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.

Efficacy of personal symptom and family history questionnaires when screening for inherited cardiac pathologies: the role of electrocardiography

AIMS

This study sought to confirm the efficacy of using resting 12-lead ECG alongside personal symptom and family history questionnaires and physical examination when screening for diseases with the potential to cause sudden cardiac death in the young.

METHODS AND RESULTS

1074 national and international junior athletes (mean age 15.8 (SD 0.7) years, range 10 to 27) and 1646 physically active schoolchildren (16.1 (SD 2.1) years, range 14 to 20) were screened using personal and family history questionnaires, physical examination and resting 12-lead ECG. Nine participants with a positive diagnosis of a disease associated with sudden cardiac death were identified. None of the participants diagnosed with a disease associated with sudden cardiac death were symptomatic or had a family history of note.

CONCLUSION

Family history and personal symptom questionnaires alone are inadequate to identify people with diseases associated with sudden cardiac death. Use of the 12-lead ECG is essential when screening for cardiac pathology in the young.

Searching for IgA nephropathy candidate genes: genetic studies combined with high throughput innovative investigations

Idiopathic IgA Nephropathy (IgAN) is the most common biopsy-proven glomerulonephritis worldwide. All races with the exception of Blacks and Indians are involved. Families with two or more relatives affected by IgAN may be observed in 15-20% of pedigrees of IgAN patients. Genome wide linkage study has been considered the most promising approach to identify IgAN susceptibility genes. Therefore, some European investigators constituted the European IgAN Consortium which was initially funded by the European Union. Data from linkage analysis studies, family association studies and case-control association studies are reported. To date, the Consortium has identified two loci (located on chromosomes 4q26-31 and 17q12-22), in addition to the previous study which described the first IgAN locus on chromosome 6q22-23. The functional mapping of genes involved in the disease proceeds from the identification of susceptibility loci identified by linkage analysis (step 1) to the isolation of candidate genes within gene disease-susceptibility loci, after obtaining information by microarray analysis carried out on peripheral leukocytes and renal tissue samples (step 2). Then, the process will proceed from the design of RNA interferenceagents against selected genes (step 3) to the application of systematically tested effect of RNA agents on functional cellular assay (step 4). The above combined high-throughput technologies will give information on the pathogenic mechanisms of IgAN. In addition, these data may indicate potential targets for screening, prevention and early diagnosis of the disease and more appropriate and effective treatment.

Impact of a multiple, IVF birth on post-partum mental health: a composite analysis

BACKGROUND

This study explored the impact of a multiple IVF birth on maternal mental health in the early post-partum period.

METHODS

A prospective study of 207 women who had conceived following IVF treatment and followed up at 6 weeks post-partum. Mothers rated their mood using the Edinburgh postnatal depression scale (EPDS) and their baby's behaviour using the Unsettled and Irregular Behaviour scale. Mothers' emotional well-being was explored using theme analysis of semi-structured telephone interviews.

RESULTS

Of the 175 (84.5%) followed up post-partum, 56 (32%) had a multiple birth (7 triplets, 49 twins). Nearly 16% of mothers in the multiple group scored>12 on the EPDS indicating clinically significant symptoms, which represented a 3-fold increased risk compared to mothers of singletons (Odds ratio=3.4, Confidence Interval=1.011-11.618, P=0.048). Unsettled and irregular infant behaviour was another independent risk factor. Qualitative analysis of interviews identified 12 themes. Mothers of multiples were more likely to express negative themes including 'tiredness' (P<0.01), 'feelings of stress/depression' (P<0.05) and 'questioning parenthood' (P<0.05). Mothers of singletons were more likely to be 'feeling wonderful', reflecting their delight in parenthood (P<0.05).

CONCLUSIONS

Mothers of multiples are at increased risk of poorer emotional well-being. Clinicians should focus on the psychological benefits of a singleton birth.

