South African Family Practice - Volume 53, Issue 6, 2011
Volume 53, Issue 6, 2011
Author Gboyega OgunbanjoSource: South African Family Practice 53 (2011)More Less
As I write this editorial, the United Nations' conference on climate change (COP17) is taking place in Durban. The theme is Working together, saving tomorrow, today. Arguments and counter arguments are being generated between developed and developing countries on how to deal with the problems of climate change. What is not clear is the political will to take bold steps to save our planet from self-destruction by its inhabitants. One of the most critical issues is an extension to the Kyoto Protocol to cut down greenhouse gas (GHG) emissions that have been linked to horrendous climate changes, in recent times. But what is the Kyoto Protocol, which is generating so much debate, and little, or no, consensus, to extend its legal binding status?
Source: South African Family Practice 53, pp 511 –515 (2011)More Less
Fibromyalgia is a chronic disorder, characterised by chronic widespread musculoskeletal pain, and the presence of multiple tender points as well as a host of associated symptomatology. Optimal management of patients with fibromyalgia requires a multidisciplinary approach, with a combination of pharmacological and non-pharmacological interventions that are tailored to the patient's pain, dysfunction and associated features, including depression, sleep disorder and fatigue. Non-pharmacological lifestyle-based interventions to treat this disorder include exercise therapy, dietary modification, and psychosocial interventions. This review outlines these three forms of lifestyle intervention in patients with fibromyalgia.
Author L. BakerSource: South African Family Practice 53, pp 517 –524 (2011)More Less
Mr Brown is going to work on a construction site in northern Mozambique, along the coastline, for a year. Mrs Brown and Jimmy, her 16-year-old son, and Julie, her four-year-old daughter, will be going to stay with him for two weeks in December. Jimmy has severe acne, and has just started a course of Roaccutane®. He is looking forward to scuba diving while there. Mrs Brown is on Cymbalta® for her depression. What malaria prophylaxis would you recommend for them?
Author E. Van der MerweSource: South African Family Practice 53, pp 525 –532 (2011)More Less
Hypertension is a major contributor to cardiovascular morbidity and mortality. However, blood pressure control in clinical practice still falls short of treatment recommendations. The reasons for this are manifold, and patient non-compliance with medication has been identified as one important factor. In this article, we discuss the various reasons for patient noncompliance and look at strategies to improve adherence, for example, simplifying the medication regimen and reducing side-effects in an asymptomatic disease such as hypertension. In this regard, combination treatment, and specifically fixed-dose combinations, have come a long way in enhancing tolerability, reducing counter-regulatory drug mechanisms and bringing blood pressure closer to target. We investigate the possibility of some combinations having clinical benefits beyond blood pressure control, as this may improve long-term cardiovascular outcomes. On the other hand, certain combinations may only have positive clinical outcomes in carefully selected patient groups, and are not recommended for the routine management of hypertension. Lastly, issues such as escape mechanisms in the renin-angiotensin-aldosterone system (RAAS) are discussed. These mechanisms play a role in treatment failure, and may require the use of new antihypertensive drug classes, such as direct renin inhibitors.
Source: South African Family Practice 53, pp 533 –539 (2011)More Less
Herpes simplex viruses (HSV) are ubiquitous in humans, and infection with HSV produces a diverse spectrum of disease. The vast majority of HSV infections in adults are easily recognised and relatively benign in their clinical manifestation, but occasionally, life-threatening infections, affecting the viscera and the central nervous system, can occur. Genital herpes simplex virus type II (HSV-II) is the most common sexually transmitted infection worldwide, and increases the risk of human immunodeficiency virus (HIV) infection. Suppressive anti-herpes therapy, despite being effective in reducing genital ulcer recurrence, does not reduce the risk of HIV transmission. Molecular diagnostic tools have revolutionised the ability to diagnose central nervous system infections and disseminated visceral disease accurately, and with the availability of relatively safe and effective antiviral therapy, potentially fatal outcomes can be averted if treatment is instituted early.
Author B. BromSource: South African Family Practice 53, pp 540 –544 (2011)More Less
Functional medicine is part of integrative medicine. There are three phases in the movement from health to disease. The first phase concerns lifestyle and how poor lifestyle choices move the system into increasing dysfunction. If the changes are rapid and severe then this is called acute disorder, and if slow and persistent then this is called chronic disorder. In the early phase of dysfunction there may be few symptoms and signs but the symptoms and signs rapidly or slowly become more obvious. The symptoms and signs at first are only recording the fact that the system as a whole in under stress and not functioning well. Over time dysfunction may lead to disease. The conventional model of medicine tends to focus its management on treating symptoms or treating the disease if possible. The integrative model pays attention to lifestyle changes, moving the dysfunction back to optimum function and only treating the disease if indicated.
