Research Articles (General Surgery)

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    Venous bicarbonate and creatine kinase as diagnostic and prognostic tools in the setting of acute traumatic rhabdomyolysis
    (Health & Medical Publishing Group, 2021-03) Buitendag, J. J. P.; Patel, M. Q.; Variawa, S.; Fichardt, J.; Mostert, B.; Goliath, A.; Clarke, D. L.; Oosthuizen, G. V.
    Background: Myorenal or crush syndrome often develops following soft-tissue traumatic injury. It is a spectrum of disease that may result in severe renal dysfunction and kidney injury requiring renal replacement therapy. Objectives: To review a large cohort of patients with so-called myorenal or crush syndrome and assess the biochemical markers of venous bicarbonate and creatine kinase as predictors for the development of acute kidney injury (AKI). Methods: All patients with myorenal syndrome who presented to Khayelitsha District Hospital, Cape Town, South Africa (SA), and Ngwelezana Hospital, Empangeni, KwaZulu-Natal, SA, between January and December 2017 were identified and reviewed. Results: A total of 212 patients were included in the study. At both hospitals, 94% of the patients were male. Using the Pearson correlation coefficient, we compared creatinine kinase (CK) against serum creatinine. The mean CK level was 5 311.8 U/L and the mean creatinine level 133.457 μmol/L. The r-value was 0.2533. Although this is a technically positive correlation, the relationship between the variables is weak. Using the Pearson R Calculator, we inserted the r-value to calculate the p-value. The p-value was 0.000208. When comparing venous bicarbonate (HCO3) against creatinine, the mean HCO3 level was 22.296 mmol/L and the mean creatinine level 162.053 μmol/L. The r-value was -0.3468. Although this is a technically negative correlation, the relationship between the variables is weak. Using the Pearson R Calculator, we inserted the r-value to calculate the p-value. The p-value was 0.000013. The inverse ratio shown with HCO3 v. creatinine, although still a weak correlation, is significantly better in predicting an increase in creatinine compared with the weak positive correlation of CK v. creatinine. Conclusions: Although both venous HCO3 and CK showed a weak correlation with creatinine, the former performed significantly better in predicting AKI. In a resource-constrained system, we recommend that HCO3 be measured to assess patients with crush injury and that CK be regarded as a complementary modality.
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    Bone health in patients undergoing surgery for primary hyperparathyroidism at Tygerberg Hospital, Cape Town, South Africa
    (Jemdsa, 2021-03) Budgea, M; Conradie, W; Beviss-Challinor, K; Martin, L; Conradie, M; Coetzee, A
    Background: Increased bone resorption is a well-described consequence of primary hyperparathyroidism (PHPT). In South Africa, little is known about the impact of PHPT on skeletal health. Objective: To determine the prevalence of decreased bone mineral density (BMD), vertebral fractures and osteitis fibrosa cystica in patients with PHPT who underwent parathyroidectomy. Methods: Retrospective study of patients who underwent parathyroidectomy for PHPT at Tygerberg Hospital in Cape Town, from January 2010 to December 2019. Clinical, biochemical and BMD parameters are described. Results: Final analysis included 56 patients (median age 63.5 years; 80.4% female). Initial calcium, parathyroid hormone (PTH) and 25-hydroxyvitamin D (25[OH]D) levels were 2.93 mmol/l, 19.4 pmol/l and 34.0 nmol/l, respectively. Of the total cohort, 71.4% had decreased BMD. The prevalence of osteoporosis and osteopenia in postmenopausal women and men ≥ 50 years was 50.0% and 39.1% respectively; low bone mass for age in premenopausal women and men < 50 years was 20.0%. Vertebral fractures were seen in 21.2% of patients on radiography. Osteitis fibrosa cystica was present in five patients (9.6%). PTH levels were significantly elevated in patients with osteoporosis compared with those with normal BMD (36.4 vs. 16.1 pmol/l; p = 0.02). Conclusion: Two-thirds of patients who underwent parathyroidectomy for PHPT had decreased BMD, with osteoporosis present in 50% of postmenopausal women and older men. One in five had vertebral fractures. These findings underscore the importance of skeletal assessment in the management of PHPT.
