Academic literature on the topic 'Hearing clinics – Management – Swaziland'

AbstractHearing aid fitting in infancy has become more common in the United States as a result of earlier identification of hearing loss. Consistency of hearing aid use is an area of concern for young children, as well as other hearing aid management challenges parents encounter that may contribute to less-than-optimal speech and language outcomes. Research that describes parent hearing aid management experiences of Spanish-speaking Hispanic families, or the extent of their needs, is not available. To effectively support parent learning, in a culturally sensitive manner, providers may benefit from having a better understanding of the needs and challenges Hispanic families experience with hearing aid management.The purpose of the current study was to describe challenges with hearing aid management and use for children from birth to 5 yr of age, as reported by Spanish-speaking parents in the United States, and factors that may influence hearing aid use.This study used a cross-sectional survey design.Forty-two Spanish-speaking parents of children up to 5 yr of age who had been fitted with hearing aids.Responses were obtained from surveys mailed to parents through early intervention programs and audiology clinics. Descriptive statistics were used to describe frequencies and variance in responses.Forty-seven percent of the parents reported the need for help from an interpreter during audiology appointments. Even though parents received information and were taught skills by their audiologist, many wanted to receive more information. For example, 59% wanted to know how to meet other parents of children who have hearing loss, although 88% had previously received this information; 56% wanted to know how to do basic hearing aid maintenance, although 71% had previously received instruction. The two most frequently reported hearing aid use challenges were fear of losing the hearing aids, and not seeing benefit from the hearing aids. Hearing aid use during all waking hours was reported by more parents (66%) when their child had a good day than when their child had a bad day (37%); during the previous two weeks, 35% of the parents indicated their child had all good days.Hispanic parents wanted more comprehensive information, concrete resources, and emotional support from the audiologist to overcome hearing aid management challenges. Understanding parents’ perspectives, experiences, and challenges is critical for audiologists to provide appropriate support in a culturally sensitive manner and to effectively address families’ needs.

Background: Although guidelines for fitting hearing aids for children are well developed and have strong basis in evidence, specific protocols for fitting and verifying some technologies are not always available. One such technology is noise management in children’s hearing aids. Children are frequently in high-level and/or noisy environments, and many options for noise management exist in modern hearing aids. Verification protocols are needed to define specific test signals and levels for use in clinical practice. Purpose: This work aims to (1) describe the variation in different brands of noise reduction processors in hearing aids and the verification of these processors and (2) determine whether these differences are perceived by 13 children who have hearing loss. Finally, we aimed to develop a verification protocol for use in pediatric clinical practice. Study Sample: A set of hearing aids was tested using both clinically available test systems and a reference system, so that the impacts of noise reduction signal processing in hearing aids could be characterized for speech in a variety of background noises. A second set of hearing aids was tested across a range of audiograms and across two clinical verification systems to characterize the variance in clinical verification measurements. Finally, a set of hearing aid recordings that varied by type of noise reduction was rated for sound quality by children with hearing loss. Results: Significant variation across makes and models of hearing aids was observed in both the speed of noise reduction activation and the magnitude of noise reduction. Reference measures indicate that noise-only testing may overestimate noise reduction magnitude compared to speech-in-noise testing. Variation across clinical test signals was also observed, indicating that some test signals may be more successful than others for characterization of hearing aid noise reduction. Children provided different sound quality ratings across hearing aids, and for one hearing aid rated the sound quality as higher with the noise reduction system activated. Conclusions: Implications for clinical verification systems may be that greater standardization and the use of speech-in-noise test signals may improve the quality and consistency of noise reduction verification cross clinics. A suggested clinical protocol for verification of noise management in children’s hearing aids is suggested.

Abstract Background Three infants with different risk factors, behavioral and physiologic audiometric histories, and diagnoses were fit with amplification between 3 and 8 months of age. Two of the three met criteria for cochlear implantation. Purpose This article aims to heighten awareness of the rare possibility of recovery from sensorineural hearing loss in infants with varying histories and emphasize the importance of a full diagnostic test battery in all infants diagnosed with sensorineural hearing loss every 3 months until objective and subjective thresholds are stable to ensure appropriate intervention. Research Design Case reports. Results All three infants demonstrated improvement or full recovery of hearing and cochlear function by approximately 12 months old. Their change in hearing was discovered due to frequent follow-up and/or caregiver report. One of these infants was tentatively scheduled to have cochlear implant surgery 2 months later. Conclusion Appropriate early intervention for infants with hearing loss is critical to ensure maximum accessibility to speech and language cues. The Federal Drug Administration approves cochlear implantation in infants as young as 12 months. When providing audiometric management of infants with sensorineural hearing loss, it is imperative to conduct a full diagnostic test battery every 3 months (including tympanometric, acoustic reflex, and otoacoustic emission measurement) until objective and subjective thresholds are stable. There was no apparent pattern of factors to predict that the infants highlighted in these cases would recover. Discussion among pediatric audiologists and otologists and comparison of data from clinics across the U.S. is needed to identify predictive patterns and determine appropriate, consistent monitoring of infants with sensorineural hearing loss.

