South African Family Practice - Volume 57, Issue 4, 2015
Volume 57, Issue 4, 2015
Author Gboyega A. OgunbanjoSource: South African Family Practice 57 (2015)More Less
A recent South African newspaper headline reads - "State employees fail to disclose chronic mental illnesses". The article states that the Government Employees Medical Scheme (Gems) data, showed that at least 32 069 state employees suffer from chronic depression. Furthermore employees and Gems principal members diagnosed with bipolar disorder stood at 5837, with those suffering from schizophrenia at 727.1 If this data is true, there are serious concerns on how we manage mental health in the civil service. Of more concern are civil servants with major depression and other mental health conditions who are managed outside Gems, which include other medical aid schemes, public health system and traditional healers whose data are not included. However, let us focus on available data.
Author P. ZinnSource: South African Family Practice 57, pp 5 –9 (2015)More Less
Chronic pelvic pain is defined as pain in the pelvis lasting for more than six months (some say three). The pain may be experienced in any of the structures of the pelvis, including the gynaecological organs; the lower urinary and gastrointestinal tract; and the vascular, neural and musculoskeletal systems. The pain can be continual, cyclical, provoked or unprovoked, and is frequently multifocal. A woman who complains of painful sex, for example, may also report vulvovaginal pain and dyspareunia; bladder frequency, urgency and suprapubic pain, as well as irritable bowel symptoms. Although an initiating event is sometimes described, such as an episode of severe "thrush" or cystitis, or following pelvic surgery or childbirth, this initial insult may be long forgotten and no longer relevant. Vulvodynia, endometriosis, bladder pain syndrome and irritable bowel syndrome are common causes of chronic pelvic pain in women but are often misdiagnosed and poorly managed.
Author S. DavisSource: South African Family Practice 57, pp 11 –15 (2015)More Less
Allergic conjunctivitis can be classified as an acute or chronic condition. Acute allergic conjunctivitis encompasses seasonal allergic conjunctivitis and perennial allergic conjunctivitis. The more severe chronic conditions include vernal keratoconjunctivitis, acute keratoconjunctivitis and giant papillary conjunctivitis. The mainstay in the treatment of allergic conjunctivitis remains the use of topical dual-acting agents which have mast cell stabilising properties and act as antihistamines. Although corticosteroids are among the most effective agents in the treatment of allergic conjunctivitis, they can cause serious adverse effects and their use should be reserved for short-term "pulse" treatment to gain quick control of the symptoms. Topical nonsteroidal anti-inflammatory drugs can also cause corneal melting. However, their use may be considered in severe cases to reduce the use of topical steroids. Several new agents acting at newly identified targets in the inflammatory process are under investigation for the treatment of allergic conjunctivitis.
Source: South African Family Practice 57, pp 17 –24 (2015)More Less
Allergic diseases are on the increase globally. There has been a doubling in the number of scholars suffering from allergy-related disease in the past two decades. This article describes the predisposing factors which contribute to an increased incidence of allergies within the population. These factors include a genetic predisposition, allergen exposure, abnormalities in the bowel flora and infection exposure. Some of these relate to the hygiene hypothesis and the micro-flora hypothesis, which are discussed in this article. Treatment options for those suffering from allergic disease are also discussed, with an emphasis on asthma, anaphylaxis, allergic rhinitis and a topic dermatitis.
Author A. MaraisSource: South African Family Practice 57, pp 27 –30 (2015)More Less
The inability to attain or maintain a penile erection sufficient for sexual intercourse is a common problem experienced by a third of men over the age of 40 years. Erectile dysfunction (ED) is a debilitating disease which can have profound psychological effects on personal relationships and the social well-being of the affected individual. The diagnosis and evaluation of sexual dysfunction has been well described, and several validated algorithms are available to quantify the classification and severity. The International Index of Erectile Function and the Sexual Health Inventory for Men questionnaires are commonly used in the initial assessment of ED. Several risk factors have been linked to the pathophysiology of ED. Endothelial damage has been the focus of many recent studies. An evaluation of cardiovascular status, in addition to the administration of questionnaires to men with ED, might reduce mortality and improve sexual quality of life.
