South African Family Practice - Volume 56, Issue 1, 2014
Volume 56, Issue 1, 2014
Source: South African Family Practice 56, pp 3 –5 (2014)More Less
Before the advent of the new communication and information technologies (NCITs), patient care was sometimes delayed because of the lengthy time it took to transmit patient information from a doctor in one location to a colleague in another. NCITs bring many advances to medicine, including to the area of communication. With a simple click, rural doctors can access their patients' laboratory test results, transmit images immediately, and receive feedback from a number of specialists working far away in teaching hospital centres. Doctors have a general obligation to preserve patient confidentiality, which includes keeping patients' information confidential. Medical confidentiality remains a vital part of ethical professional practice and it is likely that it will remain so. However, data transfer in this age of NCITs presents new ethical challenges in maintaining patient confidentiality.
Author Gboyega OgunbanjoSource: South African Family Practice 56 (2014)More Less
A snapshot of noncommunicable disease profiles and their prescription costs at ten primary healthcare facilities in the western half of the Cape Town Metropole
Hearing loss within a marriage : perceptions of the spouse with normal hearing
The prevalence of suicidal behaviour and associated risk factors in grade 8 learners in Durban
Source: South African Family Practice 56, pp 6 –8 (2014)More Less
Defensive medicine is the practice of diagnostic or therapeutic measures that are conducted primarily as a safeguard against possible malpractice liability, rather than to ensure the health of the patient. Defensive medicine, a significant problem, is discussed in this article. First, an overview of the nature of defensive medicine is provided, with a focus on how it damages the doctor-patient relationship. It has been determined that doctors who utilise defensive medicine ultimately exact more harm than good on the practice of medicine. Finally, it is suggested that through ensuring that the doctor-patient relationship is impenetrable, fear of medical litigation will dissipate. The best antidote to malpractice allegations is ethical clinical practice. Core decisions remain bound in dialogue between the doctor and his or her patient. Continuing the tradition of the therapeutic alliance, informed consent and confidentiality in medical practice will diminish threats of medical liability.
Source: South African Family Practice 56, pp 8 –14 (2014)More Less
The eye is a unique organ which is often involved in systemic disease. Patients with systemic disease may first present with eye pathology, and patients with known systemic illnesses may need to have their eyes specifically checked for ocular complications. It is thus useful for the physician to be familiar with the ocular manifestations of common systemic diseases at primary care level. Diseases like diabetes, herpes zoster ophthalmicus and thyroid ophthalmopathy often involve the eyes, and if the eye signs are not identified early, the visual consequences can be devastating. Diabetic retinopathy is an important cause of blindness in this country. These, as well as common ocular manifestations of human immunodeficiency virus/acquired immune deficiency syndrome, syphilis, some dermatological conditions and the ocular side-effects of certain drugs, are discussed in this article. It is important for the primary care physician to be familiar with the spectrum of ocular involvement in systemic diseases since appropriate intervention and referral can be sight saving for the patient.
Source: South African Family Practice 56, pp 10 –13 (2014)More Less
Healthcare fraud is a type of white-collar crime involving the filing of dishonest healthcare claims in order to achieve a profit. Healthcare fraud is a worldwide problem and is on the increase in South Africa. In this article, healthcare fraud is explored, healthcare fraud identified as a white-collar crime and the South African legal term, "fraud", defined. Common types of medical aid fraud, a rising concern within South African healthcare practice, are detailed. Finally, the role of ethical and moral reasoning is deliberated and the psychological factors that are believed to contribute to fraud discussed. Healthcare fraud is not a victimless crime. Therefore, healthcare professionals must inform on colleagues who practice it.
Source: South African Family Practice 56, pp 14 –16 (2014)More Less
Doctors have an obligation, derived from duty to protect patients from harm, to take positive action if a colleague is impaired. In this article, the Health Professions Council of South Africa ethical guidelines concerning the duty of a doctor to report impaired practitioners is reviewed, followed by an overview of the regulations relating to the impairment of students and practitioners. Problems that doctors face, which may contribute to their impairment, will be discussed. Finally, while supporting the ethical duty to report impairment, a suggestion is made that during medication education, more emphasis should be placed on doctors recognising that they are human and fallible.
