Introduction: A critical concept underpinning emergency medicine is triage. Triage is the systematic process of sorting patients based on acuity and/or resource need, with the goal of getting the right person to the right place at the right time to receive the right level of care. Triage influences a patient's clinical trajectory, hence impacts both patient outcomes and health system resource utilization. Therefore, the consequences of triage are arguably even more critical in two scenarios: first, early on in the patient's care, such as the prehospital setting; and second, care in resource-constrained health systems, such as in Africa. Prehospital emergency care, delivered by Emergency Medical Services (EMS) providers, represents one of the earliest opportunities for emergency triage of the undifferentiated patient. We conducted a series of projects to, first, understand the current global scientific context of prehospital triage and, next, to better understand how the South Africa Triage Scale (SATS) is used by Western Cape EMS providers for prehospital triage. Findings may help enhance the application of SATS for prehospital triage in the Western Cape. Additionally, findings could provide evidence to encourage the adoption, or rejection, of SATS triage by other EMS systems in resource-constrained settings, especially in Africa. Methods: This project consisted of three distinct objectives which were investigated as separate, but interconnected, studies. The first objective was answered using a secondary research method (a scoping review) designed to discover and appraise existing prehospital triage tools across the world in an effort to better contextualise the specific role filled, and value added, by SATS. The second and third objectives were answered using a quantitative and qualitative approach, respectively, to assess the validity and reliability of SATS among EMS providers, and to understand EMS providers' experiences and perspectives using SATS. We converged the quantitative and qualitative data in a mixed methods analysis. Main results: In the scoping review, we screened 1521 unique articles and completed a full review of 55 articles. We reported that the majority of publications on prehospital triage tools were focused on stroke triage (35%) and trauma triage (35%). There were 15 (27%) publications, corresponding to 11 unique tools, relevant to prehospital triage of undifferentiated patients - overall, the tools had modest triage performance characteristics in high-income settings. However, we found no publications relevant to prehospital triage with SATS in the 2009 to 2019 study period, and no triage tools were studied in low- or middle-income countries. In the quantitative study, we conducted cognitive paper-based SATS triage assessments of 102 EMS providers of all qualifications within the Western Cape Government EMS system. We found a high rate (29.5%) of under-triage and an acceptable rate (13.1 %) of over-triage. Providers' use of the Triage Early Warning Score (TEWS) and the clinical discriminators were often incorrect in 41.4% and 41.2% of cases, respectively. In the qualitative assessment, we completed three focus group discussions with 15 diverse and representative providers from the Western Cape Government EMS system, and we achieved thematic saturation. Four major themes emerged from the discussions: Limited implementation and variable use of SATS; Prehospital effectiveness of SATS; Limitations of the discriminator; and, Special EMS considerations limiting SATS. In general, participants felt SATS was fairly easy to use and an asset in their patient care, explaining that it aided them clinically and with hospital communication. Participants, however, noted that the clinical discriminators were often challenging to apply in the prehospital setting, and the TEWS often did not reflect the patient's true or changing prehospital acuity. The qualitative findings both corroborated and helped explain some of the key quantitative results, with both suggesting that many clinical discriminators are problematic for prehospital use and manually calculating TEWS is an error-prone process for Western Cape EMS providers. Conclusion: SATS is being successfully and innovatively used in the prehospital triage of undifferentiated patients in the Western Cape of South Africa. Researching prehospital SATS in South Africa fills a global scientific gap given we found no reports of prehospital triage tools from low- or middle-income countries. Western Cape EMS participants reported that SATS was generally helpful and relatively easy to use, but reported challenges using TEWS and the clinical discriminators. SATS had good inter-rater reliability, but poor validity. The under-triage rate of 30% was high and attributable to misuse of TEWS and clinical discriminators. The over-triage rate of 13% was acceptable and confirmed by experiences recounted by the EMS participants. Modest adaptations of SATS by expert stakeholders could improve its prehospital performance and utility in the Western Cape Province. SATS for prehospital triage likely has good applicability and utility in other resource-constrained systems, but further adaptation and testing are warranted.

