South African Family Practice - Volume 52, Issue 4, 2010
Volume 52, Issue 4, 2010
Source: South African Family Practice 52, pp 271 –275 (2010)More Less
This article forms part 12 of the series on the role of lifestyle modification in general practice with specific reference to patients with depression. "Depression" is a term often used to describe an entire spectrum of mental health problems, ranging from dysphoria of mood (feeling down), to a clinical disorder such as a major depressive disorder (MDD). MDD is characterised by periods of depressed mood and / or loss of interest or pleasure that lasts at least two weeks.
Author P.C. PotterSource: South African Family Practice 52, pp 277 –282 (2010)More Less
Atopic eczema is a common problem in general practice. The underlying disorder is a barrier dysfunction of the skin, but exacerbations of eczema can be triggered by a range of external and internal factors. In young children, dietary factors are important triggers of exacerbations and specific IgE sensitivity to common allergens may be confirmed by skin prick testing or ImmunoCap® RAST tests.
True sensitivity to foods is best confirmed by a controlled food challenge, and cut off values have been published which indicate the predictive values of blood or skin tests for true food sensitivity to guide the clinician.
Elimination of identifiable triggers, the use of emollients and topical corticosteroids remain the mainstay of treatments.
Calcineurin inhibitors have a place for treatment of selected cases. The use of systemic corticosteroids is discouraged and patients who do not respond to emollients, specific food avoidance and corticosteroids topically should be referred to a dermatologist. The role of maternal diet in preventing the development of eczema in the offspring remains controversial.
Source: South African Family Practice 52, pp 284 –287 (2010)More Less
The incidence of infertility is approximately 15-20% (one in every five to six couples). The investigation of the infertile couple begins with a careful history, followed by a physical examination. If any abnormality is observed in the history, the couple must be referred. The principle of evaluation of the infertile couple is to establish if the female is ovulatory or anovulatory. If ovulatory, the couple must be referred for more detailed examinations. If anovulatory and her prolactin and TSH as well as his semen analysis are normal, ovulation induction with a low dose of clomiphene citrate can be offered. On the other hand, if her prolactin and TSH as well as his semen analysis are abnormal, it is best to refer the patient.
Source: South African Family Practice 52, pp 288 –294 (2010)More Less
Pain has always been the most common reason why patients seek medical attention. A World Health Organization survey of ± 26 000 primary care patients on five continents demonstrated a prevalence of persistent pain (lasting longer than three months) in 22% of participants, mostly associated with marked reduction in several indicators of well-being (e.g. interference with activities and psychological functioning).
Acute pain serves a protective purpose, mostly signals injury or disease and has obvious value for survival. It protects the individual from further injury and promotes healing after injury. Untreated acute pain may cause unnecessary suffering and increase morbidity. There is also increasing recognition that untreated acute pain may induce long-term changes in the peripheral and central nervous system, known as centralsensitisation.
Author N. RobsonSource: South African Family Practice 52, pp 298 –303 (2010)More Less
Smoking is a major cause of cardiovascular diseases, respiratory diseases and cancer. Despite the high prevalence of smokers worldwide, smokers are often neglected and not offered effective assistance with quitting their habits. In order to overcome this public health burden, effective treatment is needed to help smokers stop smoking. Among the pharmacological treatments available, nicotine-replacement therapy (NRT), when prescribed in combination with behavioural support, has been proven to be effective in helping a wide range of smokers to quit. NRT helps smokers during the withdrawal process by replacing a proportion of the nicotine formerly obtained from cigarettes. NRT is available in many formulations. The commonly prescribed formulations are nicotine gum, nicotine patches, nicotine inhaler and nicotine nasal spray. The choice of which NRT to prescribe depends on the patient's condition, established guidelines and protocols and availability. This article aims to review the role of NRT in smoking cessation.
Author J.A. KerSource: South African Family Practice 52, pp 305 –306 (2010)More Less
Source: South African Family Practice 52, pp 308 –311 (2010)More Less
Affecting an estimated one in every 272 South Africans, or 0.37% of the population, aphasia is a neurological condition described as "any disturbance in the comprehension or expression of language caused by a brain lesion".
