South African Family Practice - Volume 56, Issue 2, 2014
Volume 56, Issue 2, 2014
What to do in the event of an adverse anaesthetic event or medical error : anaesthetics supplement : editorialAuthor Jenny ThomasSource: South African Family Practice 56, pp 2 –4 (2014)More Less
Author D. LinesSource: South African Family Practice 56, pp 5 –9 (2014)More Less
The difficulty that anaesthetists face is that they often, when seeing a patient pre-operatively, do not have the benefit of seeing the patient's "normal average" blood pressure taken at different times over a period of weeks. The decision to cancel surgery based on the blood pressure found at the pre-operative visit must, therefore, take into account the urgency of the surgery, as well as the presence of end organ damage from chronic hypertension. A detailed history and examination should be performed looking for evidence of coronary artery disease, cerebrovascular disease and renal dysfunction.
Author R. MooreSource: South African Family Practice 56, pp 10 –12 (2014)More Less
A severe burn is arguably the most significant injury that the human body can sustain. No other form of trauma causes the massive physiological changes seen in a patient with a major burn injury. This is true in the first few weeks as well as up to two years post-burn, due to the persistence of the hypermetabolic response. Both the profound alterations in physiology as well as numerous anatomical changes make anaesthesia of the severely burned patient complex and challenging.
Author N.R. MadimaSource: South African Family Practice 56, pp 14 –18 (2014)More Less
Emergence from anaesthesia is by definition the process of return to baseline physiological function of all organ systems after cessation of administration of general anaesthesia and is the stage from general anaesthetic that includes a return to spontaneous breathing, voluntary swallowing and normal consciousness. It is a time of great physiological stress for many patients and should ideally happen smoothly in a controlled environment but, unfortunately, can happen on the way to the recovery room.
Source: South African Family Practice 56, pp 19 –23 (2014)More Less
Tuberculosis is a common problem in South Africa, and provides a number of challenges for the anaesthetist. Patients may present in a variety of ways. Constitutional and pulmonary symptoms are the most common. These may impact on fitness for surgery and choice of anaesthesia. Tuberculosis treatment has the potential for a number of significant drug interactions. These are primarily mediated through induction of the cytochrome P450 enzyme system by rifampicin. Guidelines for the prevention of tuberculosis in the theatre environment need to be followed to avoid placing staff and other patients in danger.
Author C. QuanSource: South African Family Practice 56, pp 24 –26 (2014)More Less
Acute postoperative pain remains a major problem. Undertreatment can lead to serious consequences including persistent postoperative pain, impaired rehabilitation, and increased length of hospital stay, sympathetic overdrive and immunosuppression. Overtreatment can lead to serious adverse events related to analgesic use such as sedation and respiratory depression. It is therefore imperative to prevent and treat postoperative pain, but at the same time not to cause harm from our treatment.
Author N.T. HlongwaneSource: South African Family Practice 56, pp 28 –32 (2014)More Less
Appendectomy is the removal of the vermiform appendix. The term 'appendectomy' is misleading as it gives no indication of degree of clinical compromise the patient may be suffering leading to the need for this procedure. The patient presenting for appendectomy represents a clinical challenge to the anaesthetist, which requires vigilance in ascertaining the severity of illness in order to allow for good anaesthesia management.
Author D.C. NelSource: South African Family Practice 56, pp 35 –39 (2014)More Less
Surgical site infections (SSIs) are a worldwide problem that has far reaching implications on patient morbidity and mortality as well as significant financial implications. Worldwide it has an incidence of between 2-5%, with an incidence as high as 20% in colorectal surgery. It is the third most common nosocomial infection, and the most common nosocomial infection amongst surgical patients with up to 38% of nosocomial infections being due to surgical site infections. On average, it increases length of hospital stay by 7-10 days and in America in 2002, it was estimated to cost between $3 000 - $30 000 per incident of a surgical site infection. This cost estimate excluded cost to the patient after discharge from hospital. Patients whose surgery was complicated by a SSI had a 2-11% higher risk of death. In those patients who died, 75% was directly attributable to the SSI.
