Hospital In KwaZulu-Natal Province Research Articles

Towards 'Formalising' WhatsApp Teledermatology Practice in KZ-N District Hospitals: Key Informant Interviews.

District hospitals in KwaZulu-Natal Province, South Africa, do not have onsite specialist dermatology services. Doctors at these hospitals use WhatsApp instant messaging to informally seek advice from dermatologists and colleagues before possible referral. They have expressed the need to formalise WhatsApp teledermatology. To determine the views and perspectives of clinicians on the feasibility and practicality of formalising the current WhatsApp-based teledermatology activities within the KwaZulu-Natal Department of Health Dermatology Service. Key informant interviews with 12 purposively selected doctors at district hospitals and all 14 dermatologists in the KwaZulu-Natal dermatology service. Their views and perspectives on formalising the current informal use of WhatsApp for teledermatology were recorded, transcribed, and thematically analysed. Five primary themes (communication, usability, utility, process, and poor understanding of legal, regulatory, and ethical issues) and 22 sub-themes were identified. Clinicians wanted WhatsApp teledermatology to continue, be formalised, and be incorporated within the KwaZulu-Natal Department of Health, facilitated by the provision of practical guidelines addressing legal, regulatory, and ethical issues. These findings will be used to develop a policy brief, providing recommendations and proposed guidelines for formalising the teledermatology service. The findings and methods will be relevant to similar circumstances in other countries.

Resurgence of congenital syphilis: A profile of symptomatic newborns with congenital syphilis requiring admission to the nursery at a peri-urban regional hospital in KwaZulu-Natal Province, South Africa

Resurgence of congenital syphilis: A profile of symptomatic newborns with congenital syphilis requiring admission to the nursery at a peri-urban regional hospital in KwaZulu-Natal Province, South Africa

Clinical profile of children and adolescents with autism spectrum disorder in Durban, South Africa.

There are often delays in accessing care and diagnosing autism spectrum disorders (ASDs), with little data from Southern Africa on the clinical profile of affected children and adolescents. To describe the socio-demographic and clinical variables of children and adolescents with ASD attending psychiatric services at two state hospitals in eThekwini Municipality, KwaZulu-Natal province, South Africa. Two state hospitals in KwaZulu-Natal province, South Africa. The retrospective chart review examined patient records for the period 01 January 2018 to 31 December 2021. Data were collated using a structured data questionnaire on birth and family history, current presentation, comorbid conditions, medications, and non-pharmacological interventions. Of the 67 children and adolescents accessing care for ASD during the study period (including the coronavirus disease 2019 [COVID-19] pandemic lockdown period), most were males (89%), with a mean age standard deviation (s.d.) of 10.69 (s.d. 2.64) years. There was a delay between recognition of first symptoms and an ASD diagnosis of approximately three years. The most common reasons for referral were behavioural problems and speech delay, with 57 patients having delayed milestones (85%). Comorbid attention deficit hyperactivity disorder was reported in 55.2% (n = 37) of the patients and intellectual disability in 50.7% (n = 34), and the commonest comorbid medical condition was epilepsy (n = 20; 29.8%). All participants were on psychotropic medications, with 40 (59%) being on more than one agent. The delay in diagnosing ASD, high rates of comorbidity, and need for polypharmacy are concerning. The study highlights the need for greater awareness of ASD in communities and health care workers to expedite diagnosis and facilitate prompt psychosocial support and rehabilitation.

Prevalence and determinants of poor glycaemic control in individuals aged between 18-60 years, at a regional hospital in KwaZulu-Natal Province, South Africa- a cross sectional study.