Source: South African Family Practice 57, pp 31 –36 (2015)More Less
Asthma is a chronic inflammatory disease that causes hyper-responsiveness of the bronchial tree, with reversible airflow obstruction. The condition places a significant burden on our healthcare system. Chronic asthma can cause remodelling of the airway. Patients suffering from asthma should be aware of its signs and symptoms, as well as factors that can precipitate an asthmatic attack. Asthma is mostly classified as either acute or chronic. The diagnosis of asthma is based on identification of both a characteristic pattern of respiratory symptoms and variable expiratory airflow limitation. Treatment is based on how the patient presents, and includes bronchodilators, inhaled corticosteroids and mast cell stabilisers. This article provides an overview of the diagnosis, characterisation and treatment of asthma.
Source: South African Family Practice 57, pp 41 –44 (2015)More Less
The new series, "Mastering your Fellowship", provides examples of the question format encountered in the written examination, Part I of the FCFP (SA) examination. Examples of these question types (according to a theme) will be given in each printed edition of the journal. "General adult medicine" is the theme for this edition and model answers will be available online, but not in the printed edition.
Author Chris EllisSource: South African Family Practice 57 (2015)More Less
In general practice we often use many peripheral little bits of information to help us make our diagnoses and to organise our management plans. Like the title of this column they are the peripheralia and marginalia that we glean, almost subconsciously, from items or artifacts that are apart from the patient's grand narrative. It might be a photograph,a throw away comment by a staff member or a relative, a letter written to us by the patient or a paragraph in a local newspaper or some form of self-observation or reaction that one has to a patient. These sources of information from our peripheral vision and practice background are called non-obtrusive sources and the persons who interact with the index patient and ourselves are called secondary actors.
Source: South African Family Practice 57, pp 227 –230 (2015) http://dx.doi.org/10.1080/20786190.2015.1024026More Less
Background: Patients with adverse cutaneous drug reactions (ACDRs) are frequently referred from primary care to tertiary centres for further management. This causes a loss of information regarding ACDRs as these patients discontinue primary care follow-up upon referral to tertiary care. The aim of this study is to determine the prevalence and characteristics of ACDR, and to use this valuable information to enhance awareness of primary care physicians regarding this condition.
Method: A retrospective cross-sectional study on ACDR was done at the Dermatology Clinic, Kuala Lumpur General Hospital from January 2009 to December 2010.
Results: The prevalence of ACDR was 0.2%. The majority of patients (71.6%) were below 59 years of age. ACDR commonly (55.2%) occurs within hours to days of drug ingestion and is of mild to moderate severity (74.6%). About 27.6% of affected patients took 1to 5 drugs concurrently. Common cutaneous manifestation of ACDR includes maculopapular rash (22.4%) and Stevens-Johnson syndrome (SJS, 9.7%). Antibiotics (36.6%), traditional and complementary medicine (TCM, 17.9%) and analgesics (13.4%) were the most frequent agents responsible for ACDR.
Conclusion: The prevalence of ACDR in this study is low and the majority were of mild to moderate severity. The most common cutaneous manifestation was a maculo papular reaction and Stevens-Johnson syndrome. Antibiotics were the common estcausative agent for ACDR followed by traditional and complementary medicine and analgesics. Patients presenting with cutaneous disorders in primary care should be assessed for possible ACDR. A detailed drug history, time of initiation and duration of drug consumption are all valuable information required for an accurate diagnosis and proper evaluation of ACDR. It is hoped that the findings of this study will facilitate early recognition of ACDR followed by identification and elimination of any possible offending drugs that may be prescribed in primary care practice.
