South African Family Practice - Volume 55, Issue 2, 2013
Volume 55, Issue 2, 2013
Source: South African Family Practice 55 (2013)More Less
This editorial is influenced by a letter to the editor received from one of the readers of the SA Family Practice journal. The colleague titled his letter: "Where have all the children gone?" My first reaction was to ask the question: "Was there a natural disaster that wiped out children somewhere in the world that I was not aware of?" Reading through the letter, it became clear that he was responding to the Jan/Feb 2013 editorial in which I painted a grim picture of the obesity epidemic globally and locally in South Africa. I decided to publish the letter below and then respond afterwards. So sit back and enjoy the content of the letter and my response.
Source: South African Family Practice 55 (2013)More Less
Survey on the lifestyle and health-seeking behaviour of Basotho patients with diabetes
Health reform and staff morale in South Africa : a case study of Dr Yusuf Dadoo Hospital
Contraceptive knowledge and practice among HIV-positive women receiving antiretroviral therapy at a district hospital
Source: South African Family Practice 55, pp 111 –116 (2013)More Less
Extensive data from randomised controlled trials have shown the benefit of treating hypertension. The target blood pressure (BP) for antihypertensive management is < 140/90 mmHg, and < 130/80 mmHg in patients with end-organ damage, co-existing risk factors, and co-morbidity. Benefits of management include reduced risk of death, stroke, cardiac failure, chronic kidney disease, and coronary heart disease. The correct BP measurement procedure is described, and evaluation of cardiovascular risk factors and recommendations for antihypertensive therapy, are stipulated. Lifestyle modification and patient education are cornerstones in the management of every patient. Major indications, precautions, and contraindications to each recommended antihypertensive drug are listed. Combination therapy should be considered ab initio if the BP is ≥ 20/10 mmHg above goal. First-line drug therapy for uncomplicated essential hypertension includes low-dose thiazide-like diuretics, calcium-channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin-receptor blockers. The guideline was developed by the Southern African Hypertension Society.
Source: South African Family Practice 55, pp 117 –121 (2013)More Less
Allergic rhinitis (AR) is an important disease in South Africa. The South African Allergic Rhinitis Working Group (SAARWG) has published previous guidelines on AR diagnosis and management. Areas of concern have arisen that require additional information, including the management of AR in infancy, appropriate and inappropriate allergy testing, the cost of AR management, diagnosis and distinguishing the condition from sinusitis, use of over-the-counter (OTC) medications and the concept of the "united airway". Clinicians should consider the possibility of AR in infants with recurrent nasal symptoms. Allergy testing must be used wisely and be based on local allergens. Total immunoglobulin E testing is not routinely required to prove allergy. Acute and chronic sinusitis should be considered in conjunction with AR. Treatment of rhinitis will improve these conditions. OTC medications should be used sparingly and with caution. Concern for long-term use of topical decongestants must be noted. Asthma should always be considered in AR diagnosis. Immunotherapy is available in South Africa and may be extremely useful in selected AR patients. The SAARWG has proposed an algorithm for the diagnosis and management of rhinitis in South Africa. AR is common, important and troubling to patients, so every effort should be made to target therapy correctly. Patient education is important in the management of AR.
Source: South African Family Practice 55, pp 123 –131 (2013)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.
Author M.J. LabuschagneSource: South African Family Practice 55, pp 134 –141 (2013)More Less
Glaucoma is a sight-threatening condition. A general practitioner (GP) should be able to diagnose glaucoma, know about the different management options, and refer appropriately. The aim of this paper is to provide a background to glaucoma, and describe the assessment and management of glaucoma patients. The role of the GP in the management of glaucoma and in creating awareness of glaucoma is put into perspective.
Clinical practice guidelines for management of neuropathic pain : expert panel recommendations for South Africa : guidelinesSource: South African Family Practice 55, pp 143 –158 (2013)More Less
Neuropathic pain (NeuP) is challenging to diagnose and manage, despite ongoing improved understanding of the underlying mechanisms. Many patients do not respond satisfactorily to existing treatments. There are no published guidelines for diagnosis or management of NeuP in South Africa. A multidisciplinary expert panel critically reviewed available evidence to provide consensus recommendations for diagnosis and management of NeuP in South Africa. Following accurate diagnosis of NeuP, pregabalin, gabapentin, low-dose tricyclic antidepressants (e.g. amitriptyline) and serotonin norepinephrine reuptake inhibitors (duloxetine and venlafaxine) are all recommended as first-line options for the treatment of peripheral NeuP. If the response is insufficient after 2 - 4 weeks, the recommended next step is to switch to a different class, or combine different classes of agent. Opioids should be reserved for use later in the treatment pathway, if switching drugs and combination therapy fails. For central NeuP, pregabalin or amitriptyline are recommended as first-line agents. Companion treatments (cognitive behavioural therapy and physical therapy) should be administered as part of a multidisciplinary approach. Dorsal root entry zone rhizotomy (DREZ) is not recommended to treat NeuP. Given the large population of HIV/AIDS patients in South Africa, and the paucity of positive efficacy data for its management, research in the form of randomised controlled trials in painful HIV-associated sensory neuropathy (HIV-SN) must be prioritised in this country.
