South African Family Practice - Volume 53, Issue 3, May 2011

This is the third issue of the South African Family Practice journal in 2011 and as usual the CPD section is full of interesting articles for you to read.

Many patients either do not adhere to, or fail to persist with, long-term lipid-lowering therapy. This unfavourable medication utilisation behaviour compromises potential treatment benefit. In retrospective studies, patients aged 50-65 had the highest adherence rates, while both younger and older patients had lower rates. Patients with pre-existing cardiovascular disease adhere better than those in primary prevention. Financial barriers may impair adherence. At the individual patient level, health beliefs, perceptions of own cardiovascular risk and need for medication, concerns about side-effects and inconvenience of treatment may influence adherence. In clinical trials, regular reminders to patients have been shown to improve adherence, but each patient will require an individually tailored treatment strategy.

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Myopathy is the most common clinically relevant adverse effect of statins. The clinical severity of statin myopathy is highly variable, ranging from mild muscle ache to rare instances of rhabdomyolysis. Risk factors for statin myopathy include age, statin dose, hypothyroidism, medications that inhibit statin metabolism, combined statin and fibrate therapy, and renal impairment. Alternative causes of myopathy should be excluded before muscular symptoms are ascribed to statins. The management of statin myopathy is guided by the severity of symptoms and the creatine kinase level. Potential management strategies include statin dechallenge and rechallenge, statin dose reduction, statin switching, non-daily dosing and use of alternative lipid-lowering agents, such as ezetimibe.

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Statins rarely cause severe liver disease. Mild liver enzyme elevations are seen relatively frequently in patients starting statins, but are usually not clinically important. Patients with persistently elevated liver enzymes should be investigated to determine the cause of liver disease. Patients with stable, well-compensated liver disease can be prescribed statins, provided they are closely monitored.

Background: Cigarette smoking causes significant morbidity and mortality and is a major public health concern worldwide. Primary care doctors are in a unique position that enables them to promote smoking cessation, as smokers are more aware of their health at the time of their clinic visit. It is thus important to offer effective treatment to help smokers stop smoking.

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Methods: A search of PubMed was done up to 16 December 2009, using the keywords "varenicline" alone, "varenicline" and "family medicine", and "varenicline" and "primary care". The search produced 426 articles on varenicline. The articles that were chosen were case reports, meta-analyses, review articles and clinical trials published in English.

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Results: A new drug called varenicline has recently been introduced to assist smoking cessation. It is an α4β2 nicotinic acetylcholine receptor partial agonist. Varenicline has a unique action that relieves the cravings and withdrawal symptoms that occur during smoking abstinence, while blocking the receptor and preventing any reward from additional smoking. It has been shown to be efficacious for smoking cessation in normal smokers; however, its safety in smokers with mental health problems needs to be elucidated.

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Conclusion: The currently available data support the effectiveness of varenicline to treat nicotine dependence, but caution is needed in smokers with mental health problems. Thus, primary care doctors have a new pharmacological option to offer smokers who wish to stop smoking.

Otitis externa can take an acute or a chronic form, with the acute form affecting four in 1 000 persons annually and the chronic form affecting 3-5% of the population. Acute disease commonly results from bacterial (90% of cases) or fungal (10% of cases) overgrowth in an ear canal subjected to excess moisture, or to local trauma. Chronic disease often is part of a more generalised dermatologic or allergic problem. Symptoms of early acute and most chronic disease include pruritus and local discomfort. If left untreated, acute disease can be followed by canal oedema, discharge, and pain, and eventually by extra-canal manifestations. Topical application of an acidifying solution is usually adequate in treating early disease. An antimicrobial containing ototopical is the preferred treatment for later-stage acute disease, and oral antibiotic therapy is reserved for advanced disease or those who are immunocompromised. Preventative measures reduce recurrences, and typically involve minimising ear canal moisture, trauma, or exposure to materials that incite local irritation or contact dermatitis.

