Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420150006&lang=es vol. 105 num. 6 lang. es <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>A good complaints system</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600001&lng=es&nrm=iso&tlng=es <![CDATA[<b>Editor's choice</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600002&lng=es&nrm=iso&tlng=es <![CDATA[<b>Patient satisfaction with emergency departments</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600003&lng=es&nrm=iso&tlng=es <![CDATA[<b>Stellenbosch University: Africa's first WHO Bioethics Collaborating Centre</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600004&lng=es&nrm=iso&tlng=es <![CDATA[<b>Healthcare workers baulk at caring for contagious patients</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600005&lng=es&nrm=iso&tlng=es <![CDATA[<b>Judge nudges dormant euthanasia draft law</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600006&lng=es&nrm=iso&tlng=es <![CDATA[<b>The Fabricius decision on the Stransham-Ford case - an enlightened step in the right direction</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600007&lng=es&nrm=iso&tlng=es <![CDATA[<b>Robotic computer system develops high-skill 'technosurgeons'</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600008&lng=es&nrm=iso&tlng=es <![CDATA[<b>Management of pulmonary hypertension</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600009&lng=es&nrm=iso&tlng=es Pulmonary arterial hypertension (PAH) is a potentially lethal disease mainly affecting young females. Although the precise mechanism of PAH is unknown, the past decade has seen the advent of many new classes of drugs with improvement in the overall prognosis of the disease. Unfortunately the therapeutic options for PAH in South Africa are severely limited. The Working Group on PAH is a joint effort by the South African Heart Association and the South African Thoracic Society tasked with improving the recognition and management of patients with PAH. This article provides a brief summary of the disease and the recommendations of the first meeting of the Working Group. <![CDATA[<b>Rural district hospitals - essential cogs in the district health system - and primary healthcare re-engineering</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600010&lng=es&nrm=iso&tlng=es The re-engineering of primary healthcare (PHC) is regarded as an essential precursor to the implementation of National Health Insurance in South Africa, but improvements in the provision of PHC services have been patchy. The authors contend that the role of well-functioning rural district hospitals as a hub from which PHC services can be most efficiently managed has been underestimated, and that the management of district hospitals and PHC clinics need to be co-located at the level of the rural district hospital, to allow for proper integration of care and effective healthcare provision. <![CDATA[<b>Encephalopathy after persistent vomiting: Three cases of non-alcohol-related Wernicke's encephalopathy</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600011&lng=es&nrm=iso&tlng=es Wernicke's encephalopathy (WE) is a medical emergency. Although WE is commonly viewed in the context of alcoholism, it can be caused by thiamine deficiency secondary to persistent vomiting. Non-alcohol-related WE may be more catastrophic in onset and less likely to present with the classic features than WE with alcoholism as a cause. We describe three cases of WE due to persistent vomiting without alcoholism in patients with hyperemesis gravidarum, drug-induced hyperlactataemia, and an acute gastrointestinal illness in an already malnourished individual. Our cases highlight the importance of recognising WE when undernutrition, which may be caused by gastrointestinal disease or surgery, or malignancy, is compounded by vomiting. Expert guidelines suggest that WE must be considered in the emergency room in any individual with disturbed consciousness of unknown cause. Treatment is with parenteral thiamine before glucose administration. <![CDATA[<b>A bedside system for clinical grading of parotid gland enlargement</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600012&lng=es&nrm=iso&tlng=es Wernicke's encephalopathy (WE) is a medical emergency. Although WE is commonly viewed in the context of alcoholism, it can be caused by thiamine deficiency secondary to persistent vomiting. Non-alcohol-related WE may be more catastrophic in onset and less likely to present with the classic features than WE with alcoholism as a cause. We describe three cases of WE due to persistent vomiting without alcoholism in patients with hyperemesis gravidarum, drug-induced hyperlactataemia, and an acute gastrointestinal illness in an already malnourished individual. Our cases highlight the importance of recognising WE when undernutrition, which may be caused