South African Family Practice - Volume 51, Issue 6, 2009
Volume 51, Issue 6, 2009
Author Gboyega A. OgunbanjoSource: South African Family Practice 51 (2009)More Less
This is the last issue of the SAFP journal for 2009 and as usual we end the year with a bumper edition. The first CPD article, which is the 8th in the series focuses on ''Healthy lifestyle interventions in general practice and dyslipidaemia'' by Schwellinus MP et al .
Source: South African Family Practice 51, pp 453 –460 (2009)More Less
Dyslipidaemia, in particular raised plasma concentrations of total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), triglycerides as well as reduced plasma concentrations of high density lipoprotein (HDL-C) concentration is one of the major risk factors for coronary artery disease (CAD), cerebrovascular disease and peripheral vascular disease. The clinical assessment of a patient with suspected dyslipidaemia should include a medical history, clinical examination and special investigations to determine the presence and cause of dyslipidaemia, and to perform a risk assessment for cardiovascular disease using specific guidelines. Based on the risk scoring and the plasma lipid concentrations, an individualised management plan can be established for each patient. The focus of this article is on the cornerstone of management of dyslipidaemia which is lifestyle intervention. Lifestyle intervention for dyslipidaemia includes dietary intervention, increased physical activity, stress management and smoking cessation.
Author H.S. CronjeSource: South African Family Practice 51, pp 461 –465 (2009)More Less
Pelvic organ prolapse (POP) together with urinary incontinence is extremely common. About 11% of women will receive surgery for these conditions and a third of them will receive a second operation within two years. The general practitioner should be on the lookout for POP as patients may not reveal it. Parous patients with bladder symptoms, a fullness or pressure in the pelvis, or rectal symptoms (mainly obstructive defaecation) are candidates for POP, particularly in those with a previous hysterectomy. Patients in need for surgery (referral) are those with stage 3 and 4 prolapse (in or outside the introitus), or stage 2 prolapse with severe symptoms. Surgery for POP has undergone a transformation in recent years with the introduction of new surgical methods and the use of mesh to reinforce weakened pelvic support systems. However, conservative measures such as physiotherapy and medication still play a role for lesser degree of prolapse or urinary symptoms. A vaginal pessary can be used for uterine prolapse in extremely elderly women.
Author E.W. HennSource: South African Family Practice 51, pp 467 –470 (2009)More Less
Recurrent urinary tract infections occur in approximately 5% of adult women. It has a significant impact on the affected women's quality of life and on health care costs. It is important to be aware of the physiologically protective factors preventing urinary tract infections. The clinician should also be able to identify relevant risk factors for recurrent infection. Clinical evaluation is relatively straightforward in cases without underlying complicating factors, but urine culture ought to be readily utilised. Treatment should be according to local antibiogram patterns and prophylactic and postcoital preventative strategies can be used according to current evidence. Certain subpopulations such as HIV positive patients require a different approach compared to the general population.
Source: South African Family Practice 51, pp 471 –477 (2009)More Less
Great strides have been made in understanding gout as a disease over the centuries. Despite these advances, reports suggest that the management of gout is relatively suboptimal at the primary care level. This article reviews important considerations in the management of gout and provides an evidence-based approach for the management of acute and chronic gouty arthritis at the primary care level. Recurrent monoarticular pain and swelling should raise the suspicion of gout and the demonstration of urate crystals in synovial fluid during a clinical episode confirms the diagnosis. Acute gouty attacks should be managed with appropriate doses of non-steroidal anti-inflammatory drugs (NSAIDs) or colchicines or steroids. Recurrent attacks of gout, presence of tophi and urate stones necessitate urate-lowering drugs. Prophylactic anti-inflammatory agents for up to six months should be added at initiation of urate-lowering therapy to reduce flares of acute attacks. Gout management requires lifelong commitment and adherence to lifestyle modification and treatment improves clinical outcomes.
