South African Family Practice - Volume 54, Issue 1, 2012
Volume 54, Issue 1, 2012
Author Pierre J.T. De VilliersSource: South African Family Practice 54 (2012)More Less
This is my last editorial in South African Family Practice, since my term finally expired on 31 December 2011, after 13 years. I can remember how Sam Fehrsen, a former editor, always used to talk about "the journal", and so we all followed. To me, this is a term of endearment, respect, and recognition of the important role it played in the development of the discipline of family medicine.
Author L. KellySource: South African Family Practice 54, pp 6 –7 (2012)More Less
Tight glycaemic control for type 2 diabetes (T2DM) has always been a tough sell. It is rarely achieved safely, owing to noncompliance and hypoglycaemic episodes, and there has been little evidence to support it. New studies now speak of its potential harm.
The initial United Kingdom Prospective Diabetes Study (UKPDS) in 1998 was widely interpreted as evidence for tight glycaemic control, then defined as a haemoglobin A1c value of 7.0%. In fact, in this trial no reduction was demonstrated in serious clinical episodes, i.e. macrovascular events (stroke or myocardial infarction). The often quoted 22% relative risk reduction in microvascular events (renal, ophthalmic, foot) actually referred primarily to a decreased need for retinal photocoagulation. However, there was no effect on visual acuity or renal failure.
Author M.H. MotswalediSource: South African Family Practice 54, pp 10 –13 (2012)More Less
Scalp disorders are very common in general practice, and result in emotional stress in adult patients due to the associated social stigma. They occur as primary diseases of the scalp, as part of a generalised inflammatory skin disease, or as part of a systemic disease. In this article, a brief overview of clinical features, and treatment of some of these conditions, is provided.
Author D.P. SmitSource: South African Family Practice 54, pp 14 –18 (2012)More Less
Dry eye disease (DED) is a very common condition with significant morbitity. It is under-diagnosed by healthcare practitioners, since the presenting symptoms are often non-specific or misleading, and clinical signs may be subtle, or absent. To help overcome this problem, validated symptom questionnaires have been developed to aid the diagnosis, and grading of severity, of DED. Recent advances in the understanding of the multifactorial aetiology of this condition have also permitted the development of modalities aimed at treating specific underlying causes, rather than merely alleviating symptoms. An awareness of the causes and risk factors involved in this disease will assist the family practitioner in recommending lifestyle and dietary changes that, on their own, may provide sufferers with considerable symptomatic relief. A better understanding of the pathophysiology will, in turn, allow the family practitioner to make informed choices when prescribing initial treatment, and also guide the practitioner to know when to refer a patient for specialist management.
Author K. KochSource: South African Family Practice 54, pp 21 –24 (2012)More Less
Pain is one of the the most common symptoms with which patients present in primary care. Before pain can be managed, its severity and nature need to be understood. The nature of pain is important, as a good clinical history will guide further investigation, leading to diagnosis. Monitoring pain severity is critical, as pain is largely a subjective experience, which cannot be properly managed if worsening or improvement is not monitored from a baseline. Using a standard pain measurement tool will allow for pain management over time, as the response to analgesics can be properly monitored. Different tools, to allow practitioners to assess pain in any setting, are available for patients of all ages.
Source: South African Family Practice 54, pp 25 –30 (2012)More Less
All infant formulas must support the normal growth and development of infants, and this needs to be scientifically demonstrated. Formulas have to contain sufficient amounts of basic nutrients, and so are nutritionally interchangeable, with no evidence indicating that one brand is superior to another.
Combination cold and flu medicines : an overview of autonomic nervous system receptors : CPD articleAuthor A. BouwerSource: South African Family Practice 54, pp 33 –36 (2012)More Less
In the pharmacy, colds and flu are commonly treated illnesses, and medicines that contain decongestants, antihistamines, analgesics, cough suppressants and expectorants are used alone, or in combination, to relieve typical symptoms. Combination cold and flu medicines can have certain adverse effects on the autonomic nervous system. This article provides an overview of the functioning of the autonomic nervous system (ANS), the pharmacological effects of the common ingredients in cold and flu medicines on the ANS, as well as the contraindications to consider when offering these medicines.
Author D. RodsethSource: South African Family Practice 54, pp 37 –41 (2012)More Less
The excessive use of alcohol is a significant problem in South Africa. The consequences are far-reaching, both for the health of the individual, and for society as a whole. This article examines the role of the family physician in the identification and management of patients with alcohol-use disorders.
The influence of common simple investigations on treatment and outcome in hypertensive patients : review articleAuthor J.A. KerSource: South African Family Practice 54, pp 46 –47 (2012)More Less
Hypertension is a highly prevalent, major, independent contributor to atherosclerotic cardiovascular disease. Hypertension imparts a two-to-threefold increased risk of cardiovascular events.