Aim To determine the efficacy and safety of micropulse transscleral cyclodiode photocoagulation laser (MP-TSCPC), in terms of intraocular pressure (IOP) reduction, in refractory glaucoma eyes and in blind glaucomatous eyes that were not on antiglaucoma medications. Method 28 consecutive patients were prospectively recruited. Iridex G6 micropulse laser with its P3 probe was used. Baseline variables, including IOP, number of glaucoma medications and visual acuity (VA)were assessed. Success was set at a minimum of 20% reduction in baseline IOP, or a pressure drop to below 21mmHg at 6 months. Results Twenty-eight eyes of 15 female and 13 male glaucoma patients were enrolled. The mean baseline IOP was 40±11mmHg and the mean post laser pressures were 23±10mmHg at 1 week, 25±11mmHg at 4 weeks, 32±12mmHg at 12 weeks and 27±13mmHg at 24 months, representing a percentage drop of 40%, 35%, 30% and 35%, respectively. There was a reduction of one anti glaucoma agent in 11 (39%) patients. The overall success rate of MP-TSCPC was 71% with no serious complications noted. Conclusion In this small cohort of patients, micropulse transscleral laser cyclophotocoagulation was safe and effective in reducing IOP in glaucoma patients, with a success rate of 71%. Further studies are required to verify this finding.

Background: Acute respiratory failure is becoming a frequent phenomenon in the emergency department due to increasing life expectancy, and in the last two decades the number of presentations has more than doubled. Non-invasive ventilation has become the treatment modality of choice in selected patients, with a significant reduction of mortality in these cases. However, adequate monitoring of clinical and blood gas parameters is crucial to ensure treatment targets are met. Objective: This study aims to evaluate monitoring of respiratory physiological parameters in patients treated with non-invasive ventilation (NIV) in the ED in Sligo University Hospital. As a secondary objective, the study aims to evaluate how monitoring data influence treatment modification. Methodology: This was a retrospective chart review of 50 patients who presented to the ED in acute respiratory failure and were treated with non-invasive ventilation between September 2017 and March 2019. Results: A total of 50 charts were analysed, 62% female and 38% male. The average age for both genders was 76 years. Results showed that initial and ongoing monitoring of vital signs remained guideline compliant throughout the entire duration of NIV in the ED. All but one patient out of 50 had an initial blood gas analysis done prior to initiation of NIV treatment, while repeat blood gas analysis was inconsistent with 38% (n= 19) who did not have blood gas repeated. Conclusion: The study highlights the discrepancy between monitoring of vital signs and arterial blood gas during treatment of acute respiratory failure patients with non-invasive ventilation in the emergency department. A proforma may help bridge this gap to ensure a standardised care in order to improve treatment outcomes.

Introduction: The relationship between pancreatitis and dyslipidaemia is unclear and has never been studied in a South African context. Patients and methods: A prospective evaluation of all admissions with acute pancreatitis to a regional hospital general surgical service was performed to ascertain its relationship to dyslipidaemia. Aetiology was determined by history and ultrasound assessment. Disease severity was assessed using a modified Imrie score and an organ failure score. Body mass index was calculated. A lipid profile was obtained. Abnormal profiles were repeated. Secondary causes of dyslipidaemia were noted. A comparison of the demographic profile, aetiology, disease severity scores, complications and deaths were made in relationship to the lipid profiles. Results: From June 2001 to May 2005, there were 230 admissions, of whom 31% were women and 69% men. The median age was 38 years(range 13- 73). The pancreatitis was associated with alcohol in 146(63%), gallstones in 42(19%) and idiopathic in 27(12%). The amylase was significantly higher with a gallstone aetiology (p / Thesis (MMedSc)-University of KwaZulu-Natal, 2006.