by gastrointestinal disease or surgery, or malignancy, is compounded by vomiting. Expert guidelines suggest that WE must be considered in the emergency room in any individual with disturbed consciousness of unknown cause. Treatment is with parenteral thiamine before glucose administration. <![CDATA[<b>Reflections of a retiree: 40 years in public service at Chris Hani Baragwanath Academic Hospital</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600013&lng=es&nrm=iso&tlng=es Wernicke's encephalopathy (WE) is a medical emergency. Although WE is commonly viewed in the context of alcoholism, it can be caused by thiamine deficiency secondary to persistent vomiting. Non-alcohol-related WE may be more catastrophic in onset and less likely to present with the classic features than WE with alcoholism as a cause. We describe three cases of WE due to persistent vomiting without alcoholism in patients with hyperemesis gravidarum, drug-induced hyperlactataemia, and an acute gastrointestinal illness in an already malnourished individual. Our cases highlight the importance of recognising WE when undernutrition, which may be caused by gastrointestinal disease or surgery, or malignancy, is compounded by vomiting. Expert guidelines suggest that WE must be considered in the emergency room in any individual with disturbed consciousness of unknown cause. Treatment is with parenteral thiamine before glucose administration. <![CDATA[<b>Minimising the 'cost' of laparoscopic cholecystectomy</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600014&lng=es&nrm=iso&tlng=es Wernicke's encephalopathy (WE) is a medical emergency. Although WE is commonly viewed in the context of alcoholism, it can be caused by thiamine deficiency secondary to persistent vomiting. Non-alcohol-related WE may be more catastrophic in onset and less likely to present with the classic features than WE with alcoholism as a cause. We describe three cases of WE due to persistent vomiting without alcoholism in patients with hyperemesis gravidarum, drug-induced hyperlactataemia, and an acute gastrointestinal illness in an already malnourished individual. Our cases highlight the importance of recognising WE when undernutrition, which may be caused by gastrointestinal disease or surgery, or malignancy, is compounded by vomiting. Expert guidelines suggest that WE must be considered in the emergency room in any individual with disturbed consciousness of unknown cause. Treatment is with parenteral thiamine before glucose administration. <![CDATA[<b>The management of burns begins at home</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600015&lng=es&nrm=iso&tlng=es Wernicke's encephalopathy (WE) is a medical emergency. Although WE is commonly viewed in the context of alcoholism, it can be caused by thiamine deficiency secondary to persistent vomiting. Non-alcohol-related WE may be more catastrophic in onset and less likely to present with the classic features than WE with alcoholism as a cause. We describe three cases of WE due to persistent vomiting without alcoholism in patients with hyperemesis gravidarum, drug-induced hyperlactataemia, and an acute gastrointestinal illness in an already malnourished individual. Our cases highlight the importance of recognising WE when undernutrition, which may be caused by gastrointestinal disease or surgery, or malignancy, is compounded by vomiting. Expert guidelines suggest that WE must be considered in the emergency room in any individual with disturbed consciousness of unknown cause. Treatment is with parenteral thiamine before glucose administration. <![CDATA[<b>Paediatric dental sedation: Will your child return home unharmed?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600016&lng=es&nrm=iso&tlng=es Wernicke's encephalopathy (WE) is a medical emergency. Although WE is commonly viewed in the context of alcoholism, it can be caused by thiamine deficiency secondary to persistent vomiting. Non-alcohol-related WE may be more catastrophic in onset and less likely to present with the classic features than WE with alcoholism as a cause. We describe three cases of WE due to persistent vomiting without alcoholism in patients with hyperemesis gravidarum, drug-induced hyperlactataemia, and an acute gastrointestinal illness in an already malnourished individual. Our cases highlight the importance of recognising WE when undernutrition, which may be caused by gastrointestinal disease or surgery, or malignancy, is compounded by vomiting. Expert guidelines suggest that WE must be considered in the emergency room in any individual with disturbed consciousness of unknown cause. Treatment is with parenteral thiamine before glucose administration. <![CDATA[<b>A cost analysis of operative repair of major laparoscopic bile duct injuries</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600017&lng=es&nrm=iso&tlng=es BACKGROUND: Major bile duct injuries occur infrequently after laparoscopic cholecystectomy, but may result in life-threatening complications. Few data exist on the financial implications of duct repair. This study calculated the costs of operative repair in a cohort of patients who underwent reconstruction of the bile duct after major ductal injury OBJECTIVE: To calculate the total in-hospital cost of surgical repair of patients referred with major bile duct injuries METHODS: A prospective database was reviewed to identify all patients referred to the University of Cape Town Private Academic Hospital, South Africa, between 2002 and 2013 for assessment and repair of major laparoscopic bile duct injuries. The detailed clinical records and billing information were evaluated to determine all costs from admission to discharge. Total costs for each patient were adjusted for inflation between the year of repair and 2013 RESULTS: Forty-four patients (33 women, 11 men; median age 48 years, range 30 - 78) underwent reconstruction of a major bile duct injury. First-time repairs were performed at a median of 24.5 days (range 1 - 3 662) after initial surgery. Median hospital stay was 15 days (range 6 -86). Mean cost of repair was ZAR215 711 (range ZAR68 764 - 980 830). Major contributors to cost were theatre expenses (22%), admission to intensive care (21%), radiology (17%) and specialist fees (12%). Admission to a general ward (10%), consumables (7%), pharmacy (5%), endoscopy (3%) and laboratory costs (3%) made up the balance CONCLUSIONS: The cost of repair of a major laparoscopic bile duct injury is substantial owing to prolonged hospitalisation, complex surgical intervention and intensive imaging requirements. <![CDATA[<b>Prehospital cooling of severe burns: Experience of the Emergency Department at Edendale Hospital, KwaZulu-Natal, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600018&lng=es&nrm=iso&tlng=es BACKGROUND: Early cooling with 10 - 20 minutes of cool running water up to 3 hours after a burn has a direct impact on the depth of the burn and therefore on the clinical outcome of the injury. An assessment of the early cooling of burns is essential to improve this aspect of burns management OBJECTIVES: To assess the rates and adequacy of prehospital cooling received by patients with severe burns before presentation to the Emergency Department (ED) at Edendale Hospital, Pietermaritzburg, South Africa. Patients with inadequate prehospital cooling who presented to the ED within 3 hours were also identified METHODS: A retrospective review of the burns database for all the patients with severe burns admitted from the ED at Edendale Hospital from September 2012 to August 2013 was undertaken. Demographic details, characteristics and timing of the burns, and presentation were correlated with burn cooling RESULTS: Ninety patients were admitted with severe burns. None received sufficient cooling of their burns, 25.6% received cooling of inadequate duration, and 32.3% arrived at the ED within 3 hours after the burn with either inadequate or no cooling. The median time to presentation to the ED after the burn was 260 minutes CONCLUSION: Appropriate cooling of severe burns presenting to Edendale Hospital is inadequate. Education of the community and prehospital healthcare workers about the importance of early appropriate cooling of severe burns is required. Many patients would benefit from cooling of their burns in the ED, and facilities should be provided for this vital function. <![CDATA[<b>Paediatric dental chair sedation: An audit of current practice in Gauteng, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600019&lng=es&nrm=iso&tlng=es BACKGROUND: Procedural sedation and analgesia (PSA) is often required to perform dental procedures in children. Serious adverse outcomes, while rare, are usually preventable OBJECTIVES: To determine the proportion of dental practitioners making use of paediatric dental chair PSA in Gauteng Province, South Africa, describe their PSA practice, and determine compliance with recommended safety standards METHOD: A prospective, contextual, descriptive study design was used, with 222 randomly selected dental practitioners contacted to determine whether they offered paediatric dental chair PSA. Practitioners offering PSA were then asked to complete a web-based questionnaire assessing their practice RESULTS: Of the 213 dental practitioners contacted, 94 (44.1%; 95% confidence interval 37 - 51) provided PSA to children. Most patients were 1 - 5 years old, although there were practices that offered PSA to infants. While most procedures were performed under minimal to moderate sedation, deep sedation and general anaesthesia were also administered in dental rooms. Midazolam was the most frequently used sedative agent, often in conjunction with inhaled nitrous oxide; 28.1% of PSA providers administered a