Source: South African Family Practice 53, pp 545 –547 (2011)More Less
Asthma is the most common chronic disease of South African children, affecting 10-20% of the population. It is sometimes difficult to diagnose. Where uncertainty exists, it may be more beneficial to treat the child as asthmatic, and then wean him or her off the medication later once it is under control, than neglect to administer the correct therapy to a true asthmatic. The treatment of asthma is often problematic, not because of lack of access to appropriate medication, but because of the central role played by additional factors, such as patient adherence and administration of medication technique.
Source: South African Family Practice 53, pp 549 –553 (2011)More Less
Bipolar disorder is a complex mood disorder, both in terms of the diagnosis and management. It can have devastating consequences if inappropriately managed, but good management can allow sufferers to lead normal lives. While it is in the general realm of specialist diagnosis and care, general practitioners can play an important role in early identification of the disorder and long-term management, in shared care with the psychiatrist.
Author Pierre J.T. De VilliersSource: South African Family Practice 53 (2011)More Less
These are difficult times in our country. The effects of the worldwide economic recession are evident in job losses and financial hardship. Socially and morally, our country seems to be leaderless, crime ridden, and filled with corruption and mismanagement. Globally, we are facing the possible devastating effects of overpopulation: climate change, disease and wars.
Author B. MashSource: South African Family Practice 53, pp 557 –562 (2011)More Less
This article reviews how the model of family medicine has developed over the last 15 years in the Western Cape. It is based on a series of in-depth interviews with key role players. This period coincides with the immediate post-apartheid era, in which both the health system and health science education experienced rapid transformation. The new focus on primary health care, the district health system and community-based education provided an opportunity for the disciplines of family medicine and in primary care to develop. The model that emerged required the family physician to work at both the district hospital and in primary care, and to have a number of different roles: care provider, consultant, capacity builder, supervisor, manager and community leader. Family medicine was accepted as a new speciality in 2007. The first specialist family physicians will qualify in 2011, and start to consolidate the model that has been developed. Although the model shows promise, a number of challenges still remain, in relation to the health system, the relationship between universities and the province, the discipline of family medicine, research, and training programmes. It is hoped that these reflections will be of value to other provinces in South Africa, and other countries in the region, that are also thinking of including family physicians in their health systems.
Obesity and health problems among South African healthcare workers : do healthcare workers take care of themselves? : original researchSource: South African Family Practice 53, pp 563 –567 (2011)More Less
Background : Obesity has reached epidemic proportions globally. In South Africa, 56% of white men, 49% of black men and 75% of black women have been reported to be overweight or obese. The focus of this study is on South African healthcare workers (HCW), because they are considered role models for health for patients and their communities.
Objectives : The objective was to determine the prevalence of obesity and obesity-related health problems among HCW and to compare these variables between medical and nonmedical staff at one selected public hospital in South Africa.
Methods : A questionnaire was distributed to 200 respondents from a balanced pool of randomly selected HCW (100 medical staff and 100 nonmedical staff). Self-reported body mass index (BMI), obesity-related health problems and perceptions about body weight were assessed.
Results : Seventy-three per cent of the HCW were overweight or obese, and half of them had never tried to lose weight. Females and older HCW were more obese than men and younger counterparts. There was no difference in BMI distribution between medical and nonmedical staff. About one-third of HCW reported that they suffered from obesity-related noncommunicable diseases (NCDs; hypertension 20% and diabetes 10%) and stress (32.5%). The majority of HCW had an inaccurate perception of their own weight.
Conclusion : South African HCW have a high prevalence of obesity-related NCDs. A health promotion programme targeting HCW is urgently needed to encourage weight control, urge the prevention of obesity-related NCDs and change self-perceptions of body weight, in order to improve their own health and make them better role models for the general public.
The relationship between ABO/rhesus blood groups and type 2 diabetes mellitus in Maghnia, western Algeria : original researchSource: South African Family Practice 53, pp 568 –572 (2011)More Less
Background : To determine the relationship between ABO/rhesus (Rh) blood groups and type 2 diabetes mellitus in a western Algerian population.
Method : This case-control study was conducted at the Regional Hospital Centre of Maghnia, Tlemcen, from July 2008 to May 2009, involving 280 patients with type 2 diabetes mellitus and 271 healthy controls. Blood samples were collected from the patients after consent had been obtained. The samples were tested for ABO and Rh blood groups, using the Beth-Vincent and Simonin-Michon methods. The allele frequencies were calculated according to the Bernstein formulas.