Source: South African Family Practice 51, pp 478 –479 (2009)More Less
The major scientific achievement of the Twentieth Century was the discovery of the double helix, and the mapping of the human genome in 2003. Contemporary medical and scientific knowledge in the field of gene therapy has the potential to inform us about many of the known inherited genetic conditions. In addition, medicine now has the ability to identify a significant number of diseases which may be inherited from us by our children. When we discuss the ethics of gene therapy, a distinction should be made between somatic (non-reproductive) and germ (reproductive) cell therapies. In this article, we focus on the ethical issues related to prenatal screening for genetic disorders which include autonomy, cost and maternal anxiety.
Author Pierre De VilliersSource: South African Family Practice 51 (2009)More Less
South African Family Practice rejects gender-based violence in all its manifestations and will speak up by, amongst other things, publishing all valid research it can muster to highlight the problem and unmask society's inability to deal effectively with it. And, for what it is worth, I unreservedly apologise on behalf of all good men to all women and children so dear to us for what we men have done to them. What is wrong with us men?
Family medicine, primary health care and HIV medicine - a 'new' clinical speciality and its role in the South African HIV pandemic : forumAuthor D.T. HagemeisterSource: South African Family Practice 51, pp 483 –485 (2009)More Less
Context: Because of the extent of the HIV pandemic, but also due to some specific historical conditions, HIV medicine has evolved as a field of its own in South African medicine. With the massive scale of the roll-out of antiretroviral drugs (ARVs) in South Africa, the need to devolve ARV roll-out into primary health care (PHC) services is currently being discussed. Family medicine was recognised in South Africa as a specialist qualification in August 2007 and is still undergoing an exciting process of defining its content and future role in the community of medical specialities. The South African approach to family medicine focuses strongly on the role of the family physician in the PHC setting at district hospitals and in PHC facilities within the South African district health framework.
Objectives: The objectives of this article are to discuss the relation between family medicine and the field of HIV medicine.
Key message: Family medicine in the South African context is the clinical discipline most suitable to house HIV medicine. The projected future of the ARV roll-out parallels the structures necessary for the care of (other) chronic conditions in the PHC setting, and the clinical governance for this health care delivery lies in the hands of family medicine. Thus HIV medicine should be regarded and developed as part of family medicine.
Conclusion: For the future development of family medicine, it is a natural and necessary step to incorporate HIV care. The field of HIV care as a professional area will benefit from being part of a recognised clinical speciality. Training for the treatment of HIV / AIDS will have to be included as an integral part of the registrar programme in family medicine.
Sonar findings of the uterus in patients on medroxyprogesterone acetate (Depo Provera) 150 mg injection : original researchSource: South African Family Practice 51, pp 486 –488 (2009)More Less
Background: Depo Provera (medroxyprogesterone acetate) 150 mg intramuscular injection every 12 weeks is one of the most common, effective, affordable and popular methods of contraception. Depo Provera shows excellent results in comparison to oral contraceptive agents as well as the contraceptive patch.
Objective: The aim of the study was to determine the effects of the chronic use of medroxyprogesterone acetate 150 mg injections on the endometrium and myometrium of the uterus as measured by means of ultrasound.
Methods: An analytical case-control investigation was performed. Two groups were included and participants were actively selected and recruited by the researcher. Patients in both groups were similar with regard to socio-economic background, age and clinical profile. Each patient in the study group was paired with a patient in the control group. During patients' visits, measurements were performed by means of a Medison Sonoace 5500 digital ultrasound apparatus. A structured interview was conducted with each participant in order to obtain relevant patient information.
Results: Fifty participants were recruited and selected for both the study group and the control group. All the participants were women from the Thaba Nchu and Botshabelo municipal areas in the Free State Province, served by the researcher's private general practice in Botshabelo. Participants in the study group (20-46 years; median age 31 years) were treated with Depo Provera, while the control participants (19-48 years; median age 30.5 years) were not on any chronic medication or hormonal contraception, did not have intrauterine devices and were not pregnant or breastfeeding during the 12 months preceding the study. The medians of all the parameters (uterus length and width; endometrial thickness) were determined in the patients selected from the researcher's practice. The presence of uterine myomata was documented and compared between the two groups. Statistically significant differences with regard to all the measurements of the uterus and presence of myomata were observed between the study and the control group.
Conclusions: It was concluded that intramuscular administration of 150 mg medroxyprogesterone acetate was responsible for these differences.