Author N. SchellackSource: South African Family Practice 56, pp 16 –20 (2014)More Less
Nonsteroidal anti-inflammatory drugs (NSAIDs) include the nonselective and the cyclo-oxygenase-2-specific inhibitors. These agents are used for pain associated with musculoskeletal conditions. The nonselective anti-inflammatory drugs are still widely used, and are also freely available as over-the-counter analgesics. However, they carry the risk of serious cardiovascular adverse effects, especially in patients who have a high, pre-existing cardiovascular risk profile. It is imperative that physicians are aware of these risk factors and choose agents that have the best benefit-to-risk profile, while taking into consideration the patient's individual risk profile.
Source: South African Family Practice 56, pp 21 –30 (2014)More Less
Author J. BadenhorstSource: South African Family Practice 56, pp 31 –34 (2014)More Less
Coeliac disease is an autoimmune enteropathy triggered by the ingestion of gluten-containing cereals, such as wheat, rye and barley. It is estimated to occur in one per cent of people of European ancestry, and in 0.3% of black Africans. Coeliac disease has a strong genetic component as nearly all patients with the disease share the same genetic predisposition in the form of the presence of either the human leukocyte antigen (HLA)-DQ2 or HLA-DQ8 alleles. The spectrum of symptoms ranges from asymptomatic to chronic diarrhoea, flatulence, abdominal pain and weight loss. Although serological testing for tissue transglutaminase antibodies is both sensitive and specific for the disease, and reflects disease activity, small bowel biopsy is considered to be the standard when diagnosing the disease. The therapy for coeliac disease is a gluten-free diet, which may be difficult and expensive to follow. Nonadherence to a gluten-free diet is the main cause of persistent or recurrent symptoms. Coeliac disease increases the risk of malignancies, such as small bowel adenocarcinoma and enteropathy-associated T-cell lymphoma; pathologies which should be excluded in patients who are compliant with the diet but who are either persistently symptomatic or have a reoccurrence of symptoms. Because coeliac disease is an important cause of common gastrointestinal symptoms and may have significant long-term complications if left untreated, it is paramount that the family practitioner should consider it in the differential diagnosis of patients who present with suspected symptoms. The perception of coeliac disease has changed in recent years from an uncommon enteropathy to a common multisystem disease with a strong genetic predisposition.
Author Ronald IngleSource: South African Family Practice 56 (2014)More Less
For many years the task of providing health services in third world countries fell under a cloud; a fallout from the first world ("upside down" as those terms may be historically). In years past, most doctors in our rural areas had been trained in the first world or similar institutions, where specialisation prevailed. We experienced some of the restrictive aspects of professionalism, and not always the best.
The prevalence of suicidal behaviour and associated risk factors in grade 8 learners in Durban : original researchAuthor N. VawdaSource: South African Family Practice 56, pp 37 –42 (2014)More Less
Objectives : Most of the research on suicidal behaviour in youth focuses on developed countries. Less is known about the prevalence of suicidal behaviour and associated risk factors in community samples of youth who do not present for mental health care in developing countries. This study investigated the prevalence of suicidal behaviour and associated risk factors in grade 8 learners in Durban.
Setting and subjects : Grade 8 learners in a government-run, co-educational school were approached to participate in the study after parental consent and child assent were obtained. A descriptive, cross-sectional method was used to gather quantitative data. The grade 8 learners were asked to complete demographic questionnaires and various psychometric assessment scales.
Design : The gathered data were divided into two groups, i.e. those who reported personal suicidal behaviour and those who did not. The various variables in these two groups were compared using bivariate and multivariate statistical analyses.
Results : The study established that 22 participants (33.8%, n = 75) reported suicidal behaviour (thoughts, plans or attempts in this regard). They also had higher levels of depression, perceived stress, hopelessness and anger (p-value < 0.01) than those who did not report any suicidal behaviour. The same participants had lower scores on scales that assessed self-esteem and perceived social support from family (p-value < 0.01), compared to those who did not report any suicidal behaviour. Logistic regression analysis that was undertaken indicated that a friend's suicidal thoughts [odds ratio (OR) 4.27, p-value < 0.01], alcohol use (OR 3.08, p-value < 0.01), perceived stress (OR 1.05, p-value < 0.01) and depression (OR 1.04, p-value < 0.01), were strong predictors of personal suicidal behaviour in this sample.
Conclusion : There is a high prevalence of suicidal behaviour in grade 8 learners in Durban. The identified risk factors were similar to those found in developed countries. Healthcare providers and other professionals, such as school counsellors, should consider the identified risk factors when assessing suicidality and planning interventions for youth.
