School of Clinical Medicine

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An assessment of tne successes and shortfalls of the national birth defects databases and an improved data collection method of the databases.
(2018) Mtyongwe, Vuyiswa; Malherbe, Helen.; Aldous, Colleen Michelle.
The Constitution of South Africa (SA) together with the National Health Act (63 of 1977) govern the provision of health services to the residents of the country. With a three-tier system of governance consisting of national, provincial and local (district) government, each tier functions autonomously, though in unison. The National Health Act outlines the health system whilst specifying services per level of governance. In this document, medical genetic services, amongst others, are included as a health issue that needs to be addressed as part of the functions of the National Department of Health (NDOH). At this level, these services form part of the Maternal and Child Health services. Although neglected, medical genetics services are important for the prevention and management of congenital disorders (CDs) in the community. These services are implemented through the development and implementation of policy guidelines. Data on CDs form the basis for policy development, decision making and planning for services. Without empirical data, services for this vulnerable group of individuals, cannot be adequately provided. Collection of CD data was initiated in 1980, with multiple surveillance systems available in the country by the early 1990s. One system in particular (Birth Defects Surveillance System-BDSS) was successful, with its data (from 1992-2004) being submitted to the International Clearinghouse for Birth Defects Monitoring Systems (ICBDMS), whose functions include the exchange of CD birth prevalence among member countries and the promotion of epidemiologic studies. In 2006, the NDOH developed the standardized birth defect notification tool (BDNT), with the intention of substituting all existing CD surveillance systems with one notification tool and system for the entire country. The primary objective of this study was to measure the effectiveness of this system, taking into account the challenges experienced in the reporting period. This was done by analyzing the data and comparing it to other surveillance systems globally and locally. The secondary objective was to develop an improved surveillance system for the country. Data from the BDNT was analyzed for a nine year period, 2006 until 2015. Analyzed data included the number of CDs reported per year, per province and per district. CDs of all pregnancy outcomes were included e.g. live births, stillbirths, terminated pregnancies and miscarriages. Birth prevalence was calculated based on aetiology, (whether the CD was genetically or environmentally determined), and per priority condition (This list of priority conditions was defined by the NDOH in their 2001 Birth defects policy guidelines. The number of priority CDs reported by doctors versus nurses was also determined). Priority conditions are, Down syndrome, fetal alcohol syndrome, neural tube defects, oculocutaneous albinism orofacial clefts and talipes equinovarus. A total of 17 761 notifications were received from across SA, of which 16 395 (92.13%) were CD notifications and 1 366 (7.69%) were zero notifications (these are notification tools that were completed by the health facility in months when no CDs were identified by the health viii facility). Compliance was erratic with KwaZulu-Natal province reporting the most CDs, n=9 732 (59.36%), and Western Cape province reporting the least, n=389 (2.37 %). KwaZulu-Natal province’s success is largely attributed to the good medical genetics services that were administered by Professor William Winship while he was alive. Overall, the districts where medical genetics facilities are located reported more CDs. When compared to modelled estimates, the BDNT surveillance system showed an underreporting rate of 98%. Malformations accounted for most of the reported CDs with a birth prevalence of 1.02 per 1 000 live births. Birth prevalence for CDs categorized by aetiology were: single gene disorders 0.07 per 1 000 live births; chromosomal disorders 0.13 per 1 000 live births; multifactorial disorders 0.09 per 1 000 live births; CDs caused by Rh (rhesus factor) incompatibility 0.00 (0.0032) per 1 000 live births and 0.01 per 1 000 live births for CDs caused by teratogens. Birth prevalence for each priority CD was as follows: Down syndrome 0.12 per 1 000 live births, fetal alcohol syndrome 0.01 per 1 000 live births, neural tube defects 0.09 per 1 000 live births, oculocutaneous albinism 0.03 per 1 000 live births, orofacial clefts 0.10 per 1 000 live births and talipes equinovarus 0.10 per 1 000 live births. Over half (57.80%) of all reported CD cases were diagnosed by nursing staff. Following analysis of data from the BDNT, a new surveillance system was developed containing the following factors: the types of CDs to be monitored, approaches to data collection, classification of collected data and the use of data received. Initially, the new CD surveillance system was going to be integrated into the national notifiable