Renal failure in patients undergoing Aortic surgery is associated with a poor outcome. The shortcomings of serum creatinine for measuring renal function are well documented. We examined the value of alternative markers in diagnosing and predicting renal damage in patients undergoing abdominal aortic surgery and those exposed to intravascular contrast media. Cystatin C lacks some of the reservations associated with serum creatinine when used as a marker of glomerular filtration rate. The protease inhibitor alpha-glutathione Stransferase (a-GST) is recovered in urine after injury to proximal tubular cells. Urine microalbumin is a marker of glomerular permeability. Together we used all four assays to detect and characterize the nature of renal injury after surgery and contrast exposure. Cystatin C had a marginally better sensitivity than serum creatinine at detecting baseline renal impairment. It also showed earlier changes in individual patients whose renal dysfunction deteriorated over time. The urinary markers showed an earlier significant rise after the onset of surgery when compared to serum markers, but only a-GST rose significantly after contrast exposure. Patients undergoing a supra-renal cross-clamp showed significantly higher a-GST levels (and not the other three markers) when compared to the infra-renal group. Cystatin C appears to have better sensitivity and specificity for predicting the need for dialysis in patients undergoing surgery. Peak serum creatinine and cystatin C after contrast exposure show good correlation with peak values after surgery. Cystatin C is equivalent to and may be better than serum creatinine in detecting preexisting and deteriorating renal impairment. Although the urinary assays are earlier markers of renal injury, their clinical significance needs to be determined. Elevation in creatinine and cystatin C after contrast exposure parallel those after surgical intervention and may be helpful in selecting out high-risk patients prior to surgery. / Thesis (M.Med.Sc.)-University of Natal, 2003.

Objective. To assess the influence of diabetes mellitus on early morbidity and mortality following open vascular surgical interventions. Methods. Clinical data on patients subjected to open vascular surgical procedures over a 5 year period at the Durban Metropolitan Vascular Service was culled from a prospectively maintained computerized database. They were divided according to the type of surgical procedure performed. These were open abdominal aortic surgery, peripheral bypass surgery, lower extremity major amputation and carotid endarterectomy. They were further subdivided into 2 groups, diabetic and non-diabetic. Results. 1104 charts were analysed. There were no significant differences in demographics and risk factors between the two groups. 273 patients had open abdominal aortic surgery. 217 (79%) were non-diabetic. diabetic patients had significantly higher incidence of myocardial infarction (p=0.00001) (6 of 6 patients), graft sepsis (p=0.000001) (7 of 7 patients) and mortality rate (p=0.0335) (5 of 10 patients). 337 patients had peripheral bypass procedures. 204 (60%) of these were non-diabetic. There was a high prevalence of smokers among non-diabetics and of hypertension among diabetics. Diabetic patients had a preponderance of graft infection (p=0.0015) (15 of 20 patients) and cardiovascular complications (p=0.0072) (7 of 8 patients). 230 patients had lower extremity major amputations, 81 (35%) were diabetic and 149 (65%) non-diabetic. Myocardial infarction and death (6 of 8 patients each) were significantly higher among diabetics (p =0.04). 264 patients had carotid endarterectomy, 170 (64%) being non-diabetic. The surgical outcome was similar between the two groups. Conclusions. This is retrospective study and as such it has some its limitations. Not all patients might have been included in the study and some of the information might have been lost. The numbers in this study are large and these limitations would appear not to have influenced the outcome of this study. This study has shown that diabetes mellitus had diverse influence on the early outcome following different vascular surgical procedures. Diabetes mellitus significantly increased the incidence of graft sepsis among those who had aorto-bifemoral bypass and peripheral bypass procedures. The incidence of peri-operative cardiovascular morbidity was significantly increased among diabetics who had peripheral bypass procedures, open abdominal aortic surgery and lower extremity major amputations. Diabetes mellitus had no influence on the surgical outcome following carotid endarterectomy. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2012.

