South African Family Practice - Volume 51, Issue 5, 2009
Volume 51, Issue 5, 2009
Author Gboyega A. OgunbanjoSource: South African Family Practice 51 (2009)More Less
As we move towards the end of 2009, this is the second to the last edition for the year. The CPD articles are diverse and cover interesting topics that I hope you will enjoy. The first article titled ''Alzheimer's disease in family practice'' by OBW Greeff is a unique one as it deals with an important illness that affects the aged.
Author O.B.W. GreeffSource: South African Family Practice 51, pp 364 –367 (2009)More Less
21 September 2009 is hailed as World Alzheimer's Day, creating awareness for the most common type of all the dementias. Senile dementia of the Alzheimer's type (SDAT) has a four to five year survival rate if a patient is living in the community and a much shorter survival rate for institutionalised patients. The family practitioner is often consulted first by family members who seek advice for a family member with suspected dementia and possibly Alzheimer's disease. Although a multi-disciplinary team approach is mostly needed, the family practitioner will in most cases co-ordinate referrals and advise family members on practical nursing aspects and decisions about institutionalisation. This article gives a short overview on SDAT, a classification of drugs used in dementia and a treatment approach to Alzheimer-specific pharmacotherapy.
Source: South African Family Practice 51, pp 368 –374 (2009)More Less
The term ''dermatitis'' (synonym: eczema) refers to a non-infectious, inflammatory disorder of the skin. There are different forms of dermatitis including seborrhoeic dermatitis (infantile and adult types), primary irritant dermatitis, allergic contact dermatitis, dermatitis associated with venous hypertension, dyshidrotic dermatitis (synonym: idiopathic vesicular dermatitis of the hands and feet), photoallergic dermatitis, HIV-associated dermatitis, nummular dermatitis and atopic dermatitis (AD). Atopic dermatitis is common and is the only form of dermatitis that may affect virtually the entire lifespan of an individual.
Author D.E. LubbeSource: South African Family Practice 51, pp 376 –380 (2009)More Less
Post-nasal drip (PND) can be a bothersome symptom and one of the main reasons for patients visiting a general practitioner (GP), pulmonologist or ear, nose and throat (ENT) surgeon. It can be either a symptom, sometimes not appreciated by the examining practitioner, or an important clinical sign suggesting rhinosinusitis. This article aims to explain the aetiological factors and initial work-up of the patient with a PND and rhinosinusitis and suggest a treatment paradigm for practitioners.
Source: South African Family Practice 51, pp 382 –386 (2009)More Less
This article forms the seventh part of the series on the role of lifestyle modification in general practice with specific reference to hypertension. Hypertension is defined as sustained resting blood pressure (BP) above 140/90 mmHg. Approximately 17% of the adult westernised population suffer from this disease. In most cases (> 90%) the cause is unknown and this is referred to as essential or primary hypertension. Untreated hypertension is associated with an increased risk of cerebrovascular disease, heart failure, kidney disease, and coronary artery disease. Lifestyle modifications to introduce healthy behavior are important in both the prevention and management of hypertension and details of these interventions are provided in this article.
Tuberculosis of the urinary tract and male genitalia - a diagnostic challenge for the family practitioner : CPDSource: South African Family Practice 51, pp 388 –392 (2009)More Less
Tuberculosis (TB) of the urinary tract and male genital system can be very difficult to diagnose unless a high index of suspicion is maintained. The most common presenting features of urogenital tuberculosis (UGTB) are lower urinary tract symptoms (LUTS), haematuria, recurrent urinary tract infection (UTI) by Gram-negative organisms, flank pain, and scrotal swelling. The classically described sterile pyuria should arouse suspicion of UGTB, but in about a third of patients a Gram-negative organism is cultured from the urine, so recurrent bacterial UTI should always be further investigated. Intravenous pyelography (IVP) remains the best imaging study available to screen for UGTB, but ultrasound and computerised tomography (CT) imaging can also be useful. The diagnosis of UGTB is most often confirmed with urine culture: at least 3-5 early morning urine specimens must be submitted and the results may take 4-6 weeks. Histological diagnosis on bladder or testicular biopsies can be made if granulomatous inflammation and Ziehl-Neelsen (ZN) positive organisms are seen. HIV-positive individuals are at greater risk of acquiring TB, and patients with confirmed or suspected UGTB should always be tested for HIV infection. Medical treatment of UGTB requires combination anti-TB drug therapy for at least six months. Patients should be followed up closely with monthly imaging because upper tract obstruction may develop due to fibrosis while on therapy. Surgery for UGTB can be extirpative (e.g. nephrectomy) or reconstructive (e.g. enterocystoplasty, to enlarge a fibrotic bladder). The outcome of UGTB is good if the diagnosis is made early, but delayed diagnosis may lead to loss of renal function.
