Background Worldwide, the number of patients suffering from surgical complications account for a significant burden on healthcare systems. Myocardial injury after non-cardiac surgery (MINS) is a new entity that has recently been identified as an independent risk factor associated with 30-day all-cause mortality. The risk of death increases approximately 10 fold following MINS in the perioperative period. Diagnosing myocardial injury in nonsurgical patients often relies on specific symptomatology and clinical findings combined with special investigations. However, in surgical patients, more than 80% of patients with postoperative myocardial injury will be asymptomatic, and hence the majority of diagnoses will be missed. Studies identifying the prevalence and risk factors for MINS have been conducted in countries with a different surgical population to South Africa. The primary outcome of this study was to investigate the prevalence of MINS after non-cardiac, elective, elevated risk surgery in South Africa. Methods Patients undergoing elevated risk, elective, non-cardiac surgery ≥ 45 years of age were enrolled via convenience sampling. The new 5th generation, high sensitivity cardiac troponin T (hscTnT) blood test was used to identify MINS. Blood samples were taken between 24 to 72 hours after surgery. Exclusion criteria included patients with known renal disease, a recent cardiac event, pulmonary embolism or sepsis. Results A total of 244 patients were included in the study. The prevalence of MINS was 4.9% (95% CI 2.2-7.6) which was not significantly different (p=0.078) to reports from international prospective observational studies. Conclusion Elective, elevated risk surgical patients in South Africa have a similar incidence of MINS when compared to patients from international studies. As the risk profile of South African patients is significantly lower than other similar international observational studies, it is possible that the prevalence of MINS is more common in South Africa, when patients are adjusted for cardiovascular risk profile. The burden of MINS on public health morbidity is therefore likely to be proportionally more in South Africa when compared to international reports. This may suggest that the calibration of international cardiovascular risk prediction models is incorrect for South African patients, or there are confounding comorbidities which should be included in South African cardiovascular risk prediction models. Larger studies are required to confirm this hypothesis however, and should also aim to address the need for appropriate cardiovascular risk predicting models in South Africa, to ensure timeous identification of patients at risk of MINS.

The Khayelitsha District Hospital (KDH) faces the difficult challenge of managing patients with high acuity penetrating cardiothoracic injuries, but without the full complement of resources to provide optimal care. At the time of this dissertation, we were unaware of the outcome of patients cared for at KDH, and of any potential modifiable risk factors that could improve their outcome. We therefore undertook a retrospective case audit to determine the outcome of patients presenting alive at our emergency unit with penetrating chest injuries (PCI). Objective: The objective of this study is to audit the KDH experience with penetrating chest injuries and to identify potential risk factors that predict outcomes in patients who sustain these injuries and require surgery at this district level hospital. The total study duration was 34 months. Methods: A retrospective review of all medical records of patients with PCI who were alive on presentation and had undergone surgery at KDH between 1st February 2012 and 31st December 2014 was undertaken .An audit was conducted on these files. During the audit, affected patient's clinical and physiological variables on admission, intra- and post-operative were collected and evaluated as potential predictors of outcome. This study also assessed a possible relationship between physiological parameters together with arterial blood gases (ABG) on presentation with immediate 48-hour mortality. The selected variables were: SBP (systolic blood pressure) <90 mmHg or >90 mmHg, palpable pulse, presence of a precordial stab wound, vascular injury, base deficit (BD) and lactate. A logistic regression analysis was performed to investigate the relationship between the selected variables and the 48-hour mortality. The relationship between fluid, BD and lactate was compared using Pearson correlation. Continuous data is presented as means ± standard deviations. Estimates for predictor variables are presented with odd's ratios (OR) and 95% confidence intervals (95% CI). Permission of this study was gained from human research ethics committee of University of Cape town. Results: Over the 34-month study period, a total of 646 patients were admitted to KDH with penetrating cardiothoracic trauma. Fifty-six patients required surgery at KDH. These results show that KDH had a PCI incidence of 5.1%, and that this was predominantly amongst males in the 15 - 24 year age group. Fifty-five patients were male and only one female. Of the 56 operated patients, 37 (66%) presented in hemorrhagic shock with SBP < 90mmHg. The mean amount of resuscitation fluid, which included both crystalloid and colloid, administered in the Emergency Room (ER) was 2481 ml per patient. Ten (17.8%) patients had a front room thoracotomy (FRT), with a mortality rate of 6 (60%). The overall mortality rate amongst operated patients was 16 (31.3%). Thirty-three patients (58.9%) had an isolated cardiac chamber injury and 23 (41.1%) had a vascular injury. Mortality amongst patients with isolated cardiac chamber injury was 5 (31.2%) and mortality among patients with isolated vascular injury was 7 (43.7%). Two patients sustained a combined cardiac and