Perspectives of the management of childhood lymphoma: experience at Tygerberg Hospital, Western Cape, South Africa.

Hodgkin's disease (HD) in children corresponds to a large degree to HD in adults. Non-Hodgkin's Lymphoma (NHL) in children, however, differs from NHL in adults with respect to the classification, natural history, management and course. For practical reasons clinicians generally classify and treat NHL in children as either B-cell or T-cell disease. Over the past 22 years, the Paediatric Oncology Unit of the Tygerberg Hospital has treated HD with three different regimens. Use of the CLVPP and MOPP/ABVD regimens resulted in late relapses that adversely affected event free survival (EFS). For the last four years HD has been treated according to the regimen suggested by Schellong with good short term survival rates. Lymphoblastic or T-cell NHL is treated with regimens normally used for acute lymphoblastic leukaemia (e.g. BFM protocols) or modified leukaemia treatments for leukaemia-lymphoma syndromes (e.g. LSA2L2). We lately use a modified BFM regimen with a 70% EFS for all stages. Three consecutive regimens have been used to treat B-cell NHL over the past 22 years. The first was a COMP regimen, followed by the LMB-89 and LMB-96 regimens. Although toxicity has increased with the increased intensity of the treatment regimen, EFS has improved from 25% to 87% for all B-cell NHL. The majority of patients had stage III and IV disease. Although the LMB regimens are toxic, the implementation is manageable provided good laboratory back up and supportive facilities are available.     

Optimization of phenytoin therapy in adults with epilepsy in the Western Cape, South Africa

OBJECTIVE: To assess the extent to which adults with epilepsy were optimized and individualized on phenytoin monotherapy in the Western Cape, South Africa and to estimate the average optimized dose and serum phenytoin concentration, and the therapeutic range for this patient group. METHODS: Patients were considered to be optimized on phenytoin if they were seizure-free or the best compromise was achieved between seizure reduction and side-effects. RESULTS: 538 (233 black and 305 coloured) adult people with epilepsy were treated at nine epilepsy clinics as outpatients. Of these patients, 332 (226 male and 106 female, 149 black and 183 coloured) were included in the data analysis as they were considered to have reliable phenytoin levels. Phenytoin doses and steady-state serum concentrations were predicted using the Michaelis-Menten equation. Patients attended a clinical pharmacokinetic service for 7.7+/-5.3 (range 1-22) months. The average optimized dose was 305.8 (range 100-500) mg/day and the average optimized level was 62.7+/-23.9 (range 15-133) micromol/l. Most patients (61.9%) were optimized in the therapeutic range 40-79 micromol/l; 21.1% were optimized above and 17% below this range. In 1.6% of patients serum concentrations above 120 micromol/l were required. Dosage adjustments were made in 47.0% of patients, increased in 31.9% and reduced in 15.1%. CONCLUSION: These findings indicate that many patients (47%) attending outpatient clinics were not optimized on phenytoin therapy.     

Factors predicting community participation in patients living with stroke,in the Western Cape,South Africa

Abstract

Purpose: An important focus of poststroke rehabilitation is the attainment of community participation. However, several factors may influence participation some of which vary from setting to setting. The aim of this study is to investigate the factors influencing community participation among community-dwelling stroke survivors in the Western Cape, South Africa.

Materials and methods: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) and the Social Support Questionnaire 6 (SSQ6) were the instruments used to collect data. Participant demographics, clinical features and domain-specific scores of the WHODAS 2.0 were used as potential predictors. Correlation analysis and multiple regression models were used to examine determinants of community participation. All assessments were conducted using face-to-face interviews.

Results: One hundred and six stroke survivors enrolled in this cross-sectional study. Risk factors, cognition, mobility, self-care, getting along with people, household activities and total WHODAS 2.0 score were associated with participation. Four predictors of community participation were identified from multiple regression, namely mobility (38%), cognition (11%), life activities (4%) and stroke risk factors (1%). Determinants varied by gender and age group. Mobility predominated in males and younger adults, while cognition was more pronounced in females and the elderly. Lastly, the influence of social support on community participation was largely defined by the gender and age of stroke survivors.

Conclusion: The findings suggest focusing stroke rehabilitation on important factors such as mobility, cognition, life activities and risk factors to advance patients’ participation. It also emphasizes giving specific consideration to key factors specific for gender and age of stroke survivors.

