South African Family Practice - Volume 54, Issue 3, 2012
Volume 54, Issue 3, 2012
Source: South African Family Practice 54, pp 2 –6 (2012)More Less
Anaesthesia for trauma patients presents unique challenges for anaesthetists. Most urgent cases occur at night or during weekend shifts, when more experience anaesthetists are not available. Patient information is limited, and previous medical history and details of chronic medication, allergies, or genetic abnormalities, are unknown.
Source: South African Family Practice 54, pp 7 –10 (2012)More Less
In the daily practice of anaesthesia, patients who are infected with the human immunodeficiency virus (HIV) will present. These patients can be at various stages of the disease process, and may or may not be on antiretroviral therapy (ART). This article will concentrate mainly on the clinical and practical aspects of dealing with a patient with HIV for anaesthetists.
Source: South African Family Practice 54, pp 11 –13 (2012)More Less
Annually, the Society for Obstetric Anaesthesia and Perinatology recognises Gerard W Ostheimer, a former obstetric anaesthesiologist at the Brigham and Women's Hospital in Boston, by presenting an honorary lecture that highlights topics relevant to obstetric anaesthesia from the obstetrics and anaesthesia literature published the previous year. What follows is a brief discussion of the topics discussed in the 2011 lecture, namely maternal coexisting disease, complications of anaesthesia, the safe administration of oxytocin, and patient safety.
Source: South African Family Practice 54, pp 14 –16 (2012)More Less
It has long been recognised that anaesthesia-related complications, including anaesthesia-related cardiac arrest and mortality, occur more frequently in children, than in adults. While outcomes have improved over the last couple of decades, most likely as a result of better training and improved monitoring, and notably the introduction of pulse oximetry and capnography in the 1990s, paediatric anaesthesia-related cardiac arrests still occur. The incidence is 1.4-22:10 000 anaesthetics, and a subsequent mortality of approximately 30%. The incidence varies by centre, but is thought to be higher in South Africa as the studies in the literature derive either from the developed world, or from tertiary referral centres in the developing world.
Source: South African Family Practice 54, pp 17 –20 (2012)More Less
Tonsillectomy with or without adenoidectomy is one of the most frequent surgical procedures that are carried out globally. Although these children are often fit, anaesthesia for such cases can be associated with significant morbidity and mortality, and should not be undertaken lightly. An approach to the anaesthetic management of paediatric adenotonsillectomy is presented.
Source: South African Family Practice 54, pp 21 –24 (2012)More Less
Perioperative hyperglycaemia is a complex and common clinical problem, with serious adverse consequences for patient morbidity and mortality. A clinical approach to diagnosis, screening and management is offered.
Perioperative hyperglycaemia is a very common problem, both because the incidence may be increasing worldwide, and because it describes a much wider problem than diabetes mellitus only.
Source: South African Family Practice 54, pp 25 –28 (2012)More Less
Postoperative pain is the most undesired consequence of surgery, and if not managed adequately, can lead to delayed recovery and increased hospital stay. Surveys continue to reveal that postoperative pain is insufficiently managed throughout the first world, let alone in the Third World. An American survey over 20 years showed that only one in four patients had adequate relief of postoperative pain. This has led recovery room protocols to include pain as a fifth vital sign that needs to be addressed before patients are discharged to the ward. Opioid-sparing techniques are becoming more popular as they decrease the undesired side-effects from narcotic analgesics, especially since data now suggest that some patients who are treated with opioids may have paradoxical reactions, resulting in hyperalgesia, rather than analgesia. Treatment of pain has also moved to the preventive realm, and aims to block the afferent nociceptive bombardment of the central nervous system, before and during surgery. This prevents neurochemical changes that could lead to central sensitisation and chronic pain.
Author Gboyega A. OgunbanjoSource: South African Family Practice 54 (2012)More Less
In May 1934, an editorial comment titled, Sickness and the economic depression, was published. This followed a survey that had recorded illnesses for a three-month period in 1933 and an income and employment record for four years among 12 000 families in 10 USA cities following the Great Depression. The investigators concluded that: "The highest illness rate was reported by a group which was in reasonably comfortable circumstances in 1929, but which had dropped to comparative poverty by 1932".
Source: South African Family Practice 54 (2012)More Less
Reducing morbidity and mortality from traditional male circumcision in the Eastern Cape
How children access antiretroviral therapy at a district hospital
Pain as a reason for primary care visits: a cross-sectional survey
Family suicide and personal suicidal behaviour among youths in KwaZulu-Natal
Author Kim OuthoffSource: South African Family Practice 54, pp 181 –187 (2012)More Less
Agomelatine is a novel melatonergic antidepressant that restores disrupted biological rhythms, essentially by resetting the circadian clock. Two different, non-monoaminergic, and possibly synergistic pathways, appear to be involved in its mechanism of action. Agomelatine is a melatonin 1 (MT1) and melatonin 2 (MT2) receptor agonist and serotonin (5-hydroxytryptamine) 2C (5-HT2C) receptor antagonist. It is effective in treating moderate-to-severe depression, alleviating the symptoms of anxiety, and restoring the disrupted sleep patterns that often result from this potentially devastating disease. Agomelatine is generally well tolerated with little, if any, propensity for antidepressant-induced sexual dysfunction, weight gain, or discontinuation reactions. However, it has the potential to cause temporary hepatotoxicity, and liver functions need to be monitored as a result. Clinically, meaningful drug interactions are unlikely, with the exception of co-administered potent cytochrome P 1A2 (CYP1A2) enzyme inhibitors, which may increase agomelatine's plasma levels significantly. Agomelatine represents an interesting addition to the antidepressant market.