Source: South African Family Practice 57, pp 231 –235 (2015) http://dx.doi.org/10.1080/20786190.2015.1024021More Less
Background: Despite the threat of resistance, the use of antibiotics globally is high and continues to increase. Much of this use is attributed to over-prescribing by physicians. The objective of this study was to assess doctors' management of common community-acquired infections in Namibia.
Methodology: A cross-sectional survey based on a web-based self-administered questionnaire was conducted. Doctors belonging to the local professional associations comprised the study population. Data were collected from March to July 2014.
Results: A 10% (n = 44) response rate was achieved. Respondents were from across the country and practised mainly in the private health sector. Both awareness of local antimicrobial sensitivity rates and ownership of national Standard Treatment Guidelines were poor (20% and 31% respectively). Common practice in managing common infections, with the exception of chronic otitis media, cystitis and pyelonephritis, is to treat empirically. The reported first-line antibiotics of choice were the combination of amoxicillin with clavulanic acid for upper respiratory tract infections and ciprofloxacin for urinary tract infections.Management of infections was the same across all socio-demographic factors and was not influenced by patient workload.
Conclusion: This survey revealed that first-line antibiotic choices of doctors are not informed by the Namibia Standard Treatment Guidelines and the local and regional antimicrobial sensitivity data. Interventions to improve antibiotic prescribing in Namibia should include better dissemination of guidelines and information regarding local antimicrobial sensitivity rates as well as strategies for the implementation of guidelines.
Flexibility as risk factor for stress-fracture development in South African male soldiers : researchSource: South African Family Practice 57, pp 236 –240 (2015) http://dx.doi.org/10.1080/20786190.2015.1024017More Less
Background: Stress fractures are a common military training injury. Flexibility of muscles and joints may directly influence stress-fracture risk by way of altering the forces applied to bone. Hip external rotation and ankle plantar- and dorsiflexion have been inconsistently reported to pose a risk to stress fracture development in military soldiers. Thus this study aimed to present results that could help define the risk flexibility may pose in the development of stress fractures amongst military male soldiers.
Methods: An experimental one-group pretest-posttest study design assessing the injury incidence, bilateral hip externalrotation, ankle plantar- and dorsiflexion of South African male military soldiers (n = 100) undergoing 12 weeks of basic military training (BMT) was undertaken. The parametric t-test for dependent samples (Î± = 0.05) and effect size (ES) was used to analyse the data.
Results: No stress fractures were diagnosed in the 100 operational military training injuries reported. BMT resulted in significant mean decreases of 10% (L) and 17% (R) in hip external rotation and 18% (L) and 14% (R) in ankle plantar flexion respectively, whilst a significant increase of 37% (L) and 39% (R) dorsiflexion was observed.
Conclusions: Although normal ankle and limited hip external flexibility do not appear to predispose these male soldiers to stress fracture development these variables should not be excluded as possible intrinsic risk factors.
Source: South African Family Practice 57, pp 241 –246 (2015) http://dx.doi.org/10.1080/20786190.2015.1014154More Less
The promotion of epidural and spinal blocks as preferred and safe techniques for Caesarean section and the use of lumbarpuncture for diagnostic and therapeutic purposes place patients at risk of developing postdural puncture headache (PDPH). This article reviews the literature for evidence that provides an approach to diagnosis and management of this condition for the primary care physician.
A dull and throbbing, bilateral headache associated with changes in posture (worsened by sitting and standing, and better lyingdown), that develops within seven days of a lumbar puncture or an inadvertent dural puncture must raise the suspicion of PDPH. The exact causative mechanism is unclear but symptoms of PDPH are generally attributed to excessive loss of cerebrospinal fluid (CSF). The risk of PDPH is increased with the use of cutting and large-bore needles, and with horizontal orientation of the needle bevel. Given that symptoms overlap, other organic causes of headache such as intracerebral/subdural haemorrhage, pneumocephalus, central nervous system infections, adverse effects of anticoagulants and functional headaches such as migraine must be excluded.