Yield drag in a two-dimensional foam flow around a circular obstacle: effect of liquid fraction

We study the two-dimensional flow of foams around a circular obstacle within a long channel. In experiments, we confine the foam between liquid and glass surfaces. In simulations, we use a deterministic software, the Surface Evolver, for bubble details and a stochastic one, the extended Potts model, for statistics. We adopt a coherent definition of liquid fraction for all studied systems. We vary it in both experiments and simulations, and determine the yield drag of the foam, that is, the force exerted on the obstacle by the foam flowing at very low velocity. We find that the yield drag is linear over a large range of the ratio of obstacle to bubble size, and is independent of the channel width over a large range. Decreasing the liquid fraction, however, strongly increases the yield drag; we discuss and interpret this dependence.

The impact of subspecialty services on health care delivery--a community health centre based study

OBJECTIVES

The objective was to evaluate the role of a paediatric surgical consultant at a primary health care facility.

DESIGN

Descriptive and prospective.

SETTING

In the process of planning and implementation of the 2010 health plan of the Provincial Government of the Western Cape, a shift occurred in the delivery of health care to children from a provincially based hospital system to a municipally based primary health care system. To contribute towards enabling this process, the Department of Paediatric Surgery at Red Cross War Memorial Children's Hospital established a paediatric surgical day clinic at a local community health centre during 2001.

SUBJECTS

Information was obtained from patient data sheets containing details of consultations at the sub-specialist surgical clinic at Michael Mapongwana Community Health Centre.

RESULTS

Over a 58-month period 1 171 children were seen, of whom 655 were male and 427 female. Their ages ranged from 0 to 19 years, the largest group being under 1 year. Eighty per cent of patients were accompanied by their mothers. The correct diagnosis was established by the nurse practitioners in 71%. General paediatric surgical conditions predominated, followed by medical, dermatological, orthopaedic, trauma, otolaryngo-pharyngology, infectious diseases, ophthalmology, urology, neurosurgery, malignancy and maxillofacial conditions. The details are set out in the report. In total 597 patients were referred directly to an appropriate care facility and 574 patients could be managed entirely at the clinic level.

CONCLUSIONS

This study demonstrated the significant public health problem of paediatric surgical disease. It emphasized the preventative and cost-effective role of a surgical clinic at primary health care level. The clinic allowed for timely surgical intervention in 65% of surgical cases, thereby decreasing inappropriate tertiary referrals. We believe that bringing specialists into the community can only strengthen the 2010 health care plan.

High-resolution molecular characterization of the HLA class I and class II in the Tarahumara Amerindian population

We describe for the first time the high-resolution profiling of HLA-A, -B, -C, -DRB1, -DQB1 and -DPB1 in a culturally and geographically distinct Mexican ethnic group, the Tarahumaras. The alleles most frequently found by reference strand-mediated conformational analysis in this population were for class I: HLA-A*240201, *020101/09, *0206, *310102, *680102; HLA-B*4002, *1501, *510201, *3501/02/03, *4005, *4801; HLA-Cw*0304, *0801, *0102, *040101; and for class II: HLA-DRB1*080201, *1402, *040701; HLA-DQB1*0402, *0301, *0302/07; HLA-DPB1*0402, *0401, *020102. In addition, a novel allele, HLA-A*0257, was found. Based on comparison of presently known HLA-DRB1 and -DQB1 allele frequencies in Amerindian groups and worldwide populations, the Tarahumaras are unexpectedly more related to the geographically and linguistically distant Aymara and Terena Amerindian groups than they are to neighbouring tribes.

Porcine γδ T cells: Possible roles on the innate and adaptive immune responses following virus infection

