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BACKGROUND: A structured approach to perioperative patient management based on an enhanced recovery pathway protocol facilitates early recovery and reduces morbidity in high income countries. However, in low- and middle-income countries (LMICs), the feasibility of implementing enhanced recovery pathways and its influence on patient outcomes is scarcely investigated. To inform similar practice in LMICs for total hip and knee arthroplasty, it is necessary to identify potential factors for inclusion in such a programme, appropriate for LMICs. METHODS: Applying a Delphi method, 33 stakeholders (13 arthroplasty surgeons, 12 anaesthetists and 8 physiotherapists) from 10 state hospitals representing 4 South African provinces identified and prioritised i) risk factors associated with poor outcomes, ii) perioperative interventions to improve outcomes and iii) patient and clinical outcomes necessary to benchmark practice for patients scheduled for primary elective unilateral total hip and knee arthroplasty. RESULTS: Thirty of the thirty-three stakeholders completed the 3 months Delphi study. The first round yielded i) 36 suggestions to preoperative risk factors, ii) 14 (preoperative), 18 (intraoperative) and 23 (postoperative) suggestions to best practices for perioperative interventions to improve outcomes and iii) 25 suggestions to important postsurgical outcomes. These items were prioritised by the group in the consecutive rounds and consensus was reached for the top ten priorities for each category. CONCLUSION: The consensus derived risk factors, perioperative interventions and important outcomes will inform the development of a structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty. It is anticipated that this study will provide the construct necessary for developing pragmatic enhanced care pathways aimed at improving patient outcomes after arthroplasty in LMICs.

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BACKGROUND: Current literature has suggested that sentinel node biopsy may eventually replace axillary dissection as the nodal staging procedure of choice in early breast cancer. The goals of our study were to determine the accuracy of the sentinel node in predicting axillary nodal status and to evaluate the feasibility of incorporating sentinel node biopsy into a general surgical practice. METHODS: Between June 1999 and August 2000, 158 clinically node negative women with a histological diagnosis of T1 or T2 breast cancer were enrolled in the study. Both technetium sulfur colloid radiotracer and isosulfan blue dye were used to guide sentinel node biopsy. Sentinel node biopsy was always followed by a complete axillary dissection. The histopathology of sentinel nodes using serial sectioning and cytokeratin immunohistochemistry was compared with that of the nonsentinel nodes evaluated with routine hematoxylin and eosin stain. RESULTS: The overall sentinel node detection rate was 84% (89 of 106 patients). Sentinel node biopsy was most successful when a combination of radiotracer and dye was used. The staging accuracy of sentinel node biopsy was 98% (87 of 89); the sensitivity of the method was 94% (34 of 36); the false negative rate was 6% (2 of 36); the negative predictive value was 96% (53 of 55); and the rate of metastases to the sentinel node only was 56% (20 of 36). The results varied considerably among surgeons. CONCLUSIONS: The findings in our study support the hypothesis that the sentinel node is an accurate predictor of axillary nodal status in women with early breast cancer. These results suggest that the excellent findings in the literature can be reproduced by a group of general surgeons in a community-based hospital.

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We describe a locally aggressive glomus tumor that occurred in the nasal region of a 32-year-old woman. The neoplasm recurred six times over a period of 14 years following the initial excision. This aggressive behavior resulted in problems with the diagnosis of the neoplasm. Although grossly cystic, the tumor contained large areas with a solid growth pattern and exhibited an infiltrative margin. There was no cytological atypia, mitoses were scanty, and necrosis was absent. The neoplasm did not metastasize.

