South African Family Practice - Volume 50, Issue 3, 2008
Volume 50, Issue 3, 2008
Source: South African Family Practice 50 (2008)More Less
Background: There is a shortage of medical specialists within the provincial departments of health in South Africa. Telemedicine is a potential way of providing specialist services, at a distance, to rural areas. This study assesses patient and staff satisfaction and issues, technological and operational, associated with the establishment of a videoconference-based teledermatology service.
Methods: An ISDN-based videoconference link was established between Port Shepstone Hospital and the Nelson R Mandela School of Medicine in Durban. Patients with a dermatological problem that would have necessitated transfer to the academic hospital for diagnosis and / or management were entered into a prospective study which evaluated the ability to make a diagnosis and prescribe a management plan by videoconference and the patients' and doctors' satisfaction with the consultations.
Results: A total of 69 patients were seen during 12 videoconferenced consultation sessions. Seventeen patients (24.6%) were subsequently referred to the academic hospital: nine patients were sent because a definitive diagnosis could not be made; and eight patients were transferred for specialist management based on the diagnosis made. The patients' and referring doctors' satisfaction with the consultation was 80.3% and 82.1% respectively, while the dermatologist was satisfied 67.6% of the time.The dermatologist was dissatisfied with ten (14.7%) of the consultations and this was related to difficulties in making a definitive diagnosis. The referring doctors found 59 (85.9%) of the consultations to be of educational value. No problems were noted in diagnosing lesions in dark-skinned patients.
Conclusion: Videoconferenced teledermatology between district hospitals and regional hospitals is possible and can improve services to rural areas. Further studies on widespread implementation and sustainability are warranted.
Source: South African Family Practice 50 (2008)More Less
Background: Patients are using homeopathy in increasing numbers and not telling their doctors about it. It is important as family physicians that we understand the reasons why patients choose to consult homeopaths. It is important to know what our patients are looking for that they do not find in Western medicine. This information will provide valuable insights and enable us to engage with our patients in an informed and empathetic way such engagement being vital to maintaining an open relationship and providing the best possible care and advice.
Methods: The aim of this study was to understand the reasons why patients choose to consult homeopaths. Eight free-attitude interviews were conducted with purposefully selected patients who consulted a particular homeopath in Gauteng province. The exploratory question was 'Why do you choose to consult a homeopath?'. The interviews were all conducted in English, transcribed verbatim, and analysed for categories and themes using the 'cut and paste' method. Member checks were done by verifying the transcribed data with the interviewees by e-mail. Triangulation of the data was done by audio-recording of the interviews, and using transcribed notes and field notes collected during the interviews.
Results: All the participants initially consulted a homeopath after their health problems were not solved by mainstream medical treatment. Most were also concerned about the side effects of long-term mainstream medication. Many were frustrated with mainstream consultation or relationship factors, including rushed consultations, being asked too few questions and doctors being too quick to prescribe. Some participants said that doctors had a poor bedside manner, were difficult to talk to, and were judgemental or uncaring. The participants continued to consult homeopaths because they felt that the treatment was effective, natural and did not have side effects. They indicated that homeopathic treatment works with the body and health problems therefore are solved in the long term. This makes homeopathic treatment cheaper, because the same problem does not need to be treated repeatedly. Homeopathic consultations were longer, and homeopaths were easier to talk to and formed an equal partnership with them. In addition, problems were managed holistically mind, emotions and body, as well as work and family factors were considered. Homeopaths were considered competent and ethical and knew their limitations.
Conclusion: From the reasons given for consulting homeopaths, we, as family physicians, can learn a lot about what patients consider important in their consultations and management. Frustration with some aspect of mainstream care has pushed them to look for solutions elsewhere Much of what the patients did not find with doctors but found with homeopaths can be found in the principles of family medicine. It will be important to validate the findings of this study by developing a hypothesis that can be tested using a quantitative paradigm.
