South African Family Practice - Volume 55, Issue 6, 2013
Volume 55, Issue 6, 2013
Source: South African Family Practice 55 (2013)More Less
On Thursday, 5 December 2013, South Africa and the world received the shocking news that the iconic freedom fighter and founding father of the democratic republic of South Africa, Nelson Rolihlahla Mandela, was no longer with us. He had passed away peacefully after over 95 years on earth, 27 of which he was incarcerated on Robben Island near Cape Town. We were told that Madiba, as he was fondly called, inherited the name "Nelson" from Miss Mdingane, his primary school teacher in Qunu, who gave every student an English name. His Xhosa name, Rolihlahla, literally means "pulling the branch of a tree", but its colloquial meaning is "troublemaker". Madiba fought the apartheid system before and during his incarceration, as well as after his release from prison. This was exemplified during his inaugural address on 10 May 1994, which contained one of his famous quotations, which was: "Never, never, and never again, shall it be that this beautiful land will experience the oppression of one by another".
Source: South African Family Practice 55 (2013)More Less
Uptake and factors that affect enrolment into the prevention of mother-to-child transmission of the human immunodeficiency virus programme
Delays by people living with human immunodeficiency virus/acquired immune deficiency syndrome in accessing antiretroviral therapy
The prevalence of burnout and depression in medical doctors in the Cape Town Metropolitan Municipality clinics and district hospitals
Source: South African Family Practice 55, pp 493 –500 (2013)More Less
Gradual loss of vision is a clinical problem that is encountered fairly regularly in most primary healthcare settings. Patients present with chronic, slowly progressive and generally painless visual loss. The reduction in vision is usually bilateral, though frequently asymmetrical, and occurs over weeks to years. A goal-directed assessment of the patient presenting with gradual loss of vision is required. A history of the type of visual loss, e.g. central or peripheral, and whether it is worse for near vision or distance vision, is helpful. The examination should focus on visual acuity, confrontation visual field testing, pupil testing for the presence of an afferent pupil defect and assessment of the red reflex and fundoscopy. The more common conditions that cause gradual loss of vision can be divided into two groups based on the reversibility of the visual loss. Cataracts, refractive error, corneal blindness and early diabetic macular oedema are generally reversible. Optic atrophy, glaucoma, retinal degeneration and age-related macular degeneration usually cause permanent loss of vision. Most of these conditions are briefly discussed in this article. This has been performed at a level that is suitable to primary care.
Source: South African Family Practice 55, pp 501 –503 (2013)More Less
Sulphonylureas act by binding to sulphonylurea receptors and stimulating insulin secretion from pancreatic beta cells. This class of oral hypoglycaemic agents is still widely used in the management of type 2 diabetes in patients where lifestyle changes alone are insufficient. Although the older-generation sulphonylureas no longer have a place in therapy, the newer-generation sulphonylureas are a widely recognised choice, either as monotherapy, or in combination with insulin and/or other oral hypoglycaemic agents.
Source: South African Family Practice 55, pp 505 –507 (2013)More Less
Metformin is considered to be the initial drug of choice for type 2 diabetes mellitus, particularly in overweight patients. This is based on its effectiveness in achieving glycaemic control, its favourable effects on weight, its low risk of causing hypoglycaemia and its reasonable cost. More importantly, metformin has also been consistently shown to have a favourable effect on cardiovascular risk factors, and to improve cardiovascular outcomes. It can be combined with other oral hypoglycaemic agents, as well as insulin, allowing for a beneficial additive effect.
This article provides a brief overview on the use of metformin, as recommended by the Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA), in its 2012 guidelines for the management of type 2 diabetes.
Source: South African Family Practice 55, pp 508 –510 (2013)More Less
The production of glucagon-like peptide 1 (GLP-1), an incretin hormone, has been shown to be abnormally low in patients with type 2 diabetes, suggesting that GLP-1 may be a contributor in the pathogenesis of the disease. New type 2 diabetic medications target incretin hormones in their mechanism of action. The incretin effect is based on the understanding that oral glucose has a greater stimulatory effect on insulin secretion than that of intravenous glucose. Over the past few years, a number of therapeutic agents, acting either as incretin mimetics, e.g. GLP-1 agonists, or inhibitors of the breakdown of GLP-1, e.g. dipeptidyl peptidase-4 inhibitors, have become available as treatment options for the management of type 2 diabetes.