Author B.M. GardnerSource: South African Family Practice 56, pp 41 –44 (2014)More Less
Sleep-disordered breathing (SDB) disorders include: central sleep apnoea (Cheyne-Stokes respiration), obstructive sleep apnoea and mixed or complex sleep apnoea. Obstructive sleep apnoea (OSA) is the most common of these three disorders and is defined as airway obstruction during sleep, accompanied by at least five episodes of apnoea or hypopnoea per hour. Each episode is often associated with a decrease in arterial oxygen saturation of > 4%.
South Africa's National Health Insurance revisited : "Quo vadis?" ("Whither goest thou?") : editorialAuthor Gboyega OgunbanjoSource: South African Family Practice 56 (2014)More Less
By the time you receive this copy of the South African Family Practice journal, South Africa's National Health Insurance (NHI) pilot project would have completed 24 months of implementation. The first status report by Matsoso and Fryatt was published in May 2013. In my previous editorial on the pilot project, I provided a synopsis of the objectives, progress and challenges, and concluded with positive data on the satisfaction index of patients on the usage of the public health service.
Source: South African Family Practice 56, pp 88 –94 (2014)More Less
Ocular trauma is an important cause of unilateral blindness and visual impairment across the world. Most injuries are accidental, work-related injuries in developed countries, while assaults predominate as a cause in developing countries. Trauma may result in various forms of ocular injuries, ranging from minor insult to major functional impairment. Any ocular structure may be involved, and a careful, systematic approach to the examination of a patient is essential to avoid missing occult injury and resultant visual impairment. This paper highlights key points regarding the clinical evaluation of patients with ocular trauma and covers the presentation and primary care management of the more common ocular injuries.
Source: South African Family Practice 56, pp 96 –101 (2014)More Less
Currently, three phosphodiesterase type 5 (PDE5) inhibitors are available for clinical use in South Africa; sildenafil, vardenafil and tadalafil. The PDE inhibitors are used in males to treat erectile dysfunction. However, sildenafil is also registered for use in the treatment of pulmonary hypertension. Newer studies are investigating the use of these drugs for other conditions, including hypertension, ischaemia or reperfusion injury, myocardial infarction, cardiac hypertrophy, heart failure and other peripheral circulatory conditions, e.g. Raynaud's disease. The article provides a broad overview of the mechanism of action, indications, pharmacokinetics and side-effects of these agents.
Source: South African Family Practice 56, pp 102 –108 (2014)More Less
Osteoarthritis (OA) is a common chronic degenerative joint disorder and a major cause of pain and disability, especially in the elderly. The prevalence is steadily rising due to an increase in life expectancy and certain lifestyle factors. OA is a complex dynamic process involving all tissues of the joint organ. Multiple risk factors are associated with the occurrence and progression of OA. There is extreme variability in presentation at different joint sites and between individuals. Management of OA involves a comprehensive approach consisting of preventative measures and numerous therapeutic modalities which should be tailored to individual needs. The family practitioner plays a vital role in the diagnosis of OA, the initiation of treatment and the ongoing monitoring of the condition.
Author Derrick SmitSource: South African Family Practice 56, pp 110 –115 (2014)More Less
The following red eye cases and this clinical quiz is not only aimed at over the counter (OTC) medication, but also illustrates the importance of referring patients who do not respond to OTC medicines or primary medical attention. The case studies are discussed in more detail after the initial case presentations. Read the case studies and decide whether the causes are bacterial, viral, or allergic and decide what treatment you would have prescribed for the patient, or if you would refer the patient.
Source: South African Family Practice 56, pp 119 –124 (2014)More Less
Background: Toxoplasmosis is a disease caused by Toxoplasma gondii, which can infect nearly all mammalian and avian species. Approximately 25% of the global human population is thought to be infected. Interest in toxoplasmosis has surged since it was discovered that with the onset of acquired immune deficiency syndrome, acute toxoplasmosis could induce cranial calcification. The ensuing encephalitis can be fatal. The African human immunodeficiency virus (HIV) epidemic, increasing levels of other immunosuppressive infections (such as tuberculosis), poor sanitation practices and lack of monitoring of at-risk populations point to a predicament that may be underrated.
Objective: The objective was to review the available body of research on the seroepidemiology of T. gondii in Africa, in order to establish existing prevalence trends and to draw attention to available information on the pathogen in Africa.