Achieving optimal blood glucose control is imperative for preventing diabetes related complications and negative socio-economic consequences associated with them. The aim of the study was to determine the prevalence and determinants of poor glycaemic control amongst type II diabetic outpatients presenting at a regional semi-rural hospital in eThekwini district, Kwa-Zulu Natal. An observational, analytic cross-sectional study was conducted amongst 384 systematically sampled type 2 diabetes patients. Data were collected by an interviewer administered questionnaire, clinical record review and anthropometric measurements. Bivariate and multivariate analyses were performed. Ninety one percent of the study population (349/384) had poorly controlled diabetes. Amongst uncontrolled diabetics, 80% (n=281) were older than 35 years' age group; 58% (n= 203) were male; 85% (n=295) completed primary school education and 93% (n=324) were overweight. Patients that were 35 years and older, female, employed, had a high body mass index, were on oral hypoglycaemic and/or insulin in combination, and receiving treatment longer than 3 years, had an increased odd of uncontrolled diabetes. Being female and receiving oral hypoglycaemic and/or insulin were significantly associated with poor blood glucose control. Patient that were female overweight, having a lower level of education, and greater than three-year duration of medication and on oral hypoglycaemic agent and/or insulin were more likely to have poor blood glucose control. These factors should serve as early identifiers of potential poor control and an alert clinician to adopt a more active approach to optimize treatment.

Factors that influence resignations of radiographers employed by tertiary hospitals in the KwaZulu-Natal province, South Africa.

The shortage of staff in Kwa-Zulu Natal (KZN) public hospitals is evident and poses a challenge to retain radiographers. Therefore, there is need to identify the factors that influence resignations of radiographers. The aim of this study was to explore the factors that influence resignations of radiographers employed by tertiary hospitals in KZN province. The study was guided by a descriptive quantitative research method. The data was collected in the form of questionnaires. A letter of information describing the details of the study was provided to the participants. All consenting participants were requested to provide a written consent prior to completing the questionnaire. The questionnaire was completed, collected and analysed. The statistical analysis test was conducted using SPSS statistic V25. A response rate of 66.35% was received with 78.3% (n=108) female and 21.7% (n=30) male. The result suggested that participants unanimously agree that resignation of radiographers is precipitated by factors such as poor working conditions, unhygienic working environment and uncompetitive salaries. The result also suggested that moving from their current career in radiography to another career is precipitated by factors such as high stress level and long working hours. The factors identified were further analysed and results showed that the participant's personal reasons for moving from their jobs are co-related with environmental reasons. The most influential factor was stress and remuneration.

Cisplatin-associated ototoxicity amongst cervical cancer patients: A prospective cohort study in south Africa.

Concurrent chemoradiotherapy using weekly cisplatin remains standard of care for locally advanced cervical cancer in Sub-Saharan Africa. While cisplatin remains a popular cancer chemotherapeutic, it has an irreversible ototoxic effect on patients' auditory system. However, there is a paucity of epidemiological information on its extent and severity during cervical cancer treatment. In a region with a high burden of cervical cancer, this has serious consequences for aural intervention and rehabilitation. Using a prospective cohort study design, 82 patients with incident cervical cancer, receiving weekly cisplatin chemotherapy (50 mg/m2 body surface) at a tertiary level hospital in KwaZulu-Natal Province of South Africa, underwent audiological assessments at various intervals. We describe the temporal impact of cisplatin exposure on hearing loss, its combined effect with HIV-infection, and estimate ototoxicity incidence in this cohort. The median age was 52 years with Stages IIB (45%) and IIIB (35.4%) cancers being most common. Complaints of reduced hearing sensitivity increased significantly (p<0.0001). Bilateral, asymmetrical sensorineural hearing loss, with greater effect in the extended high-frequency range, was evident. Cisplatin dosage was significantly associated with ototoxicity severity at one- (p = 0.017), three- (p = 0.010), and six-month (p = 0.015) post-treatment follow-up. HIV-seropositivity (53.7%) was significantly associated with NCI-CTCAE Grading Scale at three- (p = 0.022) and six-months (p = 0.023) post-treatment. Multiple Tobit regression revealed a cumulative dose effect bilaterally, after adjustment for age and HIV status, evident from 9000Hz and above in the right ear, while a plateau effect was observed at 250mg/m2 in the left ear. The incidence was ototoxicity was 98% at a cumulative dose of 150mg/m2. The findings of this epidemiologic study highlight the temporal course and severity of ototoxicity experienced by cervical cancer patients treated with cisplatin, with greater impact in HIV-positive subgroup, thus underscores the need for audiological monitoring and timely interventions in this cohort.