Glucagon-like peptide 1 receptor agonists : a new approach to type 2 diabetes management : CPD articleAuthor Lynn LambertSource: South African Family Practice 55, pp 511 –514 (2013)More Less
Despite advances in options for the treatment of type 2 diabetes, optimal glycaemic control is often not achieved. Hypoglycaemia and weight gain that are associated with many antidiabetic medications may interfere with the implementation and long-term application of treatment strategies. Glucose homeostasis is dependent on a complex interplay of multiple hormones and gastrointestinal peptides, including glucagon-like peptide 1 (GLP-1). Abnormal regulation of these substances may contribute to the clinical presentation of diabetes. GLP-1-based therapies affect glucose control without causing hypoglycaemia through several mechanisms, including enhancement of glucose-dependent insulin secretion, slowed gastric emptying, regulation of postprandial glucagon and reduction of food intake.
Source: South African Family Practice 55, pp 515 –518 (2013)More Less
Diabetes affects an estimated 16 million people in the United States and only just over half of whom are aware they have the disease. It is one of the leading causes of disease-related deaths in the U.S. Diabetes and its related complications claim the lives of approximately 190,000 Americans annually. In South Africa the situation is just as dire with between 4 - 6 million people having Diabetes.
Author K. KochSource: South African Family Practice 55, pp 520 –524 (2013)More Less
Pain is one of the most common complaints that general practitioners encounter in everyday practice. The swift and effective management of pain is a medical mandate, not only to fulfil an ethical obligation to the patient, but also to prevent long-term complications, such as chronic pain. General practitioners are often required to manage mild-to-moderate pain, and have multiple pain management treatments available to them. The challenge is to tailor a treatment plan to suit the individual requirements of each patient. In this paper, we will explore how best to manage acute mild-to-moderate pain in general practice in a logical stepwise approach.
Anxiety and the patient with breast cancer : a review of current research and practice : review articleSource: South African Family Practice 55, pp 525 –529 (2013)More Less
Breast cancer is one of the most common cancers worldwide. Statistics reveal that the number of women diagnosed with breast cancer is increasing in South Africa. In particular, there appears to be a growing incidence in younger, black women in urban areas. Family practitioners and oncology healthcare professionals are going to be treating an increasing population of patients with breast cancer. Research has shown that in many instances, the psychological needs of patients with breast cancer are not adequately addressed, and that often the physical crisis is seen as more immediate. Also, healthcare professionals and oncologists may not be aware of the prevalence of co-morbid psychological distress, and thus do not focus on this aspect of the diagnosis. As a result, women who experience psychological distress during and after treatment may not be referred for psychological management. This may have a significant impact on their quality of life during this period and may even affect their compliance with treatment. This ultimately has implications for their ongoing health and survival. This review of the available literature aims to heighten awareness of healthcare professionals to the current situation, with a view of improving the mental health care of South African patients with breast cancer.
Source: South African Family Practice 55, pp 530 –532 (2013)More Less
Melanoma has become a common form of cancer. The incidence of melanoma tends to increase with increasing latitude, being low in southern, sunny tropical areas, where dark skins are more prevalent, and high in the north, in temperature areas, where lighter skins predominate because of a higher concentration of descendents of fair-skinned European immigrants.
Cleft lip and palate malformations : essential knowledge for the general practitioner : review articleSource: South African Family Practice 55, pp 533 –537 (2013)More Less
Cleft lip and palate malformations are a common group of congenital abnormalities, and are therefore frequently encountered by the general practitioner, who is often the primary coordinator in the management of these patients. This is especially true in a South African setting, where specialist treatment is not always readily available. An incomplete understanding of the multiple components and complexities of the condition often results in unsatisfactory patient outcomes. This article aims to improve understanding of the condition and demonstrates how a multidisciplinary team approach is essential to successfully manage these patients. The roles of the different team members are described, and include the dentist, orthodontist, paediatrician, geneticist, speech therapist, dietitian, otorhinolaryngologist, as well as plastic and reconstructive and/or maxillofacial surgeon. A flow diagram with the various role players and the timing of their interventions has been designed to simplify the referral pathway. The authors aim to assist the general practitioner with the appropriate referral of patients with cleft lip and palate.
Prevalence of raised body mass indices and the association with high blood pressure and hyperglycaemia in the rural black population of Ga-Mothapo village, Capricorn District of Limpopo province : original researchSource: South African Family Practice 55, pp 538 –544 (2013)More Less
Objective : To assess the prevalence of elevated body mass index and to establish whether there was an association between raised body mass index (BMI) and high blood pressure (BP) and hyperglycaemia in the rural population of Ga-Mothapo village, Limpopo province.
Design : Cross-sectional and prospective in nature.
Setting : Ga-Mothapo village, a rural settlement with a population of 11 000, situated in the Capricorn region of Limpopo province, approximately 28 km east of Polokwane.
Subjects : The study sample comprised 382 participants, of whom 286 were females (74.9%) and 96 males (25.1%), aged 18-65 years.
