BACKGROUND: Maternal health care in South Africa is based on the District Health System model which includes public health facilities (such as primary health care clinics, community health centers and district hospitals) as well as private health facilities. The majority of uncomplicated deliveries are expected to happen at community health centers and only complicated cases are expected to be referred to district hospitals. But in reality, the majority of deliveries in a health district happen in district hospitals. This often results in increasing utilisation of resources and decreased quality of care at these hospitals. The Ganyesa District Hospital, situated in Dr Ruth Segomotsi Mompati District in the North West Province has been facing similar challenges. Although the Hospital has been collecting routine information for the District Health Information System, it has never been analysed systematically to understand the impact of the current referral system on the performance of this Hospital. Aims: To compare maternal and neonatal profiles and outcomes between referred and self-referred patients delivered at the Ganyesa District Hospital during one year study period (1st April 2008 to 31st March 2009). Methodology: The setting of this study was Ganyesa District Hospital, in the Dr Ruth Segomotsi Mompati District in the North West Province. A Cross sectional study design was used utilising retrospective data, from the Hospital information systems. The MS excel software based data extraction tool was designed to obtain data from Hospital Information System. The variables used for this study included socio-demographic and clinical profiles of patients. A comparative statistical analysis were done to compare the profile of two groups of patients: (Referred and Self-referred) Results: The majority of the subjects were black. Most of the patients were, single and unemployed. The majority of the patients were multigravidae. The most common past and current medical disorders were diabetes and pregnancy induced hypertension (PIH). The prevalence of pre-term deliveries of the subjects was 14.8%. The majority of the subjects delivered normally (86.5%) followed by CS (13.2%). The majority of CSs were performed as emergency. PIH and previous CS were common maternal indications whereas fetal distress and mal-presentation were common fetal indications. Prolonged labour and Intra-partum haemorrhage were common maternal complications whereas fetal distress and fresh still-birth were common fetal complications. There were 26 (4.3%) post-partum maternal complications. There were 3 (4.6%) deaths during this period among the patients (Maternal mortality rate of 501/ 100,000). The incidence of low birth weight (less than 2.5 kg) was 23%. The fresh and macerated stillbirths and low Apgar score were common neonatal complications. The majority of the patients (374, 62.5%) arrived after-hours. The majority of the patients arrived by ambulance (87.3%). The median distance between places of residence and PHC facilities (Clinic and CHC) was 12 km. The median distance between places of residence and the Hospital was 45 km. There were no significant differences in socio-demographic (age, ethnicity, marital and employment status) and obstetric profiles (gravidity, prevalence of past medical disorders and antenatal disorders, prevalence of pre-term deliveries, mode of deliveries, intra-partum or post-partum complications and maternal outcomes.) between referred and self-referred patients. The two groups were not significantly different in terms of birth weight, the incidence of low birth weight, and Apgar scores (at 1 minute and 10 minutes) and neonatal complications. More referred patients arrived after hours in comparison to self-referred patients More referred patients arrived with ambulance in comparison to selfreferred patients. The self-referred patients stayed closer to health facilities. This was probably the reason these patients decided to come to Hospital instead of going to their nearby PHC clinics. Conclusion: Findings of this study will be reported to the district and provincial department of health and hopefully will be used for improvement of maternal health services in the Dr Ruth Segomotsi Mompati District.

Thesis (Ph.D.)--Aberdeen University, 2009. / Title from web page (viewed on Apr. 1, 2010). Includes bibliographical references.

