Preoperative esophageal manometry does not predict postoperative dysphagia following anti-reflux surgery

This prospective study was undertaken to determine the value of manometric studies in predicting postoperative dysphagia in patients undergoing laparoscopic Toupet fundoplication. Two hundred and twenty-nine out of 401 patients (57%) had preoperative dysphagia, and 26 patients had late postoperative dysphagia (6.5%). Eight patients who had no preoperative dysphagia developed dysphagia following surgery. There were no significant differences in esophageal motility for patients without postoperative dysphagia (n = 375) compared with those with postoperative dysphagia (n = 26). Among patients with postoperative dysphagia as a new symptom (n = 8), six had normal preoperative distal esophageal pressures, and none had esophageal hypomotility. In those with both pre- and postoperative dysphagia 15 of 18 had normal esophageal motility and hypomotility was only found in one. The positive predictive values of distal esophageal hypomotility and other measures for postoperative dysphagia are poor. In conclusion, preoperative manometry does not predict postoperative dysphagia following laparoscopic Toupet partial fundoplication.

A shotgun marriage--community health workers and government health services. Qualitative evaluation of a community health worker project in Khayelitsha

In 1988 the Western Cape Regional Services Council (RSC) initiated a community health worker (CHW) project in Khayelitsha in order to extend its preventive services to people in the community and promote 'community upliftment'. An evaluation of this project was undertaken in 1991 and 1992 in order to examine the potential of this local health authority-run CHW project to be an appropriate primary health care model. Qualitative research methods were used to explore the nature of the work done by the CHWs, whether they were accepted in their communities, and whether the project functioned as part of an integrated health service infrastructure in Khayelitsha. The CHWs were found to provide the basis for a potentially effective, community-responsive service. However, several structural problems mitigated against this service. Relations between the CHWs and nurses in all the formal public health services in the area were superficial and fraught with problems. There were significant differences and conflicting policies between the RSC's CHW project and other neighbouring non-government CHW projects, and these posed various threats to both the RSC and the non-government projects. One of the most serious of these differences was that the RSC project had no structures or plans for community involvement in the running of the project. Before a CHW project is initiated, several critical issues need to be carefully considered and discussed with all the relevant stakeholders. Furthermore, CHWs need to be flexible, and accountable to the communities in which they work. Before employing CHWs, formal public health authorities need to consider carefully whether they are able to meet these criteria.

Evaluation of a peri-urban community health worker project in the western Cape

The South African Christian Leadership Assembly (SACLA) Health Project is a non-governmental organisation that runs a community health worker (CHW) programme in 4 peri-urban townships of Cape Town. A cross-sectional descriptive community survey was conducted in April 1990 to evaluate coverage and health education on oral rehydration solution (ORS) and to plan future preventive, promotive and development programmes. Research concepts and methods were made accessible to the CHWs through a training process designed to facilitate participation in every stage of the research. A multi-stage cluster sampling scheme was used, and the CHWs interviewed 822 residents. Coverage indicators showed that over 80% of all respondents had previously known about or consulted the CHW. The most common community problems related to water, filth and refuse, toilets, housing, unemployment and lack of community facilities. The most common health problems were generalised aches and pains, chest problems, skin problems, worms, and diarrhoea. An index developed to measure knowledge of ORS showed very few respondents had 'complete knowledge'. The community's expectations of the CHW included health education, attending to sanitation problems, providing a clean environment, organising community facilities, and helping with employment.