South African Family Practice - Volume 51, Issue 2, 2009
Volume 51, Issue 2, 2009
Author D. O'MahonySource: South African Family Practice 51, pp 1 –2 (2009)More Less
Worldwide, there is an inexorable trend towards electronic medical records (EMR), particularly in developed countries. Virtually every general practice in the United Kingdom is now computerised and half use electronic patient records. The National Programme for Health and Information Technology (NPfIT), for the health and social services in England, aims that every patient's medical record will be held electronically. This EMR will be available online, as required, to healthcare professionals and patients, both for hospital and ambulatory care. In the United States (US) in 2005, it is estimated that 25% of physicians in ambulatory practice used some form of EMR. The US government has made promotion of Health Information Technology one of its highest healthcare priorities. EMRs are also used in developing countries, although they are generally small projects funded and supported by organisations in the developed world.
Source: South African Family Practice 51, pp 91 –95 (2009)More Less
This article forms the fifth part of the series on the role of lifestyle modification in general practice with specific reference to cancer. It is recognised that cancer is not a single disease entity but rather a collection of diseases with the common feature of excessive uncontrolled cellular proliferation with the potential of cellular spread to distant anatomical sites. Whilst an in-depth discussion of the various types of cancer and the interaction with various lifestyle related factors is beyond the scope of this article, the concept of cancer in general will be discussed and where relevant, comment will be addressed to individual forms of cancer. The major risk factors which constitute an unhealthy lifestyle have been discussed in Part 1 of this series, thus the focus of Part 5 will be to give specific practical guidelines which the general practitioner may incorporate into their practice when counselling patients with cancer.
Source: South African Family Practice 51, pp 97 –102 (2009)More Less
We have reviewed the various insulins available in the South African market, together with the modes of action of each of the formulations. The insulin groups discussed include the Basal insulins, the bolus or prandial insulins, and the premixed insulins. Furthermore, an approach to the designing of an insulin regimen is discussed, and comments made on how to further intensify therapy depending on the response experienced. Oral hypoglycaemic agent failure is defined by an HbA1C measurement that exceeds 7%, which is a definitive call for further therapy with insulin in type 2 diabetes.
Updated guideline for the management of upper respiratory tract infections in South Africa : 2008 : clinical guidelineAuthor A.J. BrinkSource: South African Family Practice 51, pp 105 –114 (2009)More Less
Introduction: Inappropriate use of antibiotics for non-severe upper respiratory tract infections (URTIs), many of which are viral, adds to the burden of antibiotic resistance. Antibiotic resistance is increasing in Streptococcus pneumoniae, the microorganism responsible for most cases of acute otitis media (AOM) and acute bacterial sinusitis (ABS).
Method: The Infectious Diseases Society of Southern Africa held a multidisciplinary meeting to draw up a national guideline for the management of URTIs in 2003. Background information reviewed included randomised controlled trials, existing URTI guidelines and local antibiotic susceptibility patterns. The initial document was drafted at the meeting. Subsequent drafts were circulated to members of the working group for modification. The guideline was published in the South African Medical Journal in 2004 and was a consensus document based upon the opinions of the working group. In 2008 it was decided to update and republish the guideline. This was done electronically using the same working group members, including overseas experts.
Output: Penicillin remains the drug of choice for tonsillopharyngitis. Single-dose parenteral administration of benzathine penicillin is effective, but many favour oral administration twice daily for 10 days. Amoxycillin remains the drug of choice for both AOM and ABS. A dose of 90 mg/kg/day is recommended in general, which should be effective for pneumococci with high-level penicillin resistance (this is particularly likely in children ≤2 years of age, in day-care attendees, in cases with prior AOM within the past six months, and in children who have received antibiotics within the last three months). Alternative antibiotic choices are given in the guideline with recommendations for their specific indications. These antibiotics include amoxycillin-clavulanate, some cephalosporins, the macrolide/azalide and ketolide groups of agents and the respiratory fluoroquinolones.