Rhinosinusitis is a significant and increasing health problem, resulting in a large financial burden on society. It is multifactorial in origin. With age, several predisposing factors change and rhinosinusitis manifests differently. Management thereof is evolving and controversial. Usually, rhinitis and sinusitis appear concurrently in most individuals, therefore the correct terminology is "rhinosinusitis". The case definition has been stratified into a technical description that is useful for ear, nose and throat specialists, and a clinical definition that is pertinent for other healthcare-professionals.

Muscles, tendons, joints and nerves are susceptible to injury when stressed or traumatised repetitively, or over an extended period of time. Regardless of the nature of the work, a large proportion of the working population's time is spent engaged in repetitive movements and maintaining postures for extended periods of time. The reported incidence of work-related back and neck pain, and carpal tunnel syndrome, is between 15-60%, indicating that a high proportion of the working population is at risk of developing one or more work-related musculoskeletal disorders. The parts of the body that are most commonly affected are the lower back, neck and shoulder girdle, and upper limbs. Based on current literature, we shall discuss conditions affecting these areas in order to gain a better understanding of the conditions, as well as their prevention.

Atopic eczema is a chronic, relapsing inflammatory disease of the skin. It is characterised by dry, itchy skin and a typical distribution on the elbows and knees in younger children, and the cubital and popliteal fossae in older children and adults. Treatment modalities include emollients, topical corticosteroids, calcineurin inhibitors, phototherapy and immunosuppressive therapy. This article provides a brief overview of topical treatments for atopic eczema.

Hypertension is a common medical problem. It affects approximately one in four adults worldwide, with evidence that the prevalence is rising. In the USA, approximately 30% of adults have some form of hypertension.

On June 16, Youth Day, while commemorating the Soweto uprising against oppression in the 1970s, South Africans were facing a new challenge to their hard-earned constitutional democracy. The controversial and hotly debated Protection of Information Bill, better known as the "Secrecy Bill", is threatening to relegate South Africa to the shady league of nations with severe restrictions on the media.

The intake of added dietary sugars has escalated dramatically since the 1970s, mostly due to a global increase in the consumption of sugar-sweetened beverages (SSBs). This trend has sparked concerns among scientists and consumers alike regarding the safety of added dietary sugars. The popular media often accuse dietary sugars of being detrimental to health. However, when consumed in moderate amounts, current research does not support the premise that added dietary sugar has a detrimental effect on dental health, mental health and behaviour, weight management, chronic diseases of lifestyle, or the intake of micronutrients. However, SSBs represent concentrated and energy-dense forms of dietary sugars, easily consumed in large amounts. Not surprisingly, excessive consumption of these beverages is associated with weight gain and obesity. Intake of more than one to two drinks per day is also linked to the metabolic syndrome (MS), insulin resistance, type 2 diabetes, cardiovascular diseases, hypertension, gout and non-alcoholic fatty liver disease. Experimental studies suggest that excessive fructose intake may play a direct role in the metabolic changes that manifest as the MS, but further research into this is required. Current recommendations state that added sugars may be enjoyed in moderation as part of a balanced diet, with an appropriate energy intake to achieve or maintain healthy weight. However, excessive intake of added sugars, particularly fructose-containing sugars, should be avoided, and the energy intake from SSBs should be limited to less than 400-600 kJ per day.

Background: Medically safe, elective male circumcision supports traditional and cultural rites of passage by reducing the risk of adverse events and death among men undergoing initiation. It is a way of preventing penile conditions that arise from being uncircumcised. It also protects against various sexually transmitted infections, playing a particularly important role in human immunodeficiency virus (HIV) prevention, as it protects against HIV infection in men by up to 60%. It also helps reduce herpes simplex virus type 2, a key biological co-factor thought to account for some human susceptibility to HIV infection and human papillomavirus. To address these needs and to meet the World Health Organization's call to upscale male circumcision to 80% in HIV / AIDS epidemic-gripped sub-Saharan Africa, there is a need to provide male circumcision as standard care in district health.