Two methods for treating tinnitus are compared. Tinnitus masking has been used for over 25 years, and although this method is used in clinics around the world, there are many misconceptions regarding the proper protocol for its clinical application. Tinnitus retraining therapy has been used clinically for over 12 years and has received considerable international attention. Although these methods are distinctive in their basic approach to tinnitus management, certain aspects of treatment appear similar. These aspects of treatment have created considerable confusion and controversy, especially regarding the use of "sound therapy" as a basic component of treatment. It is the objective of this article to clarify the major differences that exist between these two forms of treatment.

223 Background: Platinum-based chemotherapy agents cause significant hearing loss in 40-80% of treated cancer pts. Lack of follow-up serial testing has created gaps in knowledge regarding hearing loss onset, progression, and possible recovery between treatment cycles. This study aims to determine barriers and facilitators to implementation of a tablet-based point-of-care hearing test, as a serial screening tool to address these knowledge gaps. Methods: From Jul 2019 to Mar 2020, 53 pts receiving high dose platinum agents were recruited from three clinics (Thoracic, head and neck, and testicular cancer) at a comprehensive cancer centre, to undergo serial audiometry testing. Baseline hearing tests, mid cycles (3,6, and 9 weeks), and post treatment tests (3,6,9,12, 19 and 24 months) were completed during the pts’ clinic appointments. Clinical research coordinators (CRCs) collected feedback from physicians, nurses, and pts to identify barriers and facilitators of implementing serial point-of-care hearing tests in these clinics. An inductive and iterative approach was used to identify themes. Implementation was tailored and mapped to the CIHR Knowledge to Action Framework (KTA). Results: Barriers: Logistical barriers included: locating quiet and accessible rooms to administer the test; pts being distracted or interrupted while completing the test; presence of family members adding to noise levels; concerns over the serial testing during treatment; length of each test; and clinic staff burden. Facilitators: User-friendly self-administered tests; increasing healthcare staff education and pt management. Adapting to the local context: Logistical barriers were resolved by CRCs designating quiet spaces for the study to occur, and meeting pts upon arrival to utilize their wait time. A ‘hearing test in progress’ sign put on exam room doors prevented interruptions. CRCs utilized the test’s ‘assisted mode’ feature to keep pts attentive and/or accelerate the process. Low noise level was emphasized to obtain accurate test results. Pt engagement in their test results facilitated retention in the study. Test length may be shortened in the future by omitting low frequency testing. Conclusions: Participants and stakeholders expressed support for in-clinic hearing tests and identified personal and systemic barriers to implementation. These findings suggest that implementation should focus on addressing concerns related to accessible rooms, pt time investment and overall clinic flow.

Objectives To evaluate the acceptability and usability of the Hear Glue Ear mobile application to guide families and support speech and language development in children with otitis media with effusion (OME). To assess the validity of the app’s game-based hearing test to estimate changes in hearing levels between audiology appointments. Method This evaluation examined 60 children aged 2–8 with and without OME, attending Cambridge Community Audiology clinics. Children’s performance in the app’s hearing test was compared to their pure tone average (PTA) obtained in clinic. Children and caregivers completed questionnaires after their first interaction with the app, and after one week of using it at home. 18 clinicians completed anonymous questionnaires after trialling the app. Results Results from the app’s hearing test show a significant correlation with clinic PTA values ([Formula: see text]). 73.1% of caregivers supported their child using the app regularly and 85% thought it enabled them to give more accurate reports to clinicians. After one week, 87.0% of families downloaded and used the app at home, and 85.7% of these felt it provided strategies to help their child. 100% of children liked the app and 93.3% found it easy to use. 77.8% of clinicians supported patients using the app regularly. Conclusions Hear Glue Ear is acceptable to children, caregivers and clinicians as part of OME management. The app’s hearing test provides a valid estimate of fluctuating hearing levels. Hear Glue Ear is a free, accessible and family-centred intervention to provide trusted information and support development, as NICE guidance recommends.