combination of three or more agents. Presedation patient assessment was documented in 83.0% of cases, and informed consent for sedation was obtained in 75.6%. The survey raised several areas of concern regarding patient safety: 41.3% of dental practices did not use any monitoring equipment during sedation; the operator was responsible for the sedation and monitoring of the patient in 41.3%; 43.2% did not keep any recommended emergency drugs; and 19.6% did not have any emergency or resuscitation equipment available. Most respondents (81.8%) indicated an interest in sedation training CONCLUSION: Paediatric dental chair PSA was offered by 44.1% of dental practitioners interviewed in Gauteng. Modalities of PSA provided varied between practices, with a number of safety concerns being raised. <![CDATA[<b>The South African Surgical Outcomes Study: A 7-day prospective observational cohort study</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600020&lng=es&nrm=iso&tlng=es BACKGROUND: Non-cardiac surgical morbidity and mortality is a major global public health burden. Sub-Saharan African perioperative outcome data are scarce. South Africa (SA) faces a unique public health challenge, engulfed as it is by four simultaneous epidemics: (i) poverty-related diseases; (ii) non-communicable diseases; (iii) HIV and related diseases; and (iv) injury and violence. Understanding the effects of these epidemics on perioperative outcomes may provide an important perspective on the surgical health of the country. OBJECTIVES: To investigate the perioperative mortality and need for critical care admission in patients undergoing inpatient non-cardiac surgery in SA. METHODS: A 7-day national, multicentre, prospective, observational cohort study of all patients >16 years of age undergoing inpatient non-cardiac surgery between 19 and 26 May 2014 at 50 public sector, government-funded hospitals in SA. RESULTS: The study included 3 927/4 021 eligible patients (97.7%) recruited, with 45/50 hospitals (90.0%) submitting data that described all eligible patients. Crude in-hospital mortality was 123/3 927 (3.1%; 95% confidence interval (CI) 2.6 - 3.7). The rate of postoperative admission to critical care units was 255/3 927 (6.5%; 95% CI 5.7 - 7.3), with 43.5% of admissions being unplanned. Of the surgical procedures 2 120/3 915 (54.2%) were urgent or emergency ones, with a population-attributable risk for mortality of 25.5% (95% CI 5.1 -55.8) and a risk of admission to critical care of 23.7% (95% CI 4.7 - 51.4). CONCLUSIONS: Most patients in SA's public sector hospitals undergo urgent and emergency surgery, which is strongly associated with mortality and unplanned critical care admissions. Non-communicable diseases have a larger proportional contribution to mortality than infections and injuries. However, the most common comorbidity, HIV infection, was not associated with in-hospital mortality. The study was registered on ClinicalTrials.gov (NCT02141867). <![CDATA[<b>The impact of acute preoperative beta-blockade on perioperative cardiac morbidity and all-cause mortality in hypertensive South African vascular surgery patients</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600021&lng=es&nrm=iso&tlng=es BACKGROUND: Acute β-blockade has been associated with poor perioperative outcomes in non-cardiac surgery patients, probably as a result of β-blocker-induced haemodynamic instability during the perioperative period, which has been shown to be more severe in hypertensive patients. OBJECTIVE: To determine the impact of acute preoperative β-blockade on the incidence of perioperative cardiovascular morbidity and all-cause mortality in hypertensive South African (SA) patients who underwent vascular surgery at a tertiary hospital. METHODS: We conducted two separate case-control analyses to determine the impact of acute preoperative β-blockade on the incidence of major adverse cardiovascular events (MACEs, a composite outcome of a perioperative troponin-I leak or all-cause mortality) and perioperative troponin-I leak alone. Case and control groups were compared using χ², Fisher's exact, McNemar's or Student's t-tests, where applicable. Binary logistic regression was used to determine whether acute preoperative β-blocker use was an independent predictor of perioperative MACEs/troponin-I leak in hypertensive SA vascular surgery patients. RESULTS: We found acute preoperative β-blockade to be an independent predictor of perioperative MACEs (odds ratio (OR) 3.496; 95% confidence interval (CI) 1.948 - 6.273; p<0.001) and troponin-I leak (OR 5.962; 95% CI 3.085 - 11.52; p<0.001) in hypertensive SA vascular surgery patients. CONCLUSIONS: Our findings suggest that acute preoperative β-blockade is associated with an increased risk of perioperative cardiac morbidity and all-cause mortality in hypertensive SA vascular surgery patients. <![CDATA[<b>Granulomas