Although the initial management of PDPH comprises several conservative interventions, evidence is only available for the effectiveness of the usage of caffeine, analgesics, gabapectin, hydrocortisone, dexamethasone and cosyntropin. Epidural blood patch (EDBP) offers the most favourable outcomes for patients who fail to respond to conservative management. However, given the lack of skills for performing EDBP in primary care, such patients should be referred to secondary or tertiary level of care.
Prostate cancer profile and risk stratification of patients treated at Universitas Annex Department of Oncology, Bloemfontein, Free State, during 2008 to 2010 : researchSource: South African Family Practice 57, pp 247 –252 (2015) http://dx.doi.org/10.1080/20786190.2014.993859More Less
Background: Prostate cancer commonly occurs in older men. Since TNM staging excludes prostate-specific antigen (PSA) level and Gleason score, patients with prostate cancer are divided into risk groups when deciding on treatment options. This study determined the profile and risk stratification of patients with prostate cancer treated at the Department of Oncology, Universitas Annex in Bloemfontein, Free State, during 2008 to 2010.
Methods: This was a cross-sectional study with retrospective data collection. Information was gathered from 497 patient files on age, race, residence, Gleason score, PSA level, TNM stage, and initial treatment. The patients' risk group was determined from their Gleason score, PSA level, and T stage.
Results: Patients were mostly (45.7%) between 65 and 75 years of age and 72.8% were in the black race group. The largest percentage of patients had a Gleason score of 8 to 10 (43.7%), PSA level > 20 ng/ml (67.9%), and a T stage ≥ T3 (62.3%). Almost half of the patients (48.7%) had stage IV disease and 38.4% received palliative hormonal therapy as initial treatment. The majorityof patients (82.5%) fell into the high risk group.
Conclusions: The majority of patients in each age group fell into the high risk group, which means that these patients were at a higher risk of developing metastatic prostate cancer. We recommend better education of our patient population and local clinic staff, so that people in the community can understand the prevalence of the disease, the symptoms and effect of the cancer, and that it is treatable if detected early.
Pattern of inappropriate cases presenting to the accident and emergency department in a Nigeria tertiary hospital : researchSource: South African Family Practice 57, pp 253 –258 (2015) http://dx.doi.org/10.1080/20786190.2014.978114More Less
Background: Although the primary mission of the Accident and Emergency Department (AED) is to provide initial treatment for life-threatening conditions, some patients make inappropriate use of the service. This study is aimed to determine the level of inappropriate use and the morbidity pattern of such patients presenting to the department in a tertiary hospital in Nigeria.
Materials and methods: A cross-sectional descriptive study in which inappropriate users of the AED of University of Port Harcourt Teaching Hospital were recruited. Data on socio-demographic characteristics and diagnoses based on ICPC-2 were collected from them and analysed using SPSS version 17.
Results: A total of 430 patients were recruited with age range of 18-62 years and mean of 38.45 ± 7.2 years. Considering the socio-demographic characteristics, only the association between gender and utilisation of the AED was statistically significant (p = 0.014). The prevalence of inappropriate use of the AED was 37 7%. The most frequent diagnosis among inappropriate users using the ICPC rubrics was polyuria and glycosuria (9.88%). When the cases were listed by the organ systems according to ICPC chapters, it was found that the commonest diagnoses were gastrointestinal (20.9%) and general and unspecified conditions (17.7%). Psychological conditions were not identified in this study. The most common reason for inappropriately presentation at the AED was patients referring themselves for quick attention (46.3%).
Conclusions: The level of inappropriate utilisation of the accident and emergency department was very high in this institution. Creation of public awareness will curtail this sickness behaviour.
Source: South African Family Practice 57, pp 259 –260 (2015) http://dx.doi.org/10.1080/20786190.2014.978094More Less
Background: Very limited published data exist on the spectrum of mental health disorders encountered at primary health care (PHC) facilities in South Africa.
