The utilization of red cell concentrates at Kimberley Hospital Complex, Northern Cape Province, South Africa

This prospective clinical audit of the utilization of red cell concentrates assesses 55 consecutive transfusion episodes in chronically anaemic adult patients. It examines the appropriateness and outcome of the transfusion episodes; over-transfusion and wastage rates, assessment of anaemia, the informed consent process, and if teaching influenced these parameters when compared to an earlier retrospective audit. The audit revealed several strengths and weaknesses relating to our institution's transfusion practices. Training sessions led to clinically and economically important improvements in transfusion decisions, the investigation of anaemia and the obtainment of informed consent prior to transfusions.

Wrist buckle fractures: a survey of current practice patterns and attitudes toward immobilization

OBJECTIVES

Buckle fractures are the most common wrist fractures in children, yet there is little literature regarding their management. This study examined the management of these fractures and attitudes toward their immobilization by pediatric emergency department (ED) physicians and pediatric orthopedic surgeons.

METHODS

A standardized survey was mailed to all pediatric orthopedic surgeons and pediatric ED physicians at 8 Canadian children's hospitals.

RESULTS

Eighty-seven percent of physicians responded, including 33 of 39 pediatric orthopedic surgeons and 84 of 96 pediatric ED physicians. Sixty-four percent of respondents believe that wrist buckle fractures always need to be immobilized; pain control was most frequently cited for this belief. Physicians who did not believe that all buckle fractures need to be immobilized indicated that these fractures are inherently stable and have a low risk of refracture. Forty-eight percent of the orthopedic surgeons prefer below-elbow casts, 30% prefer a combination (splint and cast) and 12% prefer backslabs. Sixty percent of ED physicians "usually or always" use casts and 31% "usually or always" use backslabs. Although there was variation among the orthopedic surgeons regarding the recommended length of immobilization, most (70%) recommended 2 to 4 weeks, although some (12%) treated only until pain free. ED physicians showed greater diversity regarding length of immobilization.

CONCLUSIONS

Although many physicians believe that wrist buckle fractures need to be immobilized, a significant number do not. There is substantial variability in the type and length of immobilization used. This variability suggests that the optimal management strategy for wrist buckle fractures is unclear and should be determined in future prospective studies.

Depression and anxiety among Grade 11 and 12 learners attending schools in central Bloemfontein

<p><strong>Objectives.</strong> Anxiety disorders are the most common childhood psychiatric disorders. Previous research suggests that South African rates may be high. Our study examined the prevalence and severity of anxiety and depression among Grade 11 and 12 learners attending schools in central Bloemfontein. Learners’ perception of the important stressors as well as the most relevant coping strategies were investigated.<strong></strong></p><p><strong> Methods.</strong> A cross-sectional study was conducted by using self-assessment rating scales and questionnaires. The Hospital Anxiety and Depression Scale (HADS) was used to screen for anxiety and depressive symptoms. Participants were provided with an additional list of possible stressors and coping skills, from which they identified those applicable to themselves. All students enrolled in Grades 11 and 12 at the selected schools during August 2009 were eligible for inclusion.</p><p><strong>Results.</strong> Five hundred and fifteen learners participated in the study, of whom 32.0% presented with moderate or severe anxiety and 5.3% with moderate or severe depressive symptoms. Mild symptoms were reported by an additional 29.0% on the anxiety subscale and 14% on the depression subscale of the HADS. Academic workload was reported as the main source of stress (81.4%).</p><p><strong>Conclusions.</strong> Although the study has limitations in terms of methodology and size, resulting in undetermined validity, it indicates possible higher prevalence rates for anxiety and depression than in previous South African studies and worldwide prevalence rates for adolescents. Pupils were generally hesitant to seek help from formal assistance structures provided by the schools, and preferred discussing problems with parents or friends.</p>

Help-seeking by substance dependants presenting to healthcare professionals in the Free State Province