Author B.F. MtshaliSource: South African Family Practice 51, pp 489 –491 (2009)More Less
Exercise-induced asthma (EIA) is one of the major factors that affect optimal performance in sport. The prevalence of EIA is reported to be on the increase among school children worldwide. The aim of this study was to indicate EIA prevalence among primary-school children in South Africa. A field study determined the prevalence of EIA. A convenience sample of 127 children aged 8 to 16 years was selected. A health- screening questionnaire was used. The criteria for selection were that the subjects should be non- asthmatics and should not have any other illness during the screening that could interfere with the results. Peak expiratory flow rate (PEFR) was measured pre- and post-exercise using an ASSESS peak flow meter. The subjects did a six-minute run on a school playground. The post-exercise PEFR was measured within 10 minutes of exercise. The determinant of EIA was ≥ 10% decrease in PEFR after exercise. A total of 112 (88%) subjects participated in the study. Fifteen subjects were excluded (eight had asthma, five had respiratory tract infection and two had other illnesses). The average exercise heart rate was ± 80% of predicted maximal heart rate. The prevalence of EIA was 23% (n = 26). The incidence of a history of allergic rhinitis was statistically significantly increased among those with positive tests (p = 0.027). This study highlights the need to screen all children so that EIA can be determined and addressed appropriately.
Source: South African Family Practice 51, pp 492 –495 (2009)More Less
Prevention of mother-to-child transmission (PMTCT) is a major intervention world-wide in the fight against the HIV pandemic, and has resulted in markedly reduced rates of mother-to-child transmission rates in well-resourced countries.
However, it seems that barriers to implementation of the programme exist at all levels of health care at all facilities providing maternal care.
Aim: To conduct a clinical audit of the PMTCT programme at a regional hospital in Pietermaritzburg, KwaZulu-Natal, South Africa.
Methods : Data was collected from an analysis of antenatal and medical records of women who attended antenatal care and delivered at the regional hospital between January and December 2007. Only pregnant women who attended antenatal care at this regional hospital and delivered in its facilities were selected for the study. Patients eligible for review were identified using the labour ward delivery log book.
Results : Of the 499 records analysed, 479 women (96%) were offered testing, of which 473 accepted. Of those tested, 227 (48%) were HIV positive.Only 15 (6.1%) of the 246 who tested negative were re-tested. CD4 counts were done for only 159 (70%) of the 227 HIV-positive women. More importantly, only 134 (84.3%) received their results.
Of the 227 HIV-positive women, only 131 (57.7%) were given 200 mg nevirapine at ≥ 28 weeks gestation (to take home and swallow once they had strong labour pains); 185 (81.5%) took nevirapine before delivery (i.e. the total number of both those that took NVP < 2hrs and > 2hrs) 143 (77.3%) took nevirapine > 2 hours before delivery and 84 (37%) took nevirapine < 2 hours before delivery. Of the babies, 208 (91.6%) were given nevirapine within 72 hours.
Discussion : This audit shows that progress has been made in the implementation of PMTCT of HIV at this regional hospital by the high uptake of HIV testing; however, barriers to full implementation are caused by the lack of integration of testing, counselling and obtaining CD4 count results.
Implementing a structured triage system at a community health centre using Kaizen : original researchSource: South African Family Practice 51, pp 496 –501 (2009)More Less
Background: More than 100 unbooked patients present daily to the Mitchell's Plain Community Health Centre (MPCHC), and are triaged by a doctor, with the assistance of a staff nurse. The quality of the triage assessments has been found to be variable, with patients often being deferred without their vital signs being recorded. This leads to frustration, and a resultant increased workload for doctors; management is concerned with the medico-legal risk of deferring patients who have not been triaged in accordance with the guidelines; and patients are unhappy with the quality of service they receive.
Aim: We set out to standardise the triage process and to manage unbooked patients presenting to the community health centre (CHC) in a manner that is medico-legally safe, cost efficient and patient friendly, using the Kaizen method.
Methods: The principles of Kaizen were used to observe and identify inefficiencies in the existing triage process at the MPCHC. Findings were analysed and interventions introduced to improve outcomes. The new processes were, in turn, validated and standardised.
