South African Family Practice - Volume 54, Issue 4, 2012
Volume 54, Issue 4, 2012
Source: South African Family Practice 54 (2012)More Less
The 2012 Olympic Games ended recently in London, with a number of world records having been broken in various events. What did not receive a lot of publicity was how many athletes were disqualified for using performance-enhancing drugs before and during competition. Before the games, three athletes were suspended and charged with doping violations, namely Moroccan 1 500 m runner Amine Laalou, Belarus hammer thrower Ivan Tsikhan, and the Colombian 400 m runner Diego Palomeque, who was provisionally suspended after testing positive for testosterone. Immediately after the closing ceremony, Nadzeya Ostapchuk, a Belarus shot putter, was stripped of her gold medal after she tested positive for the anabolic agent metenolone during in-competition testing.
Author S. MochSource: South African Family Practice 54, pp 277 –285 (2012)More Less
Sleep is necessary for normal growth and development. Lack of sleep causes considerable personal impairment that may impose a substantial societal burden on productivity and quality of life. Insomnia, whether transient or chronic, responds to both pharmacological and non-pharmacological interventions. Cognitive behaviour therapy can effect sustained improvement in insomnia but requires motivation and commitment on the part of the patient and a trained therapist to guide the process. Benzodiazepine receptor agonists and benzodiazepines reduce sleep latency and increase total sleep time in insomniacs. However, their effects are not sustained after stopping the medication. Long-term safety of these medications has not been formally established. Combination of psychological and pharmacological therapies reduces the effect of psychological interventions. Thus, in determined patients psychological therapy should precede drug therapy.
Source: South African Family Practice 54, pp 286 –291 (2012)More Less
The true incidence of Legionella pneumophilia, Mycoplasma pneumoniae, Chlamydophila pneumoniae and Coxiella burnetti, the so-called atypical pathogens that cause adult community-acquired pneumonia in southern Africa, is unknown. Although there are a lack of community-based studies, hospital-based studies suggest that the incidence may be as high as 30% in patients admitted to, but not requiring, an intensive care unit. A lack of specific clinical features that differentiate atypical pathogens, plus the lack of reliable, simple diagnostics, compound the uncertainty regarding the contribution of atypical pathogens to the sum total of community-acquired pneumonia in southern Africa. Without reliable diagnostic tests, macrolide or azalide antibiotics are widely used for in-patients with pneumonia, potentially fuelling the rise of antibiotic resistance to macrolides in other bacteria.
Author K. KochSource: South African Family Practice 54, pp 292 –295 (2012)More Less
Pain is a subjective symptom which is particularly difficult to assess and manage in children. Often, this leads to the underestimation of pain severity in young children. Poorly managed pain can have a long-term impact on the developing child. It's important to be familiar with pain assessment tools to quantify childhood pain and the treatment options which are dependent on the degree of pain. As a general practitioner, it is essential to be familiar with the assessment and treatment of pain in children of all ages.
Author D. SmitSource: South African Family Practice 54, pp 302 –307 (2012)More Less
Ocular infections may be bacterial, viral, fungal or parasitic in aetiology. Pharmacological preparations are available to treat infections that are caused by these groups of organisms. The majority of these preparations are intended for topical administration, although some systemically administered agents may be needed to treat or prevent specific ocular infections. This article discusses the different anti-infective options that are available to general practitioners to treat infections caused by each aetiological group. It also discusses the role that is played by povidone-iodine and antibiotic-steroid combinations to manage eye infections. A summary of all these drugs is provided in table form for easy reference.
Source: South African Family Practice 54, pp 308 –311 (2012)More Less
Traumatic experiences are prevalent in South Africa and may result in psychiatric disorders such as post-traumatic stress disorder (PTSD). PTSD is accompanied by a range of psychobiological alterations, including changes in brain structure and functioning. General practitioners have an important role to play in identifying and assisting those in need of help. Efficacious psychotherapies and pharmacotherapies are available for PTSD, i.e. cognitive behavioural therapy and selective serotonin reuptake inhibitors.