Recent national estimates from the U.S. reveal that as many as one-third of all Americans experience chronic pain resulting in high prevalence rates of visits to primary care clinics (PCC). Indeed, chronic pain appears to be an emerging global health problem. Research has largely ignored the perspective of PCC staff other than physicians in providing care for patients with chronic pain. We wanted to gain insights from the experiences of Registered Nurses (RNs) and Health Technicians (HTs) who care for this patient population. Krippendorff’s method for content analysis was used to analyze comments written in an open-ended survey from fifty-seven primary care clinic staff (RNs-N=27 and HTs-N=30) respondents. This represented an overall response rate of 75%. Five themes emerged related to the experience of RNs and HTs caring for patients with chronic pain: 1) Primacy of Medications and Accompanying Clinical Quandaries; 2) System Barriers; 3) Dealing with Failure; 4) Primacy of Patient Centered Care; and 5) Importance of Team Based Care. This study demonstrates that nursing staff provide patient-centered care, recognize the importance of their role within an interdisciplinary team and can offer valuable insight about the care of patients with chronic pain. This study provides insight into strategies that can mitigate barriers to chronic pain management while sustaining those aspects that RNs and HTs view as essential for improving patient care for this vulnerable population in PCCs.

Norrie disease (ND) is a rare, X-linked condition of visual and auditory impairment, often presenting with additional neurological features and developmental delays of varying severity. While all affected patients are born blind, or lose their vision in infancy, progressive sensorineural hearing loss develops in the majority of cases and is typically detected in the second decade of life. A range of additional symptoms of ND, such as seizure disorders, typically appear from a young age, but it is difficult to predict the range of symptoms ND patients will experience. After growing up without vision, hearing loss represents the greatest worry for many patients with ND, as they may lose the ability to participate in previously enjoyed activities or to communicate with others.Dual sensory loss has a physical, psychosocial and financial impact on both patients with ND and their families. Routine monitoring of the condition is required in order to identify, treat and provide support for emerging health problems, leading to a large burden of medical appointments. Many patients need to travel long distances to meet with specialists, representing a further burden on time and finances. Additionally, the rare nature of dual sensory impairment in children means that few clinical environments are designed to meet their needs. Dual Sensory clinics are multidisciplinary environments designed for sensory-impaired children and have been suggested to alleviate the impact of diseases involving sensory loss such as ND.Here, we discuss the diagnosis, monitoring and management of ND and the impact it has on paediatric patients and their caregivers. We describe the potential for dual sensory clinics to reduce disease burden through providing an appropriate clinical environment, access to multiple clinical experts in one visit, and ease of monitoring for patients with ND.

AbstractCurrent guidelines for adult hearing aid fittings recommend the use of a prescriptive fitting rationale with real-ear verification that considers the audiogram for the determination of frequency-specific gain and ratios for wide dynamic range compression. However, the guidelines lack recommendations for how other common signal-processing features (e.g., noise reduction, frequency lowering, directional microphones) should be considered during the provision of hearing aid fittings and fine-tunings for adult patients.The purpose of this survey was to identify how audiologists make clinical decisions regarding common signal-processing features for hearing aid provision in adults.An online survey was sent to audiologists across the United States. The 22 survey questions addressed four primary topics including demographics of the responding audiologists, factors affecting selection of hearing aid devices, the approaches used in the fitting of signal-processing features, and the strategies used in the fine-tuning of these features.A total of 251 audiologists who provide hearing aid fittings to adults completed the electronically distributed survey. The respondents worked in a variety of settings including private practice, physician offices, university clinics, and hospitals/medical centers.Data analysis was based on a qualitative analysis of the question responses. The survey results for each of the four topic areas (demographics, device selection, hearing aid fitting, and hearing aid fine-tuning) are summarized descriptively.Survey responses indicate that audiologists vary in the procedures they use in fitting and fine-tuning based on the specific feature, such that the approaches used for the fitting of frequency-specific gain differ from other types of features (i.e., compression time constants, frequency lowering parameters, noise reduction strength, directional microphones, feedback management). Audiologists commonly rely on prescriptive fitting formulas and probe microphone measures for the fitting of frequency-specific gain and rely on manufacturers’ default settings and recommendations for both the initial fitting and the fine-tuning of signal-processing features other than frequency-specific gain.The survey results are consistent with a lack of published protocols and guidelines for fitting and adjusting signal-processing features beyond frequency-specific gain. To streamline current practice, a transparent evidence-based tool that enables clinicians to prescribe the setting of other features from individual patient characteristics would be desirable.

