EDITOR'S CHOICE

Handicapped in the 'sticks' - policy the real disability

For rehabilitation therapists working in rural areas, the new community-based preventive health care dispensation cannot come quickly enough, if an Izindaba snap-survey¹ of those struggling to make any impact in our most remote areas is anything to go by.

Take a very conservative 5 - 10% of our entire population suffering from some disability (excluding the burden of AIDS-driven sequelae), add skeletal rural rehab staff numbers, national and provincial 'one-size-fits-all' health policies and inappropriate budgeting, and it's small wonder quality of life for the rural disabled is so shocking that most just accept their 'fate'. Izindaba portrays often heroic attempts to cater to those most excluded and challenged, living on below-breadline incomes in remote simple khayas without electricity, running water or ready transport. The policies rural therapists have to get creative around include the national 3-day hospital bed-stay indicator with very few dedicated rehab beds or wards (a built-in recipe for conflict with doctors forced to play the 'get-a-heartbeat, get-them-out' game), no dedicated vehicles for vital clinic/home visits, and a mismatch in human resources that puts senior rehab therapists in regional directorates and juniors (needing supervision) in community-based health directorates. Also factor in scarce 'special' schools (423 nationwide), with 62% having hostels.

Diagnosis by nose

In an era where a patient's medical history and physical examination may play second fiddle to a battery of biochemical and imaging tests, Parrish and Lancaster² refreshingly return to basics and provide an olfactory diagnostic clue.

Amitraz is an agricultural insecticide and veterinary pesticide used to treat ectoparasite infections in animals. Human poisoning may be accidental or deliberate. The initial clinical presentation of amitraz and organophosphate poisoning may be similar; however, their management is different. Patients present with nausea, vomiting, bradycardia, and either miosis or mydriasis. Reduced serum pseudocholinesterase supports a diagnosis of organophosphate toxicity, but there is no similar laboratory test for amitraz poisoning. Amitraz and its metabolites or solvents may contribute to a characteristic 'mothball-like' or 'dry-cleaning' odour in the poisoned patient, which is often particularly noticeable on endotracheal suctioning.

The authors, in a blinded trial, tested 23 volunteer healthcare workers on their ability to distinguish between the odours of amitraz, organophosphate and distilled water; 83% were able to distinguish between these odours. They conclude that this simple component of bedside examination may allow earlier recognition of this potentially fatal poisoning. Severely ill patients should receive prompt vigorous resuscitation and support.

Blood culture audits valuable at peripheral hospitals

The auditing of health services has well-established benefits. However, there is little published on the practical monitoring and handling of changes to microbial threats in individual hospitals. There is concern about the rise of multidrug-resistant bacteria, and the roles of healthcare facilities. Appropriate empiric antibiotic guidelines should be based on accurate and up-to-date knowledge of local antibiotic sensitivities. Kenyon and colleagues³ therefore studied the these trends in blood culture (BC) results at G F Jooste Hospital from 2005 to 2010 using the National Health Laboratory Service (NHLS) Data Warehouse.

The authors investigated the BC contamination rate and changes in the antibiotic sensitivity profiles of selected organisms, and estimated the proportion of infections that were hospital acquired. They observed a high contamination rate with a gratifying reduction by 2010, but concluded that: (i) the contamination rate, though reduced, was unacceptably high; (ii) there was a rising rate of extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae (KP) infection, most of which was nosocomially acquired and some of which was likely to have been driven by the widespread use of ceftriaxone; and (iii) the high proportion of multiple resistant Staphylococcus aureus and ESBL-producing KP suggested a failure of basis infection control. The authors describe their interventions to improve this situation.

A simple new vision score for prostate symptoms

The international prostate symptom score (IPSS) is widely used to assess the severity of lower urinary tract symptoms (LUTS) in men with bladder outlet obstruction (BOO) and to evaluate the response to medical or surgical therapy for benign prostatic obstruction (BPO). LUTS do not correlate well with prostate volume, maximum urinary flow rate, post-void residual urine volume or BOO as determined by urodynamic evaluation. An important problem with the IPSS is that many patients, most commonly those with a lower level of education, could not complete it because they found the questions too difficult to answer.

Heyns, Van der Walt and Groenewald evaluated the correlation of a new visual prostate symptom score (VPSS) and IPSS with uroflowmetry parameters. They found that the VPSS is equivalent to the IPSS in terms of correlation with the maximum (Qmax) and the average (Qave) urinary volumes and can therefore be used instead of the IPSS to evaluate PUTS in men with limited education.

Paediatric liver transplantation in Johannesburg

The Wits Donald Gordon Medical Centre paediatric liver transplant programme is the second such unit in sub-Saharan Africa. Loveland and colleagues⁵ evaluate their progress since its initiation in 2005. Despite a shortage of organs they overcame a steep learning curve, with results comparable with other early series. The current threat to the viability of their unit is the lack of appropriately trained paediatric hepatologists and intensivists.

JPvN

References

1. Bateman C. 'One size fits all' health policies crippling rural rehab - therapists. S Afr Med J 2012;102:200-208.        [ Links ]

2. Parrish A, Lancaster R. Does the nose know? Amitraz poisoning and olfaction. S Afr Med J 2012;102:231-232.        [ Links ]

3. Kenyon CR, Fatti G, Schrueder N, Bonorchis K, Meintjies G. The value of blood culture audits at peripheral hospitals. S Afr Med J 2012;102:232-233.        [ Links ]

4. Heyns CF, Van der Walt CLE, Groeneveld AE. Correlation between a new visual prostste symptom score (VPSS) and uroflowmetry parameters in men with lower urinary tract symptoms. S Afr Med J 2012;102:245-248.        [ Links ]

5. Loveland JA, Govender T, Botha J, Britz R. Paediatric liver transplantation in Johannesburg: Initial 29 cases and prospects for the future. S Afr Med J 2012;102:241-244.        [ Links ]