Despite extensive debate throughout the history of neuropsychology there is no universal agreement on the classification of aphasia subtypes. The original localisationist model attempts to classify aphasia in terms of major characteristics, and then to link these to areas of the brain in which the damage has been caused. These initial two categories, namely fluent and non-fluent aphasia, encompass eight different subtypes of aphasia.
Aphasia occurs mostly in those of middle age and older, with males and females being affected equally. As the general practitioner is likely to have first contact with affected patients, it is important to be aware of aphasia and to diagnose and refer patients in an appropriate and expeditious manner.
In this article we will review the types of aphasia, an approach to its diagnosis, aphasia subtypes, rehabilitation and prognosis.
Source: South African Family Practice 52 (2010)More Less
Author B. BromSource: South African Family Practice 52, pp 314 –316 (2010)More Less
Leaky gut syndrome, also called increased intestinal permeability, is not a well-established diagnosis in general practice and yet is a well-recognised and common diagnosis within the community of integrative doctors. Perhaps this is because the integrative medical focus is not on the disease, but more on the functional dysregulation behind the disease. While the diagnosis of ulcerative colitis, for example, may satisfy most doctors, integrative doctors would also consider the underlying dysfunction, of which leaky gut may be an
Leaky gut is regarded as the harbinger of a great deal of ill health and the later development of many chronic diseases, such as food intolerance, inflammatory bowel disease, rheumatoid arthritis and other autoimmune diseases. The mucosa lining of the intestinal tract is a protective layer between the contents of the intestine and the inside of the body. When dysfunctional, it becomes the entry point of pathogens and micro-toxins. As indicated in previous articles, any area of dysfunction in the body becomes the source and origin of ill health. The gastrointestinal mucosa is the largest interface between the internal body and the external environment and covers more than 400 square metres, hence its importance as a possible source of ill health.
Author I. GovenderSource: South African Family Practice 52, pp 318 –321 (2010)More Less
During August 2002, at a primary school in Kwa-Dukuza, KwaZulu-Natal, 27 children who had been well when they left their homes collapsed at school, displaying tremors and shivers throughout their bodies. Many of the children also presented with abdominal cramps and nausea. Almost all the children experienced a feeling of tightness in their chests as well as hyperventilation, which was then followed by fainting. This hysteria spread by line of sight (that is, other children seeing this also collapsed). Mass hysteria had presented similarly, with only a mild variation in the hallucinations, in secondary schools in Mangaung, Bloemfontein, during 2000 and in Gauteng during 2009. Radio stations, such as Radio 702, presented these incidents for discussion and for concerned parents' questions to be answered. In all three episodes, the majority of the affected children were girls. Witchcraft, poisoning, insect bites - in the case of Mangaung - and gas leaks were proposed as causes of this strange behaviour by the previously well children. Experts who investigated these possibilities, however, excluded any identifiable cause. Nearly all the children were well again the next day. The assessment after the incidents was an outbreak of mass hysteria. The parents and the lay media, however, refused to accept this diagnosis, which added to the stress and the anxiety that the children faced when they returned to school.
Mass hysteria can be taxomised into two broad categories: the explosive type, which typically appears in small, institutionalised social networks; and the large, diffused type, during which false rumours and beliefs overwhelm a community. This discussion focuses on the second category - that which affects people in one institution.
The discussion includes the rare outbreak in Kwa-Dukuza, together with the common presentations and symptoms of mass hysteria. Also discussed are the consequences of not managing this condition well immediately on presentation. These consequences entail a perpetuation of the condition, spreading to a greater number of children, to the parents and to the teachers. This may then lead to a disruption in learning at the schools affected and, possibly, later on, to anxiety disorders.
Author Pierre J.T. De VilliersSource: South African Family Practice 52 (2010)More Less
There is a deeper question: what happened to caring in the health service? To work in the health service (and education service for that matter) is much more than a job. The mere fact that one has a job in this country is already a privilege. The fact that the job usually pays well is something to be deeply thankful for, but to serve the sick and the weak is an honour. The health service is a caring profession, and it is time that health workers ask themselves the question if they are truly committed to care for their patients.