Subjective wellbeing of primary healthcare patients in the Western Cape, South Africa : original researchSource: South African Family Practice 50 (2008)More Less
Background: Patients living with a chronic illness face many challenges in their lives such as an altered body image, physical pain or discomfort, the need for frequent medical visits and the negative side effects of treatment. To this extent their sense of personal or subjective well-being may be compromised by the severity and chronicity of their illness. The aim of the present study was to explore the level of subjective well-being and its relationship with coping, quality of life and support from family and friends among a sample of Black South Africans attending semi-rural public clinics for treatment for hypertension and diabetes. This study was part of a larger project on treatment adherence to medication among patients living with these conditions.
Methods: A convenience sample of 117 patients aged between 22 and 82 years (M=52.36, SD=13.24), receiving treatment for hypertension (n=79) or diabetes (n=24) at three primary health care clinics in the Boland area of the Western Cape were asked to participate in this study. Of the total sample, 14 (12%) were diagnosed with both conditions. Participants were asked to complete a questionnaire battery consisting of the Satisfaction with Life Scale, the Coping Strategy Indicator, the Functioning Assessment of Non-Life Threatening Conditions and the Perceived Social Support Scale.
Results: The mean score of the Satisfaction with Life Scale was 28.70, which was significantly higher than those of other studies using this measure. In order to address the problem of experiment-wise error, commonly associated with the use of multiple statistical comparisons, we used the Bonferronni correction in arriving at probability levels in determining statistical significance. On average the sample as a whole appeared to be largely satisfied. The mean scores on the two of the subscales of the Coping Strategy Indicator were significantly different from those obtained from other South African samples. On the Functioning Assessment of Non-Life Threatening Conditions, the mean scores on the subscales but not the total score was significantly higher than other South African samples.
Conclusions: In general, participants scored significantly higher on all of the measuring instruments compared with other South African samples, indicating high levels of life satisfaction, coping, and support from others. We found no relationship between life satisfaction and gender. Age however correlated positively with satisfaction with Life, Support from family, social and emotional well being and Quality of Life, which concurs with the findings of previous studies. Contrary to other studies we found a significant negative correlation between education and SWLS but no relationship between employment and SWLS. Our sample also reported higher levels of support from friends and family that were significantly higher than those of other South African samples. The mean scores on all the subscales of the Coping Strategy Indicator were higher than that of other South African samples.
Characteristics of acute poisoning at two referral hospitals in Francistown and Gaborone : original researchAuthor N. MalanguSource: South African Family Practice 50 (2008)More Less
Background: The epidemiology of acute poisoning in Botswana is not well established due to the limited availability of published data. In an attempt to fill this gap, this study aimed to characterise acute poisoning cases admitted to two urban hospitals in Francistown and Gaborone, Botswana.
Methods: This study followed a descriptive methodology involving 116 patients with the primary diagnosis of acute poisoning admitted to two referral hospitals in Botswana from January to June 2005. Data were collected by means of a pre-tested data-collection form.
Results: Overall, 58 (50%) of the victims of acute poisoning were female, accidental poisoning occurring in 89 (76.9%) of the cases. Intentional poisoning was reported in 33.3% of the females versus 13.5% of the males. With regard to demographic distribution, the majority of the victims were in the age category of 13 to 19 (20.7% versus 5.2%) for the females and in the 30-year-old group for the males (24.1% versus 10.3%). Poisoning by household chemicals, particularly paraffin, affected mainly children under 12, while poisoning by pharmaceuticals involved mainly teenagers. With regard to outcomes, three of the female victims died, representing a case fatality rate of 2.6%. One death was due to paraffin poisoning and two to traditional medicine. Those who died were two children in the 0 to 12-year group and one adult in the age category of 20 to 30.
Conclusion: The acute poisoning involved a variety of toxic agents of which household chemicals and pharmaceuticals predominated. Differences based on age category, sex, the types of toxic agents involved and the outcomes of the poisoning incidents were noted. Future interventions should take these differences into account.