medical conditions surveillance system. In addition, an electronic system (with a backup paper-based notification system) was developed together with colleagues responsible for notifiable medical conditions surveillance and the National Institute for Communicable Diseases (NICD) which is yet to be piloted. Upon further research, certain elements were lacking in the system which could negatively impact upon implementation. As a way forward, certain considerations were identified for future implementation of a CD surveillance system. These were categorized into mandatory and elective factors. The former includes political commitment to CDs as a health issue, legislation prescribing CD services including surveillance, vital registration of CDs at birth and death, and NDOH facilitating the coordination of CD surveillance systems in the country. The latter includes the use of a district based approach to data collection with specific personnel identified to collect data using an electronic system. This study lays the foundation for national CD surveillance in SA. Various surveillance systems or patient registries are available, but none operate data at a national level. This study further identified the need for coordination between the different surveillance systems and/or patient registry data sets (e.g. non-governmental organisations and laboratories) which are not included in the BDNT. The national CD surveillance system could serve as a link between the various stakeholders (provinces, academic institutions, laboratories and non-governmental institutions), allowing each entity to have a system that is suitable to their needs while collating data from these systems. The CD surveillance system should also follow patients from the point of diagnosis to treatment/management and/or death, allowing for the true burden of CDs to be measured.
Culturally competent patient-provider communication with Zulu patients diagnosed with osteosarcoma.
(2016) Brown, Ottilia.; Aldous, Colleen Michelle.
Background: Communicating the diagnosis and prognosis of cancer is widely documented as a challenging task. Furthermore, ensuring that patients understand their treatment options is considered good practice; however literature in this regard tends to be limited. Performing these tasks in cross-cultural clinical settings complicates patient-provider communication. This study focused on Zulu patients diagnosed with osteosarcoma and was conducted at a tertiary (training) hospital in the province of KwaZulu-Natal (KZN), South Africa. The primary motivation for undertaking this research stemmed from observations in clinical practice that Zulu cultural beliefs and practices play a significant role in the management of osteosarcoma and hence culturally competent communication was an essential requirement at this site. In addition, patients typically present at the study site with locally advanced or metastatic disease. The late presentation of patients and further delays stemming from patients’ preferences to fulfil cultural practices results in treatment limitations and very poor prognosis. Healthcare providers in this setting are therefore expected to simultaneously inform patients of the diagnosis of osteosarcoma, the significant limitations with regard to treatment options, and prognostic considerations in a culturally sensitive manner that engenders cooperation in the patient while allowing them the opportunity to fulfil their cultural obligations. Aim and Objectives: This study aimed to develop an evidence-based practice guideline with recommendations for engaging in culturally competent communication with adult Zulu patients regarding the diagnosis, treatment and prognosis of osteosarcoma. Four objectives were devised in order to meet the aim of the study. Objective 1: Conduct an integrative literature review to gather evidence from previous research. Objective 2: Gather evidence from healthcare providers about the approach taken when they discuss osteosarcoma, its treatment and prognosis with Zulu patients as well as the cultural aspects considered during these discussions. Objective 3: Gather evidence from Zulu patients by exploring their understanding of the osteosarcoma diagnosis, its treatment and prognosis, and their experience of patient-provider communication throughout the illness experience was conducted. Patients’ cultural descriptions related to the management of osteosarcoma were also elicited. Objective 4: Develop an evidence-based practice guideline for culturally competent patient-provider communication with osteosarcoma patients based on the evidence collected in Objectives 1, 2 and 3. Methods: Objective 1: Whittemore and Knafl’s approach to conducting an integrative literature review was used. A number of databases were systematically searched and a manual search was also conducted. Specific inclusion and exclusion criteria were set and documents were critically appraised independently by two reviewers. Thirty-five documents were included following these processes. Data extraction and synthesis followed and were also independently verified. Objective 2: We used an exploratory descriptive contextual study design and conducted focus group interviews with