The prevalence of hypertension is high (at least one in four adults), and it increases with age. In addition, hypertension has a rather large risk ratio, and these two factors contribute to the fact that approximately 35% of atherosclerotic cardiovascular events may be attributable to hypertension.
The development, implementation and evaluation of a short course in objective structured clinical examination (OSCE) skills : original researchSource: South African Family Practice 54, pp 50 –54 (2012)More Less
Background : Objective structured clinical examination (OSCE) examiner training is widely employed to address some of the reliability and validity issues that accompany the use of this assessment tool. An OSCE skills course was developed and implemented at the Stellenbosch Faculty of Health Sciences and its influence on participants (clinicians) evaluated.
Method : Participants attended the OSCE skills course, which included theoretical sessions concerning topics such as standard setting, examiner influence and assessment instruments, as well as two staged OSCEs, one at the beginning and the other at the end of the course. During the latter, each participant examined a student role-player performing a technical skill while being video recorded. Participants' behaviour and assessment results from the two OSCEs were evaluated, as well as the feedback from participants regarding the course and group interviews with student role players.
Results : There was a significant improvement in inter-rater reliability as well as a slight decrease in inappropriate examiner behaviour, such as teaching and prompting during assessment of students. Furthermore, overall feedback from participants and perceptions of student role players was positive.
Conclusions : In this study, examiner conduct and inter-rater reliability was positively influenced by the following interventions: examiner briefing, involvement of examiners in constructing assessment instruments, as well as examiners viewing (on DVD) and reflecting on their assessment behaviour. This study proposes that the development and implementation of an OSCE skills course is a worthwhile endeavour in improving validity and reliability of the OSCE as an assessment tool.
Depression in primary care : the knowledge, attitudes and practice of general practitioners in Benin City, Nigeria : original researchSource: South African Family Practice 54, pp 55 –60 (2012)More Less
Background : Depression contributes significantly to the global burden of disease in developing countries. Poor case detection and inadequate numbers of mental health staff have been associated with increased morbidity among individuals with depression presenting to primary care. In Nigeria, as in most developing countries, general practitioners (GPs) may fill this treatment gap. The knowledge of and attitudes towards depression among GPs have not been surveyed, hence the need for this study.
Method : A cross-sectional survey of 72 GPs was undertaken in Benin City, Nigeria. The 20-item Depression Attitude Questionnaire was used to determine their knowledge and attitude towards depression and its treatment in primary care settings.
Results : GPs had a limited knowledge of depression, with the majority (77.8%) expressing difficulty working with depressed patients. They exhibited moderately stigmatising attitudes towards individuals with depression. GPs were conservative in their use of antidepressants and believed that psychotherapeutic approaches were useful.
Conclusions : Training programs and awareness campaigns for GPs concerning depression are needed in order to improve attitudes towards people with depression, increase case detection and increase the proportion of people treated.
Tobacco and alcohol use among healthcare workers in three public hospitals in KwaZulu-Natal, South Africa : original researchSource: South African Family Practice 54, pp 61 –67 (2012)More Less
Background : Tobacco use is a risk factor for most of the leading causes of death in the world. Healthcare workers (HCWs) can play an important role in assisting patients to stop smoking, but this role is undermined if they themselves smoke. The study determined the prevalence of tobacco smoking and alcohol use among HCWs in public hospitals in KwaZulu-Natal, South Africa.
Methods : In a cross-sectional study, 650 self-administered anonymous questionnaires (primary and secondary questionnaires) were administered to participants between December 2009 and June 2010. Six hundred and twenty primary questionnaires (on smoking) and 630 secondary questionnaires (on alcohol use) were returned, giving a response rate of 95% and 97% respectively. The Pearson chi-square test was used to test for statistical significance.
Results : Eleven per cent of the participants were current smokers and 7.1% former smokers, while 27% of never-smokers were constantly exposed to second-hand smoke. Males were 13 times more likely to smoke than their female counterparts (P < 0.001). Never-smokers more frequently counselled their smoking patients to quit compared to former and current smokers (47.5%, 39.5% and 25.8% respectively). Alcohol use problems were reported by 22% of participants (P < 0.001). Current smokers were six times more likely to drink excessively than never-smokers (P < 0.001) and males were ten times more likely than females to drink excessively (P < 0.001).
Conclusion : The smoking rate among HCWs is still high, although lower than the national average of 21.4%. A large number of participants reported exposure to second-hand smoke and alcohol use problems. Less than half of the HCWs counselled smoking patients to quit smoking.