gammadelta T cells recognise different types of antigen in alternative ways to alphabeta T cells, and thus appear to play a complementary role in the immune response. However, unlike alphabeta T cells, the role or function of gammadelta T cells is still unclear. As pigs possess a high proportion of circulating gammadelta T cells, they are suitable large animal model to study gammadelta T cell functions. This as yet has not been fully exploited, leaving porcine gammadelta T cell biology and its role in immunity in its infancy. Foot-and-mouth disease (FMD) high potency "emergency" vaccines are able to induce early protection from challenge and it has been suggested that, in part, there is some involvement of innate immune responses. The antigen component of the vaccine is able to stimulate purified naive pig gammadelta T cells and induce the mRNA of various cytokines and chemokines. This observation suggests that gammadelta T cells probably contribute to the early phase of the immune responses to FMD vaccination, and perhaps infection. A subset of these circulating gammadelta T cells display a phenotype similar to professional antigen presenting cells and are able to take up and present soluble antigen to CD4(+) T cells in a direct cell-cell interaction via MHC class II. This direct interaction between gammadelta T cells and CD4(+) T cells is likely to have a significant influence on the out come of the adaptive immune response.

Systems for implementing best practice for a chronic disease: management of osteoarthritis of the hip and knee

BACKGROUND

Effective implementation of evidence-based care has been associated with better health outcomes; however, evidence-based clinical practice guidelines have been used with varying success.

AIMS

This study aimed to develop integrative tools to support implementation of best practice recommendations for nonsurgical management of osteoarthritis (OA) of the hip and knee and to identify barriers to effective implementation.

METHODS

Published, peer reviewed clinical practice guidelines were updated and translated into an OA care pathway. Key decision nodes in the pathway were identified by a Multidisciplinary Working Group. Qualitative research methods were used to inform pathway development and to identify barriers and enablers for pathway implementation. Qualitative components included purposively selected stakeholder focus groups, key informant interviews and patient process mapping of 10 patient journeys in different settings over a 3-month period. All interviews, facilitated by a trained project officer, were semistructured, recorded, then thematically analysed and summarized.

RESULTS

An OA care pathway, clinician and patient toolkits were developed that met the needs of multidisciplinary end-users. Several system- and setting-specific barriers to pathway implementation were identified. Opportunities to improve patient access, interprofessional communication, patient information and education and continuity of care processes were identified.

CONCLUSION

Integrative tools for implementation of best evidence care for patients with OA of the hip and knee were tailored to end-user needs and preferences. Multiple barriers exist that potentially limit effective implementation of best evidence. Comprehensive assessment of barriers and enablers to effective guideline or pathway implementation is recommended before implementation and evaluation.

Dementia care provision in rural Scotland: service users' and carers' experiences

There has been global neglect of service users' and carers' experiences of dementia care provision in rural areas. The present paper draws on a qualitative study of service provision for people with dementia and their carers in remote and rural Scotland. It draws on interviews with 15 people with dementia and 16 carers to explore their views about health and social dementia care service provision in rural Scotland. A further 14 carers of people with dementia participated in one of three focus groups. The paper discusses perceived gaps in services as well as positive aspects of dementia service provision which service users attribute to living in a rural area. The important issues this raises for the development of dementia care provision in rural areas are briefly discussed.

Weak charge-lattice coupling requires reinterpretation of stripes of charge order in La1-xCaxMnO3

Modulations in manganites attributed to stripes of charge/orbital/spin order are thought to result from strong electron-lattice interactions that lock the superlattice and parent lattice periodicities. Surprisingly in La1-xCaxMnO3 (x>0.5,90 K), convergent beam (3.6 nm spot) electron diffraction patterns rule out charge stacking faults and indicate a superlattice with uniform periodicity. Moreover, large area electron diffraction peaks are sharper than simulations with stacking faults. Since the electron-lattice coupling does not lock the two periodicities (to yield stripes) it may be too weak to strongly localize charge.

Differentiating infection from vaccination in foot-and-mouth-disease: evaluation of an ELISA based on recombinant 3ABC

Recent devastating outbreaks of foot-and-mouth disease (FMD) in Europe have reopened the discussion about the adequacy of the non-vaccination strategy implemented by the EU in 1991. Here we describe the evaluation of a new commercially available test kit for the discrimination between vaccination and infection. The test is based on the detection of antibodies against the recombinant non-structural (NS) protein 3ABC. In contrast to immunization with vaccines free of 3ABC, these antibodies are elicited as a consequence of infection. Testing more than 3600 negative sera from several countries revealed a specificity of > 99% for bovine, ovine, and porcine samples. Antibodies specific for 3ABC can be detected as soon as 10 days post-infection. As compared with the occurrence of antibodies against structural proteins of FMDV, anti-3ABC antibodies can be detected 5-10 days later, depending on the species. No anti-3ABC antibodies were detected in sera from vaccination experiments or in field sera from vaccinated animals. However, anti-3ABC antibodies can be detected in vaccinated animals upon challenge. These results provide evidence that this test can facilitate the use of vaccines in new strategies against FMD.