professional nurses, allied health professionals, and orthopaedic physicians. Three focus groups with a total of twenty-three participants were conducted. Focus group interviews were audiotaped and transcribed verbatim. We thematically analysed the interview transcripts using Guba’s Model of Trustworthiness to ensure rigour. Objective 3: We used a qualitative case study approach with in-depth interviews that were conducted in isiZulu, audiotaped and transcribed verbatim. The transcripts were translated into English and back translated. Transcripts were then analysed thematically. Data were verified using Guba’s model of trustworthiness. Objective 4: The AGREE II (Appraisal of Guidelines, Research and Evaluation) appraisal instrument was used as a guide for developing the evidence-based practice guideline. The AGREE II is a 23 item tool comprising six domains, five of which were considered in developing the guideline. Results: The integrative literature review provided directives on how to deliver culturally competent communication to cancer patients. The review also highlighted the grave need for scientifically rigorous research in the field of culturally competent communication in the management of cancer. Our research with the healthcare providers produced a number of strategies for communicating with Zulu patients about the diagnosis, treatment and prognosis of osteosarcoma. These strategies also addressed cultural considerations and provided detailed information on the cultural factors that have to be taken into account when managing Zulu patients diagnosed with osteosarcoma. Challenges encountered with regard to discussing diagnosis, treatment and prognosis also emerged. In addition to revealing strategies and challenges that are confirmed in the literature, this study also unearthed unique strategies and challenges peculiar to this cross-cultural clinical setting. Despite the uniqueness of some of these strategies, they could be useful in other cross-cultural clinical settings where patients belong to collectivistic cultures, and observe traditions and other practices that are significantly different to Western medical approaches. Our findings also emphasised the importance of training healthcare providers on communication of sensitive information in cross-cultural clinical settings. Our research with Zulu patients diagnosed with osteosarcoma revealed that these patients had extensive understanding of the diagnosis of osteosarcoma, diagnostic procedures, the treatment options applicable to treating osteosarcoma and the side-effects of chemotherapy. These findings also revealed patients’ varied perceptions of and emotional responses to diagnosis and treatment and exposed difference in healthcare provider and patient perceptions of amputation. A significant contribution of the patient study is embedded in Zulu patients’ descriptions of their cultural and health beliefs and practices. Specific rituals that are performed to ensure successful outcome of medical procedures, to cleanse patients from bad luck and to address the issue of witchcraft were outlined. Consultation with a reputable traditional healer was flagged as an important cultural practice. However, patients varied in their adherence to traditional belief systems, participation in rituals and the extent to which they deferred decision-making to the familyreinforcing the importance of not stereotyping based on pre-existing knowledge of a cultural group. The evidence-based practice guideline was developed based on the findings from the integrative literature review and the studies conducted with the healthcare providers and the Zulu patients. These three sources of evidence facilitated the development of a guideline that presents generic requirements and recommendations for culturally competent communication, and denotes specific strategies for communicating diagnosis, treatment, and prognosis to Zulu patients diagnosed with osteosarcoma. The evidence-based practice guideline also explicates areas that require further research and refinement. Conclusions: The obvious contribution of this research is represented in the evidence-based practice guideline. However, each of the objectives makes a significant contribution to knowledge and practice. This study breaks ground and alerts to the magnitude of research that is required in cross-cultural clinical settings, especially in the South African context as literature in this context with regard to culturally competent communication is very limited. The need for training our healthcare providers in communication of sensitive information in cross-cultural clinical settings strongly emerged from the data. Policy directives that support culturally competent patient-provider communication at a healthcare systems level could significantly contribute to addressing resource constraints and creating clinical environments that are conducive to culturally competent communication.
Extradural spinal mass lesions in HIV sero-positive adults.
(2017) Gonya, Sonwabile.; Enicker, Basil Claude.; Aldous, Colleen Michelle.
Abstract available in PDF file.
An integrated approach to adult chronic osteomyelitis.
(2014) Marais, Leonard Charles.; Aldous, Colleen Michelle.
