Background It is unknown whether the implementation of an information video on spinal anesthesia for caesarean section, narrated in a patient's first language, reduces anxiety, increases satisfaction, and improves doctor-patient communication if there is a language barrier. In South Africa most doctors speak English, and patients Xhosa, with educational and cultural disparities existing in many doctor-patient interactions. Methods One hundred and seventy-five Xhosa patients scheduled for elective cesarean section were enrolled in the study. The first 92 patients received “usual care” verbal explanations of the spinal anesthesia procedure (control group); the next 83 patients watched a spinal anesthesia information video (intervention group), narrated in Xhosa. Videos were displayed using smartphones. Maternal anxiety was assessed before and after spinal explanation, using a Numerical Visual Analog Anxiety Scale (NVAAS). A difference in post-explanation NVAAS score of 1.5 points between intervention and control groups was regarded as clinically significant. Patient satisfaction was assessed using the Maternal Satisfaction Scale for Cesarean Section (MSSCS). Results The mean (SD) age (31.5 (5.2) and 32.1 (5.4) years) and pre-explanation NVAAS score (4.2 (3.2) and 4.0 (3.0)) of the intervention and control groups respectively, showed no difference at baseline. The mean (SD) post-explanation decrease in NVAAS score was greater in the intervention- than in the control group (1.6 (3.5) versus .7 (2.3), P = .046, unadjusted mean difference .9 points (95% CI .02 to 1.8)). A linear regression model for the post-explanation NVAAS score showed that the intervention effect was significantly associated with the pre-explanation score (P = .002), adjusted for age and English fluency. Patients with pre-explanation NVAAS scores ³ 5 showed a statistically significant intervention effect. There was no significant difference in patient satisfaction between the intervention and control groups. The smartphone was an accessible and convenient display medium for the video. Ninety nine percent of patients exposed to the intervention would recommend watching the video prior to the procedure. Conclusion In this pilot study, lower NVAAS scores were observed in anxious patients, when a Xhosa information video was used to ameliorate challenges posed by a doctor-patient language barrier. It is easily implemented and demonstrates a novel use of mobile health technology. The study provides baseline data to inform sample size calculations for future studies. A high level of patient recommendation for the video suggests that this is an agreeable practice.

Background: Airway management is an essential skill for healthcare providers across many disciplines. Inadequate airway management leads to adverse events and deaths. Clear guidance on the use of evidence-based educational methods to train novice airway managers is limited. Best evidence suggests using a “deliberate practice for mastery learning” approach to produce expertise in complex skills. Objectives: Our primary outcome is a narrative synthesis of the evidence evaluating instructional design elements employed to train novices in airway management. Our secondary outcome is a description of how these techniques employ deliberate practice principles. These data will inform recommendations for future airway training. Methods: We conducted a systematic review of English language studies published by June 2019. Studies evaluating educational interventions to improve airway management by novices were included. Studies were excluded if they only reported learner reactions to training (Kirkpatrick Level 1 outcomes). Data extraction was performed in duplicate using a standardised form and critical appraisal of the included studies was performed using a tool developed by Hawker, et al. Due to the heterogeneity of the data and in order to best highlight important themes, we performed a narrative synthesis of included studies. Further, we explicitly reviewed the studies using a deliberate practice lens to extract features consistent with this framework. Results: Our search yielded 506 studies of which 42 were eligible for inclusion. Most studies were rated poor quality and used small convenience samples. Studies included participants from a range of disciplines who were trained using multiple different interventions on part-task trainers, manikins and real patients. Most studies (60%) used overall intubation success rate as the primary outcome measure with only 21% of studies reporting first-pass success rate. Only 10% of studies explicitly mentioned deliberate practice. Important emerging themes include using checklists as scaffolding for progression, using video laryngoscopy to augment teaching, and using different manikins to mimic variations in human anatomy. Conclusions: Reported studies evaluating airway training are of poor quality. However, available evidence offers usable instructional design elements associated with durable learning and improved expertise. We have made suggestions for incorporating deliberate practice into future airway training. A commitment to evidence-based educational design could improve expertise in this critical skill. (Prospero registration: CRD42017077843)

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.

Surgery, although required to treat most solid cancers, can increase tumour seeding and metastases. We have previously shown that surgery-induced myeloid derived suppressor cells (Sx-MDSCs) play an important role in this process by directly suppressing NK cells. The Sx- MDSCs increase significantly immediately after surgery but the exact mechanism by which Sx-MDSCs suppress NK cells is still unknown. In this work, we have discovered that CD155 poliovirus receptor is significantly and specifically upregulated on Sx-MDSCs following surgical stress but is minimally expressed on other immune cells. We also demonstrate that blocking CD155 in vivo leads to an improved NK cell phenotype, measured by DNAM-1 and NKG2D, and increased NK cytotoxicity. Additionally, ex vivo CD155 blockade significantly decreases the suppressive effect of Sx-MDSCs in cancer patients. Expansion of CD155 on Sx- MDSCs could be responsible for the profound postoperative NK cell suppression, which makes it a very appealing perioperative target for immunotherapy.

