Utilisation of outpatient services at Red Cross War Memorial Children's Hospital, Cape Town

The demand for outpatient services continues to grow at Red Cross War Memorial Children's Hospital (RCCH). To determine current utilisation patterns, we conducted a 2-week survey in the outpatient department (OPD). In addition, we reviewed the RCCH Annual Reports for the period 1961-1988. Annual outpatient attendances have increased from around 42,000 in 1957 to their highest level ever; nearly 350,000 in 1988. This steady rise in outpatient attendance was stemmed during the 1970s by the expansion of health services in the greater Cape Town area, in particular the introduction of day hospitals. In general, blacks are utilising the OPD as a primary community hospital for the treatment of infectious and environmentally induced diseases. In contrast, the white outpatient profile is more characteristic of a tertiary referral centre, with a higher proportion of specialist clinic attendances. The utilisation patterns for coloured children are intermediate. Analysis of the residential address of patients and their presenting diagnoses indicates an urgent demand for primary health care services in the most recently settled and poorest suburbs of Cape Town, many of which are remote from the hospital.     

Central venous catheters. Technique and experience at Red Cross War Memorial Children's Hospital, Cape Town, 1987-1990

Central venous catheters can be of major benefit to children in whom prolonged intravenous access is required. For their everyday use, however, the known associated morbidity needs to be at an acceptably low level. Experience with 44 central venous catheters in 31 children (3318 catheter days over a 40-month period) is reported. The complication rate of catheter sepsis (0.3/100 catheter days), thrombosis (1 catheter), and technical problems (17, of which 6 required removal) justified catheter usage. Provided catheters are correctly inserted and the patients meticulously nursed, these catheters offer major advantages to infants and children requiring long-term intravenous access, particularly for parenteral nutrition.     

Surgery of the thoracic aorta. Recent experience at Groote Schuur and Red Cross War Memorial Children's Hospitals, Cape Town

Between September 1984 and June 1988, 46 patients (8 traumatic rupture, 10 acute and 11 chronic dissection, 17 true aneurysms) with lesions of the thoracic aorta were managed surgically. Four patients died after surgery for acute dissection, 2 after management of chronic aneurysm and 1 after replacement of the descending aorta for a chronic degenerative aneurysm. In 2 patients the operation was complicated by paraplegia.     

A diversity of genetic hyperlipoproteinaemias in black patients. Experience at the Lipid Clinics at Groote Schuur Hospital and Red Cross War Memorial Children's Hospital, Cape Town

The clinical and laboratory features of genetic hyperlipoproteinaemia (HLP) in 10 black patients attending the Lipid Clinics at Groote Schuur Hospital and Red Cross War Memorial Children's Hospital are reported. Five had type III HLP characterized by severe cutaneous xanthomas, which facilitated initial detection. Three adult patients suffered from heterozygous primary hypercholesterolaemia compatible with the diagnosis of familial hypercholesterolaemia (FH) caused by a low density lipoprotein receptor defect. They differed, however, from the typical presentation in lacking the Achilles tendon xanthomas characteristic of this condition. One patient presented in childhood with an unusual form of homozygous FH; the remaining patient had type V HLP. Seven of the 10 patients were male and most had risk factors for atherosclerosis in addition to the HLP. Despite the fact that the average age of the 9 adult patients is at present 52 years, only 1 has manifested overt atherosclerotic vascular disease. Compliance with therapy was variable but a generally satisfactory response was obtained in about half the patients, the reduction of plasma lipids in the type IIa subjects being disappointing. These data point to an important area for future study.     

Anaesthesia for paediatric cardiac surgery at the Red Cross War Memorial Children's Hospital

Anaesthetic techniques for paediatric cardiac surgery are presented, with emphasis on the special problems of premedication, induction, certain specific conditions and anticoagulation.     

Laparoscopic repair of anorectal malformations at the Red Cross War Memorial Children's Hospital: taking stock

BackgroundThe current standard repair for anorectal malformations in children is a posterior sagittal anorectoplasty. Recently, laparoscopic-assisted anorectoplasty (LAARP) was performed at the Red Cross Children's Hospital.MethodsA detailed case note review was conducted. Patient outcome was prospectively evaluated by colorectal nurse specialists using the Krickenbeck standardized questionnaire. Comparison among patients undergoing posterior sagittal anorectoplasty was performed.ResultsBetween September 2005 and June 2009, 24 children underwent LAARP. Sixteen had associated anomalies, including 7 children with renal and 4 children with cardiac abnormalities. Median age at surgery was 7.5 months (range, 2.6-15.0 months). Subtypes of anorectal malformation were as follows: vestibular, 2; bulbar, 9; prostatic, 7; vesical, 3; and with no fistula, 3. There was a 16% early complication rate. Redo-anoplasty was required in 9 patients. Eleven children had difficulties with follow-up. Thirteen children had regular follow-up and were analyzed further. Toilet training had been completed in 7 children (median age, 4.3 years; range, 3.5-6 years). Six children developed voluntary bowel motions. Six children are awaiting toilet training or are unable to train because of incontinence.ConclusionsAnal stenosis was the most common complication post-LAARP. Etiology appeared to be multifactorial, but poor compliance with dilatations was a leading cause.     