Results: The majority of patients presenting to Triage were those needing reissuing of prescriptions for their chronic medication, and this prevented practitioners from timeously attending to other patients waiting to be seen. Reorganising of the process was needed; it was necessary to separate the patients needing triage from those requiring only prescriptions to be reissued. After the intervention, triage was performed by a staff nurse only, using the Cape Triage Score (CTS) method. Subsequent to the implementation of interventions, no patients have been deferred, and all patients are now assessed according to a standardised protocol. The reasons for patients requiring reissuing of prescriptions were numerous, and implementing countermeasures to the main causes thereof decreased the number of reissues by 50%.
Conclusion: The Kaizen method can be used to improve the triage process for unbooked patients at the MPCHC, thereby improving the quality of services delivered to these patients. As the needs of the various CHCs differ quite widely across the service platform, the model needs to be adapted to suit local conditions.
Source: South African Family Practice 51, pp 502 –505 (2009)More Less
Background: A worldwide increase in the prevalence of diabetes mellitus (DM) has been reported and an even further increase is expected as a result of lifestyle changes. The objectives of this study were to determine the prevalence of DM in the rural southern Free State and to investigate the contribution of risk factors such as age, physical activity, body mass index (BMI), waist-to-hip ratio and waist circumference to the development of impaired fasting glucose (IFG) or DM.
Methods: Fasting venous plasma glucose (FVPG) levels were obtained from a total of 552 participants from Springfontein (n = 195), Trompsburg (n = 162) and Philippolis (n = 180). Participants were between 25 and 64 years of age, with 28.1% male (mean age 47.3 years) and 71.9% female (mean age 46 years). Anthropometric status was determined using standardised techniques. Levels of physical activity were determined using a 24-hour recall of physical activity as well as frequency of performing certain activities. Relative risks (RR) as well as 95% confidence intervals (95% CI) were used to distinguish significant risk factors for having IFG or DM.
Results: In the study population the prevalence of DM was 7.6% (5.2% in men and 8.6% in women) and that of IFG was 6.3% (4.5% in men and 7.1% in women). The majority of nondiabetic (34%), IFG (55%) and DM (61%) participants were between the ages of 51 and 60 years. Age was found to be a statistically significant risk factor for having IFG or DM in participants older than 40 years of age (RR 2.3; 95% CI [1.22; 4.34]). Crude measurements (not age- and gender-adjusted) of waist circumference (RR 3.23; 95% CI [1.82; 5.74]), BMI (RR 2.32; 95% CI [1.43; 3.78]) and waist-to-hip ratio (RR 2.51; 95% CI [1.55; 4.07]) were statistically significant risk factors for having IFG or DM. Physical inactivity in men ≥ 40 years was also a statistically significant risk factor (RR 3.23; 95% CI [1.15; 9.05]) for having IFG or DM.
Conclusions: In this study, 37.5% of diabetics were newly discovered. A high waist circumference, BMI and waist-to-hip-ratio were associated with an increased risk for developing IFG or DM, with a high waist circumference being the most significant general risk factor. Physically inactive men (≥ 40 years) were also at a higher risk of having IFG or DM. Follow-up FVPG and glucose tolerance tests should be performed on participants in the IFG group. A need for intervention regarding the identification and treatment of DM in these rural areas has been identified.
The experiences of family caregivers concerning their care of HIV / AIDS orphans : original researchSource: South African Family Practice 51, pp 506 –511 (2009)More Less
Introduction: The HIV / AIDS pandemic is reducing life expectancy and raising mortality. An increasing orphan population is perhaps the most tragic and long-term legacy of the HIV / AIDS pandemic. By 2010 sub-Saharan Africa is expected to have an estimated 50 million orphans and it will be staggered by this challenge. By the middle of 2006, 1.5 million children under the age of 18 years were maternal orphans in South Africa, and 66% of these children had been orphaned as a result of HIV / AIDS. Although government and non-government organisations have responded by building orphanages, most of Africa's orphans have been absorbed into extended family networks. Many of these extended family caregivers are ageing and often impoverished grandparents.