Background: It has been estimated that as many as 50 million Americans do experience or have experienced tinnitus. For approximately 12 million of these individuals, tinnitus makes it impossible for them to carry out normal everyday activities without limitation. These are the patients that present to audiology clinics for assessment and management. The tinnitus evaluation includes the measurement of acoustical characteristics of tinnitus and the impact that this impairment has on health-related quality of life (HRQoL). Tinnitus is a disorder that often occurs as a result of auditory system impairment. The impairment for some can impart an activity limitation and a participation restriction (i.e., tinnitus-related disability or handicap, respectively). The goal of tinnitus management is to reduce, or eliminate, activity limitations and participation restrictions by reducing or eliminating a patient’s perception of tinnitus or their reaction to tinnitus. Implicit in this statement is the assumption that there exist standardized measures for quantifying the patient’s tinnitus perception and their reaction to it. If there existed stable and responsive standardized tinnitus measures, then it would be possible to compare a patient’s tinnitus experience at different time points (e.g., before and after treatment) to assess, for example, treatment efficacy. Purpose: The purposes of the current review are to (1) describe psychometric standards used to select outcome measurement tools; (2) discuss available measurement techniques and their application to tinnitus evaluation and treatment-related assessment within the domains established by the World Health Organization’s International Classification of Functioning, Disability and Health; (3) list and briefly describe self-report tinnitus questionnaires; (4) describe how valuation of tinnitus treatment can be assessed using economic models of treatment effectiveness; and (5) provide future directions including the development of a tinnitus outcomes test battery and treatment-related study designs. Research Design: Retrospective literature review Conclusions: Although psychometrically robust measures of tinnitus HRQoL do exist, there is no unanimity in, for example, what tests should be included in the tinnitus assessment, and how studies of HRQoL should be conducted. The current authors suggest that future studies employ more rigorous designs and contain (minimally) the following characteristics: (1) utilization of randomized control groups and blinding; (2) appropriate statistical testing including “dropouts” that should be used in an “intention to treat” analysis rather than elimination from the final data set; (3) long-term follow-up assessment to evaluate responsiveness; (4) appropriate inclusion criteria to avoid “ceiling” and “floor” effects; and (5) suitable sample sizes based on the application of power analyses.

The purpose of the study was to develop best practice guidelines to prevent permanent hearing loss associated with the management of multi-drug resistant tuberculosis (MDR-TB) through raised awareness and monitoring. The Human Immunodeficiency Virus (HIV) and MDR-TB are global public health problems requiring urgent scale-up of treatment services. Irreversible sensorineural hearing loss (SNHL) is one of the adverse drug reactions of the current World Health Organization (WHO) recommended MDR-TB chemotherapy fuelling another public health problem, that disabling hearing loss, which is the second highest contributor of Years Lived with Disability (YLD) according to the World Health Report (2003). Expansion of MDR-TB treatment threatens to increase incidence of SNHL unless there is urgent implementation of intervention towards preservation of hearing for patients on treatment. This empirical study determined and documented the incidence of SNHL in HIV positive and HIV negative patients on MDR-TB treatment, the risk factors for SNHL, from the time treatment initiation to SNHL. Based on the findings, developed and improved the understanding of best practice guidelines for monitoring and prevention of MDR-TB treatment-related SNHL. The empirical study recruited a cohort of 173 patients with normal hearing status, after diagnosis with MDR-TB and enrolled on MDR-TB therapy over thirteen month period. Patients in the cohort received monthly hearing sensitivity testing during the intensive MDR-TB therapy when injectable aminoglycoside antibiotics are part of the treatment regimen. The three study endpoints included completion of the eight-month intensive treatment phase without developing hearing loss, development incident hearing loss or loss to follow up. Data was analysed using STATA statistical software and summarised using frequencies, means, proportions, and rates. The study documented incidence of SNHL, time to hearing loss and risk factors for hearing loss. Recommendations to prevent and monitor hearing loss are made based on the the study findings.
Health Studies
D. Litt. et Phil. (Health Studies)