Defining the role of bilateral groin dissection for squamous cell carcinoma of the penis in South Africa

The current recommendation for the management of penile cancer is that all patients with palpable groin nodes should undergo a routine lymph node dissection (LND). This study reviews our yield from LND in patients with palpable lymph nodes (LNs) and penile cancer. All patients with a penile cancer, who presented to the urology departments of St Aidan's and Grey's hospitals in KwaZulu-Natal province (KZN) were reviewed. Clinical data records and histological reports of all the patients who underwent a penectomy and inguinal lymph node dissection (ILND) were analysed. A total of 93 cases of penile cancer were managed between 2014 and 2019. Of this total overall cohort, 38 patients had palpable groin nodes and underwent a bilateral ILND. The majority (84%) of these patients were human immunodeficiency virus (HIV) positive and none were circumcised. Tumour grade was mostly grade II (84%), and tumour size was an average of 6.2 cm with a range from 1.5 to 12 cm. The overall incidence of metastatic inguinal lymph nodes (ILNs) in the group undergoing dissection was 23.7%. In the remainder there was only reactive lymphadenopathy. ILND performed in patients with penile cancer and bilateral palpable ILN in our setting has a low yield. This might be a reflection on our high rate of HIV. Local validation of international cancer guidelines is essential prior to adopting them in the South African context.

Analysis of factors influencing technical efficiency of public district hospitals in KwaZulu-Natal province, South Africa

BackgroundDistrict hospitals are crucial in supporting primary health care and serve as a gateway to more specialist care through a referral system. Majority of South Africans access health care services through the public sector district health system. Given the enormous task assigned to the public district hospital within the country, this study examined factors influencing their technical efficiency.MethodData were collected for 38 public district hospitals in KwaZulu-Natal province from 2014/15 to 2016/17. Data envelopment analysis (DEA) was used to determine the technical efficiency of the hospitals, adopting both the constant return to scale (CRS) and variable return to scale (VRS) models. Tobit regression model was used to determine factors related to the technical efficiency of the district hospitals.ResultsThis study showed that a significant proportion of the district hospitals were technically inefficient. The Tobit regression model identified catchment population, the proportion of inpatients treated per medical personnel, the proportion of inpatients treated per nursing personnel and expenditure per patient day equivalent as factors influencing technical efficiency of the district hospitals.ConclusionFindings from this study suggest that the technical efficiency of the district hospitals can be enhanced through an effective referral system and improved peoples’ health-seeking behaviour. In addition, a standard mix of clinical staff toward efficient service delivery and periodic cost analysis of health services with the view to saving cost and maintaining the quality of health care should be considered.

Identifying Factors that Affect the Probability of Being Cured from MDR-TB Disease, KwaZulu-Natal, South Africa: A Competing Risks Analysis