Missing data are a problem for any clinical trial outcome but are particularly an issue for quality of life (QoL) outcomes.  To investigate the problem of missing data and methods to deal with it, this thesis uses a novel approach, illustrated using seven completed trials. Data from postal reminders were used to investigate the missing data mechanism and test the accuracy of imputation procedures (as the true value was in fact known).  The previously analysis for five of the seven example trials was an analysis of covariance adjusting for baseline QoL and other patient characteristics.  Alternative analysis strategies taking account of other interim responses are considered and contrasted with the published analyses.  The economic impact of the different data collection methods is explored using two economic decision rules. Different analysis strategies were shown to have an impact on the result of the trial.  There is no single best way of dealing with missing data, but some recommendations for researchers are provided.  The role of reminders is shown to be extremely important as the reminder system is a cost-effective use of resources to maintain the sample size, decreasing the amount of missing data and reducing the threat of bias.  Data collected by reminders can be used to inform the selection of potential imputation methods, again reducing bias.  The aim of any trial is to obtain an unbiased as possible estimate of treatment difference to help inform and improve clinical practice to the benefit of patients; the use of reminders may be pivotal in this.

Thesis (Ph. D.)--University of Virginia, 2007. / Includes bibliographical references. Also available online through Digital Dissertations.

Introdução: A energia elétrica e ultrasônica são utilizadas com freqüência na prostatectomia radical laparoscópica e podem lesar os nervos cavernosos adjacentes através da dissipação térmica. Em contrapartida, a energia laser tem potencial para proporcionar uma dissecção precisa, com boa hemostasia e pequena lesão dos tecidos adjacentes. Este estudo avalia o efeito do laser KTP na dissecção laparoscópica do feixe neuro-vascular cavernoso em modelo experimental canino. Material e Métodos: Um total de 36 cães foi dividido igualmente em três grupos. Realizou-se a dissecção unilateral do feixe neurovascular cavernoso utilizando (1) laser KTP (KTP), (2) bisturi ultrasônico (BU), e (3) tesoura e clipes metálicos (TC), mantendo o lado contralateral intacto. Realizou-se a análise do tempo operatório e sangramento em cada grupo, assim como a análise funcional, através do coeficiente entre a pressão intracavernosa e pressão arterial média (PIC/PAM) durante a estimulação do feixe neurovascular cavernoso. Metade dos animais de cada grupo foi mantida viva por 30 dias e submetidos à nova neuroestimulação. Foram avaliados ainda os efeitos da dissipação térmica através da análise termográfica em fragmentos de peritôneo parietal e a extensão histológica da necrose tecidual na fáscia prostática desde a superfície de corte de cada instrumento. Resultados: O tempo de dissecção do feixe neuro-vascular cavernoso foi similar entre os grupos (KTP vs. BU p=0.21, KTP vs. TC p=0.81, BU vs. TC p=0.22). A dissecção utilizando o BU resultou em um prejuízo significativo na resposta à neuroestimulação quando comparado aos grupos TC e KTP no experimento agudo (BU vs. KTP p<0.001, BU vs. TC p<0.001), e crônico (BU vs. KTP p=0.02, BU vs. TC p=0.02). A análise histológica demonstrou uma área de necrose desde a superfície de corte com a utilização do laser KTP de aproximadamente 500 um, enquanto que com o uso do BU essa área se extendeu em média por 2 mm. A avaliação termográfica mostrou uma dissipação térmica significativamente maior do BU comparado ao laser KTP (laser KTP 0.98 mm vs. BU 6.25 mm, p<0.0001). Conclusão: O uso do laser KTP na dissecção laparoscópica do feixe neuro-vascular cavernoso apresentou resultado funcional semelhante à técnica sem emprego de energia térmica utilizando tesoura e clipes, enquanto o bisturi ultrasônico foi associado a um prejuízo significativo na função dos nervos cavernosos. / Introduction: Electrical and ultrasonic energy used in nerve-sparing laparoscopic radical prostatectomy can compromise cavernous nerve function. Laser energy may potentially allow fine dissection with good hemostasis and minimal