Method: The National Center for Biotechnology Information, Google Scholar and ToxoDB databases were searched for peer-reviewed articles that focus specifically on seroprevalence studies of T. gondii in Africa up until the 2012 year end.
Results: Seroprevalence rates on the continent are high in humans and animals. There is a geographical trend of decreasing seroprevalence from the northern to the southern, and from the western to the eastern, regions of the continent. Most seroprevalence studies on humans were reported between 1981 and 2000.
Conclusion: There is a need for further and more consolidated information on the prevalence of T. gondii in Africa, in order to address morbidity and mortality from opportunistic but treatable diseases, such as toxoplasmosis in the ongoing HIV pandemic, and to improve the lives of the African population.
An evaluation of the assessment tool used for extensive mini-dissertations in the Master's Degree in Family Medicine, University of the Free State : original researchSource: South African Family Practice 56, pp 125 –133 (2014)More Less
Background: Family Medicine became a speciality in South Africa in 2007. Postgraduate studies in Family Medicine changed from part-time Master of Family Medicine (MFamMed) to a full-time Master of Medicine (Family Medicine) [MMed(Fam)] degree, with changes in the curriculum and assessment criteria. The overall goal of this study was to evaluate the current assessment tool for extensive mini-dissertations in the postgraduate programme for Family Medicine, at the University of the Free State, and if necessary, to produce a valid and reliable assessment tool that is user-friendly.
Method: An action research approach was used in this study, using mixed methods. Firstly, marks given by 15 assessors for four mini-dissertations using the current assessment tool were analysed quantitatively. In Phase 2, the regulation of the assessment bodies and the quantitative results of Phase 1 were discussed by assessors during a focus group interview, and data were analysed qualitatively. An adapted, improved assessment tool (Phase 3) was developed and re-evaluated in Phase 4.
Results: The current assessment tool complied with the regulations of the assessment bodies. The scores allocated to specific categories varied with a median coefficient of variation of more than 15% in four of the possible 12 assessment categories. During the focus group interview, reasons for this were identified and the assessment tool adapted accordingly. During reassessment of the tool, individual assessors were identified as the reason for poor reliability.
Conclusion: The current assessment tool was found to be valid, but was not reliable for all assessment categories. The adapted assessment tool addressed these areas, but identified lack of training and experience in the assessment of extensive mini-dissertations by certain assessors as the main reason for unreliable assessment.
Does health-related quality of life in asthma patients correlate with the clinical indices? : original researchSource: South African Family Practice 56, pp 134 –138 (2014)More Less
Background: Assessment of health-related quality of life (HRQOL) has been shown to be more relevant to patients who have chronic diseases such as asthma, as achieving the best possible quality of life is the paramount objective in the management of such patients. This study assessed the quality of life of asthma patients and correlated it with the various clinical indices of asthma, such as age, sex, the duration of the asthma, medication used and its severity.
Design: The study was a cross-sectional, analytical, case-control design, involving three approaches, i.e. quality of life, clinical assessment and lung function assessment. The patients who participated in this study completed the Asthma Quality of Life Questionnaire (AQLQ) and Asthma Control Questionnaire (ACQ). Statistical analysis was performed using Epi Info version 6.04.
Setting and subjects: The clinical setting was the respiratory unit of the department of Medicine, University of Benin Teaching Hospital, Benin City, Nigeria. The recruited patients held various professions. A diagnosis of asthma was made using the clinical features of asthma and lung function measurements with a spirometer and MicroWright® Peak flow meters.
Outcome measures: The outcome measures were the quality of life score scores and clinical indices of asthma in patients attending the respiratory unit of the University of Benin.
Results: Subjects had significantly low lung function values when compared with the controls (p-value < 0.05). The quality of life of asthmatics was 4.82 ± 1.16 (1-7) and correlated with the duration of asthma (r = -0.83), body mass index, medication used (r = 0.96), asthma severity (r = 0.96) and gender (r = 1). The difference between male and female quality-of-life values was significant (p-value < 0.05). However, there was no correlation between age and quality of life (r = 0.06).
Conclusion: The overall assessment showed that quality of life with regard to asthma was low in this study, and correlated with some clinical asthma indices. The determinants of quality of life in this study included the duration of asthma, body mass index, asthma severity, medication use and gender.