Setting: Four decentralised sites are located in rural areas and one centralised hospital in KwaZulu-Natal province, South Africa. Objective: To analyse risk factors associated with multidrug-resistant tuberculosis (MDR-TB) using competing risks analysis. Understanding factors associated with MDR-TB and obtaining valid parameter estimates could help in designing control and intervention strategies to lower TB mortality. Method: A prospective study was performed using a competing risk analysis in patients receiving treatment for MDR-TB. The study focused on 1542 patients (aged 18 years and older) who were diagnosed of MDR-TB between July 2008 and June 2010. Time to cure MDR-TB was used as the dependent variable and time to death was the competing risk event. Results: The Fine-Gray regression model indicated that baseline weight was highly significant with sub-distribution hazard ration (SHR) = 1.02, 95% CI: 1.01 - 1.02. This means that weight gain in a month increased chances of curing MDR-TB by 2%. Results show that lower chances to cure MDR-TB were among patients between 41 to 50 years compared to those patients who were between 18 to 30 years old (SHR = 0.80, 95% CI: 0.61 - 1.06). The chances of curing MDR-TB in female patients were low compared to male patients (SHR = 0.84, 95% CI = 0.68 - 1.03), however this was not significant. Furthermore, HIV negative patients had higher chances to cure MDR-TB (SHR = 1.07, 95% CI: 0.85 - 1.35) compared to HIV positive patients. Patients who were treated in the decentralised sites had lower chances to be cured of MDR-TB (SHR = 0.19, 95% CI: 0.07 - 0.54) as compared to patients who were treated in the centralised hospital. Conclusion: Identifying key factors associated with TB and specifying strategies to prevent them can reduce mortality of patients due to TB disease, hence positive treatment outcomes leading to the goal of reducing or end TB deaths. Urgent action is required to improve the coverage and quality of diagnosis, treatment and care for people with drug-resistant TB.

Alarms in the ICU: A study investigating how ICU nurses respond to clinical alarms for patient safety in a selected hospital in KwaZulu-Natal Province, South Africa.

Background Advances in technology have facilitated the implementation of improved alarm management systems in the healthcare sector. There is a need to identify challenges encountered by intensive care unit (ICU) nurses with clinical alarm management systems in South Africa (SA) to ensure utilisation of these technological resources for patient safety. Objectives To investigate how intensive care nurses respond to clinical alarms for patient safety in a selected hospital in KwaZulu-Natal Province, SA. Methods A descriptive, non-experimental research design using the census sampling strategy was used to invite 120 nurses from four ICUs to complete an adapted, structured questionnaire. Descriptive statistics were used to analyse the data. Results We had 91 respondents who completed the questionnaires (response rate of 75.8%). The majority of the respondents (85.7%) strongly knew the purpose of clinical alarms and 45.1% strongly felt confident about adjusting and monitoring the clinical alarms. More than half of the nurses (53.8 %) agreed to the existence of nuisance alarms that disrupted patient care (46.7%) and contributed to lack of responses (52.7%). While 76.9% strongly agreed with alarm sounds and displays to differentiate the priority of the alarms, 75.8% strongly agreed to the existence of proper documentation on setting alarms that are appropriate for each patient. The most frequent barriers were difficulty in setting alarms properly (51.6%) and lack of training on alarm systems (47.8%). Conclusion The complexity in setting the alarms, limited training and existence of false alarms was evident. Alarm-specific training is required to keep intensive care nurses updated with changes in technology to ensure patient safety. Contributions of the study The findings of this present study highlighted the importance of understanding the alarm management system within the ICU environment of the healthcare sector in SA. Technological improvements, specialised trainings and clear clinical policies for alarm management are essential to improve patient safety.

Patterns of emotional and behavioural challenges in children living with HIV: results from a hyperendemic South African setting

ABSTRACT This study examined the patterns of emotional and behavioural problems in children from an HIV hyperendemic sub-Saharan Africa setting. A cross-sectional questionnaire survey was administered to 198 parents/caregivers of children living with HIV aged 2–12 years, attending a paediatric HIV out-patient service at a public sector hospital in KwaZulu-Natal Province, South Africa. The parent version of the Strengths and Difficulties Questionnaire (SDQ) which consists of five sub-scales (i.e. emotional difficulties, conduct problems, hyperactivity/inattention symptoms, peer problems and prosocial behaviours) were used to capture data on emotional and behavioural problems in children. The results indicated that over half of sampled children (n = 115, 58.1%) had abnormal levels of problems in at least one sub-scale, with adjusted regression indicating that academic difficulties and delayed milestones were significantly associated (i.e. greater total SDQ score as a continuous measure). Lower parental/caregiver educational attainment (i.e. not having tertiary education) was the only parent/caregiver characteristic associated with greater emotional and behavioural problems. Given the high prevalence of emotional and behavioural problems and its link to academic difficulties and delayed milestones, the need for screening and developmental support for children living with HIV may be warranted.