A snapshot of noncommunicable disease profiles and their prescription costs at ten primary healthcare facilities in the in the western half of the Cape Town Metropole : original researchSource: South African Family Practice 56, pp 43 –49 (2014)More Less
Objectives : There has been a rapid increase in the prevalence of noncommunicable diseases globally. It is thought that this increase will have the greatest impact on developing countries, such as South Africa, where it will adversely affect quality of life and increase healthcare costs. This research was conducted to determine the disease profile and cost of treating patients at 10 facilities in the western half of the Cape Town Metropole.
Design : An analytical, cross-sectional study was carried out in order to interpret the cost of the medication in relation to the patient disease profile.
Setting and subjects : Data were collected from 10 facilities in the western half of the Cape Town Metropole over a three-month period.
Outcome measure : The outcome measure was the disease profile of patients attending the facilities and the cost of prescriptions for these patients.
Results : Most patient visits to the community health centres were to treat chronic diseases (82%). The disease profile of patients was as follows: 58.96% had hypertension, 19.67% diabetes, 12.14% asthma and chronic obstructive pulmonary disease, and 21.80% arthritis. It was found that 65% of patients with a chronic condition had co-morbidities. The cost of prescriptions was significantly higher (p-value < 0.001) for chronic conditions than for acute conditions. The number of co-morbidities per patient also influenced the cost of the prescriptions.
Conclusion : The results indicated that most of the adults attending public sector facilities in the western half of the Cape Town Metropole have chronic diseases and that the cost of treating these conditions is significantly greater than that of treating acute conditions. An integrated approach to the management of chronic diseases is important in low-resource settings for the efficient utilisation of limited resources.
Source: South African Family Practice 56, pp 50 –56 (2014)More Less
Objective : The objective of the study was to determine the perceptions of a spouse about the influence of his or her partner's hearing loss on their relationship as it may have an impact on aural rehabilitation.
Design : A descriptive survey design was utilised. A questionnaire, adapted from The Significant Other Scale for Hearing Disability was used for data collection.
Subjects : Through purposive sampling, 35 individuals who reported experiencing no hearing difficulties and who were married to a person with an acquired hearing loss contributed data for this study. These data were analysed using Stata® version 9.
Results : The majority of the participants identified a range of communication-related difficulties within their marriage, such as repeating themselves extensively in conversation with their hearing-impaired partners (97%), raising the volume of their voices (83%), and having to maintain face-to-face contact with their spouse (74%). These difficulties may have led to negative feelings within the marriage as during communication, 69% of participants reported feeling frustrated because of difficulties experienced in respect of their partner's hearing impairment. Participants reported that they had to accept a hearing impairment in their marriage. Seventy-one per cent of participants expressed concern for their hearing-impaired partners, and specifically with regard to fearing for their safety, e.g. when alarms or warning bells were not heard.
Conclusion : A partner's acquired hearing impairment may lead to the development of negative feelings within a marriage. Therefore, audiologists must be aware of the perceptions of spouses with normal hearing when providing aural rehabilitation to both the hearing-impaired individuals and their partners, and thereby preventing disharmony in the marriage, while ensuring effective service delivery.
Review of final-year medical students' rural attachment at district hospitals in KwaZulu-Natal : student perspectives : original researchSource: South African Family Practice 56, pp 57 –62 (2014)More Less
Objectives : This study aimed to investigate the views of students involved in rural community-based medical attachments during their final year at medical school. The programme has been in existence for some time, but no formal evaluation thereof has yet taken place. This paper describes the first two phases of what is described as a quality improvement project: namely to describe the problem state and to discuss possible activities to improve the programme.
Design, setting and subjects : The study adopted a mixture of quantitative and qualitative type research. Data were collected by means of a self-administered questionnaire which students at Nelson R Mandela Medical School, University of KwaZulu-Natal, completed at the end of their Family Medicine rotation. Consent was obtained from the participants and ethical approval granted by the University of KwaZulu-Natal Humanities and Social Science Ethics Committee.
Results : Students were generally positive about their rural attachment experience. The majority (86%) believed that their skills adequately prepared them to enter the community. Allocation of a supervisor and rostering were found to be of great importance. Academic activities provided adequate learning opportunities. The majority (76%) of students who used hospital accommodation found it to be satisfactory, although it was an area that needed attention. Technological support was lacking. Fewer than 50% of students had access to such facilities.