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    Impact of COVID-19 pandemic on transplantation
    (Medpharm, 2020-09) Steyn, E.; Al-Benna, S.
    The evolving epidemic has led to reduced activities in organ donation and transplantation across South Africa. Similarly, transplantation programmes have been suspended in other countries because of scarce resources (especially ICU beds) and concerns regarding immunosuppressive induction regimens.
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    Reflections on undergraduate teaching
    (Health & Medical Publishing Group, 2019) Edge, Jenny
    Introduction: After 18 years of largely being out of undergraduate teaching of medical students, I am once again immersed. It is the same as it was, but it is also very different. In trying to make sense of this difference, I reflect on what I have experienced since returning to the clinical learning environment. I trained in a large impersonal teaching hospital in London in the 1980s. All consultants were treated like gods. Professors were above them. Matrons were just below them and, working down the chain, medical students were to be seen but rarely heard, spoke only when spoken to, and were used for tasks on the wards that the student nurses felt were beneath them. The ward rounds were staged, dramatic and to be feared. As students, we were expected to be smart and presentable – I was chastised for wearing trousers. I arrived in South Africa (SA) in 1994 and joined Stellenbosch University (SU)’s surgical department as a registrar. I found the medical students to be polite and slightly old fashioned compared with their European counterparts. Then I moved to private practice and for the last 18 years have had minimal involvement with undergraduates. Now I am fortunate enough to have been given the opportunity to return to a teaching position and find myself once again engaging with medical students in the wards. So, what has changed?
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    Four-year review of admissions to a South African regional hospital general surgery department
    (Health & Medical Publishing Group, 2019) Pape, J.; Swart, O.; Duvenage, R.
    Background. There are limited published data describing surgical admissions at a regional hospital level in the South African (SA) context. Objectives. To retrospectively review data from an electronic discharge summary database at a regional SA hospital from 2012 to 2016 to describe the burden of surgical disease by analysing characteristics of the patients admitted. Methods. All discharge summary records for the 4-year period were reviewed after extraction from a database created for the surgery department. Admissions were classified into 5 types: (i) elective surgery or investigations (ESI); (ii) trauma; (iii) burns; (iv) non-traumatic surgical emergencies (NTSE); and (v) unplanned readmission within 30 days. Other variables reviewed were demographic data, the International Statistical Classification of Diseases and Related Health Problems – Version 10 (ICD-10) diagnosis; area of origin; and outcome (death, tertiary referral, discharge). Data were subgrouped into 12-month periods to facilitate trend analysis. Results. Discharge summaries (N=9 805) over the 4-year study period were assessed and 9 799 were included in the analysis. All data were entered by the attending medical personnel. A total of 5 647 male patients (57.6%) and 4 152 female patients (42.4%) were admitted, with a mean age of 43.3 years (95% confidence interval (CI) 43.0 - 43.8) and a mean length of stay of 4.9 days (95% CI 4.7 - 5.1). Male patients comprised a larger proportion of trauma (83.7%) and burn (63.9%) admissions. The mean length of stay ranged from 3.5 days for elective patients to 9.1 days for burn patients. The most common diagnoses for emergency admissions were appendicitis, peripheral vascular disease and peptic ulcer disease. Common diagnoses for elective admissions were gallstone disease, inguinal hernia, anal fistulas/fissures, and ventral and incisional hernia. The most common cancer diagnoses were of the colorectum, oesophagus, breast and stomach. The overall mortality rate was 2.2%, and highest by subtype was burn patients (6.3%). Trend analysis showed a statistically significant increase in admission for NTSE (p=0.019), trauma (p<0.001) and 30-day readmission rates (p<0.001), with a decrease in admissions for ESI (p=0.001) over the 4 years. Conclusions. A precise understanding of the burden of disease profile is essential for national, provincial and district budgeting and resource allocation. Ongoing surveillance such as that performed in the study provides this critical information.