The surgical burden of breast disease in KwaZulu-Natal province

ABSTRACT BACKGROUND: The current surgical workload assessments in KwaZulu-Natal (KZN) are inadequate to inform strategies to improve surgical services. Breast diseases have a well-defined spectrum and surgical treatment options, analysis of which could guide health policy in the field. This project aimed to quantify and analyse the operative workload for breast pathology in KZN METHOD: A retrospective review of breast-related operations conducted at public sector hospitals in KwaZulu-Natal province between 1 July and 31 December 2015 was undertaken. Data was collected from theatre operative registers and manually categorised as follows: sepsis, benign pathology, malignant pathology, and by hospital, according to geographic location, and complexity of care to determine factors to improve the service for breast care in the province RESULTS: In the 6-month study period, 13 282 general surgical procedures were performed of which 776 (5.8%) were breast-related operations. There were 372 (47.9%) operations for breast sepsis, 140 (18%) for benign breast lesions, 17 (2.2%) for cosmetic indications and 27 (3.5%) for diagnostic procedures. There were 223 (28.7%) procedures for non-benign disease: 21 (2.6%) wide local excisions (WLE), 203 (26.2%) mastectomies of which 161 (72.2%) mastectomies had an axillary lymph node dissection and 26 (11.7%) were performed as onco-plastic procedures. Hospitals in the Durban and Pietermaritzburg metropolitan areas performed 75% of the breast-related procedures. The majority (69.6%) of sepsis-related procedures were performed at secondary/regional facilities, while 58.3% of non-benign breast surgeries were performed at tertiary and quaternary centres CONCLUSION: Breast sepsis accounts for almost 50% of the surgery and is mainly dealt with at hospitals above district level. One-third of breast surgery in KZN province is for non-benign disease. There is a paucity of breast-conserving surgery. Elucidation of these observations can guide improvement in the provincial breast care service Keywords: breast surgery, breast pathology, breast cancer, general surgery

Effect of COVID-19 pandemic decisions on tertiary-level surgical services in Pietermaritzburg, KwaZulu-Natal Province, South Africa.

The COVID-19 pandemic has led to the implementation of restrictive policies on theatre procedures, with profound impacts on service delivery and theatre output. To quantify these effects at a tertiary hospital in KwaZulu-Natal Province, South Africa. A retrospective review of morbidity and mortality data was conducted. The effects on emergency and elective caseload, intensive care unit (ICU) admissions from theatre, theatre cancellations and regional techniques were noted. Theatre caseload decreased by 30% from January to April 2020 (p=0.02), ICU admissions remained constant, and theatre cancellations were proportionally reduced, as were the absolute number of regional techniques. The resulting theatre case deficit was 1 260 cases. It will take 315 days to clear this deficit if four additional surgeries are performed per day.

Laparoscopic versus open nephrectomy in resource-constrained developing world hospitals: a retrospective analysis

BackgroundLaparoscopic nephrectomy is the standard of care for nephrectomy in most developed countries. Its adoption in our setting has been limited due to lack of equipment and expertise. This paper sets out to show that laparoscopic nephrectomy is technically feasible in the state sector in South Africa.MethodsA retrospective chart review was performed of all patients having undergone nephrectomy over a five-year period at two state hospitals in KwaZulu-Natal Province, South Africa. Demographic information, pre-operative imaging findings, operative information and post-operative outcomes were analysed.ResultsNephrectomy was performed in 196 patients. Open nephrectomy (ON) was the intended surgical approach in 73% (n = 143) and laparoscopic nephrectomy (LN) in 27% (n = 53). The conversion rate from LN to ON was 11% (n = 6). For malignancies, there was no difference in surgical resection margin status across the ON, LN and conversion groups; however, tumour size was larger in the conversion group compared to the LN group. Estimated blood loss and transfusion rates were lower in the LN group. The average length of hospital stay was shorter in the LN group (5 vs 10 days). High dependency unit (HDU) admission rate was lower in the LN group (12.1%) compared to the ON group (50%) and the conversion group (40%). No difference in high-grade complications was noted between the ON and LN groups, and more patients in the LN group (82.5%) had no complications compared to the open group (9.9%).ConclusionLN is non-inferior to ON in terms of operative time, oncology outcomes and high-grade complications. LN is superior in terms of blood loss, transfusion rate, length of hospital stay and overall complication rate. LN appears to show technical feasibility in the state sector and highlights the need for laparoscopic training.

