South Africa. One hundred and thirty-eight of 240 (58%) district hospitals had surgical capacity and 86% of the population had two-hour access to these facilities.

Conclusion
Improving equitable surgical access is urgently needed in sub-Saharan Africa. This study demonstrated that in South Africa, just over half of district hospitals had surgical capacity but more than 80% of the population had two-hour access to these facilities. Strengthening district hospital surgical capacity is an international mandate and needed to improve access.

Increases in cholecystectomy for gallstone related disease in South Africa

tudies suggest that the rate gallstone disease in Africa is low. Previous studies suggested an increase in gallstone rates and cholecystectomies related to urbanization and the adoption of Western lifestyle habits. This study examined cholecystectomy rates for gallstone disease in South Africa (SA). An audit of cholecystectomies in SA was done by reviewing gallbladder specimens processed by the SA National Health Laboratory Service (NHLS) from 2004 and 2014. Urbanization rates were obtained from Statistics South Africa and BMI data from previously published studies. Fisher’s exact test, t test’s and Pearson’s R were used for comparisons; cholecystectomy rates were calculated per 100,000 population. 33,467 cholecystectomy specimens were analysed. There was a 92% absolute increase in cholecystectomies during the study period (Pearson r 0.94; p < 0.01) with the overall cholecystectomy rate increasing by 65% from 8.36 to 13.81 per 100,000 population. The data was divided into two equal periods and compared. During the second period there was a 28.8% increase in the number cholecystectomies and patients were significantly younger (46.9 vs 48.2 years; p ≤ 0.0001). The Northern Cape was the only province to show a decline in the cholecystectomy rate in this period and was also the only province to record a decline in urbanization. Population based studies in SA demonstrate increases in BMI and an association with increased urbanization. This nationwide African study demonstrates a sustained increase in cholecystectomies for gallstone disease. Increases in BMI and urbanization may be responsible for this trend.

Trauma in pregnancy at a major trauma centre in South Africa

Background. Trauma in pregnancy poses a unique challenge to clinicians. Literature on this topic is limited in South Africa (SA).

Objectives. To review our institution’s experience with the management of trauma in pregnancy in a developing-world setting.

Methods. This study was based at Grey’s Hospital, Pietermaritzburg, SA. All pregnant patients who were admitted to our institution following trauma between December 2012 and December 2018 were identified from the Hybrid Electronic Medical Registry (HEMR).

Results. During the 6-year study period, 2 990 female patients were admitted by the Pietermaritzburg Metropolitan Trauma Service (PMTS), of whom 89 were pregnant. The mean age of these patients was 25.64 (range 17 – 43) years. The mechanism of injury was road traffic crash (RTC) in 39, stab wounds (SW) in 19, assault other than SW or gunshot wounds (GSW) in 19, GSW in 8, snake bite in 5, impalement in 1, dog bite in 1, hanging in 1, sexual assault in 1 and a single case of a patient being hit by a falling object. A subset of patients sustained >1 mechanism of injury. Thirty patients were managed operatively. The mean time of gestation was 19.16 (5 – 36) weeks. Three patients died, and there were 16 fetal deaths (including 3 lost after the mother’s death). Forty-five fetuses were recorded as surviving at discharge, while 25 fetal outcomes were not specifically recorded. There were 2 threatened miscarriages and/or patients with vaginal bleeding, 1 positive pregnancy test with no recorded outcome and no premature births as a result of trauma.

Conclusions. Trauma in pregnancy is relatively uncommon and mostly due to a RTC or deliberately inflicted trauma. Fetal outcome is largely dependent on the severity of the maternal injury, with injuries requiring laparotomy leading to a high fetal mortality rate.

Foreign body ingestion in children presenting to a tertiary paediatric centre in South Africa: A retrospective analysis focusing on battery ingestion

Background. Ingestion of foreign bodies remains a frequent reason for presentation to paediatric emergency departments worldwide. Among the variety of objects ingested, button batteries are particularly harmful owing to their electrochemical properties, which can cause extensive injuries if not diagnosed and treated rapidly. International trends show an increasing incidence of button battery ingestion, leading to concern that this pattern may be occurring in South Africa. Limited local data on paediatric foreign body ingestion have been published.

Objectives. To assess battery ingestion rates in a tertiary paediatric hospital. We hypothesised that the incidence has increased, in keeping with international trends. Secondary objectives included describing admission rates, requirements for anaesthesia and surgery, and promoting awareness of the problems associated with battery ingestion.