Source: South African Family Practice 50 (2008)More Less
Background: Maternal and perinatal mortality remain a big challenge in developing countries, including South Africa, where the figures are amongst the highest in the world. Provision of adequate antenatal care is regarded as a cornerstone of maternal and perinatal health care and is expected to have a considerable impact on achieving the Millennium Development Goals. The detection of high-risk pregnancies through antenatal care has been advocated as a good tool to reduce maternal mortality in developing countries. The South African Government's response in terms of providing free maternal care in public health facilities is commendable but access to quality antenatal care is still questionable. We conducted this audit to evaluate the quality of antenatal care / services provided against the set national standards at the first (booking) visit, and visits at 28 and 36 weeks of gestation, as part of a quality improvement initiative.
Methods: A retrospective cross-sectional descriptive study was undertaken, targeting women who attended public health institutions for antenatal care in the Empangeni sub-district of Uthungulu, which is a health district in KwaZulu-Natal province. Data were collected from 244 pregnant mothers' antenatal care records after delivery, and a random selection from a total of 5 109 women who delivered in Empangeni hospital during July to December 2004. Frequency tables were produced on the predetermined selective antenatal care indicators. A Pearson correlation test was conducted to determine the significant relations, if any, among variables.
Results: The majority of the pregnant mothers were unemployed and poor. Virtually all of them (99.6%) had attended public healthcare (PHC) facilities for antenatal care (88% attended PHC clinics and the rest attended hospitals) and each woman had, on average, six antenatal visits. One quarter did not enrol for a prevention of mother-to-child transmission (PMTCT) programme. Only 9% of pregnant women booked a visit during their first trimester period but most of them (two-thirds) booked a visit during the second trimester of pregnancy. History-taking was done for every woman. Recording of haemoglobin (Hb) estimation was high at the first visit (95%) but low at 28 and 36 weeks (46% and 30% respectively). Recording of syphilis screening was very low (18%) at the first visit and only 2% was screened at 36 weeks. Only 16% received adequate treatment in cases where the results were positive. At 36 weeks, only 2% had a Wasserman reaction (WR) test done to screen syphilis at term. Over half (55%) of the pregnant women received three doses of tetanus toxoid vaccination before delivery.
Conclusion: The study showed that the standard of antenatal care offered in the Empangeni sub-district fell short of the required level. This lack of proper care represents missed opportunities to impact optimally on maternal and perinatal health outcomes. Thus strategies are urgently needed to improve antenatal care through a quality improving initiative.
Author Gboyega A. OgunbanjoSource: South African Family Practice 50 (2008)More Less
Once again we have succeeded in putting together a set of interesting articles which are relevant and topical for the family practitioner. The article on community-acquired pneumonia (CAP) by AD Black emphasizes the importance of CAP as an important cause of morbidity and mortality in the general population especially in the very young and elderly. It is interesting to note that no obvious predisposing cause is apparent in the majority of cases and even with extensive investigations; a causative agent is not identified in 98% of outpatients and 40-50% of inpatients. In those who a causative agent is found, Streptococcus pneumonia is still the predominant organism. The clinical scores proposed to differentiate between viral and bacterial CAP are neither sensitive nor specific for clinical practice, although the Bartlett score is still used for identifying specimens from lower respiratory tracts. The algorithm produced with permission from S Afr Med J summarizes the South African Thoracic Society's guideline for the management of CAP. The article covers the wide range of antibiotic regimen with the combination of amoxicillin-clavulanate still favoured as first line treatment in most cases of CAP.