Conclusion: The guideline should assist rational antibiotic prescribing for URTIs. However, it should be continuously updated when new information becomes available from randomised controlled trials and surveillance studies of local antibiotic susceptibility patterns.
Author B. BromSource: South African Family Practice 51 (2009)More Less
Many oncologists, if not most, generally advise their patients to stop taking antioxidants during chemotherapy and radiotherapy. They believe that these therapy modalities depend partly on free radical effects and therefore antioxidants would be counterproductive. In this article I wish to address this issue, and whether this advice is based on any reasonable science or is just a point of view.
Author Pierre J.T. De VilliersSource: South African Family Practice 51 (2009)More Less
Readers of South African Family Practice (SAFP) have been treated to the fascinating story of the development of family medicine in South Africa over the years, culminating in the establishment of a formal medical specialty in South Africa in 2007. The following year (2008) was almost a climactic busy year for the discipline : the various specialty training programmes started in 2008; a groundbreaking set of core skills for family physicians in the South African context was published in this journal; a very successful National Family Practitioners conference was held in August 2008, culminating in the passionate Rustenburg Resolution calling on the broad South African society to redress the inequalities in health in South Africa.
Author Robin J. GreenSource: South African Family Practice 51 (2009)More Less
The buzz word in asthma circles today is 'control'. We speak fairly glibly about measuring control and getting patients to achieve good asthma control. Whilst this is an excellent and admirable sentiment, what is seldom discussed is what measuring control involves (just how reliable are our current measures of control), what control really means and finally what we can do to improve control. Some studies talk about using defined symptom-based questions to assess control, while others utilise spirometry and or biomarkers of disease activity. If one looks critically, however, at these studies and guidelines, the critical scientific tests for reliability and validity of these purported measures are sometimes not done or their interpretation misleading. This is most acute in children. I do believe that we are on the right track when we say we want our patients with asthma to be 'well controlled'. We certainly would like them to have a normal quality of life and be free of exacerbations. Quite possibly then we should state this as our goal and not use seemingly unclear tests to mark what it is we want.
Author D.A. CameronSource: South African Family Practice 51, pp 125 –127 (2009)More Less
In the mid-1960s two doctors, one in London and the other in Chicago, set about changing the accepted medical care of dying patients. In London, Dr Cicely Saunders established St Christopher's Hospice specifically to provide compassionate care for dying patients linked to a rigorous scientific approach to relieving their unpleasant symptoms.
Across the Atlantic, in a Chicago Hospital, Dr Elizabeth Kübler-Ross, a psychiatrist who became interested in the emotional issues of dying patients, arranged seminars where dying patients could talk about their feelings.
The efforts of these two women led to a totally different way in which modern doctors deal with dying patients. Every medical student is now taught how to break bad news. The knowledge of how to control pain, nausea and other distressing symptoms is available to all doctors.
By means of four simple stories, some of the dilemmas of dealing with dying patients in South Africa today will be explored. Forty years after Cicely Saunders and Elizabeth Kübler-Ross introduced their new approaches, how well are we dying?
Percutaneous injuries in doctors in the School of Medicine, University of the Free State: incidence, reporting and adherence to precautionary and management procedures : original researchSource: South African Family Practice 51, pp 128 –131 (2009)More Less
Background: Despite the official precautionary measures against percutaneous injuries, incidents still occur. Consequently, it is possible that healthcare workers could contract infections like HBV, HCV, HGV (hepatitis B, C and G viruses) and HIV (human immune deficiency virus). The most serious problem lies in the fact that percutaneous injuries are often underestimated, resulting in non-reporting of the incident. The aim of this study was to determine the incidence of percutaneous injuries in doctors in the School of Medicine at the University of the Free State (UFS), whether the incidents were reported, and the reasons for non-reporting. The use of gloves during procedures was also evaluated.
Methods: A mainly descriptive study design was used. Questionnaires were administered from October 2006 through January 2007 to collect information. Participants were selected randomly, and the respondents were divided into surgical and non-surgical groups.