Methods: The original data from a recent study were analysed with regard to its useful set of data on patients with mental disorders in primary care clinics in Cape Town.
Results: Schizophrenia and bipolar disorder accounted for the majority of visits, with common mental disorders (depression, anxiety disorders, substance use disorders) accounting for only a minority of visits. Furthermore, the mental health population in the study had significantly fewer chronic disease co-morbidities than the non-mental health patients.
Conclusion: There is an urgent need to screen better for common mental disorders in primary care patients in South Africa, and to screen for chronic medical diseases in patients with serious mental illness.
Intern to independent doctor : basic surgical skills required for South African practice and interns' reports on their competence : researchSource: South African Family Practice 57, pp 261 –266 (2015) http://dx.doi.org/10.1080/20786190.2014.976954More Less
Background: The role and scope of general practitioners in semi-urban and rural areas is poorly understood and documented. An absence of specialist support results in generalists being called to perform surgical procedures. It is imperative that they competently and confidently perform specific surgical procedures.
Method: This cross-sectional study identified a list of agreed surgical procedures in which generalists should be competent. Enquires were made about generalists' competence in performing such skills and training junior doctors how to use these them. Interns were asked about the quality of their exposure to and their perceived competence in the skills. A questionnaire was given to interns who completed their internship in 2008 in Mpumalanga and Gauteng, and another to generalists affiliated to the University of Pretoria. Data were analysed descriptively using Microsoft® Excel®.
Results: The response rate was 31% and 21% for the interns and generalists, respectively. There was agreement on specific core skills in training. Most generalists (81%) lacked the competence to provide training on some of the specific core skills needed for independent practice. Most of the internships were completed in semi-urban areas (62%). The majority of the interns perceived themselves to be competent in Caesarean sections, the excision of lumps and bumps, and abscess drainage. Interns from urban areas rated themselves as being incompetent in the core surgical skills. Interns who worked in semi-urban regions felt competent in core surgical skills.
Conclusion: The training of interns should be supervised by senior doctors in in-service training settings. Basic surgical skills and in-service training can be taught during family medicine rotation internships by surgically skilled family physicians and generalists in semi-urban areas and district hospitals.
Author G.M. ModySource: South African Family Practice 57, pp 267 –272 (2015) http://dx.doi.org/10.1080/20786190.2015.1047148More Less
Gout is now the leading cause of inflammatory arthritis, affecting 1-2% of the population. The metabolic syndrome, cardiovascular risk factors, cardiovascular events and mortality are more common with gout. However, the role of uric acid as an independent risk factor is inconclusive. The identification of urate transporters has improved our understanding of urate homeostasis and identified targets for the development of newer drugs. Experience with ultrasound and dual energy computed tomography led to the detection of urate crystals in patients with asymptomatic hyperuricaemia. Several evidence-based management guidelines are now available. The dietary and lifestyle recommendations focus on general health and management of comorbidities. A low dose colchicine regimen is effective and better tolerated than the traditional use of higher doses in acute gout. Alternative measures for acute gout includenon-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids. Allopurinol is the most widely used initial therapy; treatment is started with 100 mg or less per day, and titrated upwards to achieve a target level of 0.36 mmol/l (in patients with tophi, a lower target of 0 30 mmol/l is recommended). A new non-purine more potent xanthine oxidase inhibitor, febuxostat, is available (currentlynot registered in South Africa). Probenecid is the most widely used uricosuric agent. Prophylactic therapy with colchicine, NSAIDs or corticosteroids is used when urate lowering therapy is initiated. Although the cause of gout is known and effective treatment is available, gout is poorly managed worldwide with failure to achieve the target urate level.