No evidence-based guidelines exist on the treatment of chronic osteomyelitis of long bones in adults. Management is still largely based on expert opinion and consensus guidelines are not available. Choosing between a palliative and curative treatment strategy requires consideration of several factors. Principle amongst these is the host’s physiological status, which determines the patient’s ability to cope with the rigours of limb salvage surgery. This fact was recognized by Cierny and Mader, when they developed their popular staging system. The authors suggested palliative treatment in C-hosts, who will not be able to cope with the metabolic demands of an aggressive treatment plan. The problem however, is that the C-host was never accurately defined. Cierny and Mader predicted in their original paper that, as a result of the inadequate definition, the selection of surgical candidates would vary from institution to institution until there was standardization of this concept. The limitations of existing classification systems prompted the development of a novel approach to chronic osteomyelitis for use in South Africa. This involved the establishment of an objective definition of a C-host, as well the development of a novel classification system and an algorithmic guideline to treatment strategy selection. By integrating the physiological status of the host (based on pragmatic predefined criteria) with the selection of the appropriate curative, palliative or alternative treatment strategy we were able to achieve favourable short term outcomes in both low and high risk cases and in addition reduce the rate of amputation. Furthermore, we were able to report novel data on the outcome of palliative treatment, as well as the outcome of treatment of chronic osteomyelitis in HIV infected patients. While the preliminary results appear promising, long term follow-up will be required in order to determine the rate of recurrence of infection. The proposed approach was designed specifically with the South African clinical environment in mind and additional development of the algorithm may be required in order to render it useful in other clinical settings. The implementation of a refined host stratification, which incorporates objective criteria for C-host classification will, however, enable the comparison of results from studies employing different therapeutic interventions in the future. In addition, selection of patient-matched treatment options closes the gap in successful outcomes between healthy and compromised patients. The major benefit of the proposed approach is therefore the fact that the integrated approach places appropriate emphasis on the importance of host factor modification prior to surgical intervention.
An investigation into the renewed need for the care and prevention of congenital disorders in South Africa.
(2017) Malherbe, Helen.; Aldous, Colleen Michelle.
Abstract available in PDF file.
The outcome of tibial non-union treatment using a revised definition, classification system and management strategy.
(2015) Ferreira, Nando.; Aldous, Colleen Michelle.
The management of tibial non-unions remains a challenge for orthopaedic surgeons. The treatment of tibial non-unions is historically based on small case series that frequently include a variety of non-union subtypes and infected cases. Fixation methods and treatment strategies also vary greatly between published series. This lack of uniformity in the available literature has rendered the establishment of evidence-based, reproducible protocols for the management of tibial non-unions difficult. Controversies regarding non-union definition and classification contribute to delays in treatment and exacerbate the morbidity that is commonly associated with non-union development. In this work we propose a new definition for non-union and introduced a novel concept of ‘potential non-union’ to emphasise the importance of early recognition and referral. The lack of reproducible, evidence-based treatment protocols, combined with the large volume of tibial non-union cases managed in KwaZulu-Natal, South Africa, lead to the development of a tibial non-union treatment algorithm. This algorithm was based on results from two retrospective audits of patients with tibial non-unions who were managed with circular external fixators over a four-year period. The algorithm classifies non-unions into four distinct groups, each with a specific treatment strategy. These reports also introduced the concept of mechano-biology to the management of tibial non-unions and were the first to use hexapod circular fixators for distraction of stiff hypertrophic tibial non-unions. Subsequently a prospective interventional study was undertaken aimed at evaluating the effectiveness of the proposed tibial non-union treatment algorithm.
Post -trauma MRI knee interpretation: our experience with a mechanism-based approach in South African setting.
(2017) Stutterheim, James.; Goodier, Matthew David Meriton.; Aldous, Colleen Michelle.
A mechanism-based approach to the interpretation of complex knee injuries at magnetic resonance imaging (MRI) is cited by several authors to provide increased reporting accuracy and efficiency by allowing accurate prediction of injury to at-risk structures. We took interest in the clinical benefits proposed for such an approach, and set out to assess the approach’s validity in our local South African setting. We identified in the recent literature a consolidated mechanism-based pattern approach to complex post-trauma MRI knee interpretation compiled by Hayes et al., which showed high validity of 85% in a North American setting, and set out to test this approach in our resource-constrained South African setting. We found a low percentage (average 19%) of knee injuries classifiable by mechanism using the Hayes et al. classification. Statistically there was fair agreement between the two observers. We conclude, based on remediable limiting factors, that the clinical benefit of a mechanism-based interpretation approach could be optimised in our resource constrained setting by focusing its application on cases imaged within a time window when key injury findings such as bone bruising and soft tissue injury will be optimally detectable, as well as in patients injured in sporting and similar athletic activities. We advocate that the development of a digital MRI image reference tool for the implementation of the Hayes et al. classification could simplify and enhance its application.