Author M.L.I. MashitishoSource: South African Family Practice 54, pp 313 –315 (2012)More Less
Angiotensin-converting enzyme (ACE) inhibitors are a class of drugs commonly used in the management of hypertension, congestive heart failure, cerebrovascular disease, stable coronary heart disease and diabetes-associated nephropathy. ACE inhibitors are divided into three classes, namely sulphydryl-containing ACE inhibitors structurally related to captopril, carboxyl-containing ACE inhibitors structurally related to enalapril, and phosphorus-containing ACE inhibitors structurally related to fosinopril. Though these classes of drugs are important in the treatment of the above conditions, they are not without side-effects. It is very important for clinicians to be aware of these side-effects so that patients can be warned, and compliance can be improved.
Source: South African Family Practice 54, pp 316 –318 (2012)More Less
Wheezing in young children is problematic for most practitioners. Difficulties arise in both the diagnosis and management of this clinical phenotype. Not all preschool children who wheeze have asthma. Therefore, we suggest that the "Ten Commandments" of managing preschool wheezing include thinking that in very young infants (< 1 year) wheezing is likely to be viral in origin; realising that allergy testing is mandatory to diagnose the cause of early wheezing; taking a history of asthma and allergy in family members; noting that chronic coughing is a pointer to asthma; using the term "asthma" if that is the diagnosis; ensuring that the environmental avoidance of triggers is addressed; using a short course of montelukast for virus-induced wheezing episodes; avoiding steroids to treat virus-induced wheezing; treating associated nasal symptoms; and making sure that the follow-up of children addresses the issue of stopping therapy if it is not working.
Source: South African Family Practice 54, pp 321 –323 (2012)More Less
Gastrointestinal flora influences health, but the composition of flora can be changed with prebiotics or probiotics. The addition of probiotics to powdered infant formula has not been demonstrated to be harmful to healthy term infants. However, evidence of clinical efficacy regarding their addition is insufficient to recommend the routine use of such formula. The administration of probiotic (single or in combination) supplementation in infant or follow-on formula, and given beyond early infancy, may be associated with some clinical benefits, such as a reduction in the risk of nonspecific gastrointestinal infections, a reduced risk of antibiotic use and a lower frequency of colic and irritability. Confirmatory well-designed clinical research studies are necessary.
Improving continuity of care through the use of electronic records : a South African perspective : forumSource: South African Family Practice 54, pp 326 –331 (2012)More Less
The fragmented nature of modern healthcare provision makes it increasingly difficult to achieve continuity of care. As a result, strong emphasis is placed on the informational dimension of continuity of care. The importance of keeping medical records is noted. Paper-based methods of record-keeping are inadequate with regard to supporting informational continuity of care. This has led to increased interest in electronic record-keeping methods. This article describes the role that various electronic records, such as personal health records (PHRs), electronic medical records (EMRs) and electronic health records (EHRs), could play in improving informational continuity of care. A scalable approach, based on the adoption of standards-based PHRs and EMRs, with a standards-based health information exchange to enable the exchange of health information, is recommended for the South African healthcare sector. The possible impact of the envisaged National Health Insurance (NHI) on current, mostly paper-based record-keeping systems, is also discussed. It is suggested that a start to the implementation of electronic records, is made at primary healthcare level. This is because the NHI will call on primary healthcare providers to act as gatekeepers to other levels of care. By ensuring that the bulk of patients' health records are stored in electronic format, it would then be possible to exchange health information with other healthcare providers once they also adopted electronic records at a later stage.
Motor neuron disease : the impact of decreased speech intelligibility on marital communication : original researchSource: South African Family Practice 54, pp 332 –338 (2012)More Less
Background : The onset of motor neuron disease (MND), a neurodegenerative disease, results in physical and communication disabilities that impinge on an individual's ability to remain functionally independent. Multiple aspects of the marital relationship are affected by the continuously changing roles and responsibilities. Communication is one of the most constructive ways of dealing with emotions that are elicited by these changes.
Method : This study explored the association between the deteriorating speech of persons with MND and couples' perception of marital communication. Fourteen couples participated in this non-experimental correlational research study. Data were collected over a 12-month period through the administration of objective and subjective measures.
Results : Results showed that despite decreased speech intelligibility, the relationship between the deteriorating speech and the couples' perception of marital communication was not statistically significant.
