South African Family Practice - Volume 55, Issue 4, 2013
Volume 55, Issue 4, 2013
Source: South African Family Practice 55, pp 203 –209 (2013)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.
Source: South African Family Practice 55 (2013)More Less
This editorial was motivated by a colleague's recent criticism of the National Health Insurance (NHI) pilot project that was launched in April 2012. He claimed that patients have not experienced any tangible difference in health service delivery from the pilot NHI districts, compared to that from other non-NHI pilot districts. The selection of 13 pilot NHI districts was based on audit findings, which included the district's health profile, demographics, income levels and other social factors that impact on health, health delivery performance, management of health institutions and compliance with quality standards. I engaged my colleague by asking him if he knew the objectives of the NHI pilots, to which his response was: "No". Obviously, from this short interaction I asked myself the question: "How many other colleagues are ill- or uninformed about the objectives of the pilot sites and implementation plan of the NHI?"
Source: South African Family Practice 55, pp 307 –312 (2013)More Less
Gout is a common crystal-induced inflammatory arthritis, the prevalence and clinical complexity of which is increasing in the face of a growing aged population with multiple co-morbidities. Recent epidemiological studies emphasise that lifestyle factors strongly influence the development of hyperuricaemia and gout. Moreover, there is growing evidence that gout is an independent risk factor for cardiovascular disease. Acute attacks of gout are extremely painful and disabling, and if repeated attacks go untreated, chronic deforming arthritis ensues. Early diagnosis and appropriate therapy is essential to reduce long-term disability. Identification of monosodium urate crystals on synovial fluid analysis is the gold standard in gout diagnosis. Nonsteroidal anti-inflammatory drugs and oral or intra-articular corticosteroids remain central to the treatment of acute attacks. Prophylactic colchicine use, during the intercritical period, reduces gout flares, a common complication on initiation of urate-lowering therapy (ULT). Allopurinol is the treatment of choice when ULT is indicated. Gout management is suboptimal in many patients because of non-adherence to treatment and underutilisation of available treatments. Treating to target: a serum uric acid level < 0.35mmol/l, prevents crystal deposition in joints and soft tissues, thereby preventing acute attacks and ongoing inflammation, as well as decreasing the size and number of tophi. Treatment strategies should include attention to cardiovascular risk. The family practitioner is paramount to gout management which should be individualised. Emphasis should be placed on ongoing education and prevention.
Source: South African Family Practice 55, pp 313 –318 (2013)More Less
Ocular allergies present in many different guises. They may vary from self-limiting episodes of acute allergic conjunctivitis, to potentially sight-threatening chronic conditions, such as vernal keratoconjunctivitis. This article provides a brief description of the different ocular allergic conditions to aid accurate diagnosis. It also focuses on the different types of anti-allergic ophthalmic preparations and how to employ them in a logical, stepwise management strategy to obtain optimal results, while minimising exposure to potent drugs with potentially serious side-effects.
Author J. KerSource: South African Family Practice 55, pp 326 –328 (2013)More Less
On average, one in four adults has hypertension. This figure is higher in certain regions of the world, and in certain areas within countries. Worldwide, however, the prevalence of hypertension is on the rise. The relationship between level of blood pressure and risk for cardiovascular events is linear and continuous. Nearly 75% of adults with other cardiovascular disease have hypertension as a comorbidity. Hypertension is associated with shorter overall life expectancy, as well as a shorter life expectancy free of cardiovascular disease. Hypertension can be said to be controlled or at goal if blood pressure is less than 140/90 mmHg, or less than 130/80 mmHg for those with diabetes, kidney disease or a previous vascular event (e.g. myocardial infarction, stroke, etc).
Colds, flu and coughing : over-the-counter products for pharyngitis and tonsillitis : review articleSource: South African Family Practice 55, pp 330 –332 (2013)More Less
Pharyngotonsillitis is an inflammatory condition of the pharyngeal wall. Respiratory viruses are the major causes of pharyngitis, while bacteria account for 5-30% of cases. Once treatment of the underlying aetiology is considered and addressed, management of pharyngotonsillitis focuses on providing symptomatic relief. A variety of systemic and topical therapies are available. This brief review discusses over-the-counter medicines that may be considered for both adults and children.
