Medical Research Council of South Africa.

Background Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes. Methods A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years) admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. The study was registered on the South African National Health Research Database, number KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899. Findings Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0•7 per 100 000 population (IQR 0•2-2•0). Maternal mortality was 20 (0•5%) of 3684 patients (95% CI 0•3-0•8). Complications occurred in 633 (17•4%) of 3636 mothers (16•2-18•6), which were predominantly severe intraoperative and postoperative bleeding (136 [3•8%] of 3612 mothers). Maternal mortality was independently associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum haemorrhage (odds ratio 4•47 [95% CI 1•46-13•65]), and perioperative severe obstetric haemorrhage (5•87 [1•99-17•34]) or anaesthesia complications (11•47 (1•20-109•20]). Neonatal mortality was 153 (4•4%) of 3506 infants (95% CI 3•7-5•0). Interpretation Maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa.

Background: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. Methods: ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery. Results: The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784. Conclusions: This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance. Clinical trial registration: NCT03044899.

Background. Cancellations of planned elective surgical operations increase financial cost to the patient and the hospital. Objectives. To determine the rate and reasons for cancellations, estimate the cost incurred by such cancellations and recommend possible solutions. Methods. We did a prospective descriptive study of cancellations of elective general surgical operations over the 1-year period JanuaryDecember 2014 in the main theatre at Pietersburg (PTB) Hospital, Limpopo Province, South Africa. All patients listed on the theatre booking slate for elective general surgical operations before the cut-off time of 13h00 on the day before the anticipated operation were included. Epi Info version 7 was used to analyse the data and derive the descriptive statistics.Results. There were 537 booked patients (median age 47 years, range 1 -94); a total of 298 operations were performed, and 239 were cancelled (cancellation rate 44.5%). Reasons for cancellation were as follows: theatre needed for an emergency n=154 (64.4%), theatre equipment failure and lack of consumables n=17 (7.1%), non-theatre equipment failure n=10 (4.2%), prolonged time of operations n=13 (5.4%), abnormal blood results n=8 (3.3%), patient comorbidity and poor general condition n=9 (3.8%), patients absent from the ward n=8 (3.3%), patients not starved n=2 (0.8%), patients' condition improved significantly n=3 (1.3%), nurses' strike n=5 (2.1%), rebooking of cases for senior surgeons or other specialty n=2 (0.8%), and other reasons n=8 (3.3%). The cost per inpatient per day was estimated at ZAR4 890 at PTB Hospital and ZAR2 100 at district hospitals, and the total cost per cancelled operation was ZAR25 860. Conclusions. Over the 1-year period 44.5% of elective operations at PTB Hospital were cancelled, 64.4% because the theatre was needed for an emergency operation. We recommend that a theatre dedicated to emergencies be opened at PTB Hospital. The cost incurred due to cancellations was about ZAR6 million for the hospital, with additional cost and emotional trauma for the patients.

Breast cancer is the most prevalent cancer and leading cause of death among women worldwide. [1] The average lifetime risk of breast cancer for a wom an in the USA has been estimated at 12.3% with about 41 400 deaths reported in 2018. [1] The global incidence increased from 1.7 million in 2005 to 2.4 million cases in 2015 [2] and in Africa is predicted to double by 2050. [3] Incidence rates are lower in low-and middle-income countries (LMICs) than in high-income countries; however, the rates are increasing very rapidly in LMICs owing to adoption of a western lifestyle, including such habits as shorter breastfeeding time, use of postmenopausal hormonal therapy, late age at first term pregnancy or lower parity. Another risk factor of breast cancer is physical inactivity, leading to obesity. [4] The incidence in sub-Saharan Africa was estimated to be 22.4 per 100 000 cases in 2018. [5] Breast cancer mortality rates in LMICs remain high as a result of late presentations and inadequate access to good healthcare. [6] Breast cancer, along with cervical cancer, has been identified as a priority for the national healthcare services in South Africa (SA). [7] The SA National Cancer Registry reported breast cancer in 2014 as a leading cause of cancer deaths among women. [8] A 5-year mortality rate of 47% was recorded for SA women. [9] Breast cancer as a social problem has become an urgent challenge in LMICs. It is increasing dramatically, with 19.7 million cases projected to occur in the next decades. [10,11] This present study is the first to report the demographic profile, stage at presentation, and the characteristics of breast cancer patients in Limpopo Province, SA. Before March 2015, breast cancer patients were managed by surgeons in the general surgery department, together with patients admitted for other surgical conditions. Breast cancer patients would wait 3 -6 months for operations. In March 2015, a multidisciplinary clinic for the care of breast cancer patients was established at Mankweng Hospital. This hospital is a tertiary teaching institution of the University of Limpopo located 30 km east of Polokwane, the provincial capital.The clinic at Mankweng is the only such facility in Limpopo serving the population of 5.98 million people. [12] The clinic operates once a week, staffed with adequate personnel, but does not have its own oncology and radiation facilities; for these services, the clinic is dependent on the radiation department at Pietersburg Hospital 30 km away.The main objective of this study was to record the demographic features of attending patients, stage at presentation and histological patterns of malignancy identified in breast cancer patients treated at Mankweng. We anticipate that the information obtained from this study will guide the authorities responsible for provincial policy on breast cancer prevention, treatment and resource allocation programmes. MethodsWe conducted a retrospective, descriptive, cross-sectional record review of patients managed at Mankweng breast cancer clinic during the...