Source: South African Family Practice 55, pp 157 –160 (2013)More Less
There has been a dramatic interest in the importance of vitamin D, "the sunshine vitamin", in the past few years with regard to its impact on various aspects of health and disease. Research into well-known skeletal effects, as well as extra-skeletal effects, has been overwhelming. At times it has been difficult to make informed clinical decisions regarding replacement, if needed at all. This article aims to provide the family practitioner with a summary of the most important clinical effects of vitamin D, as well as give guidelines on testing for possible deficiency and consideration of replacement thereof.
Author H.L. SitholeSource: South African Family Practice 55, pp 161 –163 (2013)More Less
An envenomous snakebite is an important public health problem that can lead to irreversible loss of vision. Snake venom neurotoxins mainly act on the peripheral nervous system at the neuromuscular junction, and result in the implication of the cranial nerves. Consequently, mild neurological symptoms that relate to cephalic muscle paralysis, including exotropia, ptosis, diplopia and ophthalmoplegia, can occur. This happens because the extraocular muscles are especially susceptible to neurological muscular blockage. Other neurological complications of snake venom include accommodation paralysis, optic neuritis, globe necrosis, keratomalacia, uveitis, and loss of vision due to cortical infarction. Haemostatic complications may include subconjuctival haemorrhage, hyphema, and vitreous and retinal haemorrhages. Another rare complication of a snakebite is ocular injury. Snakebite injuries are often accompanied by facial swelling, periorbital ecchymosis, massive subconjuctival haemorrhage, severe corneal oedema and exophthalmos in the affected eye. Unfortunately, such injuries result in permanent loss of vision, as early evisceration is deemed necessary to reduce the amount and effect of the venom in the affected eye. With such a variety of ocular complications as a result of a venomous snakebite, it is important for primary care physicians to have some basic knowledge of the management of these complications, as they may prove to be vital where patients present with a snakebite and possible venom injection in the eye.
Is there still a role for Caesarean section in preventing vertical HIV transmission in the era of highly active antiretroviral therapy? : review articleAuthor H.M. SebitloaneSource: South African Family Practice 55, pp 164 –167 (2013)More Less
Human immunodeficiency virus (HIV) may be transmitted from an infected mother to her child during pregnancy, delivery or breastfeeding. Without any intervention, transmission rates may range from 15-45%. However, this can be reduced to < 5% with effective drug therapy. A scheduled Caesarean section that is performed before the onset of labour or the rupture of membranes has been shown to reduce the intrapartum risk in a meta-analysis of earlier studies. The review further concluded that the benefit of performing an elective Caesarean section outweighed the risk of postpartum morbidity in HIV-infected women. However, balancing the risk to benefit ratio is influenced by the underlying rate of mother-to-child transmission (MTCT) in an individual patient.
Caesarean section, while initially shown to reduce the MTCT risk, is itself associated with significant morbidity to the mother. Pregnancy-related sepsis is among the leading causes of maternal deaths, particularly in women who deliver by Caesarean section.
Incidental finding of hypertension and diminished femoral pulses : short-segment stenosis of the aorta just distal to the origin of the left subclavian artery : case studySource: South African Family Practice 55, pp 168 –169 (2013)More Less
Coarctation of the aorta is a congenital condition generally, and may vary from mild to severe. Symptomatology depends on early or late presentation. Young patients may present within the first few weeks of life with poor feeding, tachypnea and lethargy. They usually progress to overt congestive heart failure and shock. Older children may present with a murmur or hypertension. Diagnosis is often made after hypertension is detected as an incidental finding during evaluation of other problems, such as trauma or more common illnesses. Coarctation of the aorta can be cured surgically.
Sexuality in patients with human immunodeficiency virus at Embhuleni Hospital in Mpumalanga province : original researchSource: South African Family Practice 55, pp 171 –174 (2013)More Less
Objectives : This study explored issues of sexuality in people living with AIDS who were on highly active antiretroviral therapy (HAART).
Design : This was a descriptive quantitative study. Data were collected with an administered questionnaire and entered in Excel®. Statistical analysis included frequency tables, summary statistics and 95% confidence intervals.
Setting and subjects : The respondents were purposively sampled from the 850 patients attending the antiretroviral clinic at Embhuleni Hospital in Mpumalanga province.
