South African Family Practice - Volume 54, Issue 6, 2012
Volume 54, Issue 6, 2012
Source: South African Family Practice 54 (2012)More Less
Numerous studies have been conducted on global health worker migration since the 1960s. Various ideas have been put forward on how to control the migration, but no concrete steps have been finalised on how the developed recipient countries can compensate the developing donor countries. In this editorial, I will attempt to review some of the issues responsible for the inaction in addressing this continuing global phenomenon.
Source: South African Family Practice 54, pp 472 –477 (2012)More Less
Panic disorder (PD) is an anxiety disorder that affects many South Africans. If undiagnosed or mismanaged, this condition may impact profoundly on an individual's functioning and quality of life. At the primary level, the assessment of panic attacks requires consideration of a number of differential diagnoses. General practitioners also play an invaluable role in the acute and long-term care and appropriate referral of individuals with PD. This article provides an overview of PD in general practice and includes a guideline for case identification and therapeutic options.
Source: South African Family Practice 54, pp 478 –480 (2012)More Less
Alopecia refers to loss of hair from the scalp or other hair-bearing areas of the body. Alopecia has a significant impact on quality of life. It is commonly associated with loss of self-esteem and emotional stress. It can be non-scarring (non-cicatricial) and reversible, or scarring (cicatricial) and often permanent.
Author S. MathijsSource: South African Family Practice 54, pp 482 –484 (2012)More Less
Preventing malaria in children is often neglected. Prevention is very important, as malaria is still a significant cause of childhood mortality. Parents must be aware that the same measures must be taken by children to avoid being bitten by mosquitoes. Chemoprophylaxis with mefloquine, atovaquone-proguanil, doxycycline, or chloroquine is advised. The correct dose must be given, at the correct dosing interval. The choice of drug depends on several factors, such as cost, side-effects, and other drug intake. Parents must be educated on the symptoms of malaria, as making a prompt diagnosis can reduce the incidence of further complications.
Author K. KochSource: South African Family Practice 54, pp 487 –490 (2012)More Less
Postherpetic neuralgia is a complication following 10% of herpes zoster infections. It is a complex pain syndrome, thought to be driven by peripheral factors and central nervous system sensitisation. Herpes zoster is common in South Africa. It is important to identify high-risk patients and intervene early to reduce the likelihood and severity of postherpetic neuralgia (PHN). This review discusses a stepwise approach to the treatment of PHN in primary care.
Source: South African Family Practice 54, pp 492 –494 (2012)More Less
The increase in the prevalence of asthma and allergic diseases highlights the need for devising effective prevention strategies. Several studies have investigated the preventive effect of maternal avoidance of highly allergenic foods, such as cow's milk, eggs, and nuts, during pregnancy to protect the foetus from the effect of food allergens ingested by the mother.
Source: South African Family Practice 54, pp 496 –498 (2012)More Less
Diets that exclude dairy may decrease gastrointestinal symptoms in symptomatic individuals who have lactose malabsorption or lactose intolerance. However, most lactose-intolerant adults can consume some lactose without experiencing major symptoms, thereby reducing the need for strict elimination of dairy products from the diet.
Source: South African Family Practice 54, pp 501 –506 (2012)More Less
After 1994, the post-apartheid government decided that primary health care and the district health system would be the cornerstone of their new health policy. As a consequence of this, the academic departments of Family Medicine and primary care recognised the need for a nationally agreed set of training outcomes that were more aligned with these new priorities within the public sector.
Advance directives or living wills : reflections of general practitioners and frail care coordinators in a small town in KwaZulu-Natal : original researchAuthor B. MashSource: South African Family Practice 54, pp 507 –512 (2012)More Less
Background : Living wills have long been associated with end-of-life care. This study explored the promotion of living wills by general practitioners (GPs) and frail care nursing coordinators who were directly involved in the care of the elderly in Howick, KwaZulu-Natal. The study also explored their views regarding the pro forma living will disseminated by the Living Will Society.