Background. Preoperative anaemia has been shown to be an independent risk factor for postoperative morbidity and mortality. Iron deficiency is the leading cause of anaemia globally. There are limited data describing the burden of perioperative anaemia and the relative contribution of iron deficiency in South Africa (SA). Objectives. To determine the prevalence and severity of preoperative anaemia in adults presenting for elective surgery in Western Cape Province, SA, and to investigate the contribution of iron deficiency as a cause of the anaemia. For this purpose, an investigative protocol from a recent consensus statement on the management of perioperative anaemia was applied. Methods. We performed a prospective, observational study in adult patients presenting for elective non-cardiac, non-obstetric surgery over a 5-day period at six Western Cape government-funded hospitals. The World Health Organization patient classification was applied, and patients with anaemia were investigated for iron deficiency. Results. The prevalence of preoperative anaemia was 28% (105/375; 95% confidence interval (CI) 23.5 - 32.5); 55/105 patients (52%) had moderate and 11/105 (11%) severe anaemia. Iron deficiency was the cause of anaemia in 37% (32/87; 95% CI 26.6 - 46.9), but only 9% of irondeficient patients received iron supplementation prior to surgery. Conclusions. Preoperative anaemia was common in this study, and more than half of the affected patients had moderate to severe anaemia. Iron deficiency was responsible for almost 40% of cases. Iron supplementation was under-utilised in the preoperative period as a means of increasing haemoglobin. The introduction of system-wide policies would empower perioperative physicians to mitigate the risk associated with preoperative anaemia in the Western Cape.

Background: Video laryngoscopy has directly impacted airway management, with numerous studies demonstrating its utility in clinical management of anatomically difficult airways. However, availability of video laryngoscopes in all clinical areas has been limited by cost. We used smartphone technology, miniature cameras and three-dimensional printing to design and create an innovative low-cost hyperangulated video laryngoscope. This has the potential to make the technique more widely available. Objectives: The aim of this study was to determine if time to intubation with the novel device was clinically equivalent to an existing gold-standard video laryngoscope (Storz CMAC with Dörges blade). Methods: We conducted a randomised, controlled, cross-over equivalence study with 100 skilled practitioners who had previous video laryngoscopy experience. Participants received instruction on the new device, and adequate opportunity to practice. Intubations were then performed in a randomised order on a mannikin simulating a difficult airway. Video recordings of each intubation were analysed by two independent investigators to determine time to intubation. A mean difference in intubation time of less than 10 seconds was determined a priori to denote clinical equivalence. Results: Mean difference in intubation time between the devices was 4.92 seconds, (two one-sided test 95%CI: 2.34 – 7.49 seconds). The innovative low-cost VL was thus clinically equivalent to the industry standard in a simulated difficult airway. Further testing in vivo in a clinical environment is needed. Conclusion: The results of this study show that a low-cost disposable hyperangulated video laryngoscope is clinically equivalent to the industry standard in a simulated difficult airway. In the context of the current global pandemic, video laryngoscopy has been advised in nearly all airway guidelines. Access to a low-cost VL which does not require reprocessing may be of great value.

BACKGROUND: Hypertension is a common risk factor for cardiovascular morbidity and mortality, with a high prevalence in patients presenting for elective surgery. In limited resource environments, patients have poor access to primary care physicians, limiting the efficacy of life-style modification for the initial management of hypertension in the community. In these circumstances, the perioperative period presents a unique opportunity for diagnosis and initiation and/or modification of pharmacotherapy of hypertension. Anesthesiologists are ideally placed to lead this aspect of perioperative medicine. METHODS: In collaboration with expert physicians, we designed and implemented an algorithm for the diagnosis of hypertension and subsequent initiation or modification of anti-hypertensive therapy, or referral to a physician. The study was a multi-center, cross-sectional quality improvement project in seven hospitals in the Western Cape, South Africa. On the day before scheduled elective surgery, adult inpatients had two sets of blood pressure (BP) readings taken, one by nurses and the other by anesthesiologists, using a noninvasive automated blood pressure device. These were averaged on an electronic database, to diagnose hypertension. Patients with normal BP or well-controlled hypertension required no further management. Those with borderline BP received educational pamphlets. Patients with stage 1 or 2 hypertension were managed with medication according to the algorithm, starting 1 day postoperatively, and provided with educational pamphlets. Patients with stage 3 disease were referred to a physician. The primary outcome was adherence by the anesthesiologist to the algorithm, defined as initiation of the prescribed medication. An 80% adherence rate was considered successful implementation. The secondary outcome was the issue of the antihypertensive medication at discharge. RESULTS: Two hundred and ninety-eight patients were screened for hypertension. One hundred and six patients were eligible for the quality improvement project. Thirty-seven (34.9%) had borderline blood pressure readings, 43 (40.6%) had stage 1-, 22 (20.8%) stage 2-, and 4 (3.8%) stage 3 hypertension respectively. The adherence rate by the anesthesiologist was 84.0% (95% confidence interval (CI) 77.0% to 91.0%) for initiation of anti-hypertensive therapy. It was noted that 55.5% (95% CI 46.2% to 65.1%) received their medication upon discharge. CONCLUSIONS: Anesthesiologists successfully implemented a quality improvement project for diagnosis and management of hypertension in the perioperative period. This has the potential to reduce the public health burden of hypertension in limited resource environments. Successful ongoing prescription and follow-up requires cooperation within a multi-disciplinary team involving anesthesiologists, surgeons, nurses, pharmacists and physicians.

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.