adjacent tissue injury. This study examines the electrophysiological, histological and thermal mapping features of KTP laser dissection on cavernous nerve function in the survival canine model. Materials and Methods: A total of 36 dogs were divided into 3 groups. Laparoscopic unilateral neurovascular bundle (NVB) mobilization was performed using either: (1) KTP laser (n=12), (2) ultrasonic shears (US) (n=12), or (3) athermally with cold scissors (AT) (n=12). The contralateral NVB remained undissected as an internal control. NVB function was assessed acutely in all dogs, and after 1-month survival in 50% of the dogs of each group. Peak intracavernosal pressure response to cavernous nerve stimulation was measured as a percentage of mean arterial pressure (ICP/MAP). Strips of peritoneum were sectioned ex-vivo with the KTP laser and US shears for thermographic mapping. Histological evaluation of prostatic fascia necrosis from the cutting surface was also performed. Results: Comparing KTP and AT groups, the erectile response to nerve stimulation was similar acutely and at 1 month (acute ICP/MAP: KTP 92%, AT 96% p=0.54; chronic ICP/MAP: KTP 95%, AT 98% p=0.71). In contrast, US dissection resulted in a significant decrease in the ICP response compared to the KTP and AT groups (acute ICP/MAP: US 49%, KTP 92%, AT 96%. US vs. KTP p<0.001, US vs. AT p<0.001; chronic ICP/MAP: US 58%, KTP 95%, AT 98%, US vs. KTP p=0.02, US vs. AT p=0.02). Mean NVB dissection times were similar (KTP 27.5min, US 19.9min, AT 26.6min, KTP vs. US p=0.21, KTP vs. AT p=0.81, US vs. AT p=0.22). Histopathology demonstrated an acute zone of laser-induced necrosis of approximately 500 um compared to 2 mm with US dissection. Thermographic assessment demonstrated significantly less collateral thermal spread from the KTP laser compared to US (mean thermal spread >60 oC KTP 0.98 mm vs. US 6.25 mm, p<0.0001). Conclusions: Use of KTP laser for NVB mobilization preserved cavernous nerve function comparable to standard athermal techniques using cold scissors and was superior to ultrasonic shears.

Introdução: A energia elétrica e ultrasônica são utilizadas com freqüência na prostatectomia radical laparoscópica e podem lesar os nervos cavernosos adjacentes através da dissipação térmica. Em contrapartida, a energia laser tem potencial para proporcionar uma dissecção precisa, com boa hemostasia e pequena lesão dos tecidos adjacentes. Este estudo avalia o efeito do laser KTP na dissecção laparoscópica do feixe neuro-vascular cavernoso em modelo experimental canino. Material e Métodos: Um total de 36 cães foi dividido igualmente em três grupos. Realizou-se a dissecção unilateral do feixe neurovascular cavernoso utilizando (1) laser KTP (KTP), (2) bisturi ultrasônico (BU), e (3) tesoura e clipes metálicos (TC), mantendo o lado contralateral intacto. Realizou-se a análise do tempo operatório e sangramento em cada grupo, assim como a análise funcional, através do coeficiente entre a pressão intracavernosa e pressão arterial média (PIC/PAM) durante a estimulação do feixe neurovascular cavernoso. Metade dos animais de cada grupo foi mantida viva por 30 dias e submetidos à nova neuroestimulação. Foram avaliados ainda os efeitos da dissipação térmica através da análise termográfica em fragmentos de peritôneo parietal e a extensão histológica da necrose tecidual na fáscia prostática desde a superfície de corte de cada instrumento. Resultados: O tempo de dissecção do feixe neuro-vascular cavernoso foi similar entre os grupos (KTP vs. BU p=0.21, KTP vs. TC p=0.81, BU vs. TC p=0.22). A dissecção utilizando o BU resultou em um prejuízo significativo na resposta à neuroestimulação quando comparado aos grupos TC e KTP no experimento agudo (BU vs. KTP p<0.001, BU vs. TC p<0.001), e crônico (BU vs. KTP p=0.02, BU vs. TC p=0.02). A análise histológica demonstrou uma área de necrose desde a superfície de corte com a utilização do laser KTP de aproximadamente 500 um, enquanto que com o uso do BU essa área se extendeu em média por 2 mm. A avaliação termográfica mostrou uma dissipação térmica significativamente maior do BU comparado ao laser KTP (laser KTP 0.98 mm vs. BU 6.25 mm, p<0.0001). Conclusão: O uso do laser KTP na dissecção laparoscópica do feixe neuro-vascular cavernoso apresentou resultado funcional semelhante à técnica sem emprego de energia térmica utilizando