Tracheostomy in the management of laryngotracheobronchitis. Red Cross War Memorial Children's Hospital experience, 1980-1985

In the 6-year period 1980-1985 162 children required tracheostomy during treatment of laryngotracheobronchitis at Red Cross War Memorial Children's Hospital, Cape Town. This represents 4.6% of 3,500 children with this disorder and 28% of those requiring airway intervention. Fifty-eight percent of the children were decannulated within 4 weeks and 75% within 10 weeks. Fifty-four per cent of the children required one or more further procedures before decannulation, including 7 children who required a laryngotracheoplasty. Obstructing stomal granulation tissue had to be removed from 24 children and suprastomal collapse was a cause of decannulation failure in 29 children. Use of an expiratory valve as an aid to decannulation is discussed. Three children died of tracheostomy airway complications and 6 of a medical disorder. Another complication, laryngeal incompetence, was particularly associated with herpetic laryngeal ulceration.     

The age, nutritional status and major diagnoses of outpatients at the Red Cross War Memorial Children's Hospital

In 1961 a study of the age, sex, race, nutritional status and common diagnoses of children attending the Red Cross War Memorial Children's Hospital in Cape Town during one 12-month period was reported. A similar study was undertaken during two 2-week periods in 1972--1973. Comparison of the studies shows: (i) that a greater number of older children attended the hospital in 1972/1973; (ii) that the proportion of malnourished children whose percentage of expected weight for age was less than 66% had decreased from 8--10% to 5,5--6%; and (iii) that the overall pattern of disease had not changed appreciably, most of the children presenting with minor or preventable conditions.     

Profile of children with head injuries treated at the trauma unit of Red Cross War Memorial Children's Hospital, 1991 - 2001.

OBJECTIVE: To describe the profile of childhood head injury patients treated in a trauma unit. DESIGN: A retrospective record-based study. SETTING: The trauma unit of the Red Cross War Memorial Children's Hospital. SUBJECTS: Children (under 13 years of age) presenting with head injuries between January 1991 and December 2001. RESULTS: Of the almost 94 000 records, more than one-third were children presenting with head injuries. Fifty-nine per cent were boys, with more than half the sample under 5 years of age. The majority of children presented with superficial lacerations and abrasions, mostly affecting the scalp and skull. Injuries were mainly caused by falls from a variety of heights, and traffic-related injuries. Almost two-thirds of traffic-related injuries involved children as pedestrians being struck by a motor vehicle. More than 60% of injuries occurred in or around the child's own home. CONCLUSIONS: Head injuries in children are a significant cause of morbidity. Prevention, especially in the home and on the streets, needs urgent attention.     

Liver transplantation for children: Red Cross Children's Hospital experience

BACKGROUND: The liver transplant program for infants and children at the Red Cross Children's Memorial Hospital is the only established pediatric service in sub-Saharan Africa. Since 1985, 250 infants and children have been assessed and 155 accepted for transplantation. METHODS: Since 1987, 76 children (range 6 months to 14 years) have had 79 liver transplants, with biliary atresia being the most frequent diagnosis. The indications for transplantation include biliary atresia (n = 44), metabolic (n = 7), fulminant hepatic failure (n = 10), redo transplants (n = 3), and other (n = 15). Three combined liver/kidney transplants have been performed. Forty-nine were reduced-size transplants with donor: recipient weight ratios ranging from 2:1 to 11:1, and 29 children weighed < 10 kg. RESULTS: Fifty-six (74%) patients survived 3 months to 12 years posttransplant. Cumulative 1- and 5-year patient survival data are 79% and 70%, respectively. However, with the introduction of prophylactic intravenous gancyclovir and the exclusion of hepatitis B virus (HBV) IgG core Ab-positive donors, the projected 5-year pediatric survival has been >80%. Early (<1 month) post-liver-transplant mortality was low, but included: primary malfunction (n = 1); inferior vena cava thrombosis (n = 1); bleeding esophageal ulcer (n = 1); and sepsis (n = 1). Late morbidity and mortality was mainly due to infections: de novo hepatitis B (5 patients, 2 deaths); Epstein-Barr virus (EBV)-related posttransplantation lymphoproliferative disease (12 patients, 7 deaths); and cytomegalovirus disease (10 patients, 5 deaths). Tuberculosis (TB) treatment in three patients was complicated by chronic rejection (n = 1) and TB drug-induced subfulminant liver failure (n = 1). CONCLUSIONS: Despite limited resources, a successful pediatric program has been established with good patient and graft survival figures and excellent quality of life. Shortage of donors due to HBV and human immunodeficiency virus (HIV) leads to significant waiting list mortality and infrequent transplantation.     