Author N. EbrahimSource: South African Family Practice 50, pp 5 –13 (2008)More Less
The relationship between the family practitioner and the radiographer and radiologist is of utmost importance. Radiographers are among the healthcare workers who are at the first point of care and often only communicate with a radiologist after an x-ray examination is performed. The role of the radiographer has been extended to pattern recognition of skeletal images and selected ultrasound examinations. In some countries radiographers perform and report on invasive radiological techniques. The communication among healthcare workers about the possibility of child abuse is of utmost importance in the suspicion / recognition of abuse. Non-accidental injury in children may or may not be accompanied by sexual abuse, but in any situation where telltale signs of abuse are recognised, further investigation is necessary. The aim of this article is to assist the family practitioner in recognising some of the unusual radiographic patterns seen in paediatric radiography together with mechanisms of what may have contributed to the debilitating injuries sustained by survivors of abuse.
Author A.D. BlackSource: South African Family Practice 50, pp 15 –23 (2008)More Less
Community-acquired pneumonia (CAP) remains an important cause of morbidity and mortality. The implementation of CAP guidelines can decrease patient mortality and limit antibiotic resistance. The South African Thoracic Society (SATS) has revised its guidelines for the management of CAP in adults. This article reviews the management of CAP and explores the rationale for the recommendations regarding point of care and antibiotic therapy.
Source: South African Family Practice 50, pp 24 –31 (2008)More Less
Although this article focuses predominantly on the management of paediatric burns, many of the principles and management protocols are universal and can be used for adults. Burns are defined as the coagulate destruction of tissue by thermal, chemical or electrical injury. This simplistic definition does, however, fail to incorporate the significant short- and long-term sequelae of these injuries, and the devastating social, functional and cosmetic consequences resulting from burn wounds.
Author P.M. JeenaSource: South African Family Practice 50, pp 32 –37 (2008)More Less
Respiratory distress (RD), a term utilised to summate a conglomeration of clinical features, including tachypnoea, use of accessory muscles of respiratory, lower chest wall indrawing, grunting, hypoxaemia and cyanosis, is useful in determining severity of illness in childhood. While these features commonly reflect pathology in the respiratory system, a condition accounting for the vast majority of the 10.8 million under-five childhood deaths occurring globally each year, dysfunction in other organ systems may also present with features of respiratory distress. The World Health Organization (WHO) has utilised some of these clinical findings to classify the severity of pneumonia and to advocate management under its programme of integrated management of childhood illness. The WHO has identified the following three essential steps that would help reduce mortality from pneumonia: (1) recognition of a sick child, (2) appropriate seeking of care, and (3) management of the underlying condition. Despite the WHO's acknowledgement that appropriate implementation of these steps would have a significant impact on reaching the target of Millennium Development Goal 4 (a two-thirds reduction in the global under-five mortality rates between 1990 and 2015), only about one in five health caregivers knows the danger signs of severe respiratory distress, inappropriate behaviour in seeking care is often seen in the impoverished, poorly educated communities, and effective interventions are inconsistently applied.
Source: South African Family Practice 50, pp 38 –39 (2008)More Less
This article discusses various ethical and legal concepts regarding euthanasia and includes concepts like physician assisted suicide, assisted suicide, voluntary active euthanasia, killing vs. letting die, indirect euthanasia and terminal sedation. Is there a difference if death is only foreseen but not intended? This article opens up the debate and addresses pertinent issues for the family practitioner.
Author H.P. MeyerSource: South African Family Practice 50, pp 40 –49 (2008)More Less
Neuropathic pain (NP) represents a common and diverse group of disorders with peripheral and / or central nervous system damage or dysfunction. Many patients report intractable and severe pain that is resistant to simple analgesics. The diagnosis of NP is primarily based on clinical evaluation rather than diagnostic tests. Distinct pain qualities in the patient's history and findings on clinical examination, such as hyperalgesia and other sensory findings in an area correlating with the patient's pain pattern are important in diagnosis. Various screening tools may assist in the diagnosis of NP.