HLA and NK Cell Inhibitory Receptor Genes in Resolving Hepatitis C Virus Infection

Natural killer (NK) cells provide a central defense against viral infection by using inhibitory and activation receptors for major histocompatibility complex class I molecules as a means of controlling their activity. We show that genes encoding the inhibitory NK cell receptor KIR2DL3 and its human leukocyte antigen C group 1 (HLA-C1) ligand directly influence resolution of hepatitis C virus (HCV) infection. This effect was observed in Caucasians and African Americans with expected low infectious doses of HCV but not in those with high-dose exposure, in whom the innate immune response is likely overwhelmed. The data strongly suggest that inhibitory NK cell interactions are important in determining antiviral immunity and that diminished inhibitory responses confer protection against HCV.

221.Effects of exogenous gonadotrophin stimulation on ovarian tissue grafts in the mouse

Ovarian tissue grafts commonly contain only limited numbers of follicles. The functional life span and ability to retrieve as many mature oocytes as possible from ovarian grafts is important when grafting is used to restore fertility. This study aimed to determine whether ovarian grafts responded to exogenous hormones in a similar manner to that of in situ ovaries. Ovaries of C57BlxCBA F1 mice were cut in half and grafted to one of three different graft sites in females of the same F1 line; bursal capsule (BC, n = 12), kidney capsule (KC, n = 6), subcutaneous tissue (SC, n = 24). Three weeks after grafting, half of the graft recipients in each group were treated with 5IU PMSG followed by 5IU hCG 48 hours later. Oocytes were collected directly from the grafted ovaries 10 hours after the hCG injection and fertilized in vitro. Oocytes from the ovaries of superovulated normal mice (n = 4) of the same hybrid strain were used as controls. Two-cell embryos were transferred to pseudopregnant recipients and collected at day 15 of gestation or the animals were allowed to go to term. Mature fertilisable MII oocytes were retrieved from stimulated grafts from all graft sites, however, the number (BC 9, KC 5, SC 2 oocytes per ovary) and proportion of two-cell embryos in each grafted group (BC 52%, KC 32%, SC 32%) was significantly (P < 0.05) lower than in the in vivo matured control (16 oocytes, 85% two-cell). The fetal and placental weights of fetuses produced from graft-derived oocytes were not significantly different to the control group. Phenotypically normal pups were born in each of the graft and control groups. In conclusion, ovarian grafts treated with exogenous gonadotrophins produce significantly fewer mature oocytes and two cell embryos compared to in situ ovaries. Work supported by ARC and NIH RFA.

Parental concern and distress about infant pain

OBJECTIVE

To describe parent views on infant pain care and to explore relations between parents' experience of their infant's pain care and parental stress.

DESIGN

Descriptive, cross sectional survey.

SETTING

Nine neonatal units (196 parents) in the United Kingdom and two neonatal units in the United States (61 parents).

PARTICIPANTS

Parents of preterm and full term infants admitted to hospital.

INTERVENTIONS

Parents completed a three part questionnaire after the second day of the infant's admission and after they had made at least one previous visit to see their infant in the neonatal unit.

MAIN OUTCOME MEASURES

Parent concerns about infant pain; parental stress; parent state and trait anxiety.