Subjects : Seven GPs and three frail care nursing coordinators; 10 in total.
Design : The design was qualitative in-depth interviews and analysis, using the Framework method.
Results : Both doctors and nursing staff understood the concept of living wills and acknowledged that they were beneficial to patients, their families and staff. They were concerned about the lack of legal status of the living will. They felt that the pro forma document from the Living Will Society was simple and clear. Despite identifying the low level of living will usage among patients, doctors and nursing staff felt that third-party organisations and individuals should promote living wills to patients, rather than promoting them to patients themselves.
Conclusion : GPs and frail care nurse coordinators were knowledgeable about living wills in general, and the Living Will Society pro forma document in particular. They valued the contribution that living wills make to the care of the elderly, as they benefit patients, their families, healthcare workers and the health system. They also valued the pro forma living will document from the Living Will Society for its clarity and simplicity. However, the GPs and frail care nursing coordinators viewed the living will process as patient driven. They viewed their main role to be that of custodians, and not advocates, of the living wills.
Using fourth-year medical students' reflections to propose strategies for primary care physicians, who host students in their practices, to optimise learning opportunities : original researchAuthor M. Van RooyenSource: South African Family Practice 54, pp 513 –517 (2012)More Less
Setting and subjects : Fourth-year medical students at the University of Pretoria are required to work with a primary healthcare practitioner for two weeks. After the preceptorship, reflective photo-story reports on the students' experiences and personal and academic growth are submitted.
Objectives : To identify whether the objectives of the preceptorship were met and to describe the experiences of students, the reflective reports were qualitatively analysed. A second purpose of the analysis was to propose strategies that could be implemented by the primary healthcare practitioners to optimise the learning experience of students in their practices.
Design : A qualitative approach to analyse the narratives of the photo-story reports was used. Main and subthemes were identified from the topics that were thought about. Quotes from the narratives were selected to support the themes. Each of the quotes was then scrutinised to ascertain if evidence of learning had taken place.
Results : The main themes were identified as: the impact that the visit had had on the student, the emotions that they had experienced, working with the physician, interacting with patients and the clinical care of patients. Learning was achieved under conditions that made the students feel comfortable, confident, happy and inspired; required their active participation; challenged them; inspired them to see the advantage of learning; and when feedback was given to them.
Conclusion : Strategies for use by practitioners to optimise the learning experience of students in their practices were proposed. These included active student participation, reflection, the creation of a positive environment, student participation in challenging experiences, active learning and quality time spent with patients.
The profile of maternal deaths in a district hospital : a five-year review of maternal deaths from 2006-2010 : original researchSource: South African Family Practice 54, pp 518 –524 (2012)More Less
Objectives : The objectives were to determine the clinical and demographic profile of maternal deaths, determine the most common primary causes of maternal deaths at district hospital level, compare the causes of deaths at district hospital, provincial and national level, and to investigate the quality of care that was provided to maternal deaths patients and to make recommendations.
Design : The design was a cross-sectional retrospective chart review.
Setting and subjects : Subjects were all reported maternal deaths between January 2006 and December 2010 at Northdale Hospital, KwaZulu-Natal.
Outcome measures : Outcome measures were the common characteristics and causes of maternal deaths, avoidable maternal deaths and quality of care.
Results : The mean age of the 61 maternal deaths was 28 years. Thirty-three patients attended antenatal clinics. Of these, 57.6% booked at ≤ 20th week. Of the 28 (45.9%) who died in the postpartum period, seven delivered at home and three died of anaesthetic complications. Thirty-nine patients (63.9%) tested positive for human immunodeficiency virus. Only 10 were on highly active antiretroviral therapy. The five leading causes of deaths were non-pregnancy-related sepsis, miscarriage, acute collapse, pregnancy-related sepsis and anaesthetic complications. Thirty patients (49.3%) received substandard care.