<p><strong>Introduction.</strong> Current data regarding treatment needs in South Africa for substance dependence are based on admissions to specialised treatment centres. The data therefore do not include patients presenting to independent healthcare workers and state hospitals.</p><p><strong>Aim. </strong>The aim of this study was to investigate help-seeking behaviour for substance dependence disorders from the perspective of healthcare professionals at various levels of the referral chain in Free State Province. Design. A descriptive study was performed.</p><p><strong>Setting.</strong> Treatment environments in Free State Province accessible to substance-dependent persons. Participants. General practitioners, private psychiatrists, prescribing healthcare professionals at state hospitals and treatment centres, and non-prescribing therapists responsible for management of substance-dependent persons. <strong></strong></p><p><strong>Measurements</strong>. A questionnaire was used to determine the level of help-seeking experienced by the participants regarding various classes of psycho-active substances.</p><p><strong>Findings.</strong> The presentation of alcohol, cannabis, opioid, benzodiazepine, ecstasy, cocaine and inhalant dependency at general practitioners, private psychiatrists, treatment centres and non-prescribing therapists was compared. Different patterns of help-seeking for substance dependence from the various professional groups were detected. Regarding alcohol dependence, 40.3% of private general medical practitioners reported being confronted with alcohol dependence at least once per month, compared with 100% of treatment centre representatives and private psychiatrists, 70.6% of state hospitals and 53.8% of non-prescribers. State hospitals reported the highest frequency for contact with cases of cannabis dependence, compared with the other professional groups, while psychiatrists reported the highest contact with cases involving benzodiazepine, cocaine and ecstasy. Therapists reported a higher level of contact with inhalant dependence, while this group virtually never presented at general practitioners and private psychiatrists.</p><p><strong>Conclusion.</strong> Help-seeking data can be used in conjunction with other data, such as treatment demand data, to inform and adapt policies and practice. Variations in the manifestation of help-seeking behaviour at various groups may be important pointers to conditions that influence help-seeking, and therefore should be investigated further.</p>

The effect of different treatment modalities on the calcification potential and cross-linking stability of bovine pericardium

Porcine heart valves and bovine pericardium exhibit suitable properties for use as substitutes in cardiothoracic surgery, but must meet several requirements to be safe and efficient. Treatment with glutaraldehyde (GA) render some of these requirements, but calcification and degradation post-implant remain a problem. This study aimed to identify additional biochemical treatments that will minimize calcification potential without compromising the physical properties of pericardium. Pericardium treated with GA calcified severely after 8 weeks in the subcutaneous rat model, compared to tissue treated with higher concentrations of glycosaminoglycans (GAG) and commercial Glycar patches. GA, lower concentrations GAG and Glycar pericardium had high denaturation temperatures due to enhanced cross-linking. Tensile strength of GA tissue was significantly lower than GAG-treated or Glycar tissues, due to lower water content with resultant lower flexibility and suppleness. Pericardium treated with 0.01 M GAG gave acceptable denaturation temperatures, tensile strength and reduced calcification potential. All tissue treatments evoked comparable host immune responses, and no significant difference in resistance to enzymatic degradation. Ineffective stabilization and fixation of cross-links following GAG treatment, as well as limited penetration into the pericardium, resulted in GAG leaching out into the surrounding host tissue or storage medium, and prohibits safe clinical use of such tissue.

A needs assessment for obesity-related anticipatory guidance in the paediatric emergency department

BACKGROUND

The prevalence of Canadian childhood obesity has been increasing, resulting in a call for improved prevention efforts and anticipatory guidance.

OBJECTIVE

To evaluate interest in obesity-related anticipatory guidance in a paediatric emergency department.

METHODS

Between September 2005 and September 2006, parents or patients older than 14 years of age were approached at the emergency department of the Children's Hospital (London, Ontario) to complete a survey. The survey compiled demographic data and asked questions regarding self-perceived weight status, use of dieting and/or exercise for weight loss, desire for nutrition and/or exercise information, and interest in receiving anticipatory guidance related to obesity.

RESULTS

Two hundred people completed the survey; the vast majority (92%) of respondents were parents. The mean (+/- SD) age of the children was 12.6+/-3.9 years. Forty-one per cent of the respondents indicated an interest in further information on obesity (95% CI 34% to 48%). Fifty-two per cent of respondents considered themselves overweight or obese (95% CI 45% to 59%), and 52% reported someone in their family who was dieting, exercising or both to lose weight. Parents who stated that their children considered themselves to be overweight or obese were significantly less interested in anticipatory guidance than parents who did not believe that their children considered themselves to be overweight or obese (67% versus 90%, respectively; P=0.009).

DISCUSSION

Many patients in the paediatric emergency department desire information on nutrition and exercise. Further research into risk-stratified targeting of patients and parents are needed to help identify good candidates for anticipatory guidance.