A number of pathophysiological mechanisms have been identified in NP, including sodium- and calcium-channel upregulation and spinal cord hyperexcitability (central sensitisation). Appropriate management includes evaluation of the functional impact of NP, patient education and reassurance. A multi-model biopsychosocial approach that includes various nonpharmacological modalities is recommended. Appropriate pharmacological management is based on evidence-based recommendations that provide guidance for selecting first-, second- and third-line medications, alone or in combination. It is hoped that future treatment advances will improve the care of patients who live with NP.
Source: South African Family Practice 50 (2008)More Less
Symbicord(R) Maintenance and Reliever Treatment : a SMART new treatment standard for greater overall asthma control? : press releaseSource: South African Family Practice 50 (2008)More Less
Symbicord(R) SMART (as-needed budesonide-formoterol combination) achieved a 45% reduction in severe exacerbations compared with terbutaline, partly due to formetorol's rapid- and long-acting effect. This was achieved with less recourse to additional maintenance ICS than seen in studies yielding far smaller reductions, possibly because declining lung-tissue concentrations of maintenance ICS may benefit from timely supplementation.
Author Pierre J.T. De VilliersSource: South African Family Practice 50 (2008)More Less
May 2008 has been a difficult month for South Africa. Our TV screens once again erupted with scenes of violence, murder and destruction reminiscent of the old-apartheid days during the seventies and eighties. The so-called ''xenophobic attacks'' led to untold suffering for hundreds of thousands of immigrants in South Africa, with tens of thousands fleeing the country. Some refugees told reporters that they would rather face the poverty and possible persecution back home than the violence inflicted on them by raging and violent mobs of South Africans.
Author Bob MashSource: South African Family Practice 50, pp 58 –59 (2008)More Less
At a recent presentation of the study, Exploring the key principles of family medicine in Sub-Saharan Africa, one of the audience challenged me by saying ''So, where is the definition?'' This editorial is an attempt to answer this question in the spirit of eliciting further dialogue and debate.
Exploring the key principles of Family Medicine in sub-Saharan Africa : international Delphi consensus process : open forumSource: South African Family Practice 50, pp 60 –65 (2008)More Less
Background: The purpose of this study was to establish consensus on the key principles of Family Medicine for Sub-Saharan Africa.
Methods: A three-stage Delphi technique process involving nine countries in sub-Saharan Africa and individuals from two stakeholder groups (teachers or students / graduates of family medicine programmes). Consensus in rounds one and two was defined as at least 70% agreement. Ranking in round three depended on individuals selecting and ranking the top 20 principles; following this, aggregate scores were calculated.
Results: Of the participants, 40 gave consent and 28 participated in the first round (23 teachers and 17 students / graduates); 27/40 (67.5%) participated in the second round; 22/40 (60%) in the third round. The 50 principles seen as relevant were ranked in order of importance. Core values and characteristics such as holistic, longitudinal, comprehensive and family-orientated care and community orientation were recognised as relevant, with differences from more developed settings in terms of emphasis. Several key organisational principles, such as home visiting and definition of the practice population, were seen differently. Principles relating to the scope of practice showed the greatest difference, with the need for family physicians to perform major surgery in the district hospital, to act as consultant and teacher to the first-contact primary care team and to include clinical nurse practitioners in the definition of family medicine being raised.
Conclusion: The study contributes towards a clearer definition of Family Medicine in the region, which would enable comparison between regions, influence local curriculum content and outcomes, as well as inform the policy makers and managers of the health system.
Source: South African Family Practice 50 (2008)More Less
The UFS Faculty of Health Sciences Faculty Forum : a critical evaluation by heads of department : letters : correspondenceSource: South African Family Practice 50, pp 72 –73 (2008)More Less
An evaluative study to determine the effectiveness of a primary school-based HIV / AIDS learning intervention on the knowledge of the learners : letter : correspondenceSource: South African Family Practice 50 (2008)More Less
In July 2007 a pilot study was conducted to determine whether a book designed by the author, who was an MBCHB V student at the time, to teach primary school children about HIV was successful in conveying important and difficult concepts in a way that enabled the children to understand and remember them.