Source: South African Family Practice 55, pp 334 –336 (2013)More Less
The common cold is the most frequent human illness, and may be caused by several families of viruses, particularly the more than 100 serotypes of rhinoviruses. Inaccurate perceptions that antibiotics improve patient outcomes fuel the number of doctor visits and parental requests for antibiotics. The inappropriate use of antibiotics for minor, self-limiting, usually viral, upper-respiratory tract infections does not alter the course of the disease, and adds to the burden of antibiotic resistance. In addition, there is also no evidence to suggest that antibiotics prevent secondary bacterial complications following viral upper-respiratory tract infections. While most over-the-counter cold and flu remedies have no proven efficacy, they appear to attenuate the immune response to the infecting virus, and there is little doubt that appropriate symptomatic treatment can make the patient feel better. Therefore, symptomatic therapy remains the mainstay of common cold treatment. This article briefly reviews the components of cold and flu remedies, and provides a symptom-based assessment for the selection of appropriate over-the-counter medicine.
Source: South African Family Practice 55, pp 340 –344 (2013)More Less
Preterm birth (< 37 completed weeks of gestation) is the largest direct cause of neonatal mortality, accounting for an estimated 27% of the 4-million neonatal deaths every year. Kangaroo mother care (KMC) is a type of care for preterm and premature infants whereby the infant is placed in an upright position against the parent's chest, with early skin-to-skin contact between the parent and infant. Mothers who practise KMC exhibit less maternal stress and fewer symptoms of depression, and have a better sense of the parenting role and more confidence in meeting their babies' needs than those who don't. Despite the apparent feasibility of KMC, currently, only a few preterm babies in low-income countries have access to this intervention. Knowledge of the effectiveness and safety of KMC in the community and home setting, and its effects on growth, is still incomplete. Only one study has examined KMC initiation at home. There is an immense need for the promotion of research to improve the delivery of existing cost-effective interventions in low-resource settings and to address key gaps in knowledge. KMC improves growth in low birthweight and preterm infants, and has a significant role to play in protecting them from hypothermia and sepsis, as well as promoting exclusive breastfeeding. KMC helps to reduce neonatal mortality, and inculcates confidence and a better sense of parenting in mothers with regard to their babies' needs.
Source: South African Family Practice 55, pp 345 –349 (2013)More Less
Background: Over the last few years, the types of exercises prescribed for patients with rheumatoid arthritis (RA) have changed. There is also increasing knowledge on the physical status and physical activity levels of these patients. This article aims to give an overview of the physical status, physical activity levels and appropriate exercise prescription for patients with RA.
Method: A literature search was conducted of scientific journals and text, including Medline and PubMed (1980-2012). Literature was selected for its in-depth data and well researched information. Key search terms included "RA and exercise therapy", as well as "physical activity levels and physical status of patients with RA".
Results: The literature indicated that RA has a major impact on physical and psychological health. Over the past decade, there has been growing evidence of the health benefits of physical activity for patients with RA. Despite this evidence, patients with RA are less physically active than the general population. The types of exercises prescribed for patients with RA have changed from the traditionally prescribed isometric and range-of-motion exercises. However, proper choice and appropriate utilisation of exercise is essential in order to provide a therapeutic effect.
Conclusion: Although pharmacological interventions have largely improved RA management, exercise therapy remains an important part of treatment. Despite the known benefits of physical activity and exercise, patients with RA are less physically active than the general population.
Source: South African Family Practice 55, pp 350 –353 (2013)More Less
Constipation in children is a universal problem, occurring in 0.7-28% of the population. The exact aetiology is unknown, but the majority of children have a functional, rather than organic, aetiology. Symptoms associated with constipation include abdominal pain, a poor appetite and faecal incontinence, all of which interfere with the quality of life of the child and his or her family. Early intervention with appropriate management is necessary to prevent ongoing sequelae. Once an organic cause has been excluded, a programme of intervention should be implemented, namely evacuation of any faecal mass present, followed by regular maintenance therapy to encourage evacuation of a daily soft stool for at least 2-3 months, prior to gradual withdrawal. Emotional support, exercise and dietary modification are linked to the therapy and will ensure a successful outcome. Failure to implement the protocol may result in ongoing problems in up to 50% of children as they enter adulthood.
