Evaluation of clinical teaching and professional development in a problem- and community-based nursing module.

In South Africa the main focus is on primary health care. This affects the education and training of nurses, and training schools must respond by developing appropriate teaching modules. A school of nursing developed, implemented and revised a problem- and community-based learning module over a period of three years (1996-1998). This student-centered module focuses on students' needs, active participation, collaboration, accountability, self-assessment, self-study, life-long learning and appropriate skills. In the formal clinical teaching environment PBL was the main approach. However, this approach was also supported by a variety of strategies, for example group discussions and scenarios. The knowledge, attitudes and professional development skills acquired in the PBL approach were then applied informally in the community setting (CBE). The purpose of the study was to evaluate a first year clinical teaching module as part of an extensive programme. A quantitative research method, a descriptive design, and a variety of data collection techniques were used. Conclusions were that clinical teaching was effective within the problem- (PBL) and community-based (CBE) approaches; 78% of respondents were positive about the clinical learning environment; 61% stated that expectations were met; 81% preferred group activities, and 67% indicated that they had developed professional skills. Facilitators agreed that clinical teaching met the requirements of PBL & CBE. The pass rate also improved.

New methods for the detection of viruses: call for review of drinking water quality guidelines.

Drinking water supplies which meet international recommendations for source, treatment and disinfection were analysed. Viruses recovered from 100 L-1,000 L volumes by in-line glass wool filters were inoculated in parallel into four cell culture systems. Cell culture inoculation was used to isolate cytopathogenic viruses, amplify the nucleic acid of non-cytopathogenic viruses and confirm viability of viruses. Over a period of two years, viruses were detected in 23% of 413 drinking water samples and 73% of 224 raw water samples. Cytopathogenic viruses were detected in 6% raw water samples but not in any treated drinking water supplies. Enteroviruses were detected in 17% drinking water samples, adenoviruses in 4% and hepatitis A virus in 3%. In addition to these viruses, astro- and rotaviruses were detected in raw water. All drinking water supplies had heterotrophic plate counts of < 100/mL, total and faecal coliform counts of 0/100 mL and negative results in qualitative presence-absence tests for somatic and F-RNA coliphages (500 mL samples). These results call for a revision of water quality guidelines based on indicator organisms and vague reference to the absence of viruses.

Acromegaly in the developing world--a 20-year teaching hospital experience.

A retrospective analysis was conducted to examine the long-term outcome of surgery, by a single pituitary surgeon and radiotherapy for acromegaly at Groote Schuur Hospital, Cape Town, using modern criteria for the definition of cure. Seventy-two patients (F/M ratio 1.3:1), aged 16-74 years, were eligible for inclusion. The mean follow-up period was 8.3 years. Macroadenomas were present in 79%, microadenomas in 15% and tumour size was not documented in 6%. Pretreatment GH levels were, > or = 40 m U/l in 56 patients. Postoperatively, 21% of patients were cured, 40% controlled and 40% had hypopituitarism. After radiotherapy (mean follow-up 8.7 years) 43% were cured, 66% controlled and 78% had hypopituitarism. At follow-up 37% of patients traced had died. The most common cause of death was vascular disease. The poor surgical results may be attributed to late presentation in the developing world setting, as evidenced by tumour size and invasiveness, and the degree of GH elevation. Emphasis on early diagnosis of non-invasive tumours is necessary to improve the cure rate and reduce mortality,

Hospitals in Cape Town during the Anglo-Boer War.

The choice of Cape Town as the site for the base hospitals during the Anglo-Boer War was for many reasons a logical one. The hospitals that existed in the city at the time were inadequate in size and lacked the required facilities. The unexpectedly large number of wounded and the epidemics of typhoid and plague demanded an ever-increasing number of hospital beds. These demands were met by expanding existing hospitals making use of temporary hospitals and converting other buildings into hospitals. Eventually more than 3,000 beds were made available by the 10 hospitals in Cape Town and the system, despite continuing problems, provided a reasonable service under difficult circumstances.

Assessment of cell culture and polymerase chain reaction procedures for the detection of polioviruses in wastewater.

WHO considers that environmental surveillance for wild-type polioviruses is potentially important for surveillance for acute flaccid paralysis as a means of confirming eradication of poliomyelitis. The present study investigated methods for detecting polioviruses in a variety of water environments in South Africa. Most polioviruses were isolated on L20B mouse cells, which, however, were not selective: 16 reoviruses and 8 enteroviruses, apparently animal strains, were also isolated on these cells. Vaccine strains of polioviruses were isolated from surface waters during and shortly after two rounds of mass vaccination of children in an informal settlement where there was no sewerage. The results demonstrated the feasibility of poliovirus surveillance in such settlements. It was also evident that neither poliovirus vaccine strains nor other viruses were likely to interfere significantly with the detection of wild-type polioviruses. Optimal isolation of polioviruses was accomplished by parallel inoculation of L20B mouse cells and at least the PLC/PRF/5 human liver and buffalo green monkey (BGM) kidney cell lines. Analysis of cell cultures using the polymerase chain reaction revealed that 319 test samples contained at least 263 human enteroviruses that failed to produce a cytopathogenic effect. This type of analysis thus significantly increased the sensitivity of enterovirus detection.

Malignant occipital astrocytoma in a patient with Lhermitte-Duclos disease (cerebellar dysplastic gangliocytoma).

A case of Lhermitte-Duclos disease (dysplastic gangliocytoma of the cerebellum) is described. Seventeen years after the diagnosis was made, the patient developed a malignant astrocytoma of the cerebrum, an association only once previously reported. The clinical presentation and radiological features are presented.

Surgery in South Africa.