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Method: A retrospective review of three years of circumcision services, using the sleeve method, and not the high-volume, forceps-guided method, and training at a Level 1 district hospital in South Africa.

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Results: Two hundred and twenty-one medical circumcisions were performed, increasing significantly in each successive year. Mostly, they were carried out under local anaesthetic, and there were only four complications, all of which were successfully resolved. The average age of the patients was 20, and generally, they elected to have medical circumcision carried out for cultural reasons. Some 60 students and clinicians were trained in safe medical male circumcision.

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Conclusion: To meet the growing demand for male medical circumcision, especially among teenagers and young adult men at district-level hospitals, there is a need to significantly expand the surgical competency of clinicians in this field. "Circumcision weeks" are one way of routinely upscaling surgical skill levels, while simultaneously responding to increased patient demand for safe medical circumcision.

Background: Lymphadenopathy is a rather common clinical finding in a primary healthcare setting, and may be due to inflammatory lesions and tumours. Correlation between clinical findings and laboratory data is essential in arriving at a diagnosis. This study was undertaken to study the histopathology of generalised lymphadenopathy in India, as well as the demographics of the study population.

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Method: This study was conducted for a period of 10 years (August 1997 - July 2007), of which eight years were retrospective, from August 1997 - July 2005, and two years were prospective, from August 2005 - July 2007. The source of data for this study was patients seeking medical attention, who, on clinical examination, were found to have generalised lymphadenopathy. A representative node was excised for histopathology. Tissues were routinely processed, stained with haematoxylin and eosin, and examined by means of light microscopy.

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Results: Of the 244 lymph node biopsies analysed in this study, 75 cases (30.73%) were reactive lymphadenitis, 142 cases (58.19%) showed granulomatous lymphadenitis, one case (0.40%) was Hodgkin's lymphoma, eight cases (3.27%) were non-Hodgkin's lymphoma, and 18 cases (7.37%) were metastatic malignancy.

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Conclusion: In this study, the most common cause of generalised lymphadenopathy was granulomatous lymphadenitis, followed by reactive lymphadenitis. Among the neoplastic lesions, metastatic malignancy accounted for most cases.

Background: The measurement of haemoglobin (Hb) concentration provides a reliable, primary screening test for the presence and severity of anaemia. The HemoCue^® is a point-of-care test for Hb measurement. The introduction of point-of-care testing in hospitals and general practice has improved patient care and accessibility. This study was performed to evaluate the utility of point-of-care Hb measurement with the HemoCue^® device for the diagnosis of anaemia.

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Method: In this prospective study, we compared the analytical performance of the HemoCue^® to the Coulter^® LH 750 automated haematology analyser with regard to accuracy, precision and linearity in the measurement of Hb in adult and paediatric patient samples, referred for routine laboratory testing.

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Results: Samples from 100 patients were analysed with both instruments, and the results were compared using standard scatter and difference plots. The mean Hb value of the HemoCue^® (11.3 g/dl; range 4.6-16.7) was comparable to the Coulter^® LH 750 (11.3 g/dl; range 4.7-17.2). The Bland-Altman difference plot revealed good correlation. Bias between the two methods was small, and the imprecision was within acceptable limits. Hb measurement was linear in the range of 4.8-20 g/dl.

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Conclusion: In all age groups, the HemoCue^® point-of-care device can be used to provide accurate and reliable Hb measurements with a smaller sample volume, improved turnaround time, and long-term cost saving.

Background: Community health centres (CHCs) are an important component of the health system in Mali and China. Despite patient support and commitment from the authorities, the management and the quality of care of these structures need to be improved. This research aimed to compare the management style of the relevant boards with users' satisfaction pertaining to CHC services in Mali and China.