The child rape epidemic : assessing the incidence at Red Cross Hospital, Cape Town, and establishing the need for a new national protocol.

INTRODUCTION: There were 52 733 reported rapes in South Africa in 2003/2004, almost half of them involving children. South Africa is faced with the challenge of developing an appropriate management strategy to foster effective treatment and curtail the incidence of sexual assault. A child sexual assault protocol for the Western Cape exists, but does not address the specialised needs of the child. OBJECTIVE: We aimed to ascertain the incidence of child rape seen at Red Cross War Memorial Children's Hospital, Cape Town, with emphasis on the circumstances that surround the victimisation of children. We also aimed to demonstrate the need for a new national standard protocol of specialised care for child victims' injuries. METHOD: A retrospective review of medical records of sexual assault victims from 2003 to 2005. RESULTS: There were 294 patients, 254 females and 40 males. Victims ranged from 10 months to 13 years in age (mean 5.8 years). The number of cases and severity of injuries increased annually. There were 14 third-degree, 22 second-degree and 91 first-degree injuries. Seventy-nine per cent of assaults were by a perpetrator known to the victim. All but 5 perpetrators were male. Fifty-eight per cent of rapes occurred in the patient's own home or that of a friend or relative. CONCLUSION: The number and severity of injuries have increased yearly. This shift is consistent with the overall increase in reported sexual assaults. Policy makers must respond to this call. Finalising sexual assault policy, clinical management and evidence collection guidelines and ensuring that they are disseminated and implemented nationally must be prioritised. Educational drives targeting parents and patients with the demonstrated demographics must be established.     

Tracheobronchial foreign bodies. Experience at Red Cross Children's Hospital, 1985-1990.

Ninety-six children with suspected tracheobronchial foreign bodies were referred to the Department of Cardiothoracic Surgery at Red Cross War Memorial Children's Hospital, Cape Town, between February 1985 and February 1990. Foreign bodies were removed by rigid bronchoscopy from 63 patients, 79% of whom were under 5 years of age. The majority of patients (59%) presented more than 24 hours after aspiration of the foreign body, and this delay in definitive management was associated with an increased incidence of complications (P = 0.01). Complications occurred in 28 patients, and there was one fatality at bronchoscopy due to overwhelming aspiration of an unanticipated release of pus, following the removal of a chronically impacted foreign body. The complete classic diagnostic triad (sudden onset of coughing, wheezing and decreased air entry) was seldom present, and we recommend diagnostic bronchoscopy in children presenting with either a history of sudden choking or a witnessed aspiration of a foreign body, an unexplained acute wheeze or cough or a chronic pulmonary infection. This report also highlights the continued need for increased awareness on the part of both parents and medical practitioners of the need for early referral if a foreign body is suspected. Furthermore, public education is needed as regards the dangers of allowing young children to eat peanuts. Peanuts were the commonest foreign bodies removed.     

The Hospital Information Planning Study at Groote Schuur Hospital, Cape Town

Information is an increasingly important resource in an academic hospital. Effective planning and control of this resource are essential in order to maximize its usefulness. The Hospital Information Planning Study (HIPS) undertaken at Groote Schuur Hospital, and based on the Business Systems Planning (BSP) methodology, is outlined, as are the results of the study. The recommendations arising from the study, which are of considerable significance to the hospital, are mentioned briefly.     

Tardive dyskinesia--prevalence and subtypes at Valkenberg Hospital, Cape Town

A survey of 278 White long-term inpatients at Valkenberg Hospital, Cape Town, revealed a 17% incidence of tardive dyskinesia. The heterogeneity of this condition is discussed and the incidence of the various subtypes is given. The relationship between tardive dyskinesia and certain risk variables such as age, duration of hospitalization and concomitant administration of anticholinergics, while clinically suggestive, was found to be not statistically significant.     

Hospitals in Cape Town during the Anglo-Boer War.

The choice of Cape Town as the site for the base hospitals during the Anglo-Boer War was for many reasons a logical one. The hospitals that existed in the city at the time were inadequate in size and lacked the required facilities. The unexpectedly large number of wounded and the epidemics of typhoid and plague demanded an ever-increasing number of hospital beds. These demands were met by expanding existing hospitals making use of temporary hospitals and converting other buildings into hospitals. Eventually more than 3,000 beds were made available by the 10 hospitals in Cape Town and the system, despite continuing problems, provided a reasonable service under difficult circumstances.