Author Bernard LownSource: South African Family Practice 51, pp 393 –394 (2009)More Less
I was taken aback when an elderly patient confessed dejectedly that she didn't drink the eight glasses of water her physician had prescribed. I was astounded to learn that water loading for all comers pervades medical practice. But how robust is the scientific evidence and how did this come about? Innovations in clinical practice are usually based on accumulations of scientific breakthroughs. These are first published in medical journals and then trumpeted 24/7 in the media. Yet I could not recall a single scientific study on the benefits of increased water consumption.
Source: South African Family Practice 51, pp 396 –398 (2009)More Less
Background: Few diseases that confront the 21st century clinician have documented history which dates back to early human era.
Methods: We reviewed how the understanding of the aetiogenesis, symptomatology, diagnosis and treatment of gout including myths have evolved and discussed the implications thereof.
Results: Gout has been recognized as a clinical entity before 2000BC with Hippocrates describing the five aphorism of gout. Between the 1st and the 6th century AD, the role of genetics and the association of gout with an indulgent lifestyle and tophi were described. Hemodactyl (a source of colchicines) was also first identified during this period. ''Gout'' was coined from the Latin word ''Gutta' in the 13th century and the microscopy of uric acid crystals and gout symptomatology were the focus of investigations between the 17th and 18th centuries. Several drug treatments were developed between the 19th and 20th centuries including salicylates, probenecid and allopurinol. Gout as a risk factor for metabolic syndrome, NIDDM and cardiovascular disease is a challenge for the 20th century and the future.
Conclusion: The understanding of gout has evolved with human development but the challenges for the future will include how to deal with the associated cardiovascular co-morbidities.
Author Pierre De VilliersSource: South African Family Practice 51 (2009)More Less
The debate has begun. A National Health Insurance (NHI) system for South Africa is finally on the cards. It was contemplated by the Smuts government in 1941 but abandoned because of political opposition and funding limitations. The ANC government has finally committed itself to its 1994 electoral promise. This time around there is little political opposition, but will there be enough money and knowhow?
Author R. MashSource: South African Family Practice 51, pp 404 –407 (2009)More Less
Climate change is arguably the most important public health issue of the next decade. The impact of climate change should be understood in the broader context of population growth, degradation of ecosystems, inequality, food insecurity, urbanisation, slums and peak oil. Climate change is the result of deforestation and excess greenhouse gases from the burning of fossil fuels. Environmental consequences include rising global temperatures, melting of sea ice and glaciers, rising sea levels, flooding, more frequent and severe storms and changes in climatic patterns. Medical consequences stem from extreme climatic events, changes in the patterns of infectious diseases, increased food insecurity, displacement of populations, lack of fresh water and conflict over resources. South Africa has a relatively high carbon footprint. The health profession should respond as opinion leaders, as professional bodies and as an industry.