Source: South African Family Practice 55, pp 354 –356 (2013)More Less
The development of effective methods to prevent acute gastroenteritis is an important goal for infant health. Exclusive breastfeeding and postponement of complementary foods until the age of six months is recommended for healthy infants. However, at times, infant formula is required. Various types are commercially available. Acidified cow's milk formula has been found to prevent the growth of pathogenic bacteria and concurring diarrhoeal disease.
Source: South African Family Practice 55, pp 357 –365 (2013)More Less
This article provides an overview of ototoxic medication, as well as different pharmacological and audiological monitoring strategies. Although ototoxic medications play an important role in modern medicine, they also have the capacity to do great harm and lead to significant morbidity. Physicians have to be aware of the potential effects of medication in order to identify patients who are at increased risk of developing ototoxicity. Precaution should be taken to prevent any auditory impairment that might occur through appropriate administration and monitoring. Although some otoprotective substances have been used successfully in certain studies, further trials must be performed to assess their clinical utility. The clinical pharmacist and audiologist form an important part of the ototoxicity management healthcare team.
Is screening for microalbuminuria in patients with type 2 diabetes feasible in the Cape Town public sector primary care context? A cost and consequence study : original researchAuthor B. MashSource: South African Family Practice 55, pp 367 –372 (2013)More Less
Background: Type 2 diabetes contributes significantly to the burden of disease in South Africa. Proteinuria is a marker for chronic kidney and cardiovascular disease. All guidelines recommend testing for microalbuminuria because intervention at this stage can prevent or delay the onset of disease. Currently, none of the community health centres (CHCs) in Cape Town test for microalbuminuria, and there are concerns about its costs and feasibility.
Objectives: The aim of this study was to assess the practicality, costs and consequences of introducing a screening test for microalbuminuria into primary care.
Design: Chronic care teams were trained to screen and treat all patients with diabetes (n = 1 675) over a one-year period. The fidelity of screening, costs and consequences was evaluated.
Setting and subjects: Patients with type 2 diabetes and chronic care teams at two community health centres in the Cape Town Metro district.
Outcome measures: Data to evaluate screening were extracted from the records of 342 randomly selected patients. Data to evaluate treatment were taken from the records of all 140 patients diagnosed with microalbuminuria.
Results: Of the patients with diabetes, 14.6% already had macroalbuminuria. Of the eligible patients, 69.9% completed the screening process which led to a diagnosis of microalbuminuria in another 11.7%. Of those who were positively diagnosed, the opportunity to initiate angiotensin-converting enzyme (ACE) inhibitors was missed in 20%, while 49.2% had ACE inhibitors initiated, or the dosage thereof increased. It would cost the health system an additional R1 463 to screen 100 patients and provide additional ACE inhibitor treatment for a year to the 12 that were diagnosed.
Conclusion: The study demonstrated the feasibility of incorporating microalbuminuria testing into routine care. The costs involved were minimal, compared to the likely benefits of preventing end-stage renal failure and the costs of dialysis (estimated at R120 000 per year per patient).
Sociodemographic and clinical profiles of suicidal patients requiring admission to hospitals south of Durban : original researchSource: South African Family Practice 55, pp 373 –379 (2013)More Less
Background: Suicidal behaviour has become a major public health concern worldwide. Non-fatal suicidal attempts outnumber fatal episodes by wide-ranging figures across, and within, many countries. Approximately 6 500 suicides and 130 000 suicide attempts occur annually in South Africa, with at least one suicide taking place every 40 seconds, compared to one suicide attempt every three seconds. It is more common for all forms of suicidal behaviour to occur in younger persons. This study aimed to analyse the characteristics of suicide attempters who were admitted to two community-based state hospitals in the south of Durban.
Method: Adult patients presenting at two university-affiliated state hospitals, following a suicide attempt during a two-year period, were invited to participate in the study. A World Health Organization standardised questionnaire was used to collect basic data relating to the suicide attempt. All participants provided informed consent. Data were analysed using SPSS® version 19.