End-user centeredness in antiretroviral therapy services in Nigerian public health facilities : original researchSource: South African Family Practice 56, pp 139 –146 (2014)More Less
Objective: To describe the perception of end users with regard to end-user centeredness in antiretroviral therapy (ART) service provision in Nigerian public health facilities.
Design: A qualitative design was followed.
Subjects and setting: Unstructured focus group discussions were conducted with end users (n = 64) in six locations across the six different geopolitical zones of Nigeria.
Outcome measures: Data were analysed using the framework approach and Weft QDA® version 1.0.1. qualitative data analysis software.
Results: The results focused on end users' participation in their care, ranging from understanding their diagnosis, choosing from available treatment options and places, and caring for their colleagues and themselves.
Conclusion: End-user focused ART service provision positions end users to play key roles in decision-making with regard to their care. The findings of this study will be useful for nurses and other healthcare workers when promoting end-user centeredness in ART service provision.
A focus group study on primary health care in Johannesburg Health District : "We are just pushing numbers" : original researchSource: South African Family Practice 56, pp 147 –152 (2014)More Less
Objectives: South Africa is striving towards a strong primary healthcare system. Since 2007, departments of family medicine have been established in Gauteng to improve quality of care through improved access to doctors, the coordination of health services and better referrals. There have been anecdotal difficulties around clinical quality, the role of the increasing number of doctors and the value of family medicine as a new speciality in Johannesburg since these changes. This study aimed to explore Johannesburg stakeholder views on clinical priorities, the role of doctors and family medicine in primary care.
Design: The study design comprised qualitative focus group discussions.
Setting and subjects: Groups of nurse clinicians, clinic managers, senior managers, doctors and interns within the Johannesburg Health District.
Outcome measures: The content was thematically analysed and a model developed.
Results: There were nine focus groups, with 6-13 participants per group. Addressing staff burnout and poor management were viewed as clinical priorities in primary care. Discussing the role of doctors reflected deep conflict between doctors and nurses. Nurses and managers expected doctors to help to "push the queues". It took some time for further roles, such as helping with referrals, training, research and administration, to emerge. There was initial confusion and tension when participants were asked about family medicine. However, its role was seen as useful.
Conclusion: Nurses appeared to suffer from burnout and resented the increasing burden placed on them with regard to primary care in Johannesburg. There appeared to be confusion with respect to the role of doctors, with doctor-nurse conflict and poor teamwork. This may threaten attempts to re-engineer primary health care in order to increase the presence of doctors at clinic level. The discipline of family medicine can make a difference, but reorganisation of the system is required.
Audit of antenatal care at a community health centre in Tshwane North subdistrict, Gauteng province : original researchSource: South African Family Practice 56, pp 153 –158 (2014)More Less
Objective: Few studies document the level of compliance with antenatal care protocols in primary health care in South Africa. The aim of this study was to conduct an audit of antenatal care at a community health centre in Tshwane North subdistrict in order to measure the level of compliance of maternity staff with antenatal care protocols. This study was part of a larger study on a quality improvement initiative in primary health care.
Design and setting: A retrospective cross-sectional descriptive study was undertaken of women attending antenatal care at the study clinic. Data were collected through a review of the women's antenatal cards using criteria from the Guidelines for maternity care in South Africa and the basic antenatal care (BANC) checklist. In addition, qualitative interviews of maternity staff were undertaken in order to investigate reasons for noncompliance with the maternity care guidelines.
Results: The overall rate of compliance of nurses was 85.1%. This is less than optimal. The response (decision-making and interpretation) component of compliance was only 57.6%. This represents a significant missed opportunity in terms of quality of antenatal care. Important protocols, such as that pertaining to the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus, were also not carried out correctly. The response to PMTCT protocols was 50% only, another significant opportunity missed. Administrative factors, patient-related factors and deficiencies in the knowledge and skills of nurses were identified and documented as reasons for noncompliance.
Conclusion: The study has provided a detailed picture of the situation with regard to non-compliance with the maternity care guidelines in a primary health care facility. Therefore, these data are very important in terms of quality assurance of maternity services in primary health care.