Outcome measures : The questionnaire included questions on sexual practices, number of partners, sexual experience and fertility wishes, comparing respondents' experience before and after HAART.
Results : There was a response rate of 100%, with 102 questionnaires completed. There was a significant difference between the responses to questions on sexual desire, sexual performance, sexual enjoyment and satisfaction regarding frequency of intercourse before and after HAART. Respondents reported a better sexual experience before HAART (t = 2.4387, p-value = 0.0165). There was a statistically significant difference between the number of partners before and after initiation of HAART (p-value = 0.000). Although 96% of respondents rated condom use as being very important, 11% never used condoms during sex and 21% indicated that they had had unprotected sex in the previous six months. Eighteen per cent of respondents said it was very important for them to have a child and 20% were planning to have a child in the future. A quarter of respondents had not disclosed their HIV status to their partners. The majority (95%) of respondents indicated that it was very important to them that health workers discussed their sexual needs with them.
Conclusion : Sexuality in HIV is complex, with components described as the "Ps" of sexuality: practices, partners, pleasure, pressure and pain, procreation and power. In this study, participants reported a better sexual experience before HAART. Healthcare professionals need to develop the skills to discuss sexuality, intimacy and fertility wishes with patients. This discussion will enhance healthcare professionals' understanding of patients' experiences of their illness and should allow for a more effective patient-centred approach to care.
Bridging the gap : exploring the attitudes and beliefs of nurses and patients about coexisting traditional and biomedical healthcare systems in a rural setting in KwaZulu-Natal : original researchSource: South African Family Practice 55, pp 175 –179 (2013)More Less
Objectives : Health care in South Africa takes place within a diverse cultural context and includes perceptions about health that strongly link to cultural beliefs and values. Biomedical healthcare professionals, particularly nurses, are exposed to and expected to cope with cultural challenges on a daily basis, with little or no training on how to do so. In this paper, we explore nurse and patient attitudes to and beliefs about how the systems of health care coexist, what issues this raises and how nurses and patients address these issues in their daily practice.
Design : The study employed an exploratory, qualitative research design.
Setting and subjects : Four in-depth focus group discussions were conducted with nurses and patients at a deep rural, district hospital in northern KwaZulu-Natal. Participants were selected based on their availability and willingness to contribute to the discussion.
Results : Traditional and biomedical healthcare systems coexist and are used simultaneously with the healthcare-seeking pattern of patients traversing multiple systems of care. Currently, patients and nurses have developed strategies to address this by steering a pragmatic course to minimise risks, and by doing so, bridging the gap between the two healthcare mediums.
Conclusion : Further research is required to understand which illnesses are primarily seen as traditional, how this gap can be effectively addressed, and how different healthcare co-delivery models can best be utilised and evaluated.
Hospital reform and staff morale in South Africa : a case study of Dr Yusuf Dadoo Hospital : original researchSource: South African Family Practice 55, pp 180 –185 (2013)More Less
Objectives : This study explored major factors that influenced staff motivation at a district hospital in South Africa following hospital reforms and comparison of these factors across the two main staff categories.
Design : This study was a cross-sectional descriptive survey.
Settings and subjects : This study included all medical and nursing staff working at the district hospital.
Outcome measures : A semi-structured questionnaire coded for anonymity was used. It comprised three sections: the introduction, demographic information and a list of factors to which participants responded by indicating their level of agreement or disagreement using the Likert's scale. The questionnaire's reliability was confirmed using Cronbach's coefficient alpha with a value of 0.9.
Results : Of the 179 participants, 122 returned the questionnaires. This equated to a response rate of 68%. The staff expressed more demotivation than motivation. Major factors that played a role were institutional in character, namely poor management and leadership, unfavourable institutional policies and administration practices with regard to staff development, conflictual inter- and intraprofessional relationships, a paucity of equipment and retention and recruitment strategies. The unique motivator was the individual value of the vocational aspect of the profession. Distance travelled to the workplace did not have any association with the identified motivating and demotivating factors.
Conclusion : Staff motivation is crucial in any institution or organisation. Presently, the South African healthcare sector is undergoing transformation in terms of implementation of National Health Insurance. The effectiveness of the healthcare system in achieving its goals will be impacted by the prioritisation of institutional strategies that contribute to staff motivation. Managers' skills in healthcare facilities are critical to the success of the implementation of reforms in South Africa.
Characteristics of patients presenting with complications of abortion in a tertiary health facility in south-west Nigeria : original researchSource: South African Family Practice 55, pp 186 –189 (2013)More Less
Objectives : Abortion is associated with significant healthproblem with short- and long-term complications that affect the quality of life of those who are fortunate enough to escape mortality. This study evaluated the population of patients with complications of abortion, identified the abortion providers and the pattern of contraceptive usage in these patients managed in our hospital, and suggests strategies on the required heath intervention.