Results: The majority of the 688 participants were women who were young, single, unemployed, low-income earners, of Indian ethnicity, belonged to the Christian faith, and had a primary school education. Four hundred and thirty-eight participants (63.7%) suffered from varying levels of depression. The majority of suicide attempts (97.2%) had taken place within the home environment of the attempters. Self-poisoning emerged as the dominant method that was used by 92.2% of all attempters.
Conclusion: Disturbing levels of non-fatal suicidal behaviour were found in all the population groups. A number of modifiable factors were identified. These have implications for healthcare policy planners and prevention strategies.
Consultation outcomes for musculoskeletal conditions at two community health centres in Cape Town : original researchSource: South African Family Practice 55, pp 380 –384 (2013)More Less
Objectives: To compare the proportion of patients with documented diagnoses and management plans when they presented with musculoskeletal complaints at two community health centres (CHCs) using two models of care: one with a rheumatology outreach service and the other with none. Secondly, to describe the profile of patients with rheumatoid arthritis (RA) who attended the CHC with the outreach service.
Setting: Heidelberg Community Health Centre and Vanguard Community Health Centre, Cape Town.
Subjects: A group of 59 patients at each CHC were compared regarding engagement of their musculoskeletal complaints by doctors and clinical nurse practitioners (CNPs). Secondly, 24 RA patients who attended Heideveld CHC were profiled.
Results: A comparison of the "overall engagement" between the two CHCs [risk difference (RD) -0.06, 95% confidence interval (CI): -0.17-0.05, odds ratio (OR) 0.79, 95% CI: 0.51-1.24, chi-square 0.82, p-value 0.36] was not significantly different. Comparison between doctors (RD -0.05, 95% CI: -0.05-0.08, OR 0.80, 95% CI: 0.46-1.40, chi-square 0.41, p-value 0.52) was also not significantly different. The comparison between the CNPs at the two CHCs was statistically significant (RD 0.30, 95% CI: 0.14-0.45, OR 8.37, 95% CI: 1.05-66.60, Fisherâ??s exact test 0.01), but the CI around OR was large. Patients with RA had a mean age of 60 years, an average of two co-morbidities and an average of three annual clinic visits. Eighty-three per cent resided in the drainage area of the clinic.
Conclusion: There was no significant difference in engagement between the CHCs. The potential that CNPs seemed to show of being positively influenced by the outreach service should be further researched. Patients with RA had comorbidities that required management at primary healthcare level.
The practice of exclusive breastfeeding among mothers attending a postnatal clinic in Tswaing subdistrict, North West province : original researchSource: South African Family Practice 55, pp 385 –390 (2013)More Less
Objectives: The aim of this study was to determine reported infant feeding practice with reference to exclusive breastfeeding, exclusive formula feeding and mixed feeding at six weeks postpartum among women attending a postnatal clinic in the Tswaing subdistrict of North West province, and the strength of the association between maternal human immunodeficiency virus (HIV) status and exclusive breastfeeding.
Design: Three hundred and eighty-six randomly selected women from seven primary healthcare clinics in Tswaing subdistrict, who were in their sixth postnatal week between November 2009 and February 2010, were enrolled in this study. Data were collected using a researcher-formulated questionnaire to ascertain demographics, including HIV status, as well as reported infant feeding practice. Secondary analysis was carried out to determine the strength of the association between the HIV status of the subjects and exclusive breastfeeding.
Setting and subjects: This study was conducted among women over the age of 18 years attending their first six weeks postnatal visit in seven primary healthcare clinics that provide postnatal care in the rural Tswaing subdistrict of the North West Province.
Outcome measures: The self-reported infant feeding practice at six weeks postpartum, demographic determinants of reported infant feeding practice, and the strength of the association between maternal HIV status and reported infant feeding practice, particularly exclusive breastfeeding, constituted the main outcome measures.
Results: Comparatively, more HIV-negative (n = 157), than HIV-positive women (n = 43), reported that they were breastfeeding exclusively and had received infant feeding counselling (n = 258 vs. n = 65, p-value < 0.05). Exposure to infant feeding counselling and a negative HIV status were associated with higher exclusive breastfeeding rates.
