South African Family Practice - Volume 55, Issue 3, 2013
Volume 55, Issue 3, 2013
Author Christina LundgrenSource: South African Family Practice 55 (2013)More Less
This is the 10th anniversary of our Northwest Refresher course, which started as an outreach programme to anaesthetic providers in the Northwest province. It has also been a wonderful opportunity for the Department of Anaesthesia at Chris Hani Baragwanath Academic Hospital to share our knowledge and expertise. We have grown from a 60-delegate refresher in Rustenburg in 2002, to the current event, with over 300 attendees. We have outgrown many venues in the North West as a result of the wonderful support we have received over the years. We trust this will continue, and we thank all of our colleagues, both Anaesthetic and the Trade, some of whom have attended all 10 courses.
Author L.B. BranniganSource: South African Family Practice 55, pp 3 –7 (2013)More Less
All over the world, and not least in South Africa, clinicians continue to face the scourge of traumatic injury. The regularity with which patients require the collaborative effort of all or many of an institution's resources, simultaneously, makes this disease difficult to manage clinically, as well as socio-economically.
Author N.R. MadimaSource: South African Family Practice 55, pp 8 –12 (2013)More Less
The drugs that are used daily in obstetric anaesthesia can have a huge impact on the outcome of both mother and child. Therefore, obstetric anaesthetic providers need to have a very clear understanding of the mechanism of action, doses and side-effects of the most commonly used drugs. This presentation will not address local anaesthetics and opioids, but will mainly focus on drugs used by obstetricians that have an impact on anaesthetic outcome.
Author D. LinesSource: South African Family Practice 55, pp 13 –17 (2013)More Less
Percutaneous coronary intervention (PCI) is a relatively new mode of therapy for the management of patients with coronary artery disease (CAD). Balloon angioplasty, a type of PCI, was first performed in the late 1970s, but suffered the main complications of early restenosis because of an inflammatory reaction in the media, causing neointimal proliferation that required further intervention. In 1986, the French cardiologist, Puel, implanted the first coronary stent in a human in France. However, it was only in 1994 that the US Food and Drug Administration approved the use of coronary stents in human subjects. It has been shown that PCI is no more effective in preventing a major cardiac event or death, than optimal medical therapy, in patients with stable CAD. However, PCI has shown benefits over medical therapy in patients with unstable coronary disease.
Author B.M. GardnerSource: South African Family Practice 55, pp 19 –22 (2013)More Less
Diabetes mellitus and hyperglycaemia are complex and common clinical problems that have serious adverse consequences for patient morbidity and mortality. Inthe past year, a body of revised guidelines and opinions has emerged from the South African, British, American and European diabetes authorities. An overview of these guidelines and position statements on diabetes mellitus in general, and perioperative hyperglycaemia, in particular, is offered. Perioperative hyperglycaemia is a very common problem, both because the actual incidence may be increasing worldwide, and also because it describes a much wider problem than just diabetes mellitus.
Author D. WelsSource: South African Family Practice 55, pp 23 –27 (2013)More Less
It was previously thought that infants and young children did not possess the neurological wiring to experience pain. We are now certain that the nervous systems of even the unborn foetus, as well as children, have developed enough in order for them to experience pain. In fact, they may perceive pain greater than adults can, because of increased inflammatory responses and lack of inhibitory responses to pain. It is crucial to treat pain appropriately to prevent long-term lower pain thresholds later in life.
Author L. RedhiSource: South African Family Practice 55, pp 28 –31 (2013)More Less
An adequate intravascular volume replacement is an essential part of managing a critically ill surgical or intensive care patient. Failure to treat or prevent hypovolaemia may progress to organ dysfunction, or even death.
Although the importance of adequate volume replacement is widely accepted, there are still no universally accepted recommendations. Different crystalloid solutions, the naturally occurring human albumin (HA), and different non-protein or synthetic colloids, have been promoted to treat volume deficits.
