Day-care management of sickle cell painful crisis in Jamaica: a model applicable elsewhere?

In the U.K. and the U.S.A., painful crises account for 80-90 percent of sickle-related hospital admissions, with average durations of 5-11 d. In Jamaica, many severe painful crises are managed in a day-care centre. Patients (n = 1160) with homozygous sickle cell (SS) disease aged 18 years and over were registered with the clinic during a 1-year study period. Of these, 216 patients with 476 painful crises attended the day-care facility for a total of 688 d. Most patients (119 or 55.1 percent) had single crises and for most crises (338 or 71 percent), patients attended for only 1 d, when they were given bed rest, assurance, rehydration and analgesia. Patients with complicated painful crises were usually referred for admission after initial pain relief and the rest were monitored during the day. In the evening they were given the option of hospital admission or allowed home with oral analgesia. Hospital admission for complicated painful crises or inadequate pain relief occurred in 42 (8.8 percent) crises and home management in 434 (91.2 percent) crises. Of 186 patients initially selecting home management, 20 percent returned for further day-care and five (2.7 percent) died during subsequent admission for that painful crisis, one without other known complications, two with acute chest syndrome (one associated with Salmonella septicaemia), another with Salmonella septicaemia, and one with dengue haemorrhagic fever. With suitable oral analgesia, adequate education and support, the majority of severe painful crises in SS disease in Jamaica have been managed on an outpatient basis. This model of patient care may merit assessment in other communities where painful crises are a common clinical problem.(Au)

The painful crisis of homozygous sickle cell disease: clinical features

The details of onset, perceived precipitating factors, associated symptoms, and pain distribution in the painful crisis of homozygous sickle cell (SS) disease have been prospectively recorded in 183 painful crises in 118 patients admitted to a day-care centre in Kingston, Jamaica. Painful crises developed most frequently between 3 p.m. and midnight, most commonly affected patients aged 15-29 years, affected the sexes equally, and were not obviously influenced by menstrual cycle. Of the perceived precipitating factors, skin cooling occurred in 34 percent, emotional stress in 10 percent, physical exertion in 7 percent, and pregnancy in 5 percent of women of child-bearing age. Cold as a precipitant was not less common in patients with more subcutaneous fat. Pain affected the lumbar spine in 49 percent, abdomen in 32 percent, femoral shaft in 30 percent, and knees in 21 percent. There was a highly significant excess of bilateral involvement in limb and rib pain. Recurrent painful crises occurred in 40 patients but showed no evidence of involving similar sites on successive occasions. Abdominal painful crises were associated with abdominal distention in 18 ( 31 percent) and with referred rib pain in a further 15 (26 percent) of crises. Fever was common even in apparently uncomplicated painful crises, suggesting that fever is characteristic of the painful crisis itself after and not necessarily indicative of infection. Following investigation and treatment in a day-care centre, over 90 percent of patients returned home (AU)

Day-case appendicectomy - abstract

With widespread public awareness, most cases of appendicitis now present early in the course of the disease and ruptured appendicitis is becoming uncommon. Complications following appendicectomy for ruptured appendicitis are uncommon and are chiefly of an infective nature (wound infection, pelvic abscess). Since these do not usually present before the 4th-5th day post-surgery, the patient may be safely managed as an outpatient, once he has recovered from the anaesthetic. Day-case appendicectomy puts this concept into practice. Patients receive a single parental dose of broad-spectrum antibiotic pre-operatively, and surgery is performed through a cosmetically placed muscle-splitting incision 3-5cm long. Intraperitoneal manipulation is kept to a minimum and the appendix stump is not buried. Nasogastric intubation or intravenous fluids are not used. The patient is allowed oral fluid intake 4-6 hours post-operatively, discharged on oral analgesics and reviewed 5 days post-operatively. Provision is made for earlier review if undue symptoms occur (wound pain, fever, diarrhoea). We have done 62 day-case appendicectomies in the past 3 years for unruptured appendicitis. No patient developed intra-abdominal abscess. Three developed wound infections but none required re-admission for treatment. In view of those results, day-case appendicectomy is recommended as a safe management policy for unruptured appendicitis, that would result in considerable savings to the health system (AU)

Jamaica's backyard nurseries

In Jamaica, tradition and economic necessity have required older women to play an important part in the life of the community by looking after small children whose mothers are out at work. (AU)

Nutritional status and development of St. Lucian children at day care centres

This was a comparative study of children who attended day-care centres with those who stayed at home in St. Lucia. The children came from very similar social backgrounds and were compared using anthropometry and their performances at the Bettye Caldwell Preschool Inventory and the Peabody Picture Vocabulary tests. The quality of the service given in the day care centres was assessed. Finally the environment of the centres was compared with that of the homes of the community children. The sample consisted of 60 children, 30 in three rural government centres and 30 from the communities nearest the centres. There were 28 boys and 32 girls with an age range of 40 - 64 months and a mean age of 51.7ñ5.7 months. It was found that there was no significant difference between the combined centre and the combined community anthropometry values. No significant difference was found between the centre and community children in the Peabody Picture Vocabulary raw scores (centre mean - 16.5ñ4.6; community mean - 15.9ñ6.9). However significant differences was found in the Bettye Caldwell Preschool Inventory total scores between centre ( mean = 33.8ñ7.7) and community children ( mean = 27.7ñ8.1), p<0.01. School achievement and language development test scores were similar to those of four year old Dominican children, but lower than those of Jamaican children. The centres were found to offer an environment richer in play equipment than that of the homes, but not necessarily safer or with greater adult-child interactions. The centres were found to be deficient in safety measures such as fire safety, first aid, monitoring of health and nutritional status, furniture available, toilet facilities for the children and staff, and space available for the children to play. The staff had duties other than child care, and although reasonably qualified, with a reasonable staff-child ratio of 1:12.5, interaction with the children was limited. It was concluded that a higher school achievement was associated with attendance at the centre and may be attributed mainly to the presence of the higher level of play equipment offered at the centre. Attention should be paid to the improvement of safety measures, monitoring of health and nutritional status and availability of outdoor space. It is suggested that possibly training of the mothers to interact with their children may improve the school achievement scores of the community children (Summary)