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Method: Between September 2009-January 2010, a study was conducted in eight CHCs in Mali and in 16 CHCs in China. A total of 480 householders, [60 (Mali) and 320 (China)]; and 24 management committee members (Mali) and 48 management committee members (China) were interviewed. An in-depth interview technique was used on members of the management committee, while a structured interview was carried out to collect data during face-to-face contact with householders in their residences. In residences in which there were two or more households, the first willing householder was interviewed. Questions about the level of satisfaction were coded from 1-5 and ranged from "excellent" to "very bad" respectively.

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Results: The CHCs in China were managed by the government, whereas in Mali, they were overseen by the local population. The most satisfied people in both countries were those living in the poorest socioeconomic conditions, the elderly, and those who attended the healthcare meetings. Chinese households were more satisfied with the quality of the CHC services than those in Mali. The Chinese management boards proposed standardisation of rules and more funding, whereas those in Mali advocated that government provide more funding and human resources allocation.

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Conclusion: A high level of satisfaction regarding the CHC services was observed. However, users reported on deficits in the quality of care, whereas management suggested a need for greater resource allocation.

Background: Microalbuminuria, the presence of low levels of albumin in the urine, indicates renal damage and is recognised as a risk factor for the progression of renal and cardiovascular disease. Several international scientific bodies recommend microalbuminuria screening. Point-of-care testing (POCT) of microalbuminuria allows immediate identification of risk, and monitoring of treatment effects. In this study, two POCT instruments were evaluated as microalbuminuria screening methods.

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Method: Spot urine specimens from diabetic patients were analysed with the quantitative HemoCue^® urine albumin analyser (n = 245), and the semiquantitative Clinitek^® microalbumin urine dipstick (n = 204). These results were compared to the respective data for laboratory-determined albumin (nephelometry), creatinine (modified Jaffe) and albumin-to-creatinine ratio (ACR).

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Results: Linear regression analysis demonstrated a good correlation for the HemoCue^® urine albumin with the laboratory-determined albumin concentration (y = 0.8557x + 0.2487y, r = 0.97). The sensitivities for the HemoCue^® and Clinitek^® POCT systems were 79.6% and 83.8%, and the specificities 97.1% and 93.8% respectively. Positive and negative predictive values for the HemoCue^® were 95.6% and 85.8%, and were 88.6% and 91.0% the Clinitek^®. The repeatability of both instruments was excellent. Both instruments are easy to use, and more cost-effective than the laboratory methods for albumin and ACR.

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Conclusion: Both the HemoCue^® and the Clinitek^® microalbumin POCT systems for albuminuria are easy to use and inexpensive, and are adequately accurate as a screening method. Although the HemoCue^® POCT system measures only urine albumin concentration, its sensitivity and specificity compared well with that of the Clinitek^® POCT system, which determines the ACR.

At Walter Sisulu University (WSU), postgraduate registrar training in family medicine commenced in 2008 and is based at Mthatha General Hospital, the District Hospital for King Sabata Dalindyebo Health District.

Die opgedateerde, uitgebreide, verklarende en tweetalige Woordeboek vir Gesondheidswetenskappe (WGW) is gebaseer op die Woordeboek van Afrikaanse Geneeskundeterme wat in 1979 verskyn het. Vakwoordeboeke is verouderd nog voor hulle op die rak verskyn; 'n onvermydelike gevolg van die voortdurende ontwikkeling van die mediese wetenskap en tegnologie. Die nuwe WGW bevat nagenoeg 10 000 nuwe inskrywings en die herdefiniëring van nog sowat 8 000. Daarmee is 'n waardevolle hulpbron aansienlik uitgebou en 'n wesenlike bydrae gelewer om die Afrikaanse mediese terminologie uit te brei.

A couple of decades ago, some South African mining companies formed the Supercrews. These crews worked underground mainly, but some worked on the surface in various capacities. They consisted of a mine captain, a shift boss, and a team of miners, making up about 12-20 team members. They worked very efficiently in dangerous areas, and in parts of the mines in which there were problems. All employees could apply to join, and competition was strong because of the extra remuneration.