Results: The respondents fulfilled the following roles and/or functions in their respective departments of employment: 35 (67.3%) were registrars, 12 (23.1%) were specialists/consultants, four (7.7%) were medical officers, and one (1.9%) was exclusively involved in student training. Two of the respondents did not indicate their roles and functions in their respective departments. A total of 82 incidents of percutaneous injuries occurred. Although the surgical groups handled sharp objects more frequently per week than the non-surgical groups (p-value = 0.04), more incidents occurred in the non-surgical groups (p-value = 0.02). Only 39 (47.6%) of the incidents were reported, while 44.4% of the respondents were aware of the correct reporting procedures. The reasons given for the non-reporting of these incidents were "too busy" (58.1%), "did not think it was serious" (48.8%), and "was not aware of the reporting procedures" (7%). Only 13.7% of the respondents indicated that they always used gloves when drawing blood, 17.4% used them when injections were administered, and 22.4% used gloves during intravenous cannulation. However, 86.8% of the respondents wore gloves when they used a scalpel or any other incision object. The respondents (n = 51) suggested that the three most important precautionary measures to take into consideration when working with sharp objects were (i) the use of gloves (23/51; 45.1%), (ii) never recapping a needle (9/51; 17.6%), and (iii) keeping the container for disposing of sharp objects close at hand (6/51; 11.8%).
Conclusions: Despite the risk of percutaneous injuries, non-reporting still occurs. Although the rate of reporting these incidents could be compared with international findings published in the literature, it remains too low. Drastic measures should be taken to ensure that physicians are informed of the hazards of percutaneous injuries, as well as of the appropriate mechanisms of reporting these incidents.
Source: South African Family Practice 51, pp 132 –137 (2009)More Less
Background: Chronic kidney disease (CKD) is a global public health problem, with a greater burden and prohibitive cost of care particularly in developing countries. This study determined the prevalence of chronic kidney disease and identified its associated risk factors in patients attending the Family Practice Clinic, Wesley Guild Hospital, Ilesa, Nigeria.
Method: Consecutive newly-registered patients who attended the Family Practice Clinic of Wesley Guild Hospital, Ilesa from August 2005 to January 2006 were recruited and studied. Relevant data were collected by using an interviewer-administered questionnaire, and determining the spot urinary ACR (albumin-creatinine ratio) of the subjects by using Microalbustix reagent strips and using their serum creatinine concentration. The glomerular filtration rate (GFR) of each subject was estimated using the Modification of Diet in Renal Disease (MDRD) formula. A repeat urine test was done three months after the initial screening to identify subjects with persistent microalbuminuria.
Results: The age of the study subjects ranged from 20 to 74 years, with a mean age of 50.52 + 13.03 years. There were 68 males and 182 females in the sample population, showing a male to female ratio of 1:2.7. One hundred and thirteen of the 250 subjects (45.2%) were found to have pathologic albuminuria at the initial screening, while 31 (12.4%) had persistent albuminuria three months later. Also, 51 subjects (20.4%) had estimated low GFR at the initial screening and 26 (10.4%) had persistent low GFR three months later. Significant risk factors for CKD in the study subjects were increasing age, elevated blood pressure, history of diabetes mellitus (DM), habitual intake of analgesics and herbs, and an abnormal waist to hip ratio (p < 0.05). The association between persistent abnormal ACR and low GFR did not reach statistical significance (p = 0.053). Habitual analgesic intake (p = 0.002) and age group (p = 0.0027) were true predictors of CKD among the study subjects.
Conclusions: The prevalence of CKD in the study population was high and its association with modifiable risk factors was demonstrated. Family physicians have a unique opportunity to identify and address these factors in their patients. Routine screening for CKD in family practice clinics is indicated to reduce the burden of renal disease in the population.
Source: South African Family Practice 51, pp 138 –142 (2009)More Less
Background: Access to quality health care in rural areas may be compromised not only by the inadequate numbers of skilled professional staff, but also by the lack of skills of the health professionals who are employed in rural facilities, due to inadequate continual professional learning and staff development. The objective of this paper is to examine the factors impacting on professional staff attendance of informal learning sessions in rural district hospitals and primary healthcare clinics.