at initial diagnosis of Crohn's disease signal a poor outcome</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600022&lng=es&nrm=iso&tlng=es BACKGROUND: Over time, most patients with Crohn's disease (CD) develop strictures or fistulas, resulting in hospitalisations and surgery. Timely therapy with immunomodulators and biologicals may alter this natural history, but carries a significant risk of side-effects. OBJECTIVE: To identify factors to predict poor-outcome severe CD at diagnosis, and thus patients who would benefit most from early, aggressive medical therapies. METHODS: CD patients (n=101) with uncomplicated non-stricturing, non-penetrating disease at diagnosis, and with follow-up >5 years, were retrospectively analysed using a predefined definition of severe CD (SCD) over the disease course. Clinical, demographic, laboratory and histological factors at diagnosis associated with SCD and poor outcome were evaluated by univariate and multivariate analysis. RESULTS: Overall 33.7% of the cohort developed SCD, and on multivariate Cox proportional hazard analysis the presence of granulomas on endoscopic biopsy at diagnosis was independently associated with development of SCD (hazard ratio (HR) 2.3; 95% confidence interval (CI) 1.15 - 4.64; p=0.02). Simple perianal disease was also associated with this outcome (HR 2.49; 95% CI 1.14 - 5.41; p=0.02). The presence of these variables had a specificity of 99% and a positive predictive value of 88%. CONCLUSION: At diagnosis, factors predictive of SCD in our referral centre were the presence of endoscopic biopsy granulomas and perianal disease. Patients with these risk factors should be considered for early, aggressive medical therapy, as benefit will probably outweigh risk. To our knowledge, this is the first study to show that endoscopic biopsy granulomas in patients with uncomplicated (non-stricturing, non-penetrating) CD predict the subsequent development of SCD. <![CDATA[<b>Waiting times for prostate cancer diagnosis in KwaZulu-Natal, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600023&lng=es&nrm=iso&tlng=es BACKGROUND: There is currently no evidence in the South African (SA) literature to suggest how long patients with clinically suspected prostate cancer (an elevated prostate-specific antigen level or abnormal findings on digital rectal examination) wait to have a prostate biopsy. OBJECTIVES: To improve the overall efficiency of the prostate biopsy service offered at St Aidan's Regional Hospital, Durban, SA, by quantifying the burden of disease and waiting times and to identify potential delays in management outcomes, thereby helping to alleviate patient anxiety during the stressful period of investigation. METHODS: We did a retrospective folder review of patients who underwent trans-rectal prostate biopsy at St Aidan's Hospital, where the vast majority of prostate biopsies in the KwaZulu-Natal state healthcare sector are performed, from January to June 2013. The Statistical Package for Social Sciences was used for data analysis. RESULTS: One hundred and six patients (mean age 67.6 years, 69.8% black Africans) underwent biopsy during the 6-month study period; 49.1% were found to have adenocarcinoma, and of the 80.1% of these who had a bone scan, 73.8% had skeletal metastases (p=0.1379). The median period of time from referral to biopsy was 55 days, from referral to first follow-up date (when the diagnosis is given and treatment options discussed or instituted) 100 days, and from biopsy to first follow-up date (i.e. waiting period to retrieve histological diagnosis) 36 days. CONCLUSION: Despite the late presentation of prostate cancer in KZN, patients are waiting an average of 3 months from initial referral for a prostate biopsy to institution of definitive management. <![CDATA[<b>The appropriateness of preoperative blood testing: A retrospective evaluation and cost analysis</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600024&lng=es&nrm=iso&tlng=es BACKGROUND: Inappropriate preoperative blood testing can negatively contribute to healthcare costs OBJECTIVE: To determine the extent and cost implications of inappropriate preoperative blood testing in adult patients booked for orthopaedic, general or trauma surgical procedures at a regional hospital in KwaZulu-Natal Province, South Africa (SA METHODS: We undertook a retrospective observational study using routine clinical data collected from eligible patient charts. The appropriateness of preoperative blood tests was evaluated against locally published guidelines on testing for elective and non-elective surgery. The cost of the relevant blood tests was determined using the National Health Laboratory Service 2014 State Pricing List RESULTS: A total of 320 eligible patient charts were reviewed over a 4-week period. Preoperative blood testing was performed in 318 patients. There was poor compliance