Psoas abscess - not as rare as we think?

OBJECTIVE: Iliopsoas abscess (IPA) is a rare condition with a reported worldwide incidence of 12 new cases per year with primary abscesses now predominating. The presentation is often vague and the diagnosis not considered. METHOD: The medical records of 15 consecutive patients presenting to our hospital in a 3-year period with IPA were reviewed. Demographic data, presenting features, predisposing factors and the investigations performed were recorded. Abscesses were classified as primary or secondary and the treatment provided and eventual outcomes were analysed. RESULTS: Fifteen patients (eight males) were included. Nine patients were pyrexial on admission, 14 were anaemic and all had raised inflammatory markers. Only five patients presented with the classical triad of pain, fever and limp. The median time to diagnosis was 3 days with a median hospital stay of 27 days (range 7-243 days). Fourteen patients were diagnosed by computed tomographic scan. Three patients were treated with antibiotics alone whilst 11 received percutaneous drainage (PCD) as well. Of these, five had recurrence following initial drainage, needing further PCD procedures but none needed open drainage. Only one patient underwent open drainage initially. The mortality rate was 20%. CONCLUSION: The incidence of IPA is probably under-reported. The vague presentation leads to delays in diagnosis and increases morbidity and a high index of suspicion is the key to early diagnosis. Percutaneous drainage with antibiotics is the first line of treatment although recurrence rate is high. Open drainage allows simultaneous treatment of underlying pathology in secondary abscesses.

Geriatric medicine in Grahamstown.

A developing interest in improved care of the aged by the authorities of Settlers' Hospital in Grahamstown led to an invitation to the Geriatric Unit of the University of Cape Town in March 1984 to visit the hospital. The impressions gained on this visit indicated a need to expand hospital-based geriatric medicine into total community care of the elderly. Data were gathered concerning 50 acutely ill and 31 long-stay elderly black patients in Settlers' Hospital. These findings and the recommendations of various committees are discussed against the background of a model for the delivery of better geriatric care throughout the country. The most urgent necessity for Grahamstown appeared to be provision of better care for aged black people in the community.

A geriatric service in East London.

The background and establishment of a geriatric service in East London are described. Data relating to 37 admissions for geriatric assessment to the long-stay wards at Frere Hospital and 250 patients dealt with by the District Surgeon's community geriatric service staff are analysed to indicate the multifactorial nature of the assessments and care provided. Taken in conjunction with previous experience elsewhere, the indications are that effective services for care of the aged can be developed without special facilities, by re-allocation of some duties of existing staff and without vast capital expenditure. Certain recommendations are made for the development of an effective network of services for hospital-based care of the aged throughout the RSA.

The establishment of geriatric medicine at the University of Cape Town.

The birth of modern geriatric medicine in the USA and UK is briefly described as a prelude to the recognition of the need to establish facilities to teach this discipline at South African medical schools. The response of the University of Cape Town to this clearly shown need, the steps taken to endow a chair and the subsequent plans to commence a service are outlined. Consideration of population projections for the age group above 60 years between 1970 and the year 2020 suggests that formal training in the various disciplines involved in caring for the aged has been introduced none too soon. The first incumbent of the William Slater Chair of Geriatric Medicine commenced duty on 1 October 1981 and the milestones in the subsequent development of a service based upon the University of Cape Town and Groote Schuur and other hospitals are described.

An information service in a geriatric unit.

A major deficiency during the initial stages of development of a geriatric unit was a lack of easily available information concerning facilities and services already existing in the community. A postal survey undertaken in conjunction with the Cape Peninsula Organization for the Aged resulted in the production of an information manual of services available to the elderly in the Cape Peninsula. In the introduction to this manual an invitation was extended to readers to direct requests for information to the Geriatric Unit at the Medical School of the University of Cape Town. This paper reports on the first 50 enquiries received, as a result of which 73 items of advice or information were given. Unmet community needs were revealed in 9 instances. Useful assistance was known to have resulted on 30 occasions, consisting, in the main, of arrangements initiated for appropriate residential placement, for geriatric and psychogeriatric assessments and for domiciliary assessments by community nursing sisters or social workers, sometimes assisted by an occupational therapist or physiotherapist. Those who care for the aged at home need to be put in touch with correct sources of relevant information, and this appears to have constituted an additional and useful function of our information service.

The extent of individual responsibility for an independent old age.

Encouragement of a degree of personal responsibility for the maintenance of health by individuals and communities is being increasingly advocated by planners of health care. With the increasing numbers of people reaching old age it is particularly desirable that individuals be made aware of potential measures that may ensure a reasonably independent old age. In the course of a study to identify the defining characteristics of referred geriatric patients in a teaching hospital, a number of recurring factors emerged that seemed to favour the retention of independence among the subjects studied as controls. These were adequate retirement planning, the timely development of satisfying interests, the prior adoption of a healthy lifestyle, the sensible use of health services and the presence of adequate family and community support systems. Six cases are described to illustrate the presence or absence of such factors, and these are discussed against the background of the respective degrees of responsibility to be expected of the individual and of society in securing and maintaining independence in old age.

The coloured elderly in Cape Town--a psychosocial, psychiatric and medical community survey. Part III. A survey of physical disorders and disabilities.

A representative sample of elderly Coloured persons (over the age of 65 years) in the community underwent a medical and psychosocial assessment of prevalent physical disorders and resultant disability. This revealed that hypertension, visual impairment, osteo-arthritis and chronic lung disease were the most prevalent and disabling conditions, while hearing impairment and major neurological disorders played a lesser role. Most of the individuals claimed that they had little or no disability, while 10 felt they were only moderately disabled and 21 (14,9%) that they were severely disabled. The number of disorders ranged from 2,08 in those claiming no disability to 3,28 in those who were severely disabled. Profiles of the results of biochemical investigations resembled those of other aged populations, serum cholesterol, creatinine and alkaline phosphatase levels being raised. The pattern of medical care was also examined, including medication and the use of local facilities.

Identification and definition of the geriatric patient in a teaching hospital.

A consulting service in geriatric medicine was established at Groote Schuur Hospital on 1 November 1981. The first 100 patients referred were compared with 100 patients of 65 years of age and over, selected randomly from the wards from which the referrals were coming, with a view to identifying characteristics of the geriatric patient appropriate to local needs. The findings are discussed against a background of the requirements for adequate care of the elderly, the need to teach geriatric medicine to those whose functions include care of the elderly, and some of the wider social implications in ensuring as equitable a distribution of service as possible. In conclusion a definition of the geriatric patient is offered.

Who cares? A microplan for geriatric practice.

Geriatric medicine is defined and difficulties in the attainment of its ideals are described, both in Great Britain, where the specialty was born, and in South Africa. As regards the situation in South Africa, it is likely in the foreseeable future that the load will be carried by a wide range of clinicians in hospitals and the community, and that we shall not see the emergence of geriatricians as specialists in their own right except in a few academic departments. In laying down guidelines for practice an attempt has been made to describe the elements of geriatric medicine that it is hoped can be practised by any doctor performing this work. These elements have been presented as a microplan for geriatric practice.

People, not cases.

While attempting to find out why so many of our elderly patients could not be discharged from hospital, we again observed the value of a knowledge of the patient's social background. Not only was it of great help in making a diagnosis and planning therapy, but it also stimulated our interest in the patient as a person, and was thus of mutual benefit to doctor and patient.