The role of doctors in provision of support for primary health care clinics in KwaZulu-Natal, South AfricaSource: South African Family Practice 51, pp 408 –412 (2009)More Less
Background : Most primary health care (PHC) services in South Africa are provided by registered nurses working in clinics. Workload and scope of practice of these nurses have increased in recent years, exacerbated by widespread staff shortages. However, PHC nurses often receive little support and supervision, particularly in relation to clinical practice. Doctors working at district level are usually hospital based, but in many cases they do undertake clinic visits. These visits have the potential to improve quality of care, increase continuity and provide support for PHC nurses. In this study the visits undertaken by doctors to PHC clinics are described. The interactions between visiting doctors and PHC nurses are also explored, including perceptions and experiences of the current role and activities of visiting doctors, and ways in which this role could be developed.
Methods: The study was conducted in three districts of northern KwaZulu-Natal between June and September 2007. Both quantitative and qualitative methods were used to collect data. Fifty-eight randomly selected PHC clinics were visited, and interviews were conducted with clinic managers to obtain quantitative data.
Focus group discussions (FGDs) were held with doctors and nurses in each district. The doctors' FGDs included doctors based in district hospitals who had experience of visiting clinics, and medical managers. Nurses currently working in PHC services were included in the nurses' FGDs.
Results: Fifty of the 58 clinics reported having regular visits from a doctor. On average, doctors spent three hours at the clinic. Activities during visits were mainly clinical: 49 clinics reported that doctors saw patients on chronic medication and 45 clinics reported that doctors attended to patients referred by the nurses. Twelve clinics reported that doctors spent time teaching staff during the visit. Thirty-two clinics reported that the doctor had attended all scheduled visits over the previous three months.
During focus group discussions, both doctors and nurses stated that doctors' visits were generally helpful, but both groups felt strongly that the time spent in the clinic during visits was too short, and that the doctor visiting the clinic changed too frequently. This disrupted the development of meaningful relationships between the visiting doctor and clinic staff.
The current role of the visiting doctor was mainly clinical, with up to 30 patients booked for each visit. Some concern was expressed about the care given to patients on chronic medication given the time pressures. Doctors felt that a lack of essential equipment and drugs at the clinic limited the value of the visits, and that patients frequently were referred inappropriately. Nurses expressed concern that doctors often arrived late and were unwilling to help with the heavy patient workload at the clinic.
Additional roles identified for doctors included an increased role in teaching, development of teamwork and communication, as well as an increased administrative role.
Conclusions: Doctors' visits are not being utilised to their full potential. Additional support for PHC nurses could be provided by doctors if clear roles and activities were set out for clinic visits. These should include skills training for clinic nurses, development of clear referral criteria, and improved communication and feedback. Doctors should spend more time at the clinic during visits and work at the same clinic for a longer period. Expanding the doctors' role would improve teamwork within districts, leading to improvements in the work environment and quality of care. However, this requires commitment of district hospital managers to support doctors in their role and ensure that clinic visits are given priority.
Prescribing of methylphenidate to children and adolescents in South Africa : a pharmacoepidemiological investigation : original researchAuthor I. TruterSource: South African Family Practice 51, pp 413 –417 (2009)More Less
Background: Pharmacoepidemiological studies on ADHD are limited in South Africa. The primary aim was to analyse the prescribing of methylphenidate to patients aged 18 years and younger in the private health care sector.
Methods: Data for a one-month period in 2004 were obtained from a large medical aid administrator. Data were retrospectively analysed. The total database contained medicine records for 355 998 patients.
Results: A total of 66 450 medicine items were prescribed to 34 733 patients aged 18 years and younger. A total of 1 028 patients received prescriptions for methylphenidate. Nearly 3% of children and adolescents therefore received prescriptions for methylphenidate. The average age of these patients was 10.87 (SD = 2.79) years. Most of these prescriptions (63.14%) were for children between seven and twelve years of age. Most prescriptions were for long-acting methylphenidate in 20 mg, 30 mg and 40 mg capsules (48.87%). The average prescribed daily dose (PDD) for methylphenidate was 19.27 (SD = 11.87) mg. The most popular average PDD was 20 mg (42.63% of all methylphenidate prescriptions). The highest average percentage of methylphenidate prescriptions was in the Western Cape (2.58%), and the lowest in the Northern Cape (0.63%).