Profile of forensic psychiatric inpatients referred to the Free State Psychiatric Complex, 2004–2008

<p><strong>Introduction:</strong> An accused found unfit to stand trial and/or not responsible for his/her actions because of mental illness, is declared a state patient by the court. <strong></strong></p><p><strong>Aim:</strong> The aim of the study was to analyse the biographical data and relevant particulars of forensic psychiatric inpatients who were admitted to the Free State Psychiatric Complex (FSPC) according to section 42 of the Mental Health Care Act (no. 17 of 2002), from 2004 to 2008. Study design A descriptive, retrospective study was conducted. Method One hundred and twenty forensic psychiatric inpatients admitted to the FSCP in the terms of section 42 of the Mental Health Care Act in the period 2004–2008, were included in the study.</p><p><strong>Results:</strong> The majority (95.8%) of the offenders were male, unmarried (83.8%) and unemployed (81.5%). The median age was 32.5 years. Most of the offenses against persons were of a sexual nature (45.8%). More than half (55.5%) of the forensic inpatients were diagnosed with schizophrenia, followed by mental retardation (10%) and bipolar mood disorder. Eighty percent (80%) of these patients were found not competent to stand trial and unaccountable. Fifty percent (50%) of the participants received treatment for a mental illness prior to the crime, and were also known to have poor compliance and defaulted from treatment in the past.</p><p><strong>Conclusion:</strong> The findings of this study can contribute to implement effective management and training programmes for the benefit of state patients.</p>

The demographic, clinical and forensic profile of offenders diagnosed with epilepsy referred to the Free State Psychiatric Complex Observation Unit in terms of section 77 and/or 78 of the Criminal Procedure Act 51 of 1977

<p><strong>Introduction.</strong> Limited information regarding the relation between psychopathology associated with epilepsy, crime and the legal aspects thereof is available in South Africa.</p><p><strong>Objectives:</strong> The demographic, clinical and forensic profile of alleged offenders diagnosed with epilepsy and referred to the Free State Psychiatric Complex (FSPC) Observation Unit from 2001 to 2006, was investigated. Design A retrospective cross-sectional study was conducted.</p><p><strong> Results:</strong> Of the 69 alleged offenders, aged 17–79 years (median 30 years), 94.2% were male, 81.2% Black, 72.5% single, and 69.9% unemployed. The median qualification was grade six. Offences were violent in nature and committed against a person in 75% of cases. A direct link between epilepsy and the alleged offences occurred in 7% of cases. Generalised epilepsy (34.8%) and interictal psychosis (20.3%) were the most commonly diagnosed conditions. Twenty-nine (42%) alleged offenders lacked criminal responsibility and were not fit to stand trial. Most observati (79.2%) diagnosed with generalised epilepsy were criminally liable and fit to stand trial. The highest rate of criminal incapacity was found among observati with interictal psychoses (85.7%) and comorbid mental retardation (90%). Almost 60% of referred cases were declared as state patients by the court.</p><p><strong>Conclusion:</strong> In only 16% of cases, observati were found unaccountable because of epilepsy (automatisms) or postictal confusional states. Our findings confirmed an increased prevalence of violent behaviour during seizure-free periods. This contributes to evidence that factors associated with epilepsy, rather than the epilepsy itself, play an important role in the possible increased risk of violent behaviour in people with epilepsy.</p>

Prospective assessment of practice pattern variations in the treatment of pediatric gastroenteritis

OBJECTIVES

We aimed to determine whether significant variations in the use of intravenous rehydration existed among institutions, controlling for clinical variables, and to assess variations in the use of ancillary therapeutic and diagnostic modalities.

METHODS

We conducted a prospective cohort study of children 3 to 48 months of age who presented to 11 emergency departments with acute gastroenteritis, using surveys, medical record reviews, and telephone follow-up evaluations.

RESULTS

A total of 647 eligible children were enrolled and underwent chart review; 69% (446 of 647 children) participated in the survey, and 89% of survey participants (398 of 446 children) had complete follow-up data. Twenty-three percent (149 of 647 children) received intravenous rehydration (range: 6%-66%; P < .001) and 13% (81 of 647 children) received ondansetron (range: 0%-38%; P < .001). Children who received intravenous rehydration had lower Canadian Triage Acuity Scale scores at presentation (3.1 ± 0.5 vs 3.5 ± 0.5; P < .0001). Regression analysis revealed that the greatest predictor of intravenous rehydration was institution location (odds ratio: 3.0 [95% confidence interval: 1.8-5.0]). Children who received intravenous rehydration at the index visit were more likely to have an unscheduled follow-up health care provider visit (29% vs 19%; P = .05) and to revisit an emergency department (20% vs 9%; P = .002).