with current departmental guidelines, with an estimated over-expenditure of ZAR81 019. Non-compliance was particularly prevalent in younger patients, patients graded as American Society of Anesthesiologists 1 and 2, and low-risk surgery groups CONCLUSION: Inappropriate preoperative blood testing is common in our hospital, particularly in low-risk patients. This is associated with an increase in healthcare costs, and highlights the need for SA doctors to become more cost-conscious in their approach to blood testing practices. <![CDATA[<b>Analysis of referrals and triage patterns in a South African metropolitan adult intensive care service</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600025&lng=es&nrm=iso&tlng=es BACKGROUND: Intensive care unit (ICU) beds are scarce resources in low- and middle-income countries. Currently there is little literature that quantifies the extent of the demand placed on these resources or examines their allocation. OBJECTIVES: To analyse the number and nature of referrals to ICUs in the Pietermaritzburg metropolitan area, South Africa, over a 1-year period, to observe the triage process involved in selecting patients for admission. METHODS: A retrospective review of the patients referred to ICUs at Grey's and Edendale hospitals, Pietermaritzburg, was performed over a year. The spectrum of patients was evaluated with respect to various demographics, and the current triage process was observed. RESULTS: The Pietermaritzburg Metropolitan Critical Care service (PMCCS) received 2 081 patient referrals, 53.4% (1 111/2 081) of males and 46.6% (970/2 081) of females, with a mean patient age of 32 years. The majority of referrals were of surgical patients (39.3%, 818/2 081), followed by medical (18.9%, 393/2 081), trauma (18.6%, 387/2 081) and obstetrics and gynaecology (11.7%, 244/2 081). The chief indications for referral were the need for cardiovascular and respiratory support. Of these referrals, 72.0% (1 499/2 081) were accepted and planned for admission and 28.0% (582/2 081) were refused ICU care. Of the patients accepted, 60.7% (910/1 499) experienced delays prior to admission and 37.4% (561/1 499) were never physically admitted to the units. CONCLUSIONS: The PMCCS receives a far greater number of patient referrals than it is able to accommodate, necessitating triage. Patient demographics reflect a young patient population referred with chiefly surgical pathology needing physiological support. <![CDATA[<b>Outcomes of vitrectomy for advanced diabetic retinopathy at Groote Schuur Hospital, Cape Town, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600026&lng=es&nrm=iso&tlng=es BACKGROUND: Present limitations in primary and secondary prevention of diabetic retinopathy mean that many patients with diabetes present with advanced retinal complications, often requiring surgery (vitrectomy). OBJECTIVES: To determine the outcomes of vitrectomy for advanced diabetic retinopathy and to examine context-specific risk factors that may influence outcomes and decisions affecting resource allocation. METHODS: This was a retrospective cohort study of 124 vitrectomies with up to 6 months' follow-up. RESULTS: Visual acuity was 6/60 or worse in the better eye in 23.4% of patients at presentation. The mean visual acuity of the listed eye was 2/60. The fellow eye was considered inoperable in 20.2% of cases. Visual function declined significantly in 26.2% of patients while awaiting surgery. The average waiting time until surgery was 2.9 months (range 1 day - 9 months). Epiretinal membranes were present in 93.6% of cases, and posterior iatrogenic breaks occurred in 49.2%. Silicone oil was used in 24.2%. Visual acuity improved in 54.9%, was unchanged in 30.1%, and worsened in 14.0% of cases at 6 months. Patients with poorer vision at surgery were more likely to improve (odds ratio 2.15; p=0.048). Factors associated with a worse visual outcome were increased age at surgery (p=0.042) and posterior iatrogenic retinal breaks (p=0.007). Renal dysfunction was not associated with worse visual outcomes. CONCLUSION: Vitrectomy improved or stabilised vision in 85.0% of cases, although outcomes were unpredictable. A long waiting time to surgery contributed to patient morbidity. The presence of renal dysfunction did not predict poorer visual outcomes. <![CDATA[<b>Trauma care - the Eastern Cape story</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600027&lng=es&nrm=iso&tlng=es BACKGROUND: Present limitations in primary and secondary prevention of diabetic retinopathy mean that many patients with diabetes present with advanced retinal complications, often requiring surgery (vitrectomy). OBJECTIVES: To determine the outcomes of vitrectomy for advanced diabetic retinopathy and to examine context-specific risk factors that may influence outcomes and decisions affecting resource allocation. METHODS: This