Conclusions: Numerous claims are being made that methylphenidate is overused or even abused, especially in children of school-going age. Most prescriptions were issued in metropolitan areas in this study, but overuse could not be established. This study was a preliminary study that can lead to more comprehensive studies in future.
An investigation into the dramatic increase in deaths from gastroenteritis during the summer of 2007 / 08 at National District Hospital, Bloemfontein, Free State : original researchSource: South African Family Practice 51, pp 418 –422 (2009)More Less
Introduction and background: Despite national guidelines and agreed upon admission and referral criteria for children in National District Hospital (NDH), Bloemfontein, the number of children admitted with gastroenteritis (GE) has increased dramatically since December 2007. From the previous year's Child Healthcare Problem Identification Programme (Child PIP) data the increase in GE admissions was evident in NDH. During the preceding year, 123 children were admitted for GE and during the audit period 267. The number of deaths in NDH also increased from an average of 2.25 a month over the past 3 years to 10 a month during January and February 2008.
Aim: The aims of the study were: to determine the causes of death of children in NDH; to determine the relationship between nutritional status, HIV disease, laboratory results, demographic data, time of admission, duration of admission and other diseases or conditions and GE child deaths in NDH; to determine whether doctors adhered to prescribed GE treatment protocols; to determine whether nursing personnel carried out doctors' orders as prescribed; and to identify other factors that contributed to GE deaths.
Methodology: A cross-sectional study design was used. All child deaths, as well as all children admitted with GE to Ward 3 in NDH from May 2007 to April 2008 were included in the study. The first author collected the information on a cause of death form, a data form and an audit tool. As part of the quality-improvement project, 10 items were assessed to determine whether doctors adhered to treatment protocols, and 10 items were assessed to determine whether nurses adhered to nursing orders and basic nursing care. Any other factors that contributed to poor care were also noted.
Results: 1. Cause of death: During this period, 49 children died, 33 (67%) due to GE, 6 (12%) due to tuberculosis (TB), 5 (10%) due to septicaemia, 4 (8%) due to pneumonia and 1 (2%) due to congenital abnormalities. Only 4.1% of the children who died were considered as normal weight for age according to their Road to Health Chart (RTHC). Regarding HIV status, 82.5% of the children who died tested HIV positive. In total, 19.4% of all GE admissions died during this one-year period. 2. GE deaths : Demographic data such as gender and age did not influence the outcome of GE. As expected, severe malnutrition, HIV-positive status and severe dehydration all contributed statistically significantly to high mortality in GE. Severe abnormalities occurred in the laboratory results of most of the children who died and indicated the severity of their disease(s). No specific organisms were cultured from stool specimens and the quality of drinking water in Bloemfontein was declared safe for human consumption. 3. Other factors that contributed to GE deaths : Medical and nursing care were of a high standard and treatment protocols were followed. Pre-admission factors such as transport, non-availability of 24-hour medical services, non-initiation of emergency treatment before referral, and caregivers not realising the severity of the disease need urgent attention to prevent further deaths.
Conclusion: GE contributed to 67% of deaths in the paediatric ward of NDH. Underlying poor nutritional status and / or HIV disease were present in 96% of the GE deaths. In more than nine out of ten cases the doctors and nurses in the hospital rendered medical care in accordance with standard guidelines. Pre-admission factors need to be addressed in order to prevent more deaths.
An evaluation of the knowledge, attitude and practices of South African university students regarding the use of emergency contraception and of art as an advocacy tool : original researchSource: South African Family Practice 51, pp 423 –426 (2009)More Less
Background: This study assessed the knowledge and use of emergency contraception (EC) against the background of current sexual practices among a multi-racial student population at the Durban University of Technology (DUT) in the province of KwaZulu-Natal, South Africa. In addition, the use of art as an advocacy tool in promoting awareness of EC and related sexual issues was also evaluated.