vascular injury with a mortality of 12.5%. The results of the logistic regression analysis revealed no statistically significant correlation between the selected predictors and 48-hour mortality (p-values: BP<90mmH p=0.27, palpable pulse p=0.181, precordial stab p=1.17, vascular injury p=0.38, BE p=0.98, Lactate p=0.06). Additionally, there was no statistically significant relationship between administered EC fluids and the acid base severity (Pearson correlation coefficient: BD r =0.091, Lactate r = -0.13). Conclusion: Physiological (blood pressure, pulse) and ABG parameters (lactate and base deficit) were not identified as significant risk factors for survival in the sample studied. The risk factor of isolated cardiac injury carried a better prognosis. Logistic regression analysis did not support the initial observation of higher mortality in patients with vascular injury. Additionally, there was no correlation between the severity of the acid base disturbance and the volume of fluid administered during resuscitation in ER. The outcomes of patients with PCIs presenting at KDH was within those published in the literature (range of published mortality: 17%-80%, survival 3-84%). The ideal predictor for PCI outcome in our cohort was indeterminate. Limitations of this study that include a small sample size and incomplete medical records, may have led to a type 2 error. A more comprehensive prospective study with meticulous record keeping is required to identify the factors that can influence the outcome of patients with PCI.

Introduction: Phantom limb pain is a common complication in people who have undergone limb amputation, with prevalence estimates ranging between 29% and 85.6%. Current systematic-review evidence suggests that recommended treatments are no more effective than placebo for reducing Phantom Limb Pain (PLP). Moreover, there is evidence suggesting that people with amputations may not be getting the treatment they want at different time-points after amputation. In consideration of these points, a research project comprised of a series of interconnected studies aimed to develop an in-depth understanding of the global burden of PLP and patient care priorities after limb amputations, and generate expert recommendations on the best management of PLP in people with amputations. Methods: The research project is comprised of a series of four interconnected studies addressing the four primary aims of the project. A systematic review and meta-analysis were conducted to determine the pooled prevalence estimate and risk factors for PLP in people with amputations. A cross sectional study was conducted to determine the prevalence and risk factors for PLP in people who had undergone lower limb amputations at Groote Schuur Hospital. An expert Delphi study was conducted to reach expert consensus and make recommendations on the effective treatments for PLP in people with limb amputations. Lastly, a patient Delphi study was conducted to generate patient consensus on care priorities for people who have had lower limb amputation for a year or less and for those who have had lower limb amputations for more than a year. Results: The systematic review and meta-analysis of 39 studies revealed a pooled PLP prevalence estimate of 64% [95%CI: 60.01 – 68.05], with a significantly higher prevalence estimate in studies conducted in developed countries 66.55% [95% CI: 62.02 –71.64] than those conducted in developing countries 53.98% [95% CI: 44.79–63.05] (U = 57, p = 0.03). Risk factors that were consistently positively associated with PLP included having an amputation of a lower limb, stump pain, non-painful phantom sensations, persistent pre-amputation pain, proximal site of amputation, and diabetic cause of amputation. The cross-sectional study using a sample of African people with amputations showed a PLP prevalence of 50.78% [95% CI: 41.80 – 59.72] during the week preceding data collection. In this group of patients, persistent pre-operative pain was the only risk factor associated with PLP in the multivariate logistic regression analysis [OR 2.25 (1.03 – 5.05); P=0.04]. In the expert Delphi study, consensus was reached on one pharmacological (amitriptyline) and six nonpharmacological (Graded Motor Imagery, mirror therapy, Cognitive Behavioural Therapy, virtual reality training, sensory discrimination training, use of a functional prosthesis) treatments that were considered effective for managing PLP, and on two treatments [citalopram (60%) and Pulsed Radiofrequency Stimulation of the dorsal root ganglion (70%)] that were considered ineffective. In the patient Delphi study, consensus was reached on 24 short-term care priorities and 12 long-term care priorities. The general consensus among the participants was that pre-amputation, they wanted education support to help them manage their expectations and prepare for life after amputation. In the early stage after amputation, they wanted help with dealing with the psychological trauma of having lost a limb. In the long-term, however, the participants prioritised the need for living a functional and normal life, with respect and dignity like everyone else. Conclusion: The prevalence of PLP in people with limb amputations is high, and awareness of this condition needs to be raised among healthcare professionals to implement evidence-based strategies for alleviating PLP by targeting the relevant underlying mechanisms and modifiable risk factors. Evidence-based medicine indicates that PLP is best managed using non-pharmacological and noninterventional treatments addressing biopsychosocial contributors for PLP. Finally, preparing people for life after amputation and helping them deal with the psychological trauma of having lost a limb may contribute to improved clinical outcomes that may enable them to live a functional and normal life, with respect and dignity.