Depression, anxiety and treatment satisfaction in the parents of children on antiretroviral therapy in South Africa

ABSTRACT Parents of children living with HIV are at increased risk of emotional distress, with negative implications for both their health outcomes. There is limited data on depression and anxiety symptoms in the biological parents as caregivers of children on antiretroviral therapy (ART) in South Africa. We investigated the prevalence and correlates associated with depressive and anxiety symptoms in 200 biological caregiving parents of children on ART at a public hospital in KwaZulu-Natal Province, South Africa. Data were obtained from the Patient Health Questionnaire (PHQ-9) for depressive symptoms and the Generalized Anxiety Depression (GAD-7) for anxiety symptoms, along with sociodemographic questionnaire. Most of the parent caregivers assessed were female (n = 190, 95%), younger than 40 years (n = 151, 75.5%), single (n = 173, 86.5%), unemployed (n = 156, 78%) and HIV+ (n = 183, 91.9%). Sixty-five (32.5%) parents screened positive for depression, 37 (18.5%) for anxiety and 31 (n = 31, 15.5%) for both disorders (i.e. depression/anxiety comorbidity). There were significant associations between death of a child to HIV (aOR = 4.66, 95% CI: 1.33–16.28) with depression/anxiety comorbidity as well as with treatment dissatisfaction (aOR = 13.98, CI: 2.09–93.66), but not with other socio-demographic factors. The high prevalence of depression and anxiety amongst the parent caregivers of children living with HIV suggests the need for mental health screening and care among parents of children attending pediatric HIV services, and particularly for those with history of children lost to HIV.

Major Depression and Stigma among Individuals with Multidrug-Resistant Tuberculosis in South Africa.

Stigma is an important social determinant of health-seeking behavior; however, the nature and extent of its association with depression among people living with multidrug-resistant tuberculosis (MDR-TB) are not well-understood. We enrolled 200 microbiologically confirmed MDR-TB inpatients at a TB specialist hospital in KwaZulu-Natal Province, an area considered the epicenter for MDR-TB coinfection in South Africa. Four aspects of stigma and their association with major depression were assessed through individual interviews: 1) community and 2) patient perspectives toward TB, and 3) community and 4) patient perspectives toward HIV. A major depressive episode (MDE), HIV coinfection, and low income were significantly associated with greater stigma subscales. Based on an adjusted regression model, the MDE was the only factor independently associated with (all aspects of) stigma. These results indicate the potential utility of addressing stigma associated with the MDE as an important step in improving health-seeking behavior to promote adherence and retention in care.

Determining the Need for After-Hours Diagnostic Radiological Reporting in Emergency Departments at Public Hospitals in South Africa: Perceptions of Emergency Physicians in KwaZulu-Natal