Methods: Structured, self-administered surveys, adapted from the Dimensions of a Learning Organization Questionnaire, were completed by professional staff on duty during data collection in 18 rural hospitals and their associated primary healthcare services facilities in three rural districts. The impacts of characteristics of staff, such as age, gender, professional experience and length of service, staffing levels, and the dimensions of a learning organisation, viz leadership, culture of change and teamwork, on attendance of learning sessions were considered.
Results: Among professional nurses, attendance of learning sessions was significantly associated with the number of years of professional experience, length of service at the health facility, and scores on the teamwork dimension. While in the case of professional nurses attendance was not correlated with the staffing levels, the percentage of posts filled at the respective facilities and the assessment of hospital leadership as being supportive of learning were significant predictors of attendance among doctors.
Conclusions: Despite severe staff shortages in these rural districts, at facilities where there was a perception of leadership and teamwork the professional staff generally attended learning sessions.
Evaluation of the effect of the introduction of a hypertension club on the management of hypertension at a community health centre in the Cape Town Metropole : original researchSource: South African Family Practice 51, pp 143 –147 (2009)More Less
BackgroundHypertension is a widespread problem of immense economic importance in sub-Saharan Africa because of its high prevalence in urban areas, its frequent under-diagnosis, and the severity of its complications. A systematic review of interventions used to improve the management of hypertension in primary care showed that effective delivery of hypertensive care requires a systematic approach in the community. The rationale for establishing a hypertension club at the Mitchell's Plain Community Health Centre (MPCHC), Cape Town, South Africa is based on the findings of and recommendations made by a study done previously at MPCHC by the Chronic Diseases of Lifestyle Programme of the Medical Research Council. This study found that the blood pressure of hypertensive patients was not optimally controlled and both the drug and non-drug management of hypertension needed to be improved. The patients had asked for the introduction of a dedicated hypertension club.
Methods: A dedicated hypertension club was started at MPCHC and hypertensive patients were enrolled. A booking system with an appointment register was initiated. A hypertension record sheet was kept in the patient's folder. Observations like blood pressure (BP), weight, and urinalysis were recorded by the club's nurses. Health information officers were used to educate the patients about hypertension, its treatment and complications. The doctors' role was to fully assess the patients' risk profiles and to develop a management plan. To audit the club, a questionnaire was conducted on an initial group of 100 patients at the inception of the club and repeated on a group of 100 patients after six months. The aim was to assess the patients' knowledge of issues affecting the management of hypertension and their satisfaction with the service received at MPCHC. A folder review was done on the second group of patients. The intention was to evaluate whether there had been a change in the patients' BP over the preceding six months, whether the patients were compliant and whether observations were made regularly.
Results: The average age of the study population was early sixties. More women than men were studied. The knowledge of the follow-up group regarding factors affecting hypertension control was slightly better than that of the initial group, but remained poor. The knowledge of the consequences of poor hypertension control did not improve after six months. Salt use stayed the same. The patients were satisfied with the service received, although shorter waiting times were desired. About 64% of the patients had collected their medication as per schedule. In the initial group, 48% of the patients had a BP > 140/90 mmHg. After six months, 33% of the patients had a BP > 140/90 mmHg.
Conclusions: The study did not show much change in the patients' knowledge in the first six months after the institution of the hypertension club. Compliance was poor, although BP control improved somewhat. The benefit was in setting up the system.
Source: South African Family Practice 51, pp 148 –151 (2009)More Less
Background: The aim of this study was to identify procedures, areas of activity, occupational groups and other variables that carry a high risk of transmission of bloodborne infections from patients to healthcare workers (HCWs) at Witbank Hospital.
Method: This was a descriptive cross-sectional study, conducted among HCWs of Witbank Hospital who were directly involved in patient care over the two-year period under consideration (1.01.03 - 31.12.04). A directed questionnaire was used to carry out the study.
Results: A total of 435 HCWs completed the questionnaire.
- A total of 46.7% of respondents had suffered from either needlestick/sharps injury (74.47%) or contamination of skin/mucous membranes (25.53%).