CONCLUSIONS

In this cohort, intravenous rehydration and ondansetron use varied dramatically. Use of intravenous rehydration at the index visit was significantly associated with the institution providing care and was not associated with a reduction in the need for follow-up care.

Cost-effectiveness of epinephrine and dexamethasone in children with bronchiolitis

OBJECTIVE

Using data from the Canadian Bronchiolitis Epinephrine Steroid Trial we assessed the cost-effectiveness of treatments with epinephrine and dexamethasone for infants between 6 weeks and 12 months of age with bronchiolitis.

METHODS

An economic evaluation was conducted from both the societal and health care system perspectives including all costs during 22 days after enrollment. The effectiveness of therapy was measured by the duration of symptoms of feeding problems, sleeping problems, coughing, and noisy breathing. Comparators were nebulized epinephrine plus oral dexamethasone, nebulized epinephrine alone, oral dexamethasone alone, and no active treatment. Uncertainty around estimates was assessed through nonparametric bootstrapping.

RESULTS

The combination of nebulized epinephrine plus oral dexamethasone was dominant over the other 3 comparators in that it was both the most effective and least costly. Average societal costs were $1115 (95% credible interval [CI]: 919-1325) for the combination therapy, $1210 (95% CI: 1004-1441) for no active treatment, $1322 (95% CI: 1093-1571) for epinephrine alone, and $1360 (95% CI: 1124-1624) for dexamethasone alone. The average time to curtailment of all symptoms was 12.1 days (95% CI: 11-13) for the combination therapy, 12.7 days (95% CI: 12-13) for no active treatment, 13.0 days (95% CI: 12-14) for epinephrine alone, and 12.6 days (95% CI: 12-13) for dexamethasone alone.

CONCLUSION

Treating infants with bronchiolitis with a combination of nebulized epinephrine plus oral dexamethasone is the most cost-effective treatment option, because it is the most effective in controlling symptoms and is associated with the least costs.

The knowledge and acceptance of the HIV prevention program in pregnant women in the Free State Province of South Africa

HIV infection has a major impact on the health of children in South Africa because the current prevention programs are ineffective. We evaluated the knowledge of prevention of mother to child transmission at a level-two hospital in the Free State Province of South Africa. A descriptive study was done using interviews of postpartum mothers during a 1-month period. Our results show a population vulnerable to the HIV epidemic, but with inadequate knowledge about perinatal HIV transmission. This implies that a more effective perinatal and especially postnatal antiretroviral regimen should be a priority for our health planners.

CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury

BACKGROUND

There is controversy about which children with minor head injury need to undergo computed tomography (CT). We aimed to develop a highly sensitive clinical decision rule for the use of CT in children with minor head injury.

METHODS

For this multicentre cohort study, we enrolled consecutive children with blunt head trauma presenting with a score of 13-15 on the Glasgow Coma Scale and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. For each child, staff in the emergency department completed a standardized assessment form before any CT. The main outcomes were need for neurologic intervention and presence of brain injury as determined by CT. We developed a decision rule by using recursive partitioning to combine variables that were both reliable and strongly associated with the outcome measures and thus to find the best combinations of predictor variables that were highly sensitive for detecting the outcome measures with maximal specificity.

RESULTS

Among the 3866 patients enrolled (mean age 9.2 years), 95 (2.5%) had a score of 13 on the Glasgow Coma Scale, 282 (7.3%) had a score of 14, and 3489 (90.2%) had a score of 15. CT revealed that 159 (4.1%) had a brain injury, and 24 (0.6%) underwent neurologic intervention. We derived a decision rule for CT of the head consisting of four high-risk factors (failure to reach score of 15 on the Glasgow coma scale within two hours, suspicion of open skull fracture, worsening headache and irritability) and three additional medium-risk factors (large, boggy hematoma of the scalp; signs of basal skull fracture; dangerous mechanism of injury). The high-risk factors were 100.0% sensitive (95% CI 86.2%-100.0%) for predicting the need for neurologic intervention and would require that 30.2% of patients undergo CT. The medium-risk factors resulted in 98.1% sensitivity (95% CI 94.6%-99.4%) for the prediction of brain injury by CT and would require that 52.0% of patients undergo CT.

INTERPRETATION

The decision rule developed in this study identifies children at two levels of risk. Once the decision rule has been prospectively validated, it has the potential to standardize and improve the use of CT for children with minor head injury.