Conclusion : Students' responses were generally positive about the rural attachment experience, but logistical and technological support issues, as well as that of accommodation, need to be addressed if the programme is to flourish. Community-based education in a rural district hospital can provide unique learning opportunities for students if the opportunities are identified and the programme is well managed.
Lactic acidosis, risk factors and predictive laboratory markers : a nested case control study in South Africa : original researchSource: South African Family Practice 56, pp 63 –68 (2014)More Less
Background : The incidence of antiretroviral therapy (ART)-induced lactic acidosis and its associated mortality may be reduced by appropriate dosing, risk stratification and early detection.
Objectives : To describe the epidemiology of lactic acidosis, define the risk factors and identify predictive laboratory markers in the context of the roll-out of ART in South Africa.
Design : A nested case control study. Risk factor analysis was adjusted for the established risk factors of weight and gender.
Setting and subjects : Persons commenced on stavudine-containing therapy between 2004 and 2007 at Port Shepstone Hospital in KwaZulu-Natal were included. Persons with a body weight above 60 kg received Stavudine 40 mg twice daily, and those with a body weight below 60 kg, 30 mg twice daily.
Outcome measures : Assessed risk factors included weight, gender, age, alanine transaminase (ALT), urea, creatinine, albumin, cholesterol, triglyceride (TG) levels, CD4 counts and viral loads.
Results : Lactic acidosis occurred in 79 (17 per 1 000 person-years) of 1 762 people living with HIV on ART. Significant factors were being female [adjusted odds ratio (AOR) of 5.4] and increased body weight (adjusted OR of 1.1 per kg). The risk of lactic acidosis increased 6.6, 6.9 and 95 times (adjusted ORs) as weight increased from a baseline weight of < 60 kg to 60-69 kg, 70-79 kg or > 80 kg, respectively. Six months into therapy, predictors of developing lactic acidosis were an ALT > 50 IU/l (adjusted OR of 11.1) and a higher TG (adjusted OR of 8.8 per mmol/l). No associations were found with regard to age, CD4 count, viral load, and creatinine or albumin levels.
Conclusion : Obese females are at greatest risk of lactic acidosis, with an exponential increase in risk above 80 kg. The 30-mg dose may be preferable, given that a sharp increase in risk occurred at 60 kg, was most likely dose related, and that 30 mg has been shown to provide adequate virological suppression. Additional risk factors for lactic acidosis include a high ALT and TG levels at treatment.
An evaluation of the Triage Early Warning Score in an urban accident and emergency department in KwaZulu-Natal : original researchSource: South African Family Practice 56, pp 69 –73 (2014)More Less
Objective : Triage is an essential first step in the efficient and effective running of any emergency department. A good triage tool saves lives and reduces mortality. The Triage Early Warning Score (TEWS) is a useful tool used to identify patients in emergency departments who are at risk of deterioration and who may require admission. As this triage tool has only been evaluated to a limited extent, this study assessed its effectiveness in identifying patients at risk of early deterioration to enable timely medical intervention.
Design and setting : This was a retrospective study of medical records within the accident and emergency department of an urban public hospital.
Outcome measures : The calculated TEWS was compared to one of four possible outcomes viz. discharge within 24 hours, admission to the ward, admission to the intensive care unit (ICU), or death in hospital. Pearson's chi-squared tests and cross-tabulation was used to determine the statistical significance of the association.
Results : Of the 265 patient records analysed, 233 (87.9%) had a TEWS of < 7. Of patients with a TEWS of < 7, 53.7% were discharged, compared to 18.7% with a score ≥ 7, who were discharged. The average score of the four patients who died was 9.5, and 8.2 for the three admitted to ICU. Higher TEWS were significantly associated with increased admission to hospital and in-hospital deaths (p-value 0.032).
Conclusion : An effective triage scoring system ensures that those requiring emergency care are appropriately categorised. Prompt intervention will either reverse further physiological decline or facilitate timely referral to the appropriate service level, including ICU.
Author Chris EllisSource: South African Family Practice 56 (2014)More Less
Several decades ago, the concept of the "heart sink" patient was described. It is a phenomenon that occurs when a doctor sees that a particular patient has booked for an appointment and his or her heart sinks in anticipation of the consultation. A collection of negative premonitions and expectations arise in the doctor's mind which are not exactly consistent with being a member of a healing profession.