Cold comfort for health care workers? Medico-ethical dilemmas facing a health care worker after occupational exposure to HIV : forumSource: South African Family Practice 52, pp 327 –331 (2010)More Less
Following exposure to the human immunodeficiency virus (HIV) it is advisable for the health care worker (HCW) to take post-exposure prophylaxis. A prerequisite for this is the establishment of the HIV status of the HCW and the patient. Ordinarily, this would be preceded by the ascertainment of the HIV status of the HCW and the patient. This should be done as soon as possible after exposure, usually within 24 hours. If the exposure takes place when the patient is under anaesthetic, which is often the case, consent for HIV testing is not readily forthcoming and this poses an ethical dilemma. A similar dilemma is posed by a patient who, having awoken, is not in a position or is unwilling to give consent. This paper discusses the ethical and legal constraints on the HCW and the employer in circumstances where the patient is not in a position to give consent. The paper concludes by restating the need to respect confidentiality and the autonomy of the patient and that informed consent is paramount in testing for HIV status. The paper proffers the view that testing the patient will not substantially alter the course of action open to the HCW and, in any event, will do little to allay the fears of HCWs.
Source: South African Family Practice 52, pp 332 –335 (2010)More Less
Background: Up to 8 000 South Africans commit suicide annually. This study aimed to investigate the profile of suicide cases in Bloemfontein and the southern Free State province.
Methods: A cross-sectional descriptive study was performed. Suicides in the Bloemfontein and southern Free State areas (Xhariep and Motheo districts) investigated at the state mortuary in Bloemfontein in 2003 to 2007 were included. Data were collected retrospectively by using a specially designed data-capturing form.
Results: A total of 469 suicide cases were included in the study. The estimated suicide rate for this part of the Free State province was 10.9/100 000 of the population per year. The majority (82.1%) of the victims were men. In total, 338 (72.1%) of the victims were black, 122 (26.0%) were white, five (1.1%) were coloured and three (0.6%) were Indian. The most common methods were hanging (262; 55.9%), shooting (99; 21.1%) and overdosing on pills (43; 9.2%). Most cases (57.8%) occurred in victims 21 to 40 years of age. Five (1.1%) victims were children younger than 11 years of age, while 12 (2.6%) were older than 65 years. More than half (267 cases; 56.9%) of the suicide victims were unemployed. The majority (43.1%) of suicides occurred in January to April of each year, with the highest incidence (67 cases; 14.3%) in January.
Conclusion: The rate of suicide and the profile of victims with regard to the variables investigated corresponded to findings reported from other studies. The information obtained could make a meaningful contribution to suicide-prevention programmes.
Source: South African Family Practice 52, pp 336 –340 (2010)More Less
Background: This paper examines factors influencing physicians' decisions to practise in rural communities as well as the results of a programme focused on rural recruitment and retention.
Methods: Data from two sources were analysed and discussed: 1) telephone interviews with 20 of 33 (61%) recently located rural physicians regarding practice and community factors influencing their practice decisions and 2) a database of 107 graduates of a rural medical education programme who have been in practice for at least three years to examine specialty choice and practice location(s), including moves from their original practice sites.
Results: Most rural physicians in this study decided to practise in rural areas because of family ties. Eighty per cent of the physicians participating in the interviews mentioned no negative personal or family factors related to their community of practice. Outcome data on graduates from the rural medical education programme are encouraging. Over 70% opt for primary care and rural practice. Over 80% have remained in their original rural practice location.
Conclusion: Keys to success in rural physician retention seem to include identifying and recruiting medical students of rural origin and focusing on a healthy practice environment. Policy makers need to work with local government, schools and employers to offer programmes that provide information on health careers in rural areas and begin to identify local youth for induction in rural health care.
Primary health eye care : evaluation of the competence of medical students in performing fundoscopy with the direct ophthalmoscope : original researchSource: South African Family Practice 52, pp 341 –343 (2010)More Less
Background: To evaluate the skill of fifth-year medical students at the University of Cape Town in the performance of fundoscopy at the end of their ophthalmology rotation.
Methods: The design was a prospective cohort study. The study was conducted at Groote Schuur Hospital in Cape Town. The ability of fifth-year medical students to perform fundoscopy on mannequin heads fitted with fundus photographs using direct ophthalmoscopes was evaluated. The outcome measures used were ability to see the fundus and ability to recognise fundus pathology.
Results: The fundus photographs could be seen in 95% of cases. The correct diagnosis could be made in only 57% of cases.