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. / Thesis (M.D.)-University of Natal, 1993.

Health care spending in Canada has been increasing faster than the rate of gross domestic product (GDP). A disproportionate amount of the health care spending is allocated to care of older adults. Non-elective abdominal surgery is an expensive area of care for older adults. Despite this, the factors associated with cost in this patient population remain unclear. OBJECTIVES The primary objective of this study was to estimate the association between perioperative factors (age, American Society of Anesthetists (ASA) classification, operative severity (OS), frailty index (FI), complication severity) and health care costs among older adults undergoing non-elective abdominal surgery. The secondary objectives were: 1. to provide a comprehensive description of costs based on patient-level resource utilization; and 2. to examine the relationship between hospital costs and adverse events (non-fatal complication severity, mortality, and change in living arrangement). METHODS This study was an observational prospective cohort study. Over a 15 month period all patients 70 years or older who underwent non-elective abdominal surgery at the QEII Health Sciences Centre, Nova Scotia, were enrolled. Data were collected on patient demographics, investigations, treatments, and outcomes. Direct hospital health care costs (2012 $CAD) were calculated by tabulating patient-level resource use and assigning specific costs. The association between five perioperative factors and costs were analyzed using univariate non-parametric tests and multiple linear regression. The associations between adverse events and costs were assessed using univariate non-parametric tests and multiple linear regression. RESULTS During the study period, 212 patients who underwent abdominal surgery (median age 78 years (range 70-97)) were enrolled. The median costs of care were $9,166 (range $1,993-$104,403). The largest proportions of spending were non-procedural costs (65% [$2,176,875]) and intensive care costs (16% [$554,523]). The perioperative factors ASA classification (p=0.0010), OS (p<0.0001), FI (p=0.0002) and complication severity (p<0.0001) were all independently associated with health care costs, while age was not (p=0.5330). The following adverse events were independently associated with health care costs: non-fatal complication severity (p<0.0001), change in living arrangement (p=0.0002), and mortality (p=0.0337). Non-fatal complications had the strongest association with hospital costs (standardized β coefficient = 0.3931). CONCLUSION Four perioperative factors (ASA, OS, FI and complication severity) are associated with costs; therefore, representing a potential cost prediction model for this patient group. This study is important for health care administrators, identifying targets for cost reduction. Cost reduction strategies and research should concentrate on mitigating or preventing complications and high cost areas, such as non-procedural costs and intensive care, in order to achieve cost savings.

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BACKGROUND: Nationally, 85% of general surgery graduates pursue fellowships reducing the incoming general surgical workforce with a predicted shortage of 41,000 general surgeons by 2025. In recent studies, the lack of confidence appears to be a major factor contributing to resident decision to pursue fellowship. The aim of the study was to determine if a hybrid academic/community program contributes to early autonomy and the decision to pursue fellowship in general surgery graduates. METHODS: We evaluated the level of confidence, level of autonomy, and decision to pursue fellowship at a hybrid academic/community program that historically graduates 70% of their residents into general surgery practice through an anonymous survey. Participants responded using Likert scales along with simple polar questions. RESULTS: Most current residents (90%) reported, upon graduation, that they feel very confident (45%) or fairly confident (45%) performing major cases independently. Most attendings (64%) reported that during their third year of residency, they began performing the majority (more than 75%) of their major cases as surgeon junior while current residents (55%) reported they were performing the majority as a second-year resident. Fifty-five percent of residents felt that confidence played a role in the decision to pursue fellowship. Thirty-three percent of our current chief residents and only 34% of the total general surgery residents plan to pursue fellowships. Conclusions: Our study showed that our residents appear to have earlier levels of autonomy than that experienced by our practicing surgeons when they were residents. Confidence continues to play a role in the decision to pursue fellowship and overall our residents are confident in technical skills at graduation. Our unique program continues to graduate the majority of our surgical residents into successful general surgery practice.