Author Karen KochSource: South African Family Practice 54, pp 189 –191 (2012)More Less
Pain is one of the most common complaints that general practitioners encounter in everyday practice. The swift and effective management of pain is a medical mandate, not only to fulfil an ethical obligation to the patient, but also to prevent long-term complications, such as chronic pain. General practitioners are often required to manage mild-to-moderate pain, and have multiple pain management treatments available to them. The challenge is to tailor a treatment plan to suit the individual requirements of each patient. In this paper, we will explore how best to manage acute mild-to-moderate pain in general practice in a logical stepwise approach.
Source: South African Family Practice 54, pp 193 –197 (2012)More Less
Physicians are often asked to evaluate a patient prior to elective surgery for the purpose of risk identification and modification. Postoperative pulmonary complications are the most costly of the major postoperative medical complications, including cardiac, thromboembolic and infectious, and result in the lengthiest hospital stays. Therefore, estimation of respiratory risk should be a routine element of all preoperative medical evaluations. A diligent preoperative clinical evaluation, supplemented with appropriate preoperative pulmonary function testing, would identify the majority of important risk factors for postoperative complications. Risk reduction strategies can then be implemented to reduce complications, cost, and hospital stay.
Source: South African Family Practice 54, pp 199 –201 (2012)More Less
Exclusive breastfeeding and postponement of complementary foods to four to six months of age are recommended for the prevention of food allergies. However, many infants receive formula milk for a number of reasons. Various types of formula are indicated to prevent or treat allergy and food intolerance.
Source: South African Family Practice 54, pp 203 –209 (2012)More Less
One in ten South Africans will be diagnosed with major depressive disorder (MDD) at some point in their lives. MDD is a potentially disabling condition that affects many spheres of an individual's life and leads to marked social and occupational dysfunction. General practitioners are frequently required to diagnose and manage MDD, often in a time-pressured primary healthcare setting. This article aims to provide practitioners with an overview of MDD. It covers aspects of diagnosis, co-morbidity, pharmacology and special patient groups.
Angiotensin II type 1 receptor antagonists and their combinations in the treatment of hypertension : review articleSource: South African Family Practice 54, pp 210 –211 (2012)More Less
The pathophysiology of hypertension is not multifactorial in nature, and there is a complex interplay of mechanisms of control and counter-regulatory responses activated by drugs. The problem for clinicians is that it is not really possible to recognise the various clinical phenotypes of hypertension. In other words, the heterogeneity of hypertension remains a clinical problem. Current overwhelming evidence is that the most important treatment concept in the management of hypertension is that treatment should reduce blood pressure to goal levels. The majority of hypertensive patients will need two or more antihypertensive drugs to control their blood pressure at goal. Conceptually, a strong case can be made for the early use of combination therapy in the treatment of hypertension.
Source: South African Family Practice 54, pp 214 –220 (2012)More Less
General practitioners are often confronted with complaints regarding the eyelids. The author presents a number of clinical cases that illustrate common eyelid problems, and provides a discussion of each case to highlight the important features of the condition. Appropriate treatment for each condition is also covered. Many eyelid conditions are amenable to treatment from general practitioners, but those conditions requiring specialist management need to be identified, and referred appropriately.
Source: South African Family Practice 54, pp 222 –227 (2012)More Less
Background : Anaemia in pregnancy persists, especially in third world countries where poor diet, low levels of literacy, infections, infestations and cultural practices predispose pregnant women to being anaemic. The aim of this study was to determine the prevalence of anaemia in pregnancy and to identify the possible associations between socio-economic status and anaemia in pregnancy among antenatal care seekers at Baptist Medical Centre, Ogbomoso, Oyo State, Nigeria.
Method : A total of 350 pregnant women were recruited at booking from the antenatal clinic of the hospital. A standardised questionnaire was administered to collect socio-demographic data. The subjects were stratified into upper, middle and lower socio-economic groups according to a scoring system designed by Olusanya et al. for Nigeria and other African countries. Anaemia is defined as a haemoglobin level of less than 11 g/dl by the World Health Organization.
Results : The prevalence of anaemia in pregnancy was 58.0% in the study population. Anaemia prevalence was significantly higher among the subjects in the middle and lower socio-economic classes: 78.3% and 80.3% respectively (P < 0.05). The majority of the severely anaemic subjects (80.0%) were from the lower social class.