Conclusion : Overall, the results proved that the supposition that communication between couples will invariably deteriorate as a result of progressively reduced speech intelligibility is not necessarily valid. The fundamental importance of effective communication in marriage is highlighted. It is well established that augmentative and alternative communication strategies can preserve the ability to develop and maintain intimate rewarding relationships, even in the face of profound physical disabilities.
A medical audit of the management of cryptococcal meningitis in HIV-positive patients in the Cape Winelands (East) district, Western Cape : original researchSource: South African Family Practice 54, pp 339 –346 (2012)More Less
Background : Cryptococcal meningitis (CM) has become the most common type of community-acquired meningitis. CM has a poor outcome if the initial in-hospital treatment does not adhere to standard guidelines. The aim of this audit was to improve the quality of the care of human immunodeficiency virus (HIV) positive patients with CM in the Cape Winelands District.
Method : Following an initial audit in 2008, the researchers and a new audit team introduced interventions, and planned a second audit cycle. The folders of 25 HIV-positive adults (admitted to three district hospitals, one regional hospital, and one tuberculosis hospital) were audited.
Results : Spinal manometry was performed more consistently in the regional hospital, than in the district hospitals. Reasons for failing to reach the 14-day amphotericin B target were in-patient deaths, drug stock problems, and renal impairment. The renal monitoring of amphotericin B treatment was suboptimal. The quality of care at district hospitals appeared to be comparable to that found at the regional hospital. The in-patient referral for antiretroviral treatment (ART) counselling was better in the district hospital setting. However, both levels of care had difficulty in achieving the four-week target between the onset of amphotericin B and onset of ART.
Conclusion : Deficiencies in the quality of care remained. Between the prior and current audit cycles, there was no consistent improvement in care at the regional hospital. An integrated care pathway document has been developed, and adopted as policy in the Cape Winelands district. Its impact on the quality of care will be evaluated by a dedicated audit team in the future.
Knowledge of primary school teachers about asthma : a cross-sectional survey in the Umdoni sub-district, KwaZulu-Natal : original researchAuthor A. GraySource: South African Family Practice 54, pp 347 –351 (2012)More Less
Background : Asthma is one of the most common chronic respiratory conditions affecting young children. It is estimated that asthma affects 20% of schoolchildren in South Africa. The school setting represents "home" for most children, and teachers are recognised as in loco parentis. Therefore, it is imperative that primary school teachers have sufficient knowledge of asthma and its management, in order to be able to make rational and safe decisions about the children in their care. This study was undertaken to assess the levels of asthma knowledge and its management among primary school teachers.
Method : Data were collected from 226 consenting schoolteachers in 19 randomly selected primary schools in the Umdoni sub-district of KwaZulu-Natal, using a cellular telephone Mobile Researcher® application. A total of 55 questions relating to knowledge of asthma were posed, together with questions about motivation for, and confidence in managing, an asthma emergency.
Results : Overall, 38.5% of teachers were able to answer < 50% of the knowledge questions correctly. Teachers' level of asthma knowledge was not significantly associated with age, gender, years of teaching experience, educational qualification, or contact with an asthmatic individual (p-value = 0.153, p-value = 0.870, p-value = 0.070, p-value = 0.082 and p-value = 0.176, respectively). Areas of particular concern included knowledge regarding the signs and symptoms of a severe acute asthma attack, asthma medication and management, and asthma and sports.
Conclusion : This study demonstrates deficiencies in teachers' knowledge of asthma, which will need to be addressed if they are to safely discharge their duty of care. Teachers are supportive of in-service training in asthma management.
Evaluating the rural health placements of the Rural Support Network at the Faculty of Health Sciences, University of Cape Town : original researchSource: South African Family Practice 54, pp 352 –357 (2012)More Less
Objectives : The Rural Support Network (RSN) is an undergraduate student society that aims to raise awareness among the student body of the plight of rural health in South Africa, and organises individual and group placements in rural hospitals during vacations. This research aimed to evaluate these placements from the students' perspectives.
Design : In-depth, face-to-face interviews were conducted with 10 students and nine placement-reflective reports were reviewed. The data were analysed and coded for key themes using a constant, comparative grounded theory approach.
Setting : Faculty of Health Sciences (FHS) at the University of Cape Town.