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This paper describes an unusual malignant mixed tumor of the bronchus arising in a 71-yr-old male and provides evidence of an epithelial-myoepithelial origin based on the findings on light microscopy and immunohistochemistry. The neoplasm contained elements of recognizable benign tumor resembling salivary gland-type pleomorphic adenoma, adenosquamous carcinoma, and a spindle-cell sarcomatous component. Immunohistochemical stains showed the characteristic relationship between epithelial and myoepithelial cells in the benign component of the neoplasm. In addition, the spindle cells stained for myoepithelial markers (S-100 protein and actin) but were also positive for keratin (AE1/AE3). The relationship of this neoplasm to classical carcinosarcoma and the recently described adenosquamous carcinoma with amyloid-like stroma is discussed.

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The authors report their experience with 17 cases of cystic hygroma diagnosed in utero over a period of 6 years and followed to early infancy. Attempts were made to determine which ultrasonographic features were significant in predicting the outcome of this condition. The intrauterine course of the 6 fetuses with a normal karyotype and the 11 fetuses with Turner's syndrome or another form of aneuploidy was analysed to determine whether the size of the hygroma or the presence of septation or nonimmune hydrops could be used to predict the eventual outcome of the pregnancy. An association between the presence of septation and outcome was not demonstrated, but there was a strong association between septation and aneuploidy. Septate lesions were present in 6 of the 10 fetuses with Turner's syndrome and only 2 of the 6 fetuses with a normal karyotype. In this series the most significant features indicating a favourable outcome were the size of the hygroma (no fetus in which the hygroma had a diameter greater than 6 cm survived) and the change in size from the time of diagnosis until 24 weeks' gestation. Of the three fetuses in which the hygroma did not regress by 24 weeks, two died in utero.

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A case of pneumonia and acute tubular necrosis was caused by an initially unknown species of Legionella. The organism was later identified as Legionella maceachernii by a combination of cultural, biochemical, and serological methods along with a gas-liquid chromatographic profile.

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1. Cationic chymotrypsinogen from the pancreas of the ostrich was purified to homogeneity by sulfuric acid extraction of pancrei, (NH4)2SO4 fractionation and SP-Sephadex C-50 and Sephadex G-100 chromatography. 2. The final preparation was homogeneous when subjected to SDS-PAGE, isoelectric focusing and sedimentation equilibrium centrifugation. The Mmin value obtained from amino acid analysis was 25,572 Da. A mean sedimentation coefficient of 2.575 S was obtained by sedimentation velocity centrifugation. 3. N-terminal analysis by dansylation showed an Ala residue which is the N-terminal of a neochymotrypsinogen. 4. The effects of pH, temperature and inhibitors (LBTI, PMSF, TPCK and DFP) on the chymotryptic activity were examined. A Km-value for ATEE as substrate was found to be 0.57 mM.

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In a clinicopathological study of 70 Brenner tumours in 61 patients seen at Groote Schuur Hospital during the 30-year period 1956-1985, 68 were benign, 1 malignant and 1 proliferating. Fifty-seven were pure tumours and the remainder were mixed with other ovarian neoplasms. The age range of patients was 26-71 years (median 49 years). Most of the Brenner tumours were incidental findings and probably not responsible for the symptoms or signs, which were most commonly a pelvic mass (28 patients) and abnormal vaginal bleeding (15).

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Out of 29 patients with right-sided infective endocarditis 13 had associated congenital heart disease and none was a drug addict. Staphylococcus aureus was the commonest organism isolated. The tricuspid valve was infected twice as commonly as the pulmonary valve. Only 11 out of the 29 patients had valvular infection potentially amenable to surgical therapy at the time of death. Ring abscesses were present in 10 patients.

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A series of 105 patients with organophosphate poisoning admitted to Harari Hospital during the past 4 years is described. Poisoning with organophosphate compounds is being seen more frequently in hospital practice in Rhodesia. Many of the cases are attempted suicides, but frequently there is no positive history of contact with the poison. The majority of patients exhibit the classic clinical features of parasympathetic overactivity, but diagnosis may be obscured by atypical presentation. Rapid diagnosis and utilization of the treatment regimen outlined in this article should reduce the mortality to less than 15%.

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