tesoura e clipes, enquanto o bisturi ultrasônico foi associado a um prejuízo significativo na função dos nervos cavernosos. / Introduction: Electrical and ultrasonic energy used in nerve-sparing laparoscopic radical prostatectomy can compromise cavernous nerve function. Laser energy may potentially allow fine dissection with good hemostasis and minimal adjacent tissue injury. This study examines the electrophysiological, histological and thermal mapping features of KTP laser dissection on cavernous nerve function in the survival canine model. Materials and Methods: A total of 36 dogs were divided into 3 groups. Laparoscopic unilateral neurovascular bundle (NVB) mobilization was performed using either: (1) KTP laser (n=12), (2) ultrasonic shears (US) (n=12), or (3) athermally with cold scissors (AT) (n=12). The contralateral NVB remained undissected as an internal control. NVB function was assessed acutely in all dogs, and after 1-month survival in 50% of the dogs of each group. Peak intracavernosal pressure response to cavernous nerve stimulation was measured as a percentage of mean arterial pressure (ICP/MAP). Strips of peritoneum were sectioned ex-vivo with the KTP laser and US shears for thermographic mapping. Histological evaluation of prostatic fascia necrosis from the cutting surface was also performed. Results: Comparing KTP and AT groups, the erectile response to nerve stimulation was similar acutely and at 1 month (acute ICP/MAP: KTP 92%, AT 96% p=0.54; chronic ICP/MAP: KTP 95%, AT 98% p=0.71). In contrast, US dissection resulted in a significant decrease in the ICP response compared to the KTP and AT groups (acute ICP/MAP: US 49%, KTP 92%, AT 96%. US vs. KTP p<0.001, US vs. AT p<0.001; chronic ICP/MAP: US 58%, KTP 95%, AT 98%, US vs. KTP p=0.02, US vs. AT p=0.02). Mean NVB dissection times were similar (KTP 27.5min, US 19.9min, AT 26.6min, KTP vs. US p=0.21, KTP vs. AT p=0.81, US vs. AT p=0.22). Histopathology demonstrated an acute zone of laser-induced necrosis of approximately 500 um compared to 2 mm with US dissection. Thermographic assessment demonstrated significantly less collateral thermal spread from the KTP laser compared to US (mean thermal spread >60 oC KTP 0.98 mm vs. US 6.25 mm, p<0.0001). Conclusions: Use of KTP laser for NVB mobilization preserved cavernous nerve function comparable to standard athermal techniques using cold scissors and was superior to ultrasonic shears.

Adams et al. was the first to demonstrate an association between improved outcomes and provider experience in a 1973 study examining complication rates from coronary arteriograms.[1] In this study, a questionnaire was mailed to the directors of coronary arteriography laboratories throughout the US. They found that mortality was eight times higher in institutions performing fewer than 200 examinations per two-year period compared to institutions performing more than 800 examinations per two-year period. It was not until 1979, however, that efforts to systematically study outcomes in surgery were made by Luft and colleagues.[2] They demonstrated lower mortality rates at high-volume centers compared with low-volume centers for several high risk procedures, such as coronary artery bypass graft surgery (CABG) and vascular surgery. This landmark study set the stage for outcomes research in surgery. Over the past decade, additional studies have continued to show higher surgeon or hospital volumes to be associated with improved patient outcomes. [3-13] To what degree surgeon versus hospital volume each contribute to outcomes is controversial and depends on the procedure examined. Nevertheless, formal recommendations encouraging certain high-risk procedures be performed at high-volume hospitals began as early as 2000 by the Leapfrog group and other policy initiatives.[14, 15] Formal recommendations for surgeon volume, on the other hand, have been lacking. There has been mounting evidence, particularly in the last decade, that surgeon volume is associated with improved patient outcomes, independent of hospital volume. To what measure these data have influenced referral patterns from low- to high-volume surgeons is unknown.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2009. / Härtill 4 uppsatser.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2010.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.