The practice of surgery in South Africa ranges from full-time service in state-funded and academic hospitals serving a largely indigent population to a private sector for medically insured patients. Surgical training occurs at eight medical schools, and specialist registration is obtained after 4 to 5 years with either a university-conferred degree or a fellowship from the College of Surgeons of South Africa. The wide spectrum of First- to Third-World diseases and the high incidence of trauma provide comprehensive experience for practical training. Surgical standards are uniformly high, matching and sometimes pioneering the very best of Western medicine. The health care system is undergoing radical change to correct the imbalances of the apartheid era. Academic institutions are under pressure, and with incipient major financial cutbacks, there is concern that the proud record of service, teaching, and research excellence may be compromised. To facilitate the mission of broadening health care services, diploma training in surgery for rural practitioners is being developed. Outreach programs and closer liaisons with surgical societies in sub-Saharan African countries have also been initiated.

Arteriovenous malformations of the scalp.

We report twenty-four patients with cirsoid aneurysms of the scalp. For nine patients (38%), the lesions were related to trauma. Each of the patients presented with a pulsatile scalp swelling with a bruit. No focal neurological deficits were noted in any of the patients. Scalp malformations in all patients were confirmed by selective internal and external carotid angiography, with no intracerebral component revealed in any of the patients. Twenty-one patients had the lesions surgically excised, with good results. The remaining three refused surgical intervention. Meticulous surgical technique, which includes removal of the pericranial component of the malformation, was paramount.

Pituitary function after selective adenomectomy for Cushing's disease.

This retrospective analysis was undertaken to determine whether selective adenomectomy for Cushing's disease can achieve acceptable cure rates while causing minimal pituitary dysfunction. Tumour size, histology and pituitary function were evaluated in 34 consecutive patients (26 F: 8 M, mean age 33.6 years) undergoing transphenoidal adenomectomy for Cushing's disease from 1975 to 1992. Follow-up averaged 5.8 years. Cure was defined as resolution of symptoms and signs and normalization of urinary cortisol excretion. Sixty-three per cent of patients achieved cure after selective adenomectomy, repeat adenomectomy cured an additional four patients. Twenty-eight per cent required bilateral adrenalectomy and/or pituitary irradiation. Postoperative pituitary function remained completely intact in 81%. Secondary hypogonadism occurred in 8%, hypothyroidism in 155 and permanent diabetes insipidus in 4%. There was recurrence in 26% after a mean of 4.6 years (range 1-7). It is concluded that selective adenomectomy can achieve acceptable cure rates with a low prevalence of postoperative hypopituitarism, although an increase of recurrence may be the result of conservative surgery.

Low-velocity penetrating craniocerebral injury in childhood.

Fifty-four children with low-velocity penetrating injury of the skull and brain are described. The incidence of septic complications was 43%, which is significantly higher than that seen in adults. Nine percent of children developed vascular complications. Due to the high septic complication rate, a more aggressive management protocol consisting of craniectomy and dural repair under antibiotic cover is suggested.

Hydatid infestation of the brain: difficulties with computed tomography diagnosis and surgical treatment.

The radiological, surgical and pharmacological management of 11 children with cerebral hydatid disease is presented with special emphasis on the varying CT and MRI appearances and the surgical difficulties we have encountered. All but 2 had enhanced CT scanning and 2 had an MRI. The typical CT appearance of a large non-enhancing cyst of CSF density with minimal oedema was only seen in 3 children. Atypical appearances included irregularity of the cyst wall contour (2), enhancement of the surrounding rim (3), isodensity or heterogeneity of the cyst content (4), surrounding oedema (4) and globular as opposed to curvilinear calcification (2). Complete intact cyst removal was achieved in 3 patients. The reasons for puncturing the cysts or rupturing them at operation were failure to make a definitive pre-operative diagnosis (5), dense adhesions to the skull, dura or falx (3) and the misdiagnosis of an arachnoid cyst and the subsequent placement of a cystoperitoneal shunt (1). Pathological examination suggests that the degree of the inflammatory response to the ectocyst may determine the enhancement characteristics and the ease of surgical removal. There was 1 recurrence which responded well to four 28-day treatment cycles of albendazole.

A few thoughts on the history of epilepsy.

The history of epilepsy is a saga of the struggle by which scientific understanding of an unusual disease was gained by a long and circuitous route. In the beginning this affliction was attributed to demon possession and defied understanding for centuries when it was still regarded as a sacred disease and surrounded by superstition and mysticism; therapy of necessity had to follow similar lines of reasoning. The gradual realisation that cerebral dysfunction was the cause of this disease was highly significant although still followed by misunderstanding and misinterpretation--those two essential steps to progress. Clear, inspired reasoning and lucid clinical descriptions of epilepsy by John Hughlings Jackson and William Gowers set the scene for what was to follow. Experimental neurophysiology, cortical simulation, cortical localisation, new technologies of electro-encephalography, modes of visualisation of structures histologically and radiologically led to our present-day concepts of this complex disorder. We have been brought to new thresholds of understanding through the co-operative exertions of many workers from all parts of the world and this saga tells of some of the highest scientific accomplishments in medicine.

Post-traumatic chiasmatic disruption.

Ten patients with traumatic disruption of the optic chiasm are presented. The clinical sequence of fronto-facial trauma and CSF rhinorrhoea, followed days later by diabetes insipidus and discovery of a bi-temporal visual field loss constitute a characteristic syndrome which should be recognized by the attending medical staff. Magnetic resonance imaging, not previously reported, and post-mortem evidence point to a physical disruption of the chiasm and infundibulum as the cause of the visual and hypothalamic signs. The resulting field defect is permanent but the diabetes insipidus is transient in 50% of patients and can be adequately managed with manipulation of the patient's fluid intake.