Methods: A random sample of 162 students with equal representation of race and gender was interviewed. The questionnaire used addressed knowledge, attitudes and practices regarding contraception, with emphasis on EC and current sexual practices. It was administered by trained interviewers at three different sites at the DUT, where the Kara Walker image was also displayed on banners by Art for Humanity (AFH).
Results: Over 77% of participants indicated that EC was some sort of birth control or contraceptive method. Only 51% of the respondents felt that EC was a good form of contraception and 27% of all students indicated that it should not be used at all. However, given a choice, 66% of African students would use it, compared to 46% Indian, 31% coloured and 52% white students. The various levels of undergraduate study (i.e. first to third year) did not impact on the level of knowledge of or attitude towards the use of EC among students. Students had health and social concerns, including that if more men were informed about EC, they may use it to pressure women into having unprotected sex. Over 90% of students knew that EC did not provide protection from HIV, AIDS and STDs. Of the 162 students questioned, only 21% had seen the Kara Walker poster and their responses to the banner were varied. While a few students thought that it was an inappropriate portrayal of women, most students who saw the banner thought it was effective in drawing attention to the consequences of unsafe sexual practices.
Conclusion: It is imperative that concise information and pre- and post-counselling be provided by health care professionals to empower individuals at tertiary institutions to make informed choices with respect to reproductive health. Proper dissemination of information will create awareness and enhance wider acceptance and the use of the arts as an advocacy tool may further promote health education.
Systemic isotretinoin in the management of acne - a patient questionnaire survey : original researchSource: South African Family Practice 51, pp 427 –433 (2009)More Less
Background: The primary aim was to investigate the appropriateness (as outlined in the South African Acne Treatment Guideline) for the prescription of systemic isotretinoin in the management and counselling of acne in the Nelson Mandela Bay Metropole.
Methods: A questionnaire was distributed to patients receiving systemic isotretinoin by 30 community pharmacies. The response rate was 29.2% (57 respondents).
Results: The acne medication history revealed that commercial brands of beauty products were used by 57.9% of respondents, topical benzoyl peroxide by 22.8%, and systemic cotrimoxazole by 19.3%. Only nine females used an oral contraceptive as acne treatment prior to isotretinoin. The average daily dose of isotretinoin was 44.2 (SD=16.9) mg. Half of the respondents received a suboptimal cumulative dosage of isotretinoin. The average prescribed duration of isotretinoin therapy was 6.2 months. Adequate counselling was received by only 57.9% of patients. A third of the patients who were able to fall pregnant received recommendations for contraception. Pregnancy tests were conducted in only two females. Just over40% of patients reported a complete clearance of acne lesions.
Conclusions: Many prescribers did not follow the recommendations for isotretinoin prescription. The counselling of patients regarding isotretinoin therapy was substandard, especially with respect to pregnancy prevention.
Letter : protective role of vitamin D as a cellular immuno-modulator in Mycobacterium tuberculosis infected health care workers : correspondenceAuthor M. PanajatovicSource: South African Family Practice 51 (2009)More Less
I would like to raise a concern about health care workers' (HCW) exposure to Mycobacterium tuberculosis. Tuberculosis (TB) is a significant occupational problem among HCW in low- and middle-income countries. The greatest single risk factor for developing TB from infection is concurrent HIV infection. In the period from 1994 to 2006, TB incidence increased 4.2 times in South Africa (SA) while it was halved in the United States of America (USA). The risk ratio, based on the ratio of the incidence of TB, is over 300 times higher for HCW in SA than in the USA in 2006 (1 133 vs 3.7 per 100 000).
Letter : why do patients leave our practice? A qualitative investigation into the reasons contributing to patients' decisions to leave a multi-partner general practice : correspondenceSource: South African Family Practice 51 (2009)More Less
Doctors in private practice have by and large been uncertain as to the reasons why often their most loyal patients are the ones that leave them to attend another practice. Studies abound on the determinants of patient satisfaction in specific areas of general practitioner (GP) practice, but very little research has been conducted on the key determinants which cause a patient to leave a GP practice.