BackgroundEmergency departments in South African public hospitals have a high patient load after hours, with inadequate numbers of health care professionals available to satisfy patient influx. In addition, there is often no provision of after-hours diagnostic reporting services in public hospitals, to an extent that the emergency physician is responsible for interpreting all radiographic images requested themseves.Emergency physicians, in this study, can be described as any medical doctor registered with the Health Professions Council of South Africa and working in the emergency department as a registrar or consultant physician because there were no physicians specialized in emergency medicine working at the hospitals selected for this study. AimThe aim of this study was to determine the views of emergency physicians on whether there is a need for an after-hours diagnostic radiological reporting service in selected public hospitals in KwaZulu-Natal Province, South Africa. MethodsA descriptive cross-sectional quantitative research design was utilized, through means of a survey, to assess the emergency physicians’ perceptions regarding the need for after-hours diagnostic radiological reporting. In addition, the study used a descriptive quantitative research design to record the number of conventional diagnostic radiographic examinations performed at the selected hospitals, after hours, and the proportional number of these radiographic examinations that were reported on by radiologists during office hours, the following day. The distribution of questionnaires and data collection, with regard to the number of examinations reported on, and those not reported on, were carried out simultaneously during the execution of this study. The study was conducted over a three-month period in 2017, at four public hospitals in KwaZulu-Natal—one of the nine provinces of South Africa. ResultsThis study found that, during the study period, between 0.1% and 0.6% of the conventional diagnostic radiographic examinations performed, after hours, were reported on by radiologists during office hours, the following day. The surveyed emergency physicians felt that the interpretation of diagnostic images took up valuable time that could be spent on patient management, and there was near-total agreement, whereby 92% (n = 36) of the physicians would have preferred after-hours reporting to be performed by a radiologist. Physicians agreed that having a radiologist or reporting radiographer to provide radiological reports would allow for more effective and efficient patient management. ConclusionThe results of this study indicated that there is a need for after-hours radiographic reporting at the selected public hospitals and for the further training of emergency physicians in radiographic image interpretation. Based on the findings of this study, it is recommended that after-hours radiological reporting services be considered for public hospitals and that courses be offered to emergency physicians on the interpretation of diagnostic radiographic images. A hospital policy review may therefore be needed to adjust the focus of hospitals toward reducing the workload of emergency physicians, wherever possible, such as by incorporating support services like radiographic reporting and by providing further training on the interpretation of diagnostic radiographic images, which will both act to reduce the potential risk of misdiagnosis.

Neurocognitive functioning in MDR-TB patients with and without HIV in KwaZulu-Natal, South Africa.

Optimising medication adherence is one of the essential factors in reversing the tide of a TB-HIV syndemic in sub-Saharan Africa, especially South Africa. Impairment in key neurocognitive domains may impair patients' ability to maintain adherence to treatment, but the level of cognition and its relationship to HIV status has not been examined in individuals with drug-resistant TB. We therefore investigated performance on several key neurocognitive domains in relationship to HIV status in a multidrug-resistant tuberculosis patients (MDR-TB) sample. We enrolled microbiologically confirmed MDR-TB inpatients at a TB-specialist referral hospital in KwaZulu-Natal province, South Africa. We collected cross-sectional data on sociodemographic, clinical and neurocognitive function (e.g. attention, memory, executive functioning, language fluency, visual-spatial, eye-hand coordination). For the primary analysis, we excluded participants with major depressive episode/substance use disorder (MDE/SUD). We fitted adjusted Poisson regression models to explore the association between HIV and neurocognitive function. We enrolled 200 people with MDR-TB; 33 had MDE/SUD, and data of 167 were analysed (151 HIV+, 16 HIV-). The mean age of participants was 34.2years; the majority were female (83%), and 53% had not completed secondary school. There was evidence of impaired neurocognitive functioning across all domains in both HIV+/- study participants. Based on the regression analyses, individuals with co-infection (MDR-TB/HIV+), as well as those who had longer duration of hospital stays experienced significantly lower cognitive performance in several domains. Poor cognitive performance was significantly related to older age and lower educational attainment. The presence of major depression or substance use disorders did not influence the significance of the findings. Adults with MDR-TB have significant neurocognitive impairment, especially if HIV positive. An integrated approach is necessary in the management of MDR-TB as cognitive health influences the ability to adhere to chronic treatment, clinical outcomes and functionality.

