Browsing by Author "Louw, Stephen"

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    Organised care of acute stroke at Groote Schuur Hospital : a controlled trial
    (2000) Patel, Nilesh-Kumar; Louw, Stephen; Myers, Jonny
    Background and purpose: Groote Schuur Hospital (GSH) admits about 570 stroke patients annually. These patients about occupy 10% of acute medical beds. Recent investigations have demonstrated that stroke services are poorly organised Although "Organised stroke care" has been shown to improve outcomes, this has not been demonstrated locally. This study was undertaken to determine whether stroke unit care within a general medical ward improves outcomes. Study design and sampling: The study was a prospective non-randomised controlled trial, with systematic allocation by admission day. of all acute stroke admissions to the Department of Medicine from 1 January to 15 May 1996. Intervention: There were three comparison groups: in the Stroke Intervention Ward, the intervention was implemented by the author; in the Guidelines Ward, the manner in which the intervention can be set up and implemented was provided in the form of a Guidelines Booklet and in the Control Ward, stroke patients received routine care. The intervention consisted of (i) geographic/spatial unity and allocation of a designated nurse; (ii) use of a Stroke Clerking Pro forma and (iii) a multidisciplinary Team Care Plan and Post Intake Stroke Ward Round. Results: 58 patients were admitted to the Stroke Intervention Ward, 40 patients were admitted to the Guidelines Ward and 91 were admitted to the 2 Control Wards. The groups had similar baseline characteristics, except for the percentage of patients continent on admission. There were no significant differences in the Modified Barthel Index prior to admission, at discharge or at follow-up. There were no significant differences in the principal outcome measures (death, dependency, death or dependency, institutionalisation and death or institutionalisation) between the comparison groups. The median [inter-quartile range] length of hospital stay in days was significantly reduced in the Stroke Intervention Ward (6.5[5-9]) compared to the Guidelines Ward (9[7-14]) and the Control Wards (8[5-12]). The referral rates to Professionals Allied to Medicine were significantly increased in the Stroke Intervention Ward, except for referrals to the Community Liaison Sister. The referral rates to rehabilitation resources on discharge were significantly increased in the Stroke Intervention Ward, except for referrals to physiotherapy. Conclusions: Organised Stroke Care is feasible in our setting and results in improved utilisation of resources without increasing length of stay. However, principle outcome measures were not significantly altered in this study.
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    A pilot study on the development and testing of an instrument for assessment of dependency needs of older persons in South Africa
    (2000) Kalula, Sebastiana Zimba; Louw, Stephen
    With the advent of the new government and the end of the apartheid era, the Department of Welfare investigated methods whereby the demand for equitable access to state subsidised homes for the aged might be met. It was decided to develop an instrument to assess dependency needs of older persons that might warrant admission to homes for the aged. Financial constraints dictated that only 2% of those over the age of 65 years could be institutionalised in state subsidised homes. An instrument with high specificity and sensitivity and good face and construct validity was required in order not to exclude the needy or include the undeserving in subsidised institutional care. The instrument formerly used in South Africa was designed to assess dependency needs of urban-living individuals and assumed relative affluence in contrast to the reality of the situation of the bulk of the South African population. The instrument was deficient in that it assessed only mental and physical disabilities. It did not take into account the wide disparities relating to primary needs (such as water, food, sanitation and security) that exist among communities with widely disparate socio-economic status. Since South Africa is a developing country, a significant component of the elderly population live in extreme poverty, often in rural subsistence-economy conditions. Instruments used in other countries, which assume a certain level affluence, are thus not applicable to the majority of the South African population.
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    The prevalence of Legionella and mycoplasma seropositivity in the elderly in Cape Town
    (1997) Muller, Greta; Louw, Stephen; Roditi, Denise
    Background: Community acquired pneumonia causes 5,9% of deaths in elderly South Africans. Mortality rates are increased in those in whom initiation of therapy with an appropriate agent has been delayed. Whereas Mycoplasma pneumoniae and Legionella pneumophila are sensitive to the macrolides or tetracycline, they do not respond to the currently recommended first-line agents for community acquired pneumonia, penicillin or a cephalosporin. It was therefore necessary to assess the prevalence of exposure to these 2 organisms in the elderly in order to determine whether a modification in the recommendations may be justified. Methods: Study population and survey: Subjects were residents of 4 old age homes in Cape Town who were older than 60 years and willing to participate. Written consent was obtained, a demographic and medical history questionnaire was completed, and a sample of blood was drawn. Laboratory methods: The indirect fluorescent antibody tests (Zeus Scientific Inc, New Jersey, USA) were used to detect the presence of antibodies to Mycoplasma pneumoniae and Legionella pneumophila. Results: The participation rate in this study was high, with 88,4% (677/766) taking part. Seropositivity for both of these organisms was low. There were 17 participants (2, 51 %) with antibodies to mycoplasma (IgG only in 8, IgM only in 1, and both IgG and IgM in the remaining 8). Titres were low with only 1 IgM titre of 16, and only 3 IgG titres of 64. Antibodies to Legionella were demonstrated in only 9 participants (1,33%). All these titres were 128 or above. Conclusions: It is concluded that first-line therapy for community acquired pneumonia should adhere to the current guidelines published by the South African Pulmonology Society. There is no indication for the routine use of agents active against Legionella or mycoplasma. Clearly, these antibiotics should be introduced if specific pointers to infection with one of these organisms are found. Because of the low seropositivity rate, the indirect fluorescent antibody test for these 2 agents has a high specificity in this population. This may be of use in making a diagnosis in an acute infection Further studies are required to elucidate the immunological response to these organisms in elderly persons. A further survey should be done to determine the seropositivity rate to these agents in community dwelling elderly.