Evaluation of general practitioners' routine assessment of patients with diabetes in Tshwane, South Africa : original researchAuthor L. NkombuaSource: South African Family Practice 54, pp 68 –71 (2012)More Less
Background : Diabetes mellitus is a composite disease that, if not well managed and controlled, may lead to severe complications. To avoid or delay these debilitating complications, it is necessary for the practitioner to implement adequate management of the disease by using currently available clinical guidelines. The authors wished to establish the use of existing diabetes management guidelines by general practitioners (GPs) in the City of Tshwane (Pretoria) Metropolitan Municipality of South Africa.
Method : A cross0sectional and descriptive study was conducted. A total of 50 randomly selected general practitioners participated in the survey.
Results : A large majority of the participants (92%) was aware of the existence of the latest guidelines for the management of diabetes in South Africa. The assessments performed by most GPs were body mass index and lipid profile, as reported by 96% of the respondents, followed by foot examination, microalbumin (88%) and glycated haemoglobin (84%) measurements. The practice of eye specialist referrals was found adequate in 22% of the participants. Fifty-four per cent reported that they did not undertake any continuing professional development activity regarding diabetes in the preceding year.
Conclusion : Although the GPs surveyed in the Tshwane district were aware of the existence of guidelines for the assessment of patients with diabetes, their implementation was not satisfactory. Training institutions play a pivotal role in guiding future practitioners to improve such implementation. Also, the improvement of the quality of primary health care systems is of great importance.
An audit of surgical termination of pregnancy at a level 1 health facility in South Africa : original researchSource: South African Family Practice 54, pp 72 –76 (2012)More Less
Background : It was alleged that the termination of pregnancy (TOP) services in a certain district health facility were forgoing the opportunity to offer screening tests for human immunodeficiency virus (HIV) and syphilis for women seeking legal medical abortions. In addition, there were concerns regarding the lack of provision of contraceptive services, particularly in view of media reports of young women having repeated TOP procedures as a family planning method. It was therefore decided to perform an audit of the TOP services at this district health facility.
Method : A semi-structured questionnaire was used to obtain information from all women undergoing a TOP during a six-month period at a district hospital in KwaZulu-Natal. Demographic information, clinical details and attitudes towards TOP were obtained. All women were interviewed in private prior to discharge from the clinic.
Results : A total of 645 women were enrolled. Their mean age was 23 (range 15-44) years and 437 (67.8%) were primiparous. Of the 645 women, contraceptive failure (condom) occurred in 38 cases (6%). Two hundred and twenty-two (34.4%) had previously used a family planning method, the most common being depot preparations (35.1%), followed by condoms (28.9%) and oral contraception (15.8%). One hundred and nine (16.9%) women accepted the condoms offered while the remainder indicated that they would obtain contraceptives from the family planning clinic in their area of residence. Twenty-nine (5%) had at least one previous TOP while 25 (86%) and four (14%) had second and third requests for TOP respectively. None of the women had any serological screening tests performed or were given information about testing for sexually transmitted diseases, including HIV screening, prior to discharge from the clinic.
Conclusion : Women having TOP at this district hospital are not offered counselling and information on screening for sexually transmitted diseases. In addition, few women take up the offer of contraceptives. There is a need for health care providers to strengthen reproductive health services at TOP clinics.
Measuring adherence to antiretroviral treatment and assessing factors affecting adherence in a state primary healthcare clinic, Mitchells Plain Community Health Centre : scientific letterSource: South African Family Practice 54, pp 77 –78 (2012)More Less
Background : A need was identified to measure adherence levels to antiretroviral treatment (ART) in a resource-poor setting and to assess the impact on adherence to ART of partner disclosure, partner support, other support, and length of time between diagnosis and ART commencement.
Method : A retrospective case-control study was conducted and the information was obtained by means of a file audit. One hundred and ninety-nine participants were chosen based on the inclusion and exclusion criteria. Adherence for each patient was measured using a formula documented in a published study. For the comparison group, 82 cases (non-adherent patients) were matched for age and gender with 82 adherent controls.
Results : The mean adherence for the initial group of 199 participants was 80.1%. Disclosure to a partner and partner support were not found to affect adherence significantly. The time between human immunodeficiency virus (HIV) diagnosis and ART commencement was also not found to make a statistically significant difference to adherence. There appeared to be an association, though not statistically significant, between support from other sources than the partner and equal to or greater than 95% adherence (P = 0.0579).
Conclusion : It can be concluded that adherence is probably influenced by a wide variety of factors. More qualitative studies or larger samples are recommended for better assessment of the impact on adherence of partner support and acceptance of HIV. Approaches to partner disclosure prior to commencing ART should be reviewed. The mean adherence level of 80.1% is an indication that more work is urgently needed to improve adherence levels in state-run clinics in South Africa.