Outcome measures : Fasting blood glucose samples were analysed using the ILab 300 Plus®. BP pressure was measured using an automatic BP monitor. Height and weight were measured using a height-measuring rod and weighing scale, respectively. The BMI was calculated.
Results : The overall prevalence rates of overweight, obesity, high BP and hyperglycaemia were 30.6%, 23.6%, 27% and 11.8%, respectively. The prevalence rates of overweight, obesity, high BP and hyperglycaemia in females were 34.6%, 29.4%, 27.3% and 13.6% respectively. They were 18%, 6.3%, 26.1% and 6.3%, in the males, respectively.
Conclusion : The study revealed high prevalence rates of raised BMI, high BP and hyperglycaemia in the Ga-Mothapo population. Females had higher prevalence rates of raised BMI and hyperglycaemia than males. The study highlighted the fact that raised BMI and hyperglycaemia were significantly associated with high BP.
A South African perspective on factors that impact on the adoption and meaningful use of health information technologies : original researchSource: South African Family Practice 55, pp 545 –554 (2013)More Less
Objective : Various benefits are associated with the adoption and meaningful use of health information technologies (HITs) in the healthcare sector. Despite the associated advantages with the adoption and use of HITs, the South African healthcare sector has been slow to adopt HITs, such as electronic record systems. The purpose of this study was to identify factors that should be addressed to encourage the adoption and meaningful use of HITs in the South African healthcare landscape.
Design : A three-round Delphi study was conducted to identify such factors.
Setting and subjects : The Delphi panel included 21 participants who were considered to be suitably knowledgeable about the acceptance and significant use of HITs in the context of the South African healthcare setting.
Results : A total of 58 factors were uncovered by the participants. Consensus was reached on 42 factors that were considered to have a direct to significant impact on the adoption and meaningful use of HITs in the South African healthcare sector.
Conclusion : The results of this study highlight factors that should be addressed to encourage the adoption and meaningful use of HITs in South Africa's healthcare setting. These results indicate that a wide range of factors need to be addressed and involve a multitude of stakeholders.
Uptake and factors that affect enrolment into the prevention of mother-to-child transmission of human immunodeficiency virus programme in rural Limpopo Province : original researchSource: South African Family Practice 55, pp 555 –560 (2013)More Less
Background : Before 2006, the uptake into the prevention of mother-to-child transmission (PMTCT) for HIV programme was low in South Africa. We determined PMTCT programme uptake, and identified factors that affected enrolment into the PMTCT programme in the rural Limpopo province.
Method : This cross-sectional study, conducted from 21 July to 20 August 2008, involved 200 consecutive women who met the inclusion criteria in the immediate postpartum period. An interviewer-administered questionnaire was used to obtain information on participants' knowledge and experience of, satisfaction with, and motivation for, enrolling in the PMTCT programme. Main outcome measures included voluntary counselling and testing (VCT) and PMTCT programme uptake rates, and factors reported to influence enrolment into the programme.
Results : Of the 200 invited women, 169 (84.5%) responded. The mean age of participants was 25 years ± standard deviation. The human immunodeficiency virus prevalence rate was 23.6%. VCT and PMTCT programme uptakes were 96.9% and 90.9% respectively. Participants reported being aware of (95.2%) and satisfied with (81.6-97.4%) various aspects of the PMTCT programme.The safety of their babies was reported by most participants to be their motivation for enrolment (71.1%). Participants in the age-group 20-29 years were more likely than others to enrol in the PMTCT programme (p-value = 0.01).
Conclusion : VCT and PMTCT programme uptakes were high and influenced by good knowledge, satisfaction with the PMTCT programme and participants' concern for the safety of their babies.
The role of private general practitioners in the treatment of alcohol dependence in the Free State province : original researchSource: South African Family Practice 55, pp 561 –566 (2013)More Less
Objectives : The study was undertaken to investigate the role of private general practitioners (GPs) in the treatment of alcohol dependence in the Free State province.
Design : A descriptive cross-sectional study. A questionnaire was used to describe the experiences of GPs with patients with alcohol dependence.
Outcome measures : The treatment role of individual participants was defined in terms of the range of services provided and the enablers and obstacles faced in performing interventions in their local context.
Setting and subjects : Seventy-seven private GPs were selected by means of a stratified randomised sampling process from areas in the immediate proximity of regional hospitals, district hospitals, or basic environments (without local hospital services), in three geographical areas defined by existing health service delivery boundaries.
Results : 29.9% of participants practised medical detoxification, either in hospital or in outpatient settings. Involvement related to the local organisation of treatment services in a geographical area. GPs in resource-constrained environments played an extended role outside of the traditional office-based model of care. Medical scheme funding policies were regarded as an obstacle to involvement in the treatment of alcohol-dependent patients by 76.5% of participants. Other major obstacles were lack of multidisciplinary teams, in-patient facilities and referral structures.