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    Pulmonary tuberculosis in the elderly : diagnostic criteria and its epidemiology in old age homes
    (1993) Morris, Charles David Wilkie; Louw, Stephen
    The majority of today's elderly people were primarily infected with Mycobacterium tuberculosis at a time when no effective chemotherapeutic treatment was available. With the progressive decline in cell mediated immunity that accompanies aging, the potential to reactivate a dormant lesion, or to be re-infected increases. The latter particularly applies in areas of high density living e.g. homes for the elderly. The incidence of pulmonary tuberculosis in whites in South Africa is very similar to that in industrialized countries (approximately 16/100 000). In a survey of old age homes in East London (South Africa) involving 809 white subjects the prevalence rate was found to be 1403/100 000; clusters were found in individual homes where up to 10% of residents had tuberculosis. The age specific incidence in the community for whites was 86/100 000, and in homes for the aged the incidence in 648 elderly subjects followed for 2 years was 1080/100 000. It is concluded that the elderly living in high density accommodation constitute a high-risk group for the development of the disease. The diagnosis of pulmonary tuberculosis in the elderly may be complicated by the high prevalence of atypical radiographic changes, difficulty in obtaining sputum, and the high false-negative rate of the tuberculin skin test. Thus, the value of haematological and biochemical abnormalities in 93 elderly tuberculotics, 113 elderly non-tuberculotics and 264 young tuberculotics were investigated. The results in the elderly tuberculotic patients were: Normochromic normocytic anaemia (70%), leucocytosis (55%), thrombocytosis (33%), rapid ESR in 90%, lymphopenia (22%) and monocytopenia (37%); hyponatraemia (60%), hypokalaemia (42%) and hypoalbuminaemia (83%), serum bilirubin (20%) and alkaline phosphatase, aspartic transaminase and lactic dehydrogenase are elevated in approximately 2/3 of patients. In comparison with the younger group (mean age 48 years) with cavitating tuberculosis, the prevalence of elderly patients (with generally mild and non-cavitating disease) with elevated bilirubin, alkaline phosphatase and liver enzymes was approximately 50% higher. When the results of liver enzyme elevations in the elderly tuberculotics were compared retrospectively with elderly patients with non-tuberculotic destructive lung disease, the former group had significantly higher values. The sensitivity (76%), specificity (48%) and positive predictive value (60%) suggest that liver enzyme abnormalities may provide useful contributory data in the non-invasive diagnosis of pulmonary tuberculosis in the elderly. The chest radiographs in 93 consecutive cases of bacteriologically proven pulmonary tuberculosis showed infrequent apical involvement (7%), with the most frequent abnormality being opacification of the middle and lower zones of the lungs; half the cases had a pleural reaction. cavitation occurs in only 1/3 of patients, and was sited equally in the apical zones and in the mid and lower zones. These findings contrast with the pattern of cavitating apico-posterior disease commonly seen in reactivated tuberculosis in younger adults. A series of 21 patients was studied to compare the yield of sputum smear examination with sputum culture for M. tuberculosis. Sputum production in non-cavitating disease was found to be infrequent and unpredictable and the number of bacilli is usually scanty. Repeated Culture of sputum for M. tuberculosis is required to improve the likelihood of obtaining a positive bacteriological diagnosis. On the basis of this study at least 4 negative sputum cultures are required to exclude the disease. In a study of 10 patients the impact of 4-drug therapy on the viability of M. tubercle in their sputum was assessed. Viable tubercle bacilli continue to be excreted in patients with cavitating pulmonary disease on treatment for up to 9 weeks. It is suggested that patients with cavitating disease should probably not be allowed to return to high density accommodation for the elderly until their sputum is clear of acid fast bacilli on sputum smear examinations. The usefulness of using annual tuberculin skin reaction (Mantoux) tests as a screening procedure was evaluated in 648 residents in old age homes. The criteria for further investigation for pulmonary tuberculosis was either recent conversion to positive (reaction equal to 10 mm or more) or a year-on-year increase of greater than 12 mm, or any reaction> 20 mm. 206 subjects were identified as "possibly having the disease" and of these the diagnosis of pulmonary tuberculosis confirmed in 13 cases. 10/13 patients had Mantoux reactions of greater than 20 mm and 3/13 between 10 mm and 19 mm. As a result of this study the recommendation is made that a yearly Mantoux test is a useful screening procedure, and will help identify a population who should be further investigated with chest radiographs and sputum cultures.