- A total of 76.9% of all needlestick/sharps injuries were inflicted by injection needles.
- Taking blood was the most dangerous procedure/activity: it was responsible for 29.56% of all injuries.
- A total of 44.61% of injured HCWs reported one injury, 45.59% reported two to three injuries and 9,8% were injured more than three times.
- The youngest interviewed group (20-29 years old) was injured most frequently (61.9%).
- Professional nurses, who are the largest professional group employed at the hospital, were involved in 41.38% of all reported injuries.
- House doctors reported the highest rates of injury: 84.37% of them were injured at least once.
Conclusion: This study showed that there is a well-defined pattern of injuries that can lead to transmission of bloodborne infections from patients to HCWs at Witbank Hospital. The areas of activity, procedures and occupational groups that result in a high risk of transmission of bloodborne infections to HCWs were identified, and will be used to design the preventive strategies.
General practitioners' familiarity, attitudes and practices with regard to Attention Deficit Hyperactivity Disorder (ADHD) in children and adults : original researchSource: South African Family Practice 51, pp 152 –157 (2009)More Less
Background: Attention-Deficit Hyperactivity Disorder (ADHD) is a common disorder, affecting 4% to 5% of South African children. Recent studies reveal that 30% to 70% of children continue to experience problems related to ADHD in adulthood. Adults are becoming increasingly aware of adult ADHD as a result of public awareness campaigns in the media. Their first line of action is to visit their family physician (GP), but the question that arises is whether these practitioners are ready to take on patients with ADHD. The aims of this study were to determine the familiarity, attitudes and practices of general practitioners (GPs) in South Africa with regard to ADHD in both children and adults, and whether there are differences in children and adults with regard to depression and generalised anxiety disorders as comorbid disorders. The study also briefly explored the training models of GPs in South Africa.
Methods: The research questions were addressed by means of a survey approach, using quantitative measures. An e-mail message with a covering letter, explaining the purpose of the research project, provided a link to a web-based questionnaire. It was relayed to 6 704 GPs on the database of the company MEDpages, which managed the distribution. A questionnaire attached to an e-mail message was sent to all departments of Family Health at universities in the country to obtain information with regard to the training models of GPs. The questionnaire was completed by 229 respondents. The data were statistically analysed using Statistica Version 7.0.
Results: The most significant outcome of the study revealed a considerable need among GPs to increase their knowledge base with regard to ADHD (87% with regard to children and 89% with regard to adults). As they were of the opinion that they should be able to diagnose and manage ADHD in both children (90%) and adults (85%) a significant need for a screening tool (83%) was also found. The GPs' knowledge and training with regard to depression and generalised anxiety disorders were significantly more extensive with regard to adults than to children. Training with regard to ADHD in adults was almost non-existent. With regard to children the most important barriers were uninformed parents (70%), limited funds (61%), uninformed teachers (58%), and with regard to adults these barriers were uninformed patients (64%), lack of knowledge on ADHD in adults on the part of the GPs (63%), and consultation time (58%). Although GPs did seem to have an awareness of the important role of the psychologist in the diagnosis and effective management of patients with ADHD, their referral practices generally involved a limited interdisciplinary approach.
Conclusion: It is recommended that the limited knowledge base of GPs with regard to ADHD should be addressed by adapting the curriculum of undergraduate medical students and providing opportunities for continued medical education that focuses on the diagnosis and management of ADHD, in both children and adults. GPs should acknowledge the educational psychologist as an equal partner within a multidisciplinary team.
Profile of research methodology and statistics training of undergraduate medical students at South African universities : original researchSource: South African Family Practice 51, pp 158 –161 (2009)More Less
Background Medical practitioners need to have knowledge of statistics and research principles, especially with the increasing emphasis on evidence-based medicine. The aim of this study was to determine the profile of research methodology and statistics training of undergraduate medical students at South African universities in terms of which topics are taught, by whom teaching is done, when these topics are taught and how they are taught.