Conclusion : The profile of maternal deaths at this district hospital differs from the national profile published in 2005-2007 Saving Mothers Report. While there was an increase in maternal deaths at national level, maternal death numbers decreased at this district hospital. Non-pregnancy-related sepsis remained the leading cause of deaths at national and facility level, but the other four major causes at the hospital level differed from those at the national level.
An evaluation of insulin therapy initiation among patients with type 2 diabetes attending a public health facility in South Africa : original researchSource: South African Family Practice 54, pp 525 –530 (2012)More Less
Background : Clinically effective interventions that could reduce diabetic patients' risk of long-term complications are needed to contain the rising cost of diabetes care associated with the increasing prevalence of this condition. Good glycaemic control needs to be rapidly attained and maintained by the appropriate initiation and adjustment of glucose-lowering therapy. In patients with insulin-requiring type 2 diabetes who are not at goal glycaemia, this translates to the initiation and intensification of insulin therapy. The aim of this study was to evaluate the appropriateness of the initiation of insulin therapy in patients with poorly controlled insulin-requiring type 2 diabetes.
Method : This descriptive retrospective study evaluated treatment regimens, dose adjustments and glycated haemoglobin A1c (HbA1c) measurements extracted from records of patients with type 2 diabetes suitable for inclusion. The observation period spanned the 24 months retrospective to study start. Data collected were transcribed into a spreadsheet suitable for statistical analysis.
Results : Of the overall cohort of patients with insulin-requiring type 2 diabetes (n = 131), only 45.8% (n = 60) were commenced on insulin during the observation period, of whom 51.7% had subsequent adjustment of insulin dosage. Mean HbA1c at insulin initiation was 10.29% (± 2.42), and 10.63% (± 1.93) after adjustment of insulin dose (p-value > 0.05). Of those who remained on oral glucose-lowering therapy (n = 71), 57.7% had no change in medication dosage throughout the study period. Overall, 81.35% remained ≥ 1% above goal HbA1c by the end of the study period.
Conclusion : This study found a discrepancy in the appropriate use and adjustment of insulin therapy according to metabolic status.
Adverse effects profile of multidrug-resistant tuberculosis treatment in a South African outpatient clinic : original researchSource: South African Family Practice 54, pp 531 –539 (2012)More Less
Background : Highly active antiretroviral therapy (HAART) and drugs that are used to treat multidrug-resistant tuberculosis have potentially overlapping adverse effects. Few South African studies have documented adverse effects in the multidrug-resistant tuberculosis population. This study examined the adverse effects profile in a sample of the outpatient population at the King George V Hospital Multidrug-Resistant Tuberculosis Clinic in Durban, KwaZulu-Natal.
Method : The method was an anonymous, retrospective record review of 350 patients with multidrug-resistant tuberculosis, who were attending the King George V Hospital Multidrug-Resistant Tuberculosis Clinic (2010-2011). Adverse effect profiles in patients with multidrug-resistant tuberculosis only, and those who were co-infected with the human immunodeficiency virus (HIV) who were on and not on HAART, were documented and analysed.
Results : Adverse events were recorded for 80.6% of patients. These included hearing loss (28.7%); peripheral neuropathy (23.2%); diarrhoea, nausea and vomiting (20.5%); arthralgia (15.9%); rashes and dermatological effects (excluding Stevens-Johnson syndrome) (14%); abdominal pain and dyspepsia (10.3%); and psychoses and confusion (8.3%). In this study population, 72.6% of patients were HIV positive, and 85% were concomitantly on HAART and multidrug-resistant tuberculosis treatment. Adverse events were significantly more common in patients who were HIV positive than in patients who were HIV negative with regard to peripheral neuropathy (p-value < 0.001), psychosis and confusion (p-value = 0.04), hearing loss (p-value = 0.047), and thyroid disease (p-value < 0.001). The use of HAART in patients who were HIV positive and on multidrug-resistant tuberculosis treatment was not significantly associated with the overall incidence of adverse events (p-value = 0.432). However, the calculated likelihood ratios of several individual adverse events occurring in these patients was greater. Patients who were HIV negative experienced the least adverse events.