RESULTS

Parents reported that their infants had experienced moderate to severe pain that was greater than they had expected (p < 0.001). Few parents (4%) received written information, although 58% reported that they received verbal information about infant pain or pain management. Only 18% of parents reported that they were shown signs of infant pain, but 55% were shown how to comfort their infant. Parents had numerous worries about pain and pain treatments. Parental stress was independently predicted by parents' estimation of their infant's worst pain, worries about pain and its treatment, and dissatisfaction with pain information received, after controlling for state anxiety and satisfaction with overall care (F = 29.56, df 6, p < 0.001, R(2) = 0.44). The findings were similar across sites, despite differences in infant characteristics.

CONCLUSIONS

Parents have unmet information needs about infant pain and wish greater involvement in their infant's pain care. Parent concerns about infant pain may contribute to parental stress.

Does HIV adversely influence the outcome in advanced non-small-cell lung cancer in the era of HAART?

The objectives of the study are to assess the impact of HIV status on the outcome of patients with non-small-cell lung cancer (NSCLC) in the era of highly active antiretroviral therapy (HAART). Patients diagnosed with HIV-related NSCLC in the HAART era (since January 1996) were identified from a prospective single-centre lung cancer database. The clinicopathological characteristics and outcome of each HIV-positive patient were compared to three age- and stage-matched HIV-negative controls with NSCLC who were diagnosed over the same time period and treated in an identical manner. The results showed that the two groups had similar disease characteristics and received a similar amount of chemotherapy. The median overall survival of the two groups was the same (4 months, log rank P=0.55). None of the HIV-positive patients developed an AIDS defining illness or died of HIV during treatment or follow-up. In conclusion, in this cohort, HIV status does not influence the prognosis of advanced NSCLC. This suggests that the survival of patients with HIV-related NSCLC may have improved since the introduction of HAART, and this may be due to a decrease in HIV-related deaths.

Towards efficient guidelines: how to monitor guideline use in primary care

OBJECTIVES

To develop a model for using routine data monitoring in the evaluation of clinical guideline usage in primary healthcare settings.

DESIGN

A monitoring framework was developed following a number of semistructured interviews with potential users. These data informed a postal survey among a random sample of primary healthcare professionals. Then to test out the framework, a further semistructured interview study was used to explore the practical issues relating to monitoring guideline use. Case studies were then undertaken to investigate the use of evidence-based review criteria and patient-centred outcome measures as methods for providing monitoring information. A case study in one general practice used interviews to examine the possible costs associated with guideline-use monitoring.

SETTING AND PARTICIPANTS

Interviews were undertaken with primary care professionals from one local health community. The postal survey was undertaken among staff from a purposive sample of Health Authorities in England and a random sample of general practitioners and practice nurses from the selected Health Authority areas. The second phase involved interviews with Health Authority, Primary Care Group and general practice staff from three Health Authority areas. Case studies were undertaken in volunteer general practices and among patients who consented to provide confidential health outcome information.

RESULTS

Interviewees recognised some value in guideline-use monitoring, however they were concerned about the practicalities from two perspectives. First, although primary care computing systems were to be found in most general practices, the technology for monitoring was absent in many practices. Training in these skills would be required before monitoring of guideline use could be a practical reality. Second, there were clear signals of a more general lack of interest or awareness in the subject of continuous review of care. This, together with a feeling of being overloaded with new initiatives, meant that implementation of a monitoring framework could be problematic and might need considerable support in order to make progress.

CONCLUSIONS

Effective methods can be developed for monitoring guideline use in primary care. However there is a need to address the degree of understanding that many primary healthcare professionals have of the concepts and practical issues in the area of guideline-use monitoring, and of expectations of this within the NHS. In addition there are a number of technical issues concerned with efficient capture of clinical information and its evaluation. Further research is recommended in the following areas: the extent to which patient concordance with the guideline recommendations be taken into account in the assessment of clinician conformance with guideline recommendations; the costs and benefits to patient care of guideline-use monitoring; the most efficient methods of developing valid and reliable review criteria which are policy and evidence (guidelines) based; whether review criteria are more useful than guidelines in improving quality of care; what additional benefits to patient care can offered by monitoring patient-centred health outcomes in addition to process of care, and at what cost?