Results : The Χ2 test results showed that there was no association between the ABO blood group and type 2 diabetes mellitus. It was also noted that the O blood group was distributed with the highest frequency among diabetic subjects (52.85%). For the Rh system, d allele frequency presence was higher in diabetics than in nondiabetics (0.3778 and 0.3644 respectively). The difference between phenotype frequencies was not significant (p = 0.733). The distribution of ABO/Rh blood groups between gender and ethnic group showed no significant difference (p > 0.05).
Conclusion : Our study confirms that there is no association between ABO/Rh blood group and diabetes mellitus in this Algerian population.
Private healthcare sector doctors and HIV testing practices in the eThekwini Metro of KwaZulu-Natal : original researchAuthor P. NaidooSource: South African Family Practice 53, pp 573 –578 (2011)More Less
Background : Human immunodeficiency virus (HIV) testing has many logistic and ethical challenges. The UNAIDS/WHO policy statement states that the testing of individuals must be confidential, be accompanied by counselling, and be conducted with informed consent. HIV testing is integral to the management of the epidemic, and since KwaZulu-Natal (KZN) has the highest prevalence of AIDS in South Africa, it is vital that doctors in this province are knowledgeable about HIV testing practices. This study was undertaken in view of the lack of data on private sector doctors' HIV testing practices in KwaZulu-Natal.
Method : A descriptive cross-sectional study was conducted among private sector doctors who manage HIV and AIDS patients in the eThekwini Metro of KZN. One hundred private practitioners were randomly selected from a sample of 175 consenting private sector doctors. These doctors were asked to fill in an anonymous questionnaire. The questionnaires were collected and analysed using SPSS® version 15.
Results : A response rate of 60% was obtained, with 57 (95%) indicating that they do HIV testing after obtaining patients' consent. Over 96% of the doctors carried out pre-test counselling, while over 98% did post-test counselling. Eighty-one per cent did a confirmatory test if the patient tested positive, while 49% performed a confirmatory test if the patient tested negative; over 50% did the test after three months. Forty-seven per cent did not know or failed to indicate what confirmatory test they used. The majority did not disclose patient status or do counselling in the presence of others. However, if it was done, it was done with the consent of the patient or the parents in cases where the patient was a minor. The majority stated that they follow the guidelines when testing.
Conclusion : The HIV testing practices of private sector doctors who participated in the study are compliant with the UNAIDS/WHO policy statement regarding confidentiality, informed consent and counselling. However, doctors' knowledge of confirmatory test appears to be inadequate.
The state of affairs of the public sector mammography service in the Free State Province of South Africa : original researchSource: South African Family Practice 53, pp 579 –582 (2011)More Less
Background : The Cancer Association of South Africa stated that breast health services in South Africa were "fragmented and not comprehensive." The aim of study was to investigate the current state of public sector mammography in the Free State, and to recommend a way forward.
Method : A retrospective review of data was performed. Data on all female patients who received mammograms at Universitas Academic Hospital, Bloemfontein, South Africa from April 2008 to March 2010 were evaluated, as well as data on patients diagnosed with breast cancer during this period. A comparison was made between the number of mammograms performed and the number of breast cancer diagnoses during these two years at the hospital. A literature review of screening protocols and burden of disease was also carried out.
Results : A complete mammography service breakdown occurred during June 2009. During service breakdown, an average reduction of 72% was observed in the number of mammograms performed monthly, while a reduction of 41% in breast cancer diagnoses occurred. However, breast cancer has a lower burden of disease compared to many other diseases in South Africa. Effective management of breast cancer has a much greater impact on patient outcomes than screening, and should receive priority.
Conclusion : Breast health services, specifically mammography, are very limited in the Free State. However, priority may be given to other disease with a greater burden. Breast health care should initially focus on effective management of breast cancer.
The perceptions of pregnant women, attending antenatal clinics, on the prevention of mother-to-child transmission of HIV programme : original researchSource: South African Family Practice 53, pp 583 –589 (2011)More Less
Background : The prevalence of human immunodeficiency virus (HIV) infection among women of reproductive age and children below the age of 15 years continues to increase, especially in the countries hardest hit by the acquired immunodeficiency syndrome (AIDS) epidemic.
Method : A qualitative method was used to determine perceptions. It involved four focus group discussions among antenatal clinic attendees in the 27 primary healthcare clinics in Qwa-Qwa, Free State province, South Africa.
Results : Participants indicated good knowledge about the prevention of mother-to-child transmission of HIV (PMTCT) programme. Participants expressed fears that included stopping the treatment after delivery, the family neglecting the baby if the mother died, stigma, discrimination and domestic violence. The majority of the participants were happy with their relationship with the clinic staff. More than half of the participants expected negative reactions from family members if they followed the programme advice, because of the negative attitudes of their male partners and the elders' resistance to change, owing to their cultural beliefs. Participants agreed that the programme provided adequate knowledge about HIV, modes of mother-to-child transmission of HIV, and how to prevent it.