Method: Respondents for this descriptive study were persons responsible for the teaching of statistics and research methodology at the eight medical schools in South Africa. They were identified by the head of each school who also gave permission for the school to participate. The respondents completed a questionnaire and checklist after giving informed consent. No response was obtained from one university. Responses were compared to international guidelines.
Results: At five universities the material is taught in the first year, at one in the second year and one in the third or fourth year, depending on when it is selected as an elective. The material is reinforced in other modules in the medical programme at three universities. The persons responsible for teaching are mainly statisticians (six universities). Class sizes vary from 40 to 320 students with four universities having 200 or more students per class. At two universities the current course has been in place since 2003, at two since 2000, and at two since the 1970/80s. The following topics are taught at the majority of universities: study designs in medical research, exploring and presenting data, summarising data, probability, sampling, statistical inference, analysis of cross tabulation and critical reading. At four universities there are practical classes, three of these mainly for computer work. At three universities tutors are used, at two of these the tutors are postgraduate students in statistics whereas at one university registrars, doctors and researchers are used as tutors. Students at three of the universities complete a research project, at two of these the students complete the full research process from planning up to reporting, whereas the project at the other university focuses mainly on the analysis of data.
Conclusion: Recommendations have been made regarding topics which should be covered and teaching methods which should be used at all universities. Doctors should be involved in the training to ensure clinically appropriate material and examples.
Inpatient blood glucose management of diabetic patients in a large secondary hospital : original researchSource: South African Family Practice 51, pp 162 –165 (2009)More Less
Background: Diabetes has become a major health problem worldwide, as well as in South Africa. This, coupled with the chronicity of the disease, relate to an increasing burden on health care facilities and an increasing number of hospital admissions of patients suffering from diabetes. Admissions are mostly related to diabetes itself, but the frequency of admissions for problems not related to diabetes is increasing as the prevalence of diabetes increases in the population. Proper inpatient glycaemic management is important for improving patient outcome and for reducing the risk of inpatient complications.
Objectives: The objective of this study was to evaluate current practices in the care of diabetic inpatients as well as to assess the glycaemic control that is achieved during hospitalisation.
Methods: An audit was done of clinical hospital records of adult diabetic patients admitted to Kalafong Hospital, a large secondary hospital in South Africa. All patients admitted who had type 1 or type 2 diabetes before admission, or who were newly diagnosed on admission or in hospital were included, irrespective of the discipline to which the patient was admitted. All patient admissions in the eight-month period preceding the initiation of the audit were included.
Results: The hospital records of 164 diabetic patients were audited. With regard to glucose monitoring, 60.8% of patients had irregular and erratic glucose monitoring, 37.2% had regular (either four- or six-hourly) monitoring and only 2% were monitored in relation to meals. Of the 164 patients, 160 were not fasting, 27 were treated with an insulin sliding scale at some stage during their admission, and in 14 (52%) of the patients who were on sliding scales the scale was used inappropriately. Most hospital inpatients with diabetes, i.e. 48 (30.4%), were treated with oral agents only; 29 (18.4%) were treated with oral agents plus a daily dose of NPH insulin and 17 (10.8%) with mixed insulin twice daily. Only three patients (1.9%) received insulin supplemental to their regimen. The glycaemic control treatment schedule was appropriate in only 19.5% of cases.
Conclusions: Based on our findings, the monitoring and management of blood glucose in patients with diabetes during hospitalisation in a large secondary hospital in South Africa is currently inadequate. This calls for an educational intervention for doctors and nurses working with diabetic inpatients as well as the introduction of a blood glucose management protocol.
Hear today - hearing loss tomorrow : a preliminary survey of the personal audio player user habits and knowledge of South African first-year university students : scientific letterSource: South African Family Practice 51, pp 166 –167 (2009)More Less
Different types of personal audio devices (PADs), such as cell phones, Mp3 players and iPods, are increasingly used by young people. Many of these players can generate loudness levels in excess of 115 dB, which can cause severe damage to the ears. Research in other countries has found that between 45 and 53% of university students listen to their devices for more than an hour a day, and that they listen to them tuned to loud or very loud.