Over the years, some misconceptions about volume replacement have been established and these need to be reconsidered and corrected.
Author C. QuanSource: South African Family Practice 55, pp 32 –35 (2013)More Less
I will be addressing concepts related to regional anaesthesia which are pertinent to practice in South Africa.
Awake or not: Should regional anaesthesia be performed in awake or anaesthetised patients?
B mode ultrasound: Should regional anaesthesia be carried out under ultrasound or not?
Cancer surgery: Should anaesthesia for cancer surgery involve regional anaesthesia?
The oversimplified answers to each question are:
B mode ultrasound: Yes.
Cancer surgery: Yes.
Author P. MoganeSource: South African Family Practice 55, pp 36 –39 (2013)More Less
The importance of blood pressure (BP) monitoring in the perioperative and intensive care setting is very clear. Data from adult and paediatric victims of trauma have suggested that systolic blood pressure (SBP) is a predictor of mortality. In many other settings, the mean arterial pressure (MAP) has been used as a surrogate for tissue perfusion and cardiac output (MAP = cardiac output x systemic vascular resistance). Routine monitoring of BP has thus been set as one of the recommended standards of care by the American Society of Anesthesiologists (ASA). Paediatric anesthesiologists routinely monitor the BP of their patients and make major diagnostic and therapeutic decisions, e.g. blood transfusion and the commencement of inotropes and resuscitation, based on deviations from "normal".
Author B. GardnerSource: South African Family Practice 55, pp 40 –43 (2013)More Less
Author Pierre De VilliersSource: South African Family Practice 55 (2013)More Less
This year, we celebrate the first 10 years since the Health Professions Council of South Africa (HPCSA) approved the specialty of Family Medicine in 2003. It is an opportune time to review the progress made. Elsewhere in this journal, Couper, Fehrsen and Hugo1 raise concerns about the "state" of family medicine in South Africa at the present time. They postulate that we need to change direction, as we are training the wrong kind of family physician for the needs of the South African population. They argue that we should have shorter postgraduate training that focuses more on "primary care" skills necessary for ambulatory care in clinics, and that we should conduct less training on"procedural and technical" skills required to work in a district hospital, citing the examples of Brazil and Cuba as the models we should follow.
Response to discussion paper : thoughts on the state ofFamily Medicine training in South Africa : correspondenceAuthor Paul HillSource: South African Family Practice 55, pp 211 –212 (2013)More Less
To the Editor : the following views are my own, and are not necessarily the views of any university department. I am responding to the discussion paper handed out on Thoughts on the state of Family Medicine in South Africa at the 16th National Family Practitioners Conference recently held in Cape Town.
Author M. DednamSource: South African Family Practice 55, pp 216 –222 (2013)More Less
This short review is intended to simplify the interpretation of thyroid function tests (TFTs) in general practice. The relationship between thyroid hormones and the use of TFTs, as well as thyroid antibodies, is discussed. An overview of the management of common thyroid disorders is included. Less common conditions, e.g. thyroid-stimulating hormone-secreting pituitary tumour and thyroid hormone resistance, are not discussed in this review.
Author K. OuthoffSource: South African Family Practice 55, pp 223 –229 (2013)More Less
Given that anxiety disorders are common and chronic and often co-morbid with both medical and psychiatric conditions, effective and safe anxiolytic drugs are in great demand. Serotonergic agents, in particular the selective serotonin reuptake inhibitors and serotonin and noradrenaline re-uptake inhibitors, have an established track record for the pharmacological treatment of a wide range of anxiety disorders. Despite their slow onset of therapeutic action, their initial exacerbation of anxiety and some of their long-term unwanted effects, they remain the drugs of first choice in primary care. They are relatively safe and exhibit both anxiolytic and antidepressant effects. Other antidepressants, such as mirtazapine, reboxetine and agomelatine, and the 5-HT1A agonist, buspirone, are alternative agents, although the evidence of their efficacy covers a narrower spectrum of anxiety disorders. Patients with anxiety disorders who are resistant to these drugs may benefit from second-line (tricyclic antidepressants or monoamine oxidase inhibitors) or even specialist initiated third-line (benzodiazepine, anticonvulsant or antipsychotic) therapy. None of the currently available drugs are ideal for every patient and the advantages and disadvantages of each are best considered when treatment is individualised.