Methods. We performed a retrospective, descriptive analysis of the Red Cross War Memorial Children’s Hospital trauma database, including all children under 13 years of age seen between 1 January 2010 and 31 December 2015 with suspected ingestion of a foreign body. The ward admissions database was then examined to find additional cases in which children were admitted directly. After exclusion of duplicate records, cases were classified by type of foreign body, management, requirement for admission, anaesthesia and surgery. Descriptive statistics were used to analyse the data in comparison with previous studies published from this database.

Results. Patient age and gender patterns matched the literature, with a peak incidence in children under 2 years of age. Over the 6-year period, 180 patients presented with food foreign bodies, whereas 497 objects were classified as non-food. After exclusion of misdiagnosed cases, the remaining 462 objects were dominated by coins (44.2%). Batteries were the causative agent in 4.8% (22/462). Although the subtypes of batteries were not reliably recorded, button batteries accounted for at least 64% (14/22). Most children who ingested batteries presented early, but more required admission, anaesthesia and surgery than children who ingested other forms of foreign body.

Conclusions. The study demonstrated that the local incidence of button battery ingestion may be increasing, although data are still limited.Admission, anaesthesia and surgery rates for batteries were higher in this cohort than for all other foreign bodies. As button batteries can mimic coins, with much more dire consequences on ingestion, our ability to expedite diagnosis and management hinges on a high index of suspicion. It is imperative to increase awareness among healthcare workers and parents.

A review of the epidemiology, post-neurosurgical closure complications and outcomes of neonates with open spina bifida

Background. Spina bifida (SB) is a neural tube defect (NTD) that has an increased risk of fatal and disabling effects if not repaired early, i.e. within the first 24 to 48 hours of life. Its diagnosis holds an increased burden for the patient and the caregiver owing to secondary complications. The effects of the disease are detrimental even with early repair, because of the long-term disabling nature of the disease.

Objective. This retrospective study aimed to assess the effects of demographics, immediate post-surgical complications and impact of time to surgical intervention on the outcome of neonates with open SB (OSB) admitted to the neonatal intensive care unit (NICU) at Inkosi Albert Luthuli Central Hospital (IALCH) in KwaZulu-Natal, South Africa (SA), between January 2011 and December 2015.

Methods. A retrospective chart review was conducted at the NICU of IALCH. All neonates diagnosed with SB were identified. The study period was from 1 January 2011 to 31 December 2015. Data were collected from the IALCH electronic database. All neonates with SB admitted to the IALCH NICU were included; any patient who presented beyond the neonatal period (i.e. >28 days) was excluded from the study. Data collected included maternal demographics. Additionally, neonatal history was reviewed and post surgery complications evaluated. Outpatient management post discharge was reviewed.

Results. One hundred and fifty neonates were included (58% male). The mean (standard deviation) maternal age was 26.7 (6.6) years. Only 10% had an antenatal diagnosis of OSB. Seventy-eight percent were born at term and 22% prematurely. The lumbar/sacral region was the most commonly affected. More males (14%) had thoraco/lumbar lesions than females (7.8%). Forty-eight percent presented before 3 days of life (early presentation). In the late-presentation group, there was an association with wound sepsis (p=0.003). Twenty-five percent were repaired between days 0 and 3 of life and 75% after 3 days. Postoperative complications in patients whose open SBs were repaired beyond 3 days of life were not statistically significant compared with those with early repair; all were p>0.05. There was a borderline association of prolonged hospitalisation with wound sepsis (p=0.07). Long-term outcomes showed that 68% had lower limb dysfunction, 18% urological complications, 14% limb deformity, and 11% hydrocephalus. A minority had psychomotor (7%) and developmental (15%) disorders. Ten percent required readmission secondary to shunt complications, and 7% died.

Conclusion. SB remains a significant disease burden that affects outcome and survival of neonates in SA. Lack of good antenatal care, which includes early ultrasound and timely referral to centres, are barriers to good outcomes. Long-term follow-up is also necessary to prevent morbidity.

Salome Maswime: dynamic leader in global surgery

As Associate Professor and Head of Global Surgery at the University of Cape Town (UCT), South Africa, Salome Maswime is aware of the scale of the job in front of her. “For me the big problem is the disconnect between health systems and clinical care in low and middle income countries, especially concerning surgical care. Outcomes are often poor, there being not enough focus on the quality of surgery, and how it relates to integrated health care and overarching health systems performance”, she explains. Maswime saw such shortcomings first hand in her clinical career in obstetrics and gynaecology, before she took up the new post as Head of Global Surgery at UCT in July, 2019.