Conclusion : The high level of knowledge among the participants could be attributed to the counselling and health talk sessions offered by clinic staff.
Comparison of men with acute versus chronic urinary retention : aetiology, clinical features and complications : original researchSource: South African Family Practice 53, pp 590 –594 (2011)More Less
Background : The objectives were to investigate the aetiology and clinical features of urinary retention and to analyse differences between acute urinary retention (AUR) and chronic urinary retention (CUR).
Method : We analysed the clinical data of 558 men admitted to our institution with urinary retention between September 1998 and June 2007. Statistical analysis was performed with Student's t-test, Mann-Whitney and Fisher's exact tests, where appropriate.
Results : The mean age of the men was 66.4 years (range 12.8-94.7). AUR was present in 90.7% and CUR in 9.3%. The most common causes were benign prostatic hyperplasia in 36.6%, adenocarcinoma of the prostate (ACP) in 36.0% and urethral stricture in 14.3%. Mean prostate volume was 56.6 cc (range 15-262). Comparing the groups with AUR versus CUR, a positive urine culture was significantly more common in the group with AUR (34.1% vs. 8%), whereas anaemia (15.9% vs. 34.1%), renal failure (9.1% vs. 46.2%) and hydronephrosis (23.9% vs. 53.9%) were significantly more common in the group with CUR. There was no significant difference in prostate volume or the proportion of men with histological prostatitis (29.5% vs. 23.1%).
Conclusion : The prevalence of ACP and urethral stricture as aetiology of retention was higher than reported in the literature. The prevalence of anaemia, renal failure and hydronephrosis was significantly greater in patients with CUR compared to AUR. There was no significant difference in prostate volume or the prevalence of histological prostatitis, indicating that factors other than prostate size or histological prostatitis determine the development of AUR rather than CUR.
Author Chris EllisSource: South African Family Practice 53 (2011)More Less
Several years ago, I was driving my bakkie on a farm in the Drakensberg. We were passing a field in which a herd of Hereford cows were grazing. The farmer, who was in the passenger seat, casually mentioned that he noticed that one of the cows was ready for the bull. I asked him how he knew that he was in the presence of bovine ovulation. He responded by saying that he had had his milk herd for over 30 years, and knew most of the cows by name. He thought that he caught a movement of the cow out of the corner of his eye, and from experience and stored informal memory, he knew she was ready for the bull (as we fertility experts say).
Source: South African Family Practice 53, pp 597 –600 (2011)More Less
The Consumer Protection Act (CPA) 68 of 2008, and the Regulations in terms thereof, became effective on 31 March 2011, and 1 April 2011, respectively. Potentially, the CPA has far-reaching implications for medical practice. Under the CPA, patients could be regarded as consumers, and medical practitioners as suppliers or service providers, depending on the context. Medical practitioners could also be regarded as consumers. However, when they practise in partnerships or incorporated companies, i.e. as juristic persons, and their turnover equals or exceeds R2 million, the CPA would not apply.
This article briefly reviews some of the provisions of the CPA that could impact on medical practice.
Source: South African Family Practice 53, pp 601 –604 (2011)More Less
The Green Paper on National Health Insurance (NHI) was published on 12 August 2011. It is open for public comment until 30 December 2011. The Green Paper contains the draft proposals of government for NHI. Once adopted by Parliament, it will be called a White Paper, and will then constitute official government policy. Although the Green Paper only contains high-level proposals, it provides a framework for the implementation of NHI. This article briefly reviews these proposals, and their implications for medical practice.
Source: South African Family Practice 53, pp 605 –609 (2011)More Less
South Africa is the epicentre of the human immunodeficiency virus (HIV) pandemic. Based on a wide range of data, including household and antenatal studies, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that HIV prevalence was 17.8% among 15-49 year-olds at the end of 2009. Their high and low estimates were 17.2% and 18.3% respectively. According to their own total population estimation, this implies that at the end of 2009, around 5.6 million South Africans were living with HIV, including 300 000 children under 15 years old. The national prevalence of HIV is around 11%. In 2008, an estimated 5.2 million people were living with HIV and acquired immune deficiency syndrome (AIDS) in South Africa, and it is believed that over 250 000 people died of AIDS. AIDS is a major factor in the overall rising number of deaths. Around 70 000 babies are born with HIV every year. Statistics South Africa (SSA) reveals that the annual number of deaths rose by 93% between 1997-2006. Among those aged 25-49 years, the rise was 173% in the same nine-year period. The overall increase in the number of deaths, as reported by SSA, is attributed to population growth. However, as they point out, these figures do not clarify the disparity in the rise in deaths among people aged 25-49 years. It is believed that AIDS-related deaths are underestimated because many doctors avoid mentioning the cause of death on the death certificates.