Conclusion : Private GPs in the Free State play a context-dependent role in the treatment of alcohol-dependent patients in the province. This compensatory role needs to be acknowledged in service delivery planning in under-resourced areas, especially to ensure access to treatment and cost-effective management.
The prevalence of burnout and depression in medical doctors working in the Cape Town Metropolitan Municipality community healthcare clinics and district hospitals of the Provincial Government of the Western Cape : a cross-sectional study : original researchSource: South African Family Practice 55, pp 567 –573 (2013)More Less
Aim : This study investigated burnout and depression in medical doctors in the context of work-related conditions and the role of resilience as a modifiable factor.
Method : A cross-sectional, observational study was conducted on consenting medical doctors (n = 132) working at Cape Town Metropolitan Municipality primary healthcare facilities of the Provincial Government of the Western Cape. Data were collected from doctors at 27 facilities by means of a self-administered questionnaire battery, containing socio-demographic information, the Beck Depression Inventory (BDI), the Maslach Burnout Inventory (MBI) and the Connor-Davidson Resilience Scale (CD-RISC).
Results : Of 132 doctors included in the analysis, 76% experienced burnout, as indicated by high scores in either the emotional exhaustion or depersonalisation subscales. In addition, 27% of doctors had cut-off scores on the BDI indicating moderate depression, while 3% were identified to have severe depression. The number of hours, work load, working conditions and system-related frustrations were ranked as the most important contributing factors to burnout. More experienced doctors and those with higher resilience scores had lower levels of burnout, as evident by their lower scores in the emotional exhaustion and depersonalisation domains of the MBI.
Conclusion : Both burnout and depression are prevalent problems in doctors working at district level and in communities. Resilience appears to be protective and may be a useful target for future intervention.
Source: South African Family Practice 55, pp 574 –578 (2013)More Less
Objective : To understand, by qualitative enquiry, the underlying reasons and narratives for patients that delay in accessing antiretroviral treatment.
Design : A qualitative design was used, where patients were interviewed using the free attitude interview technique, after being selected based on a screening question: "How long did it take you to present at a clinic or hospital for treatment after receiving your human immunodeficiency virus-positive result?"
Setting and subjects : Eight patients from the human immunodeficiency virus clinic at Potchefstroom were interviewed.
Outcome measures : The interviews were transcribed verbatim and organised into themes.
Results : The following themes were identified: stigma and discrimination, ignorance and lack of perceived risk of infection, denial and healthcare system constraints. These are discussed and quotations from the interviewed patients included.
Conclusion : This qualitative study has contributed to an understanding of why patients delay in accessing highly active antiretroviral therapy. Some of the reasons supplied by patients have been documented globally. Others are poignantly coloured by personal stories. By understanding patients' perspectives and feelings, emphasis can be placed on the reduction of stigma, denial, practical clinic constraints and appropriate types of health education.
The validity of monitoring the control of diabetes with random blood glucose testing : scientific letterSource: South African Family Practice 55, pp 579 –580 (2013)More Less
It is important to decide if a patient with diabetes has good glycaemic control in order to guide treatment and to offer behaviour change counselling. Currently, determining random blood glucose (RBG) is usually carried out in primary care in the public sector to make this decision. This study investigates the validity of these decisions. Retrospective data from a district hospital setting were used to analyse the correlation between glycated haemoglobin (HbA1c) and RBG, the best predictive value of RBG, and its predictive properties. The best value of RBG to predict control (HbA1c ≤ 7%) was 9.8 mmol/l. However, this threshold only gave a sensitivity of 77% and a specificity of 75%. Clinicians would be wrong 23% of the time when using RBG to determine glycaemic control. Attempts should be made to make HbA1c more available for clinical decision-making. Point-of-care testing for HbA1c should be considered.
Source: South African Family Practice 55, pp 581 –582 (2013)More Less
Meeting nutritional demand is of paramount significance in any stage of life to ensure positive health. Safeguarding maternal nutritional requirements during pregnancy deserves ancillary attention as the diet has an inarguable impact on the health of both the mother and the newborn baby. In a study that was carried out in India in seven states (Himachal Pradesh, Haryana, Assam, Orissa, Kerala, Tamil Nadu and Madhya Pradesh) on 1 751 pregnant women, it was revealed that 84% of the study participants suffered from nutrition-related iron deficiency. Another multi-country study reported that the prevalence of anaemia in pregnant women was 63%, 68% and 74%, in Nepal, Bhutan and Bangladesh, respectively. Multiple studies from different developing countries have also established nutritional imbalance in pregnancy in different settings.