Conclusion : The high percentage of patients in the sample population (45%) who was found to be multidrug-resistant tuberculosis positive de novo or while on standard tuberculosis treatment suggests that drug sensitivity testing for all patients with tuberculosis should be considered. The findings of this study support the current national policy that all patients with tuberculosis should be tested for HIV, and that all patients who are HIV positive and with multidrug-resistant tuberculosis should be on HAART. Clinicians should be supported in their function of examining, managing and recording adverse events. Reporting adverse events to the Department of Health should be encouraged. The development of a standardised recording instrument may mitigate the under-reporting of adverse events. The adverse effects profile in this study population differs from that reported in other studies.
The perspectives of users of antiretroviral therapy on structural barriers to adherence in South Africa : original researchSource: South African Family Practice 54, pp 540 –544 (2012)More Less
Background : The effectiveness of antiretroviral therapy (ART) and the importance of adherence to treatment regimens are widely known. Yet, suboptimal adherence to ART and retention in care of patients still persists and, by many accounts, is fairly widespread. The aim of this study was to identify the structural barriers that influenced adherence among patients who were enrolled in the national ART programme in South Africa.
Method : In this qualitative study, semi-structured interviews were conducted with a sample of 10 patients receiving ART at a public hospital in South Africa.
Results : The results of the interviews were categorised according to poverty-related, institution-related and social barriers to clinic attendance and pill-taking, which collectively formed the structural barriers to adherence. The chief structural barriers to clinic attendance were time away from work, transport expenses, long waiting times and negative experiences with clinic staff. The chief barriers to pill-taking were food insecurity, stigma and discrimination.
Conclusion : The barriers to adherence are discussed. Attention is called to the extra-individual factors that influenced ART adherence. We conclude that contextual factors, such as a healthcare-enabling environment, might play an important role in influencing healthcare-promoting behaviour among patients.
Advanced oral HIV-associated Kaposi sarcoma with facial lymphoedoema as an indicator of poor prognosis : case studySource: South African Family Practice 54, pp 545 –547 (2012)More Less
Rapidly progressive facial lymphoedoema that develops concurrently with or immediately after rapid enlargement of oral Kaposi sarcoma in human immunodeficiency virus (HIV) -seropositive persons forebodes death. Previously, we reported on three patients with HIV-associated Kaposi sarcoma who had not been exposed to highly active antiretroviral therapy (HAART) and had extensive oral HIV-associated Kaposi sarcoma and rapidly increasing facial lymphoedoema. They died within three weeks of developing facial lymphoedoema. We present a similar case of an HIV-seropositive patient with extensive oral Kaposi sarcoma and associated facial lymphoedoema. She died three weeks after developing facial lymphoedoema. In contrast to our other previously reported cases, this patient had been on HAART for three months before she died. In light of this, we implore medical colleagues to treat patients with oral HIV-associated Kaposi sarcoma with HAART during the early maculopapular stage of Kaposi sarcoma. If the oral Kaposi sarcoma does not respond, as would be evident by the regression or disappearance of the lesions, then systemic chemotherapy should be added promptly, in order to prevent or delay the development of extensive exophytic oral lesions with facial lymphoedoema. These appear to be indicative of a very poor prognosis.
Author Chris EllisSource: South African Family Practice 54 (2012)More Less
In the early 1970s, I dropped out of medical practice and went "walk about" in Mexico and Central America. On returning, I went into practice in a small Natal Midlands town, but I retained my long hair and beard from my hippie excursion. One Saturday, my family weren't at home and I was in the garden, digging away in a shabby shirt and a pair of ragged old trousers, when the teenage girl from next door came over to say that her family had also gone out and that their dog was sick. Would I have a look at it?