Conclusion : The prevalence of anaemia in pregnancy was found to be high in this population. Low socio-economic status is significantly associated with increased prevalence and severity of anaemia. It is recommended that the socio-economic situation of women be improved. This no doubt will help to reduce anaemia in pregnancy.
How children access antiretroviral treatment at Kgapane District Hospital, Limpopo, South Africa : original researchSource: South African Family Practice 54, pp 229 –236 (2012)More Less
Background : At Kgapane Hospital, Limpopo Province, only 20% of eligible children initiated antiretroviral treatment (ART) in 2007. The aim of this study was to improve the ART programme by assessing how children were accessing ART, and to explore the factors that facilitate or obstruct this access.
Method : Mixed methods were used in a descriptive study of human immunodeficiency virus (HIV)-infected children admitted to the hospital over a seven-month period and their caregivers. Children's subsequent attendance for ART was tracked and caregivers were interviewed about factors influencing access and attendance.
Results : Of 132 children initially admitted, 14 (10.6%) subsequently died and 13 (9.8%) relocated. Sixty of the remaining 105 (57.1%) returned within one month to the antiretroviral clinic, three (2.9%) attended later and 42 (40.0%) did not return at all. Quantitative data associated with poor attendance were younger age, higher CD4 count, maternal caregiver, no income and participation in the prevention of mother-to-child transmission program. Qualitative factors included a lack of money for transport, poor social support, and mothers who struggled to accept their diagnosis, had poor understanding of HIV and strong traditional beliefs. Primary care providers delayed HIV testing and referral, displayed poor attitudes, and were insufficient in number. Quantitative factors significantly associated with good attendance were prior knowledge of the child/mother's HIV status, mother's ART treatment and referral to the dietician.
Conclusion : There are serious deficiencies in the prevention, diagnosis and treatment of HIV in children. Factors were identified to improve health services and these highlight the need for broader strategies aimed at addressing poverty, stigma and education.
Evaluation of a project to reduce morbidity and mortality from traditional male circumcision in Umlamli, Eastern Cape, South Africa : outcome mapping : original researchSource: South African Family Practice 54, pp 237 –243 (2012)More Less
Background : Traditional circumcision is common among the amaXhosa in Umlamli, Eastern Cape. Circumcision is associated with high morbidity and mortality. The need to reduce complications was identified as a priority by the local community. The aim was to design, implement and evaluate a project to improve the safety of traditional circumcision.
Method : A safe circumcision team was established and comprised health workers, community leaders and traditional surgeons. Outcome mapping involved three stages: intentional design, outcome, and performance monitoring and evaluation. The eight boundary partners were the initiates, parents, community leaders, traditional surgeons, the District Health Services, the provincial Department of Health, the emergency services and the police. Outcomes, progress markers and strategies were designed for each boundary partner. The team kept an outcome and strategy journal and evaluated hospital admissions, genital amputations and mortality.
Results : Ninety-two initiates were circumcised, with two admissions for minor complications, compared to 10 admissions, two amputations and two deaths previously. More than 70% of the outcome measures were achieved in all boundary partners, except emergency services and the Department of Health. The key aspects were: the use of outcome mapping, the participatory process, a lower age limit, closure of illegal schools, consolidation of accredited schools, training workshops for traditional surgeons, private treatment room for initiates, assistance with medical materials, pre-circumcision examination, certificates of fitness.
Conclusion : This study has shown the value of community-orientated primary care initiatives to address local health problems. Key lessons were identified and the project could easily be replicated in communities facing similar challenges.
Associations between family suicide and personal suicidal behaviour among youth in KwaZulu-Natal, South Africa : original researchAuthor N.B.M. VawdaSource: South African Family Practice 54, pp 244 –249 (2012)More Less
Background : For every suicide, a minimum of six people are affected. Given the increasing number of suicide deaths in South Africa, the associations between the suicide of a family member and personal suicidal behaviour were explored in grade 8 students.
Method : Grade 8 students were asked to participate with parental consent and child assent. Demographic questionnaires were completed and formal psychometric assessment instruments were used.
Results : Thirty-five (15.98%) students reported knowing that a family member had committed suicide. The mean age was 13.3 years (range 13-15 years). There were significant associations between family suicide and students' self-reported involvement in physical fights, use of alcohol and concerns about physical health. Family suicide was associated with personal suicidal ideation, suicidal plans and suicide attempts. Higher scores were reported on the scales assessing depression, perceived stress and feelings of hopelessness by those having had a family member commit suicide. There were low scores for having a sense of mastery, self-esteem and perceived social support among those who had experienced a family member commit suicide.
Conclusion : Significant associations were found between the suicide of a family member and personal suicidal behaviour among the participants. There appear to be negative associations at a psychological level for the youth in a family in which a family member has committed suicide. Family practitioners play an important role in the identification and management of suicidal behaviour. While there are organisations in South Africa that offer help to the family and friends of those who have committed suicide, specific programmes directed towards child/adolescent survivors appear to be limited, and this needs to be addressed. The limitations of the study are discussed.