INTRODUCTION: Poor management of health-care waste can cause serious disease to health-care personnel, waste workers, patients and the general public. The greatest risk is posed by infectious waste. Through the observation of the researcher, the management of sharp waste in rural clinics in Swaziland seemed to be poor because waste was often seen scattered around the clinics. This motivated the researcher to scrutinize the reason behind the situation in clinics. AIMS OF THE STUDY: The aim of the study was to evaluate the management of sharp waste in 35 rural clinics in Swaziland. OBJECTIVES OF THE STUDY a) To assess the degree to which resources are available to enable staff to adhere to procedures regarding the segregation, storage, transportation and treatment of sharp waste in rural clinics in Swaziland. b) To determine if relevant documents to address the management of sharp waste in rural clinics are available and accessible. c) To determine perceptions of clinic managers for failures to comply fully with sharp waste management standards. MATERIALS AND METHODS: The study design was a cross-sectional descriptive survey. Methods of data acquisition were by acquiring observation checklist and interviewing clinic managers on sharp waste management practices in their clinics. The researcher sampled 35 clinics. A convenience sample method was used. RESULTS: NATIONALLY Ninety four percent (94%) of the sampled clinics had sharp waste containers to segregate sharp waste properly. Sixty five percent (65%) had punctured proof containers. Eighty percent (80%) had sharp waste containers. Eighty six percentage (86%) sealed sharp waste at ¾ full. Twenty percentage (20%) did not have storage areas for sharp waste. Only one (3%) had a waste trolley. There was availability of protective clothing for all health personnel. Seventy seven percentage (77%) clinics did not have full protective clothing for waste handlers. Fifty one percent (51%) did not have risk waste pit/incinerator. Most of the clinics in the four regions did not have the Waste Regulation 2000, Health Care Waste Management plan document or the National Health Care Waste Guidelines. Twenty nine percent (29%) had done trainings on health care waste management. REGIONALLY Almost all the clinics had 100% compliance in the availability of sharp waste containers for segregating health care waste except the Lubombo region that had 78% compliance. There was no 100% compliance in all the regions on the availability of puncture proof containers. The Shiselweni region had a very poor compliance as compared to other regions. It was observed that not all clinics sealed their containers when ¾ full. The Shiselweni region had lower compliance by 78% and Hhohho region had the highest compliancy of 100%. There was poor availability of storage areas. All the regions were less than 50% compliance in the provision of the storage area. Shiselweni region was the only region that was above 50% compliancy. There was very poor availability of transportation waste trolleys. Only one clinic in Shiselweni region had transportation waste trolley. There was 100% compliance in the availability of protective clothing for health personnel. There was poor availability of protective clothing for waste handlers. Shiselweni region was the only region that was above 50% compliance, the rest had a very low compliance. There was poor availability of risk waste pit/incinerator in Hhohho and Manzini region. Their compliance was less than 50%. Shiselweni andLubombo region were above 50% compliance. Availability of legislation was very poor in regions. The Hhohho and Manzini were the worst regions in terms of compliancy. They had 0% compliancy. The Lubombo region had the highest compliancy of 33% and this was very low since it was below 50%. INTERVIEWS Eighty six percent (86%) clinic managers revealed that there was poor availability of resources in their clinics and that was why their clinics were not complying. Eighty six percent (86%) of clinic managers recommended that there should be availability of resources; few recommended that there should be availability of protective clothing for the waste handlers and regulations. Seventy one percent (71%) clinic managers needed technical support on incinerators/risk waste pit, Twenty percent (20%) need supported on trainings of health care waste. CONCLUSION: There was poor availability of resources and there were poor relevant documents to address the management of sharp waste containers in most clinics. All clinic managers during their interviews felt that they needed close supervision and technical support from their supervisors so that it could be easy for the supervisors to identify any problems associated in clinics. RECOMMENDATIONS: The study revealed that sharp waste management was not well managed in all the stages from segregation to disposal. It is the responsibility of Supervisors in clinics to make sure that there is availability of resources in clinics to enable staff to adhere to procedures regarding the segregation, storage, transportation and treatment of sharp waste in rural clinics in Swaziland. Relevant documents should be available to address the management of sharp waste containers. There should be close supervision in clinics from supervisors