Technical Efficiency and Productivity of Public District Hospitals in Kwazulu-Natal Province, South Africa

Background: District hospitals (DHs) constitute a significant proportion of public hospitals and consume a more substantial percentage of the government’s total hospital budget. With the level of resources disbursed to DHs, it is essential to ensure efficient allocation and utilization. Hence, this study set out to assess the technical efficiency and productivity of public DHs in KwaZulu- Natal province, South Africa.Methods: Data envelopment analysis (DEA) and Malmquist total factor productivity (MTFP) were used to assess technical efficiency, identify adjustments required to make inefficient facilities more efficient, and determine overall productivity growth. Input data such as medical personnel and output information such as outpatient visits were retrieved from the databases of the district health information system (DHIS), and personnel salary systems (PERSAL) for three consecutive financial years (2014/15, 2015/16 and 2016/17). A total of 38 district hospitals were included in the study.Results: The proportion of technically efficient facilities according to constant return to scale (CRS) were 12 (31.6%), 16 (42.1%) and 14 (36.8%) in 2014/15, 2015/16 and 2016/17 respectively while according to the variable return to scale (VRS) technically efficient facilities were 22 (57.9%), 19 (50.0) and 21 (55.2%) respectively for the three consecutive years. On average, the total productivity of DHs increased by 4.8 percent over the three years, which is attributed majorly to technical growth of 6.9 percent.Conclusion: This study showed that a significant proportion of the district hospitals were technically inefficiency. Also, steps that could enable more efficient use of healthcare resources to yield optimal health service delivery were recommended.Significance for public healthThe public health sector in South Africa is responsible for catering for the preventative and curative health care needs of more than 80% of the population. Since 1994, Government expenditure on has significantly increased for all levels of healthcare including public hospitals. District hospitals play a central role in supporting Primary health care (PHC) and at same time serves as a gateway to more specialist care offered at provincial and tertiary healthcare facilities. Assessing the efficiency of health facilities on a continual basis is critical in optimising scarce resource utilisation and minimising wastage. Such an assessment will allow policy and decision makers in health sector to make better allocative decisions towards more effective, and efficient use of health resources. Hence, this study is important as it was undertaken to assess the efficient utilization of resources at district hospitals which play a pivotal and central role in supporting primary health care service delivery.

Soft Tissue Sepsis Places a Massive Burden on Regional and Tertiary Surgical Services in KZN Province South Africa.

Frequently, surgical intervention is needed to treat soft tissue sepsis (STS). Ideally, most STS should be managed at the lowest level of surgical care close to the patient's home and a well-functioning surgical service will be able to deliver this safely and effectively. This study interrogates the burden of STS in the province of KwaZulu-Natal and reviews at which level in the health system the operative management of STS is being dealt with. This study describes the operations for soft tissue sepsis conducted at all regional and tertiary hospitals in KwaZulu-Natal province for the period of 1 July to 31 December 2015. All procedures for soft tissue sepsis were identified for closer review. Between 1 June and 31 December 2015, a total 6302 soft tissue-related procedures were performed in the regional and tertiary hospitals of KZN. The breakdown by anatomical region was as follows, 618 (9.8%) head and neck surgeries, 895 (14.2%) chest and back, 277 (4.4%) abdominal wall, 818 (13%) pelvis/perineal/buttock and 3070 (48.7%) extremity-related surgeries. There were a further 815 (12.9%) soft tissue-related procedures where the anatomical region was unspecified. Of the soft tissue procedures, 3943 (62.6%) were for the management of soft tissue sepsis. The anatomical regions involved included 316 (8%) head and neck, 485 (12.3%) chest and back, 194 (4.9%) abdominal wall, 589 (14.9%) pelvic, perineal and buttock, 2054 (52.1%) extremity and 365 unspecified operations. Peri-anal sepsis contributed 315 (8%), breast sepsis contributed to 372 (9.4%) of all soft tissue sepsis and amputations of extremities 658 (16.7%) of septic soft tissue procedures. There is a significant burden of soft tissue sepsis requiring surgical treatment each month at regional and tertiary hospitals in KZN. This is made up of breast sepsis, peri-anal sepsis and diabetic foot sepsis. This burden is being managed at an inappropriate level of care.