• Implications for Rehabilitation

• Community participation in the general population of stroke survivors’ is largely determined by their mobility function.

• Determinants of community participation among stroke survivors essentially vary according to age and gender.

• Clinically, this study suggests that focusing on specific determinants of improved community participation according to stroke patients’ demographic categories (gender and age) may be an important impetus to enhance rehabilitation outcome.

     

Hospital disaster preparedness in Osaka, Japan

PURPOSE: To investigate the adequacy of hospital disaster preparedness in the Osaka, Japan area. METHODS: Questionnaires were constructed to elicit information from hospital administrators, pharmacists, and safety personnel about self-sufficiency in electrical, gas, water, food, and medical supplies in the event of a disaster. Questionnaires were mailed to 553 hospitals. RESULTS: A total of 265 were completed and returned (Recovery rate; 48%). Of the respondents, 16% of hospitals that returned the completed surveys had an external disaster plan, 93% did not have back-up plans to accept casualties during a disaster if all beds were occupied, 8% had drugs and 6% had medical supplies stockpiled for disasters. In 78% of hospitals, independent electric power generating plants had been installed. However, despite a high proportion of power-plant equipment available, 57% of hospitals responding estimated that emergency power generation would not exceed six hours due to a shortage of reserve fuel. Of the hospitals responding, 71% had reserve water supply, 15% of hospitals responding had stockpiles of food for emergency use, and 83% reported that it would be impossible to provide meals for patients and staff with no main gas supply. CONCLUSIONS: No hospitals fulfilled the criteria for adequate disaster preparedness based on the categories queried. Areas of greatest concern requiring improvement were: 1) lack of an external disaster plan; and 2) self-sufficiency in back-up energy, water, and food supply. It is recommended that hospitals in Japan be required to develop plans for emergency operations in case of an external disaster. This should be linked with hospital accreditation as is done for internal disaster plans.     

Responding to the Boxing Day tsunami disaster in Aceh, Indonesia: Western and South Australian contributions

Objective: To describe the Western and South Australian response to the Boxing Day tsunami disaster in Aceh, Indonesia. Method: Reports from three of the responders. Results: Comment has been made on organising a response, the first team to Banda Aceh, the second team to Banda Aceh, and lessons learned. Conclusions: These experiences have identified areas in which we could be better prepared for the next international disaster response.     

An audit of the use of platelet transfusions at Universitas Academic Hospital,Bloemfontein, South Africa

An audit was performed at a tertiary hospital in Bloemfontein, South Africa, to establish whether clinicians adhered to local platelet transfusion guidelines. The audit showed poor compliance with local guidelines, with 34% of platelet transfusions not aligned with guidelines and 29.9% of transfusions administered to patients with platelet counts of ≥150 × 10⁹/L. When compared to medical disciplines, surgical disciplines tended significantly more to transfuse platelets inappropriately (17.1% and 53.7%, respectively; p < 0.0001). Documentation was poor and in 48.4% of orders for platelets, the indication for the platelet transfusion was not clearly stated. Considerable cost could be avoided with improved adherence to guidelines. This study emphasises the need for improving education in transfusion medicine amongst medical doctors. It is hoped that the information gleaned from this study would assist in the design of educational programmes in transfusion medicine as we attempt to close the existing gaps in knowledge and skills in the field, while ensuring that blood is transfused in a cost-effective and appropriate manner.     

Emergency nurses in community disaster planning

Nurses in hospital and nonhospital settings have long played a role in disaster management. The history of nursing is partially a response to needs created by wars. It is appropriate that nursing, particularly emergency nursing, recognize that active involvement in community disaster planning is both an opportunity and an obligation.     

Exploring ICF components in a survey among Xhosa speakers in Eastern & Western Cape, South Africa

Purpose. To contribute to the testing and development of the ICF model by exploring the relationship between activity limitations, participation restrictions and environmental barriers.

Method. Structured questionnaire-based interviews were carried out among a convenience sample of 950 households counting 4917 individuals in Eastern and Western Cape, South Africa. Approximately half of the households had at least one individual with disability, while the other half represented controls in the study. Activity limitations, participation restrictions and environmental barriers were operationalized by means of questions drawn directly from the ICF checklist.