Subjects : Students who had been on RSN placements in 2010.
Results : Students reported that the experience exceeded their expectations of learning new skills and observing and performing procedures. They gained significant insights into rural health care and were inspired to contribute to rural health in future. Their experiences helped them to gain confidence and an appreciation of the psycho-social aspects of patient care. The importance of community empowerment and of connecting and building relationships with communities was also emphasised. Challenges pertained to conflict within groups, incidents of unprofessional health care and being unable to help as much as they would have liked.
Conclusion : The study highlights the impact that positive experiences of rural health may have on health science students' interest in, passion for, and commitment to practising in underserved rural areas. Students' key recommendations for the FHS included the development of a rural programme within the undergraduate curriculum. Better group composition and improved planning and co-ordination of placements by the RSN were also recommended.
Exploration of pain in children on antiretroviral treatment in a regional hospital in South Africa : original researchSource: South African Family Practice 54, pp 358 –362 (2012)More Less
Background : Patients with human immunodeficiency virus (HIV) disease on antiretroviral therapy (ART) may experience pain for a variety of reasons, including the effects of the virus itself, associated opportunistic infections and the ART. Studies indicate that pain in adults on ART is frequent, can be severe, and is often undertreated. This study sought to explore the experience, and the prevalence of pain in young children aged 3-13 years on ART.
Method : Primary caregivers of children aged 3-13 years on ART attending a paediatric ART clinic at a regional hospital in Durban participated in the study. Convenience sampling was used. The Wong-Baker FACES Pain Rating Scale and a questionnaire adapted from Hirshefeld were used to investigate variables such as age, cluster of differentiation 4 (CD4) count, ART regimen, ART duration, and site, prevalence and impact of pain during activities. Data were analysed using a standard statistical programme.
Results : Four hundred and twenty primary caregivers were interviewed. Most were mothers caring for their HIV-positive children, and the majority of the children were aged 3-7 years. Most children were on a first-line ART regimen, and half reported pain. Nociceptive pain (visceral or somatic) was the most common type of pain, and pain interfered with the daily activities of a third of the children. There was a significant association between CD4 count and pain (p-value = 0.040). Paracetamol was the most commonly used analgesic.
Conclusion : Pain was a common problem, and generally was undertreated with analgesia. A need to improve pain assessment and management in this population group was identified.
Source: South African Family Practice 54, pp 363 –366 (2012)More Less
Background : This study aimed to determine the attitudes of pregnant women attending the antenatal clinic at Federal Medical Centre, Owo, Ondo State, Nigeria, towards female genital cutting.
Method : The study was conducted over a period of six months, between November 2010-April 2011, at the antenatal clinic of the hospital. Prior to commencement of this study, ethical clearance was obtained from the ethical review committee of the hospital. The respondents were interviewed by the authors and three trained research assistants, with the aid of a questionnaire. The obtained data were collated and analysed with SPSS® 15.0.1 statistical software.
Results : Most respondents (72; 56.3%) had undergone female genital cutting. The majority (90; 70.3%) were aware of female genital cutting. Less than half supported discontinuation of female genital cutting (63; 49.2%) and legislation against it (57; 44.9%). A quarter of respondents (33; 25.8%) would allow their daughters to undergo female genital cutting.
Conclusion : The majority of the respondents had undergone female genital cutting, which was sometimes carried out by a medical practitioner. Less than half supported the discontinuation of female genital cutting and legislation against it. Medical practitioners should be prevented from performing female genital cutting.
Author Chris EllisSource: South African Family Practice 54 (2012)More Less
Recently, I had reason to suggest to a confused registrar that the words that a patient speaks may sometimes be the illness itself. I am not sure whether she entirely believed me. It's a concept that was first proposed by, among others, the Cambridge philosopher, Ludwig Wittgenstein. He suggested that we often assume that language works one way by literally translating our thoughts. He proposed that language also creates reality, as well as attempting to describe reality. This is especially relevant when a patient presents his or her felt symptoms and sensations, as well as life narratives in the consultation. Usually, in a routine day of continuous consultations and the immediate need for factual information, we take the words at their face value. In our trusting context, "face value" means that the genuineness or exactness of the words are not questioned.