碩士
國立陽明大學
公共衛生研究所
93
Part I: Abstract The purposes of the study are to compare medical waste management policies and practices of Swaziland, Taiwan and US, to make suggestions for improvement of the system in Swaziland. The three countries are at different socio economical statuses; therefore their resources for resolving medical waste management problems are different. The methodology used for this part was literature search; by reading and analyzing articles, workshop reports and internet communication. Results were that there were some similarities and differences identified. Similarities are such as; all of them use one government agency to be over all responsible for environmental issues. There is a broad spectrum of intersectoral involvement. Medical waste is defined in similar terms though categorized and termed differently. They all stress waste segregation. The differences are; naming of the agency in charge of environmental issues; in Swaziland, it called the Environmental Authority (EA), in Taiwan, Environmental Protection Administration (EPA) and in US Environmental Protection Agency (EPA). The current waste management strategies started in different periods when each country’s environmental act was passed; in Swaziland in 2003, Taiwan in 1986 and US in 1976. The extent of decentralization including devolution of power to promulgate laws, regulations and policies at local level differ; in Swaziland and in Taiwan, the promulgation of laws and policies are still centralized, in US there are four levels of decentralization, the federal, state, county and municipality. In Swaziland the private sector is not yet participating. In Taiwan, there is a moderate involvement of the private sector, for instance capacity of private waste handling firms is currently 20% of the waste produced. In US the involvement of the private sector is more predominant; there are varieties of waste treatment methods by private waste treatment companies. Swaziland is estimated to generate 3313 tons of medical waste; Taiwan is estimated to generate 90,000 tons of medical waste and US was estimated to generate 356,001 tons of medical waste in 2002. Waste generation rates are commensurate with each country’s level of economy. Color coding of medical waste containers is different in each country from the other. In Swaziland no classification of medical waste generators is done, where as in Taiwan and US the waste generators are classified according to quantities they generate for licensing purposes In Taiwan, if a health facility has more than ten beds it should apply for a clearance from the EPA and should have an infectious waste treatment plan before it can operate. If a health facility has more than fifty beds it is required to report the amount of waste produced on daily basis and the details of transportation and method of disposal as well as the clearance agent through the website. Companies dealing with waste handling apply for a permit to generate, clearance and disposal of waste. The maximum allowed duration of stay of waste within the premises of a health facility is one week if the temperatures are controlled bellow room temperature 5o C. In Taiwan clearance companies are required to install geo positioning satellite (GPS) in their waste transportation vehicles to enable EPA to locate them wherever they are. In Taiwan waste is also converted into energy and income generation business by recycling companies. In US there are three categories of hazardous waste generators as follows: conditionally exempt a small quantity generator (CESQG) generates waste less than 100 kg per month; small quantity generators (SQG) generate more than 100 kg per month; and large quantity generators (LQG) generate more than 1000 kg per month. Both the quantity of hazardous waste generated each month and the cumulative amount of hazardous waste at a facility at any time determines which category a facility belongs, with a limit of 1000kg, 6000kg. CESQG and SQG are inspected biennially where as the LQG are inspected annually. The waste tracking is both by internet and paper work in Taiwan and US. The higher the generation rate the stricter are the regulations. The more the country is developed the more resources such as financial, human, technology and material it has, to deal with medical waste problems. It is recommended that Swaziland provide incentives for the private sector to be motivated to participate in medical waste management as it is effective in Taiwan and US. It is advisable for Swaziland to take precautions when changing from public to private to monitor illegal dumping. There should be capacity building for the public sector to monitor and enforce the laws, regulations and policies. The University of Swaziland must be encouraged to conduct studies on waste management in the country. Recording of the waste types, quantities and documentation should be improved. The positive results of the pilot project in the few health facilities should be replicated to the rest of the health facilities without delay. Part II The purposes of the study are to determine the current status of medical waste disposal in Taipei clinics, to identify if there are gaps between medical waste management policies and the current medical waste management practice and to specify the exact areas where the shortfalls may be located. Participants were persons in charge of clinics during the period of study mainly doctors and nurses. The methodology used was a cross-sectional, descriptive study and a stratified random sampling was used. The unit of analysis was a clinic. An SPSS 11.0 computer soft ware was used for descriptive statistics and a biviriate correlation for the relationship between quantity of waste generated and number of patients. The exclusion criterion was unspecified clinic type, lack address or lack e-mail, and others of very few types, less than 10 in the group. Participating clinics were 82. The survey indicated that 73% of the clinics do not have beds. The average number of outpatients is 38/day. Medical waste generation is 9.1 kg/ week. The largest quantity is general combustible waste at 3.6 kg/week and the smallest is radio active waste ≤ 0.01kg/week. Particular attention was given to clinics that generate infectious waste in the analysis of the policies and the practices. Non infectious waste generators and non responses were excluded. Only 31.7% clinics trained their medical waste handlers when including even non infectious waste generators. It is not a regulatory requirement for clinics in Taiwan to train their workers formerly in medical waste handling. Those few did it at their own initiative. There are 75.0% of infectious waste generating clinics having records of medical waste. All the infectious waste generating clinics 100% store their infectious waste for refrigerator below 5oC in compliance with the waste disposal act. Policies on medical waste handling more than a day in a are available to 56.8% but and 72.0% of those who have them, have them written. Clinics are not obligated by regulations to have written policies but it is a good practice to do it. Average knowledge on color coding and symbols were 13.4% and 31.0% respectively. Private contractors are used by 54.5% of the clinics which generate infectious waste. About 66.1% of the clinics know how their medical waste is finally disposed. These results exclude non generators of infectious waste and missing responses. Occurrence of injuries due to waste handling was 9.8% needle pricks. 82% of the clinics were inspected at least once by the responsible agency during the year under review. The conclusion is that generally there is no disparity between practice and policies at clinic level since most of strict requirements are for bigger facilities such as clinics above 10 beds who are required to submit a waste management plan even before operation and hospitals especially those above 50 beds who are even required to report daily to the responsible agency. Key words: medical waste, infectious waste, segregation, medical waste treatment, incineration and disposal.