Revisiting the critical role of minimal invasive surgery (laparoscopy) in the management of trauma patients at a dedicated trauma unit at the Dr George Mukhari Academic Hospital, Pretoria, South Africa.
(2018) Modise, Zacharia Koto.; Aldous, Colleen Michelle.; Madiba, Thandinkosi Enos.
Background South Africa, as a low to middle income country (LMIC), is plagued by a quadruple burden on health-care, namely trauma; the human immuno-deficiency virus (HIV) with concomitant tuberculosis infection; maternal death; non-communicable diseases such as diabetes and hypertension. The impact of trauma on an already over-burdened public sector has been profound. Improving surgical outcomes is a global health priority according to the Lancet commission. One of the World Health Organization (WHO) mandates is to improve surgical care across the globe. In addressing this question, the WHO has suggested what is referred to as a list of Bellwether procedures. This is a list of important and common procedures that account for major mortalities in developing countries. The main goal of the list is to build proficiency and dexterity in these procedures so as to reduce mortality. This includes trauma laparotomy and other surgical procedures in emergencies. The traditional approach to managing trauma patients is premised on the well-established Advanced Trauma Life Support (ATLS) principles. This well documented approach has been shown to significantly improve health outcomes of trauma victims. Closely connected to this treatment pathway are surgical interventions that have also been shown to improve the health outcomes of trauma patients. At the heart of surgical intervention for abdominal trauma, is the tried and tested laparotomy. When one looks at this, from a health economics stand-point and a cost-effective platform, laparotomy has been shown to be cost-effective and life-saving. That said, laparotomy is not without major adverse outcomes; there has been significant morbidity and, in some cases, even mortality resulting from laparotomy reported by some investigators. Laparoscopy started in earnest during the 1980s with the first laparoscopic cholecystectomy described by Muhë from Germany and later popularised by Phillip Mourret of France. This was the start of a major surgical revolution that engulfed the whole surgical community. Laparoscopic cholecystectomy became the pivot around which this revolution evolved and gathered momentum. Indeed, there has been a sea-change of surgical procedures carried out laparoscopically since its evolution and rapid development of laparoscopic cholecystectomy. The benefits of laparoscopy and other minimally invasive procedures are well documented. Despite overwhelming evidence that supports the use of laparoscopy in surgery in general, there has been reluctance in the uptake of this procedure in trauma for a number of reasons; chief of which is the fear of missed injuries. This fear was fuelled by the publication by Ivatury and colleagues citing a high rate of missed small bowel injuries in trauma patients. Consequently, there was a large hiatus in the application of this technique in the management of trauma patients and, as expected, trauma has lagged behind in the uptake of laparoscopy and continues to do so today. A great deal has happened since the publication of the work by Ivatury and colleagues. The quality of laparoscopic cameras has improved significantly and more importantly, the average surgeon’s skills-set in laparoscopy has improved considerably. The rationale for my research was to look critically at our experience with laparoscopy, appraise the available data and see how this would impact on the tried and tested practice prevalent in the trauma arena, leading to a new paradigm being set in the laparoscopic management of trauma patients that are hemodynamically stable in the South African milieu. Aims The aim of this work was to critically evaluate the role and safety of laparoscopy in the management of stable trauma patients presenting at the dedicated trauma unit of the Dr George Mukhari Academic Hospital (DGMAH). Objectives We set out to investigate the role of laparoscopy in the following ways, in trauma scenarios: • laparoscopy as a diagnostic tool and how the risk of missed injuries should be addressed and minimized; • the role of laparoscopy in the management of thoraco-abdominal injuries, including right-sided injuries and also in patients with generalized peritonitis who are hemodynamically stable; • the appropriate access technique by a way of randomized controlled trial when offering these patients laparoscopy; • diagnostic accuracy of laparoscopy in trauma - how not to miss injuries; laparoscopic-assisted techniques as a strategy to address multiple injuries and therefore address gaps in skills-set