was a retrospective cohort study of 124 vitrectomies with up to 6 months' follow-up. RESULTS: Visual acuity was 6/60 or worse in the better eye in 23.4% of patients at presentation. The mean visual acuity of the listed eye was 2/60. The fellow eye was considered inoperable in 20.2% of cases. Visual function declined significantly in 26.2% of patients while awaiting surgery. The average waiting time until surgery was 2.9 months (range 1 day - 9 months). Epiretinal membranes were present in 93.6% of cases, and posterior iatrogenic breaks occurred in 49.2%. Silicone oil was used in 24.2%. Visual acuity improved in 54.9%, was unchanged in 30.1%, and worsened in 14.0% of cases at 6 months. Patients with poorer vision at surgery were more likely to improve (odds ratio 2.15; p=0.048). Factors associated with a worse visual outcome were increased age at surgery (p=0.042) and posterior iatrogenic retinal breaks (p=0.007). Renal dysfunction was not associated with worse visual outcomes. CONCLUSION: Vitrectomy improved or stabilised vision in 85.0% of cases, although outcomes were unpredictable. A long waiting time to surgery contributed to patient morbidity. The presence of renal dysfunction did not predict poorer visual outcomes. <![CDATA[<b>Introduction to algorithms for managing the common trauma patient</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600028&lng=es&nrm=iso&tlng=es BACKGROUND: Present limitations in primary and secondary prevention of diabetic retinopathy mean that many patients with diabetes present with advanced retinal complications, often requiring surgery (vitrectomy). OBJECTIVES: To determine the outcomes of vitrectomy for advanced diabetic retinopathy and to examine context-specific risk factors that may influence outcomes and decisions affecting resource allocation. METHODS: This was a retrospective cohort study of 124 vitrectomies with up to 6 months' follow-up. RESULTS: Visual acuity was 6/60 or worse in the better eye in 23.4% of patients at presentation. The mean visual acuity of the listed eye was 2/60. The fellow eye was considered inoperable in 20.2% of cases. Visual function declined significantly in 26.2% of patients while awaiting surgery. The average waiting time until surgery was 2.9 months (range 1 day - 9 months). Epiretinal membranes were present in 93.6% of cases, and posterior iatrogenic breaks occurred in 49.2%. Silicone oil was used in 24.2%. Visual acuity improved in 54.9%, was unchanged in 30.1%, and worsened in 14.0% of cases at 6 months. Patients with poorer vision at surgery were more likely to improve (odds ratio 2.15; p=0.048). Factors associated with a worse visual outcome were increased age at surgery (p=0.042) and posterior iatrogenic retinal breaks (p=0.007). Renal dysfunction was not associated with worse visual outcomes. CONCLUSION: Vitrectomy improved or stabilised vision in 85.0% of cases, although outcomes were unpredictable. A long waiting time to surgery contributed to patient morbidity. The presence of renal dysfunction did not predict poorer visual outcomes. <![CDATA[<b>Algorithms for managing the common trauma patient</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742015000600029&lng=es&nrm=iso&tlng=es BACKGROUND: Present limitations in primary and secondary prevention of diabetic retinopathy mean that many patients with diabetes present with advanced retinal complications, often requiring surgery (vitrectomy). OBJECTIVES: To determine the outcomes of vitrectomy for advanced diabetic retinopathy and to examine context-specific risk factors that may influence outcomes and decisions affecting resource allocation. METHODS: This was a retrospective cohort study of 124 vitrectomies with up to 6 months' follow-up. RESULTS: Visual acuity was 6/60 or worse in the better eye in 23.4% of patients at presentation. The mean visual acuity of the listed eye was 2/60. The fellow eye was considered inoperable in 20.2% of cases. Visual function declined significantly in 26.2% of patients while awaiting surgery. The average waiting time until surgery was 2.9 months (range 1 day - 9 months). Epiretinal membranes were present in 93.6% of cases, and posterior iatrogenic breaks occurred in 49.2%. Silicone oil was used in 24.2%. Visual acuity improved in 54.9%, was unchanged in 30.1%, and worsened in 14.0% of cases at 6 months. Patients with poorer vision at surgery were more likely to improve (odds ratio 2.15; p=0.048). Factors associated with a worse visual outcome were increased age at surgery (p=0.042) and posterior iatrogenic retinal breaks (p=0.007). Renal dysfunction was not associated with worse visual outcomes. CONCLUSION: Vitrectomy improved or stabilised vision in 85.0% of cases, although outcomes were unpredictable. A long waiting time to surgery contributed to patient morbidity. The presence of renal dysfunction did not predict poorer visual outcomes.