An observational study on factors influencing antibiotic use in chronic obstructive pulmonary disease at Universitas Academic Hospital, Bloemfontein : researchSource: South African Family Practice 57, pp 273 –276 (2015) http://dx.doi.org/10.1080/20786190.2015.1047144More Less
Background: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are often precipitated by excessive airway inflammation caused by viral or bacterial infections. Current guidelines suggest prescribing antibiotics to patients with AECOPD and purulent sputum production, but this may lead to unnecessary or inappropriate antibiotic use. The aim of this study was to identify clinical and laboratory variables influencing antibiotic prescriptions of clinicians managing patients hospitalised for AECOPD.
Methods: An observational study was conducted among patients hospitalised with AECOPD. Antibiotic prescriptions were compared with sputum appearance, white blood cell count, C-reactive protein (CRP) levels and sputum cultures. Treatment outcomes were assessed on days 3 and 5 after admission.
Results: Thirteen patients were included in the study, from July to October 2013, at Universitas Academic Hospital, Bloemfontein. Antibiotics were prescribed in seven out of eight patients with an elevated CRP level. None of the patients with reported sputumpurulence received antibiotics. White blood cell count and sputum cultures did not seem to influence antibiotic prescription habits.
Conclusions: Clinicians managing patients with AECOPD do not follow guidelines that suggest prescribing antibiotics to patients presenting with purulent sputum production. Further studies on whether biomarkers such as CRP may be more acceptable as a deciding factor on which to base antibiotic prescriptions are required.
Sex differences in correlates of obesity indices and blood pressure among Malay adults in Selangor, Malaysia : researchSource: South African Family Practice 57, pp 277 –281 (2015) http://dx.doi.org/10.1080/20786190.2015.1016719More Less
Background: Obesity is a risk factor for many chronic diseases and related morbidity and mortality. It is imperative to identify the best index of obesity which has the strongest relationship to blood pressure in various populations. The main aim of this study was to determine the sex differences in correlates of four frequently used obesity indices among Malaysians.
Method: A cross-sectional study which recruited 1 530 Malay respondents was conducted in four villages in a district of Selangor state, Malaysia from June until October 2011. Blood pressure and anthropometric indices were recorded using a structured data sheet and data were analysed using SPSS version 17.0.
Results: The body mass index cut-off point for the general population shows more overweight than obese respondents for both sexes (male [overweight: 30.7%, obese: 13.8%]), (female [overweight: 32.8%, obese: 21.8%]). The body mass index cutoff point for Asians shows more overweight males compared with obese male respondents (35.8% vs 26.1% respectively) and more obese female compared with overweight female respondents (36.1% vs 32.9% respectively). There were more respondents with abdominal obesity by Asians' cut-off point for waist circumference across sexes. Almost half of the male respondents have abdominal obesity by waist circumference with both cut-off points. Female respondents according to Asians' cut-off point have a higher prevalence of abdominal obesity by waist-to-hip ratio compared with women categorised by the general population cut-off point (76 3% vs 55.1% respectively). The majority of the respondents across sexes have a high prevalence of abdominal obesity by waist-to-height ratio. Males had significantly higher mean values for systolic blood pressure, diastolic blood pressure and waist-to-hip ratio compared with female respondents, while females had a significantly higher mean for body mass index and waist-to-height ratio compared with male respondents. There was no significant mean difference for WC betweensexes. All indices of obesity were significantly and positively correlated with both systolic blood pressure and diastolic blood pressure. The waist-to-height ratio shows the strongest correlates with systolic blood pressure across sexes (male: r = 0.291 and female: r = 0.294) compared with diastolic blood pressure. Waist circumference correlates most strongly with diastolic blood pressure among male respondents (r = 0.266) and body mass index correlates most strongly with diastolic blood pressure amongfemale respondents (r = 0.250).
Conclusion: Waist-to-height ratio performed better than BMI, WC and WHR for its correlates with systolic blood pressure across sexes. Diastolic blood pressure correlates most strongly with waist circumference among male respondents and it correlates most strongly with body mass index among female respondents. The waist-to-height ratio could be a simple and effective tool to screen for high blood pressure among the Malay population. Future research might look into a sex-specific abdominal obesity index for screening of cardiovascular risk factors.