Author Leilani JohnstonSource: South African Family Practice 55, pp 230 –234 (2013)More Less
Keratoconjuctivitis sicca, more commonly known as dry eye, or dry eye disease, is common. It results from improper functioning of the lacrimal functional unit. First-line treatment with tear substitutes, such as eye drops, gels and ointments, have an essential role. However, a newer understanding of the inflammatory aetiology of the disease has resulted in a shift in treatment strategies.
Author N. Du ToitSource: South African Family Practice 55, pp 235 –240 (2013)More Less
Sudden loss of vision, which causes consternation for both the patient and clinician, is a clinical problem that is encountered fairly regularly in most primary healthcare settings. Sudden visual loss or obscuration which is transient may simply be a symptom of a dry eye or a migraine, but it may also be the onset of irreversible visual loss or a stroke. Most cases of sudden loss of vision are serious, require referral and have an associated underlying systemic disease. Visual loss is usually unilateral, but may be bilateral. This clinical problem may present a diagnostic challenge. No cause may be found in some instances. However, it is important to remember that the more sinister causes of sudden visual loss, such as temporal arteritis, carotid or cardiac emboli that cause retinal vascular occlusion, retinal detachment, vitreous haemorrhage and orbital masses, need to be identified early. Using the duration of the visual loss as the primary differentiating factor, with associated symptoms and signs as supplementary factors, the causes can be narrowed down. A thorough history, goal-directed examination, proper investigation and appropriate referral should enable early diagnosis and adequate management. This will prevent further ocular morbidity, and even patient mortality.
Author M.H. MotswalediSource: South African Family Practice 55, pp 241 –244 (2013)More Less
Acne is a chronic inflammatory disease of the pilosebaceous units. It is the most common diagnosis in dermatology and regularly affects adolescents and young adults. Acne can be mild, moderate or severe. Treatment includes topical keratolytics, topical retinoids, antibiotics, hormonal therapy and systemic retinoids in severe cases.
Author K. KochSource: South African Family Practice 55, pp 245 –248 (2013)More Less
Pain is the most common reason why patients seek medical help. Persistent and unrelieved pain can frustrate both the sufferer and the physician trying to alleviate it. Relief from chronic pain may be particularly difficult to achieve and can be fraught with misconceptions. Neuropathic pain is widely recognised as one of the most difficult pain syndromes to treat and presents a significant challenge for pain clinicians and general practitioners. Often, patients have poor pain resolution. It is important that patients with any chronic pain are identified and managed appropriately according to their distinct treatment needs.
Source: South African Family Practice 55, pp 249 –251 (2013)More Less
Formalised exercise programmes for children and adolescents are becoming increasingly important. There has been a drastic increase in documented childhood morbidity and mortality relating to poor nutrition and low activity levels in recent years. Regular physical activity decreases the risk of chronic disease and is also a fundamental component in the management of illnesses. Recommendations for the paediatric population remain insufficient and ill-defined. This article revisits the risks of physical inactivity in childhood and provides the latest recommendations for exercise prescription in the paediatric population. Inactive children have a higher risk of developing chronic diseases, such as obesity, type 2 diabetes, high blood cholesterol and hypertension. Other undesirable consequences include orthopaedic problems, cardiovascular disease and various psychological complications. Both aerobic and resistance training should be incorporated into paediatric exercise programmes. The recommended guidelines for childhood activity are 60 minutes of moderate-intensity exercise every day of the week. This article highlights the importance of formalised paediatric exercise programmes in disease prevention and health promotion. A healthy and happy adolescent population ultimately contributes to an adult population with a low riskof ill health.