Methods: This was a descriptive, qualitative study using the free attitude interview technique. All family caregivers who consulted at the Hoekfontein Clinic, North West Province, South Africa between March and June 2006 formed the study population. A total of nine one-on-one interviews had been conducted by the time saturation of data was reached.
Results: All nine caregivers were women, mostly grandmothers (67%), and the orphans were between the ages of 5 and 20 years. Emergent themes were : poverty and lack of money; bureaucratic difficulties and lack of assistance from the social support services; lack of support (financial, physical and emotional) from other family members; frustrations of coping with rebellious orphans; pain of caring for the terminally ill family members; feelings of despondency (hopelessness); conflicts in the family; and the rejection of orphans by their fathers.
Conclusions: The study showed that the family caregivers experienced a lack of welfare and family/emotional support in their care of HIV / AIDS orphans. It is recommended that health care workers, including social workers and home-based caregivers be trained on available social support from government and non-governmental organisations for caregivers of HIV / AIDS orphans.
What are the reasons for patients not adhering to their anti-TB treatment in a South African district hospital? : original researchAuthor R. MashSource: South African Family Practice 51, pp 512 –516 (2009)More Less
Introduction: TB is a major health problem in South Africa, with increasing numbers of patients notified, inadequate successful treatment rates and an emerging problem with resistant strains. This study was conducted at a District Hospital in KwaZulu-Natal where the successful treatment rate was as low as 23%. The aim of this study was to identify key factors at the hospital that may affect adherence to TB treatment and to recommend interventions that could improve adherence.
Methods: The study design was a case control study using prospectively collected data. Information was collected over an 8-month period, when the patients started their anti-TB treatment, according to the known factors that influence TB adherence. The patients were then followed up to determine those who did not adhere to their treatment, and those who successfully completed treatment. The two groups involved, therefore, were the controls (those who did adhere) and the cases (those who did not adhere). The data previously collected were then compared for significant associations with the controls and cases.
Results: Data were obtained from 159 TB patients, 105 (66%) were adherent and 54 (34%) non-adherent. The following variables showed a significant association (p < 0.05) with non-adherence: higher level of education; distance from the hospital; time taken to travel; the method of transport; satisfaction with the hospital; food security; income; the smoking of tobacco and / or marijuana; the patients' perspective and beliefs; HIV testing and status; functional status; social support; the relationship with the TB nurse; depression score; and self-rating of confidence. A stepwise logistic regression was performed, and only two variables remained significantly associated: travel time (OR7.9, 95%CI 1.4-44.1) and the relationship with the TB nurse (OR2.6, 95%CI 1.3-5.1).
Conclusions: The most important recommendation is to improve the relationship between patients and TB nurses through training in communication skills. A more holistic assessment of patients would help identify issues such as depression, and a more patient-centred approach would help to understand and address patient's concerns, beliefs and expectations. It may also be important to ensure that management and administrative systems support a more patient-centred approach. It may be important to encourage the recruitment of family physicians who are trained in communication skills and a patient-centred approach, to work in the rural areas, where they can mentor and teach other colleagues and staff. More needs to be done in terms of helping patients to access facilities through transport, or in making services more available at the community level through DOTS (Directly Observed Treatment) supporters and adequate home-based carer support.
Smart Health Choices : Making sense of health advice, L. Irwig, J. Irwig, L. Trevena, M. Sweet : book reviewAuthor Ian CouperSource: South African Family Practice 51 (2009)More Less
Author R.F. IngleSource: South African Family Practice 51 (2009)More Less
Source: South African Family Practice 51, pp 519 –520 (2009)More Less
Dementia is a condition that is frequently associated with ageing. However, many fail to recognise that dementia is a treatable condition if detected early. This case report illustrates a 64-year-old man who was initially presented in a primary health care (PHC) centre in Kuala Lumpur Malaysia, with gradual changes in his behaviour. Initial assessment concluded that he suffered from depression and he was treated accordingly. However, over time his condition deteriorated and the diagnosis was re-evaluated from depression to dementia when he developed poor cognitive and memory function. The patient defaulted on his follow-up appointments due to poor understanding of the illness and poor family support.