and shorten the operative time of these trauma victims; • laparoscopic management of hemodynamically stable patients with blunt abdominal trauma; • the role of laparoscopy in the management of penetrating retroperitoneal injuries in hemodynamically stable patients. Methods The Trauma Unit of DGMAH has a prospectively collected database which was used to peruse the records of recruited participants for this work. Permission was sought from the Institutional Review Board of the Sefako Makgatho Health Sciences University (SMU) in accordance with the Helsinki Declaration that guides the conduct of biomedical research. Inclusion criteria were set for the various objectives of the study. We investigated the cohort of patients where laparoscopy was used within the setting of diagnosis of abdominal injuries and identified defined primary endpoints and outcomes. We also analysed the interventional strategies that were employed to achieve the desired end result. To begin with a laparoscope, the first step is safe access into the peritoneal cavity. A one-toone computer-generated randomized study was carried out comparing the traditional laparoscopic access to peritoneal cavity using Veress needle with the open Hasson technique. Unlike other studies, in this series we included patients who had had a previous laparotomy to address the question of safe abdominal access during laparoscopic procedures. We identified all major and minor complications as the primary outcome. We determined the outcomes of patients offered laparoscopic procedure in the following situations: thoraco-abdominal injuries where the primary focus was diaphragmatic injuries both on the left and right diaphragms. In this study we included patients with both peritonitis and right sided thoraco-abdominal injuries. We studied the outcomes of laparoscopy in the case of blunt trauma, penetrating retroperitoneal injuries. We also investigated the role of laparoscopy in the context of diagnosis and specifically identified factors that mitigate against missing injuries and suggested a management pathway to minimize the incidence of missed injuries. The overall primary outcome was all-cause mortality and complications. Findings Fifty (52%) patients were randomized to the closed Veress needle and 46 (48%) patients to the open Hasson technique. Six (6%) adverse events were recorded in the Veress needle arm (p=0.03). The Veress needle technique failed to establish pneumoperitoneum in three patients (6%), the port-site bleeding was observed in one (2%) and extraperitoneal insufflation in two (4%) patients. All patients with the adverse events had previous abdominal surgery. There were no adverse events in the open Hasson group. In the work on laparoscopy and how not to miss injuries, out of 250 patients managed with laparoscopy for penetrating abdominal trauma(PAT), 113(45%) underwent diagnostic laparoscopy (DL), of these 94(83%) of patients underwent stab wounds. The penetration of the peritoneal cavity or retroperitoneal cavity or peritoneal cavity was documented in 67(59%) of the patients. Organ evisceration was present in 21(19%) of patients. Multiple injuries were present in 22% of cases. The chest was most common associated injury. Two (1,8%) iatrogenic injuries were recorded. There was conversion rate of 1,7%(2/115). The mean length of hospital stay was 4 days. There were no missed injuries. Laparoscopic assisted approach (LAA)in multiple injuries is work aimed at addressing the problem of multiple injuries in laparoscopy. This work demonstrates the utility of laparoscopy in this setting. The procedure is to evaluate the effect LAA in multiple injuries. Over 2-year period 23 patients were managed with LAA and of these 13 were patients with stab wounds and 10 with gunshot wounds. Commonly performed procedure was repair of hollow viscus injury For thoracoabdominal injury, a total of 83 patients with thoracoabdomial injuries met the seletcion criteria. The injury sverity score (ISS) ranged from 8 to 24 with a median of 18. The incidence of diaphragmatic hernia was 54%. Majority (46,8%) had grade3 (2-10cm) laceration. Associated injuries encountered reqiring interventions we encountered in 28(62%). At least 93,3% of the patients wee treated exclusively with laparoscopy . the morbidity was encountrerd in 7(16%) of the patients. The commonest was cloteed hemothorax Clavian Dindo (ii)b , but only one patient required decortication.There was one procedure related mortality. In laparoscopy management of retropritoneal injuries in hemodynamically stable patients, of 284 with PAT 56 had involvement of the retroperitoneum. Stab wounds accounted accounted for 62,5% of the patients . the mean ISS score was 7,4(4-20). Amongst the the retroperitoneal injuries the colon (27%) was the most commonly injured