AIM: To examine the safety and acceptability of providing antiretroviral therapy (ART) in a resource poor setting. DESIGN: Two-stage observational and qualitative study. SETTING: Rural hospital in Southern Africa. METHODS: Structured observation using failure modes and effects analysis (FMEA) of the drug supply, dispensing, prescribing and administration processes. The findings from the FMEA were explored further in qualitative interviews with eight health professionals involved in the delivery of ART. To obtain a patient perspective, a stratified sample of 14 patients receiving ART was also interviewed. RESULTS: Key vulnerabilities in the process of ART provision include supply problems, poor packaging and labelling, inadequate knowledge among staff and lack of staff. Key barriers to successful patient adherence include transport inconsistency in supply and personal financial difficulties. There is, however, strong evidence of patient commitment and adherence. IMPLICATIONS AND CONCLUSION: Medication safety is relatively unexplored in the developing world. This study reveals an encouraging resilience in the health system and adherence among patients in the delivery of complex ART. The vulnerabilities identified, however, undermine patient safety and effectiveness of ART. There are implications for drug manufacturers; international aid agencies funding and supplying ART; and local practitioners. FMEA can help identify potential vulnerabilities and inform safety improvement interventions.

Hearing loss is highly prevalent and increases as a function of age. Although hearing loss affects many aspects of ageing and communication, it is often overlooked and treated as a rather inconsequential side effect of ageing. The purpose of this chapter is to introduce age-related hearing loss, the broader implications of age-related hearing loss as it relates to healthy ageing, and practical strategies for primary care management of hearing loss. A majority of the cases of age-related hearing loss remain untreated. Primary and/or geriatric care clinics may serve as the entry point for many older adults with hearing loss. Including questions about hearing loss or screening for hearing loss at other health encounters may increase access for older adults to hearing loss treatment.

Chapter 35 provides an overview of ear, nose, and throat (ENT) surgery. The most common presentations encountered in ENT surgery are summarized including acute tonsillitis and quinsy, otitis externa, head and neck cancer, and airway emergencies. A more detailed description of the clinical presentation of common diseases encountered in ENT clinics is provided covering otitis externa, lower motor neuron facial nerve palsy, nasal fractures, acute otitis media, neck lumps, and vertigo. The roles of investigations used to support diagnosis in ENT including audiography, ultrasound, and magnetic resonance imaging are described. The presentation and management of acute presentations in ENT seen in emergency departments including epistaxis, acute peritonsillar abscess, airway emergencies, periorbital cellulitis, including airway assessment are described. An overview of commonly performed ENT operations is provided including tonsillectomy, grommet insertion, thyroidectomy, neck dissection, and tracheostomy. An approach to clinical skills in ENT (including common OSCE stations in exams) is described, including history taking, examination of neck lumps, thyroid exam, and ear examination. Clinical tests of hearing are presented and their interpretation described.