Conclusion: Medical students at the University of Cape Town need more than the current one week of practical ophthalmology training to improve their fundoscopy skills.
Misconceptions about diabetes mellitus among adult male attendees of primary health care centres in Eastern Saudi Arabia : original researchSource: South African Family Practice 52, pp 344 –349 (2010)More Less
Background: Diabetes mellitus (DM) is a major public health problem in Saudi Arabia. Its prevalence is on the increase, being as high as 23.7% among adult citizens. Misconceptions and wrong beliefs regarding DM and its management among those attending primary health care centres (PHCCs) can result in poor control, more complications and increased incidence of morbidity and mortality.
Methods: This was a cross-sectional study conducted in eight randomly selected PHCCs in the Eastern Province of Saudi Arabia. The study population comprised all adult male attendees older than 15 years. The total number of attendees interviewed was 1 030, giving a response rate of 84.1%. Data were collected through an interviewer-administered questionnaire pertaining to the following: socio-demographic characteristics, misconceptions of PHCC attendees about DM regarding the aetiology, general concepts, diabetic diet, treatment and herbal treatment. Chi-square and logistic regression were used for statistical analysis.
Results: The majority of the attendees were Saudi (92%) of young age (15-34 years; 60.7%). Only 12% had DM. A high proportion of the attendees had misconceptions about the aetiology of DM (21.2%), general concepts of the disease (13.8%) and the diet of diabetic patients (10.7%). Moreover, 11.8% of the attendees had misconceptions about all aspects of DM. The factors that were found to be independently and significantly associated with increased levels of misconception were a low level of education (OR = 0.752) and lower family income (OR = 0.684).
Conclusion: There is a great need for continuous health education of PHCC attendees in general and regarding diabetics in particular to raise their knowledge and awareness of DM. This can be done by all primary health care team members.
Adherence to antiretroviral therapy, virologic failure and workload at the Rustenburg Provincial Hospital : original researchSource: South African Family Practice 52, pp 350 –355 (2010)More Less
Background: Adherence to antiretroviral therapy (ART) is a strong predictor of progression to AIDS and death. It remains the most important potentially alterable factor that determines treatment outcomes.
Methods: The study is a cross-sectional survey of self-reported adherence to ART and associated factors. It included a randomly selected sample of 100 adult patients who began ART between June 2006 and December 2007. A modified Adult AIDS Clinical Trials Group questionnaire was used. The analysis compared self-reported adherence levels by factor and viral load test results.
Results: Only 71% of patients had an adherence > 95%. Poor adherence was related to changes in daily routines (being away from home [21%] and busy with other things [17%]). All patients with symptoms suggestive of clinical depression had virologic failure. More unemployed patients (50.7%) had virologic failure than did employed patients (40%) (p = < 0.05). The clinic had a tenfold increase in patient enrolment and a ninefold decline in staff-to-patient ratio, and the proportion of patients lost to follow-up doubled in the preceding four years.
Conclusion: Adherence to ART was poor. The capacity of the clinic to manage patients adequately has declined significantly. Decentralisation of ART services to primary health care facilities should be considered.
Emotional reactions of medical doctors and students following the loss of their patients at the Dr George Mukhari Hospital emergency unit, South Africa : original researchSource: South African Family Practice 52, pp 356 –363 (2010)More Less
Background: Studies on death and dying predominantly emphasise the needs of the dying patient and the process of bereavement. Few studies have focused on the reactions of medical doctors and students when the patients they have cared for die.
Methods: The aim of the study was to explore the thoughts and feelings of doctors and medical students who have lost patients while under their care at the Dr George Mukhari Hospital emergency unit in Ga-Rankuwa, South Africa. The participants included 10 medical doctors and final-year medical students. A qualitative study methodology using a phenomenological approach was used.
Results: Meanings were formulated from transcriptions and themes were identified. The following themes emerged: emotional reactions, which included anger, helplessness, guilt and pain; recurrent thoughts about the incident; blame; perceived incompetence; detachment from emotions; religion; death of a paediatric patient; medical training; psychological services; work environment; coping with the family of the deceased; and facing mortality.
Conclusion: From the study it was concluded that doctors needed enhanced training in communication skills and communicating death to the patients' families. Bereavement counselling and debriefing should be available to provide them with an opportunity to share emotional responses and reflect on patients' fatality.