Conclusion: HIV-positive women are still at risk of transmitting HIV to their nursing infants on account of suboptimal infant feeding methods in the prevention of mother-to-child transmission (PMTCT) context. This calls for further research in this area, and in the interim, more support to pregnant and nursing HIV-positive mothers, with a view to achieving the aims of the PMTCT programme.
Evaluation of a school-based nutrition and physical activity programme for Grade 4 learners in the Western Cape province : original researchSource: South African Family Practice 55, pp 391 –397 (2013)More Less
Objective: This study aimed to evaluate the effectiveness of the Making the Difference programme (MTDP), an education and activity-based intervention for Grade 4 learners at primary schools in the Western Cape.
Design: This was a cross-sectional, post-intervention survey of an existing programme, using control schools as a comparator.
Setting and subjects: The study involved Western Cape primary schools in the 2009 school year. Schools were randomly sampled from two regions. Four intervention (active in the MTDP) and five control (non-participating) schools (n = 325 learners) were selected.
Outcome measures: The following outcome measures were assessed using an administered questionnaire to learners: learners' knowledge of, attitudes towards, and behaviour in relation to nutrition and physical activity.
Results: A small but significant improvement (eating vegetables and taking lunch boxes to school) was demonstrated with regard to self-reported behaviour in relation to nutrition in the intervention group. However, this behaviour was not explained by differences in barriers to healthy eating, self-efficacy or knowledge, which were not different between the groups, or by perceived social support, which was actually significantly increased in the control group. Groups displayed no differences in physical activity or sedentary behaviour. However, the results showed a significant difference between the groups in terms of a reduction in perceived barriers to physical activity and increased physical activity self-efficacy in the active group.
Conclusion: While the MTDP only had a modest effect on the self-reported nutrition and physical activity behaviour of the learners, results regarding lower perceived barriers to physical activity and increased physical activity self-efficacy were promising.
Healthcare professionals' perceptions of alcohol intoxicated trauma patients : implications for healthcare delivery at South Rand Hospital Emergency Department : original researchSource: South African Family Practice 55, pp 398 –402 (2013)More Less
Objectives: The objectives of this study were to explore healthcare professionals' (HCPs) perceptions about patients who had been assaulted, who consult under the influence of alcohol, and to make them aware of their attitudes towards these patients, with a view to improving their care.
Design: An explorative, descriptive study with 15 HCPs purposively selected across professional categories, qualifications, work experience, gender and age. These HCPs participated in four focus group interviews on intoxicated patients who had been assaulted. The interviews were audio-taped and supplemented with field and observational notes. Themes were identified using the cut-and-paste method and grouped into categories. Findings were subjected to mental triangulation, peer review and member check, and were compared with those in the literature.
Settings and subjects: HCPs who treat assault patients within the emergency department (ED) of South Rand Hospital, Rosettenville, comprised the study population. They expressed their perceptions and inner feeling about patients under the influence of alcohol who had been assaulted. Interviews were carried out in the boardroom of the hospital.
Outcome measures: HCPs' awareness of their attitudes towards assaulted patients under the influence of alcohol.
Results: Frustration, anger, a desire to punish intoxicated patients and concern about wastage of hospital resources were some of the stressors experienced by HCPs. Exposure to health hazards and a poor security system were concerns that arose following intimidation, aggression and verbal abuse from alcohol-intoxicated patients who had been assaulted.
Conclusion: HCPs experience negative emotions and develop negative attitudes in response to alcohol-intoxicated patients who have been assaulted.
Author Bob MashSource: South African Family Practice 55, pp 403 –404 (2013)More Less
Over 200 family practitioners gathered in Cape Town for the annual conference organised by the Academy of Family Physicians. The conference offered 12 continuing professional development workshops, five plenary speakers and 44 research presentations over one-and-a-half days. It enabled family practitioners from all over South Africa, from the private and public sectors, health centres and district hospitals, as well as registrars in training and university professors, to come together and engage in dialogue on the contribution that the discipline can make to health care in South Africa. We are grateful to the conference sponsors and to Prof Sam Fehrsen for speaking at the social evening.