Background: There is no established costing model for operating theatres in South Africa, yet both sectors have existing charges for operating theatre (OT) time: in the state sector, Uniform Patient Fee Schedule (UPFS) rates, and in the private sector, Rands/minute (R/min) rates for OT time. Understanding the cost of providing the separate components of a health service is important for planning and funding purposes. Objective: The primary objective of this study was to develop a costing model that would allow the calculation of the R/min cost of OT time. The secondary objective was to determine the actual costs, in order to establish the comparable costs that would be included in the R/min charges for OTs in the private health sector. Method: The OTs in a secondary level, state sector hospital in Cape Town were used in this quantitative observational study to develop a top-down costing model for OTs in South Africa. The inclusive costing model was developed in a consultative process with professionals, managers and experts from the state and private sector. The model was then populated with utility measurements (water and electricity) for the month of August 2018, staff salaries, excluding surgeons and anaesthetists, and other costs for the 2018/19 financial year. Results: Costs were considered in the categories of full costs, shared costs and capital or annualised costs. Due to uncertainty in costing of OTs, two models - with different annualisation times assigned to the capital costs - were developed to demonstrate the difference. For shared costs, correction factors were determined using either an activity based (work-load) factor, or a more generic estimation of workload using theatre nursing staff as a percentage of total hospital nursing staff. To determine a R/min cost of creating a minute of available theatre time, all the annual costs were divided by minutes that the OTs are explicitly available, each year, to provide patient care. The model was then populated with costs using the appropriate correction factors. The longer annualisation model costed OT time at R31,46 per minute, and the shorter annualisation model at R33,77 per minute. In both the longer and shorter capital annualisation models, nursing was the largest contributor to costs at 36% and 33% respectively, followed by construction costs at 9% and 11%, and then OT equipment at 8% and 11%. Conclusion: An inclusive, top-down costing model for OTs in South Africa was developed. This costing model will support work to develop costing for individual procedures, the appropriate charge for planned and emergency OT time, and to better determine budgeting for OT services. Meaningful critique of the model will improve its fidelity, and likely increase its utility, especially as SA moves towards universal health coverage.

Introduction Chronic pain affects 10- 25% of the population worldwide. However, studies of people with chronic pain have primarily been conducted in WEIRD (Western, Educated, Industrialised, Rich and Democratic) countries. There is a paucity of data from developing countries with the existing biased data being used to guide treatment of patients in developing countries. To address this knowledge gap, we have analysed the data of 623 patients attending the Chronic Pain Management Clinic (CPMC), at a tertiary facility in Cape Town, South Africa. The profile of the patients was compared to the global data. Methods A cross-sectional study of patients who attended the CPMC was conducted to describe their profile according to age, sociodemographic characteristics, health, gender and use of illicit drugs. Results The typical patient attending the CPMC was of middle age, female gender, of low educational level and less advantageous socio-economic status. They were also more likely to be on a disability grant and suffer from anxiety and depression. Conclusion The profile of the patients attending the CPMC was found to be similar to those from WEIRD countries. These results suggest that we can apply global data of people with chronic pain to patients attending this clinic.