Design : The design was a descriptive study of cases of abortions with complications.
Setting and subjects : We reviewed all (225) cases of abortions with complications managed at Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Nigeria, over a five-year period.
Outcome measures : Records of patients managed for abortion-related complications were retrieved, data were extracted and analysis was carried out for socio-demographic factors and other abortion-related characteristics.
Results : The study showed a more common occurrence of abortions among middle-aged (64.4%), multiparous (53.3%) women with a low socio-economic background (62.6%), and they were performed mostly by medical doctors in private settings (37.8%). The low usage of contraception (11.1%) was of significance.
Conclusion : This study provided considerable insight into the complications of abortion in a tertiary institution in Nigeria. Most of the patients were aware of contraception, but usage, which mainly constituted emergency contraception, was low. Despite prophylactic antibiotics, sepsis was the most common observed complication. Healthcare intervention should be re-focused through the encouragement of the adoption of effective methods to prevent unwanted pregnancies. Healthcare providers should re-appraise their antibiotics regimen.
A cross-sectional survey on the lifestyle and health-seeking behaviour of Basotho patients with diabetes : original researchSource: South African Family Practice 55, pp 190 –195 (2013)More Less
Objectives : The objectives of the study were to determine the level of practice of a healthy lifestyle, to assess the health education provided to patients with diabetes and to determine the prevalence of obesity among Basotho patients with diabetes.
Design : A cross-sectional study enrolled 192 patients between November 2004 and July 2005. Descriptive statistics on demographic, socio-economic and lifestyle data were computed. Weight, waist circumference and hip circumference measurements were taken to compute body mass index (BMI), waist-to-hip ratio (WHpR) and waist-to-height ratio (WHtR).
Setting and subjects : Patients with diabetes attending three hospitals in Lesotho were recruited in the study.
Outcome measures : These included obesity indices, the quality and quantity of physical exercises, the quality and quantity of provided health education and the frequency with which the subjects sought medical help.
Results : The participants' mean age was 54.73 years. The prevalence of smoking (14.6%) was higher than that of drinking (9.4%). Only 20.8% of the participants participated in recommended physical exercise. Most participants (95%) consulted their physicians on a regular basis. The Health Education Quantity Index was very low: 49.9%. The prevalence of obesity measured by BMI, WHpR and WHtR was 67.7%, 69.8% and 95.3% respectively.
Conclusion : The practice of a healthy lifestyle was suboptimal, but help-seeking behaviour was satisfactory among participants. It is recommended that health education and the promotion of a healthy lifestyle are encouraged, that diabetes education is rendered by accredited educators or healthcare providers trained in communicating health messages, and that the fight against obesity is made a priority.
Contraceptive knowledge and practice among HIV-positive women receiving antiretroviral therapy at a district hospital in KwaZulu-Natal : original researchSource: South African Family Practice 55, pp 196 –200 (2013)More Less
Objectives : To determine the knowledge and use of contraceptives by HIV-positive women attending an ART clinic.
Design : Observational descriptive cross-sectional study.
Setting and subjects : Many human immunodeficiency virus (HIV)-positive South African women fall pregnant each year while receiving antiretroviral therapy (ART). In 2010, 2 056 women of childbearing age attended the ART clinic at a district hospital south of Durban. Between October 2010 and June 2011, data were collected using a validated questionnaire from 400 women on their contraceptive knowledge and use. Women over 18 years of age who consented to participate, and who had been receiving ART for more than a month, were eligible for participation in the study.
Outcome measures : Contraceptive knowledge and use.
Results : All participants had received counselling on male condom use. The majority of HIV-positive women receiving ART preferred the male condom as their contraception of choice. Knowledge of male condoms was excellent, but only 66% of the study group used condoms, and just over 50% used a dual method of contraception (male condoms plus another contraceptive method). While 97% of participants were knowledgeable about injectable contraception, only 40% used the latter as a form of contraception. Ninety-two per cent of the participants reported recent sexual activity, 14% had fallen pregnant while receiving ART, and 64% planned on having a child in the future.
Conclusion : The low use of dual contraception was a cause for concern. Recommendations include the integration of family planning services into HIV care at all ART sites. This should promote proper fertility management for women receiving ART.
Author Chris EllisSource: South African Family Practice 55 (2013)More Less
The family have begun to suspect that, at times, I may drift off to faraway places. This may also happen in the consulting room in the late summer afternoons. A retreat occurs into the deep recesses and lacunae of the cerebral hemispheres. I can be woken from this fugue-like state when the conversation stops, or the tone of the enquiry alters and there are signals that a response is required. Those of us who are members of the school of advanced daydreaming know the rules.