Results. Principal component analyses supported a four-component solution for the activity and participation variables, and a two-component solution for the barrier variables. Scales for each sub-component were produced by adding the individual items under each sub-component. Male respondents are more restricted than females when it comes to social activities, individual care, education and mobility barriers. While respondents in Western Cape scored higher (more limitations and restrictions) on the activity and participation sub-scales individual care, daily activities and education, Eastern Cape respondents scored higher on both the environmental barrier sub-scales.

Conclusions. A viable structure of sub-components under the broader ICF concepts has been demonstrated. The study has provided some support to viewing activity limitations and participation restrictions as two independent dimensions, but also invites further studies and refinement of the model.     

Upgrading and Extending Existing Neonatal Intensive Care Facilities at Life Westville Hospital,Kwazulu-Natal,South Africa

Our world is shrinking due to computerized linkages and the mobility of society. Information is shared rapidly around the world. Issues surrounding newborn and infant nursing are global. In efforts to acknowledge the international community, each Newborn and Infant Nursing Review (NAINR) issue will feature a column that highlights care and educational-related issues from a featured country or region of the world. This article focuses on one example of a redesign of a neonatal intensive care unit (NICU). Newborn and infant health issues are global ones. To review issues occurring in different areas of the world, a different area of the globe will be featured that addresses NAINR's theme-oriented topic. This month, South Africa will be featured. Our guest author is Ann Leslie, RN, registered midwife, postgraduate certificate cardiovascular surgery, and intensive care nursing (Glasgow Royal Infirmary), treasurer of Neonatal Nursing Association of Southern Africa (NNASA). This month's article focuses on NICU design.     

Infective endocarditis in the Western Cape Province of South Africa: a three-year prospective study

BACKGROUND: The last 50 years have seen major changes in the epidemiology of infective endocarditis (IE). AIM: To evaluate local patient characteristics, risk factors, clinical sequelae, microbiology, morbidity and mortality in patients with definite IE. DESIGN: Prospective observational study. METHODS: Over a three-year period, patients referred with probable IE were prospectively enrolled. All received a standardized diagnostic evaluation. Epidemiological data were documented; underlying risk factors for IE were sought. Initial evaluation and follow-up (to 6 months) included the documentation of vascular or immunological phenomena, morbidity and mortality. RESULTS: Of 92 patients referred with probable IE, 47 had definite IE. These patients had a mean age of 37.7 years with a male predominance (1.6:1). Rheumatic heart disease was present in 36 (76.6%). Eight had prosthetic valves. Three had congenital heart disease, mitral valve prolapse or multiple central intravascular catheters, respectively. All denied the use of intravenous recreational drugs and only one tested seropositive for HIV. Renal involvement (59.6%) and clubbing (29.8%) were commonly observed. The 6-month mortality rate was 35.6%, while 44.7% needed valvular replacement. An aetiological diagnosis was made in 21, with viridans streptococci the most common isolate. DISCUSSION: Infective endocarditis in the Western Cape of South Africa is a disease of younger adults, with a male predominance. Rheumatic heart disease is the major predisposing factor. Degenerative heart disease and intravenous drug abuse are not important risk factors. Our data do not support the notion that HIV infection is an independent risk factor for IE. Local mortality rates are much higher than recent international figures, as is the proportion of 'culture-negative' IE.     

Social audit of provincial health services: building the community voice into planning in South Africa

Social audits of health services in three South African provinces (Limpopo 2001, Gauteng 2003 and Eastern Cape 2001) demonstrated a fusion of participatory research, qualitative data collection, epidemiological surveys and analysis, and socialising of evidence for action. The social audit in each province involved the community in covering eight principles of service delivery. In the particular case of Gauteng province, householders answered a questionnaire on public perceptions of government health services. In each sentinel community, the results were returned for discussion in focus groups, made up of a sample that had answered the household questionnaire. Institutional reviews of health facilities and interviews with health workers in those facilities gave the government side of the story. Five actions came from the community-based focus groups, all accepted by the provincial government. Firstly, redesigned communication strategies will aim to reach those with lower levels of education. The second set of actions involves rebuilding the culture of care. Thirdly, the public knowledge of ways to complain was closely related to levels of public satisfaction. Leadership in the health services turned out to be a fourth area for development. And finally, related to this, is the longer-term challenge of establishing and reinforcing community consultation mechanisms.