hollow viscus followed bt the duodenum (5%). The kidney (5%) and pancrease(4%) were the commonly injured solid organs. The conversion rate was 19,6% and this was mainly due to active bleeding. Significantly more patients were with GSW had their procedures converted to open laparotomy(38% vs 9%). Therapeutic laparoscopy wa sperformed in 36% of the pateints. The were no recorded missed injuries. Five (9%) patients developed Clavien-Dindo grade 3 complications , three were managed with reoperation, one with drainage and one with endovascular technique In laparoscopy for blunt trauma, a chalenging endeavour- Thirty-five stable patients underwent laparoscopy. The mean Injury Severity score was 12 (4-38). Therapeutic laparoscopy was performed in 15 (56%) and diagnostic in 12 (44%) patients. Eight (23%) patients were converted to therapeutic laparotomy. Intraoperative bleeding, complex injuries, visualization problem and equipment failure necessitated conversion. Three (30%) patients with negative CT scan had therapeutic laparoscopy for mesenteric injuries. There were no missed injuries. The mean length of hospital stay was 11 days in both groups. This series of studies shows that laparoscopy in all the stated objectives was safe and feasible. Multiple laparoscopic interventions in the different trauma scenarios have demonstrated the safety of laparoscopy in haemodynamically stable trauma patients. Contrary to the suggestion by other investigators, that laparoscopy is contraindicated in retroperitoneal injuries, the current study in retroperitoneal trauma has shown that it was safe and accurate in this cohort of patients. Therapeutic laparoscopy was feasible in 36% of the patients and the conversion rate was 19%. Importantly there were no missed injuries or mortality when managing penetrating trauma patients with retroperitoneal injuries. Therapeutic laparoscopy was feasible in thoraco-abdominal injuries and these patients were successfully managed, including those with generalized peritonitis. The study of thoracoabdominal injuries, including those with peritonitis, also included patients with injuries to the right side of the abdomen, as well as individuals with generalized peritonitis. We were able to offer therapeutic and diagnostic laparoscopy to this cohort of patient. Conclusions In conclusion, laparoscopy is feasible and safe in hemodynamically stable trauma patients in the context of thoraco-abdominal injuries, blunt abdominal trauma, in the presence of peritonitis as well as in laparoscopic-assisted setting, both as a strategy to reduce the incidence of nonremedial laparotomies as well as a diagnostic tool.
Spectrum and cost of road traffic crashes : data from a regional South African hospital.
(2014) Parkinson, Frances.; Clarke, Damian Luiz.; Aldous, Colleen Michelle.
Road traffic crashes (RTCs) are a worldwide phenomenon, but a disproportionate number of deaths and injuries caused by RTCs occur in developing countries. A number of international organisations have drawn attention to the problem and called for a comprehensive public health response. Such a programme needs to be multi-faceted and use preventative and therapeutic strategies and also involve a wide range of stakeholders from government and civil society. In South Africa, the Province of KwaZulu-Natal (KZN) has the worst record for the number of deaths and injuries sustained on the roads. Despite the urgent need for such programmes in the Province there is a paucity of local research on the problem. This project sees itself as part of an ongoing systematic comprehensive quality improvement initiative. The objectives of this single-centre study are to determine common patterns of injury associated with road traffic crashes in KZN, to identify risk factors which may be targeted by specific injury prevention programmes and to establish the in-hospital cost of RTCs. This will be done by identifying a cohort of patients with injuries sustained in RTCs, gathering data on their injuries and circumstances of the crash, and costing their inpatient stay using micro-costing methods. It is hoped that this information on the burden of disease (including cost) will be incentive for investment in local healthcare and risk-reducing measures (relevant to local risk factors). The costs may also serve as a baseline for larger province-wide costing studies.
The spectrum, outcomes and costs of acute appendicitis at Edendale Hospital and its related catchment areas.
(2014) Kong, Victor.; Aldous, Colleen Michelle.; Clarke, Damian Luiz.
Abstract available in PDF file.
The use of paper tape application in skin tissue expansion and abnormal scar modulation.
(2016) Daya, Mahendra.; Aldous, Colleen Michelle.; Orgill, Dennis.
Abstract available PDF file.

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