South African Family Practice - Volume 54, Issue 5, 2012
Volume 54, Issue 5, 2012
Source: South African Family Practice 54 (2012)More Less
It is reported that there is grade I evidence that male circumcision reduces the risk of men acquiring human immunodeficiency virus (HIV) infection. This is based on three large randomised controlled trials (RCTs) on male circumcision that were undertaken in Africa, at Orange Farm, South Africa; Rakai, Uganda; and Kisumu, Kenya. The findings were published in The Lancet and The Journal of Infectious Diseases between 2007 and 2009. Over 10 000 men were circumcised at the three sites. The reported protective effect of male circumcision against HIV were Orange Farm (60%), Rakai (48%), and Kisumu (53%).
Author S. AbbottSource: South African Family Practice 54, pp 379 –381 (2012)More Less
Children with upper respiratory tract infections are commonly encountered in general practice. Most respiratory infections, including acute otitis media, a sore throat and sinusitis, are self-limiting, and symptomatic treatment is usually adequate. Despite this, upper respiratory tract infection may still be problematic owing to inappropriate use of corticosteroids, over-the-counter medicines and antibiotics in an attempt to prevent secondary bacterial infection. This increases the burden of antibiotic resistance and causes unnecessary side-effects for the patient. Usually, little benefit is obtained as the course of the disease is not altered. The South African guideline for the management of upper respiratory tract infections has made recommendations based on appropriate pathogens and relevant publications.
Author D.Y. GaitondeSource: South African Family Practice 54, pp 384 –390 (2012)More Less
Hypothyroidism is a clinical disorder commonly encountered by the primary care physician. Untreated hypothyroidism can contribute to hypertension, dyslipidaemia, infertility, cognitive impairment, and neuromuscular dysfunction. Data derived from the National Health and Nutrition Examination Survey suggest that about one in 300 persons in the United States has hypothyroidism. The prevalence increases with age, and is higher in females than in males. Hypothyroidism may occur as a result of primary gland failure or insufficient thyroid gland stimulation by the hypothalamus or pituitary gland. Autoimmune thyroid disease is the most common aetiology of hypothyroidism in the United States. Clinical symptoms of hypothyroidism are nonspecific and may be subtle, especially in older persons. The best laboratory assessment of thyroid function is a serum thyroid-stimulating hormone test. There is no evidence that screening asymptomatic adults improves outcomes. In the majority of patients, alleviation of symptoms can be accomplished through oral administration of synthetic levothyroxine, and most patients will require lifelong therapy. Combination triiodothyronine/thyroxine therapy has no advantages over thyroxine monotherapy and is not recommended. Among patients with subclinical hypothyroidism, those at greater risk of progressing to clinical disease, and who may be considered for therapy, include patients with thyroid-stimulating hormone levels greater than 10 mIU/l and those who have elevated thyroid peroxidase antibody titres.
A practical approach to urine dipstick test abnormalities in relation to kidney and urinary tract disorders in children : CPD articleAuthor G. Van BiljonSource: South African Family Practice 54, pp 392 –396 (2012)More Less
The routine use of urine dipstick testing in the consulting room of the family physician has fallen into disfavour for several reasons. One of the arguments cited most often is that it is time consuming and not cost beneficial. This is particularly true with respect to small children, because of the difficulties experienced collecting urine from this group of patients. The aim of this review is to stress the important role that urine dipstick testing plays in the diagnostic work-up of any patient with a kidney or urinary tract disorder. A practical approach is provided on urine dipstick test abnormalities in relation to kidney and urinary tract disorders in children.
The management of acute low back pain in adults : a guide for the primary care physician : CPD articleAuthor S.W. BrightonSource: South African Family Practice 54, pp 398 –403 (2012)More Less
To diagnose patients with acute low back pain (LBP), a focused physical examination needs to be conducted and a detailed history obtained. The patient should then be placed into one of three broad categories, namely nonspecific LBP, pain associated with radiculopathy or spinal stenosis, or back pain potentially associated with serious organic disease. The history should include an assessment of psychosocial risk factors that predict delayed healing and progression to chronic pain. Routine imaging is not required within the first three weeks of nonspecific LBP. Imaging should be performed for patients with severe or progressive neurological deficits, or when serious underlying pathology is suspected, based on the history and the physical examination. Patients should be advised of the benign course of nonspecific LBP and that over 90% of patients recover within a few weeks. Occasionally, the pain may last for a few months. Patients should be advised to remain active and should be provided with information on effective self-care options. Usually, first-line medication options are paracetamol or nonsteroidal anti-inflammatory drugs. To treat severe pain, a stronger drug approach that includes opioids may be considered, but only for a short time. Other therapies to be taken into account are spinal manipulation, intensive interdisciplinary rehabilitation, exercise therapy, massage therapy, or progressive relaxation. Spinal surgery is an option in the event of progressive neurological fallout, severe persistent pain of more than three months and patient unresponsiveness to recommended treatment, or if there is acute cauda equina syndrome.
Source: South African Family Practice 54, pp 404 –407 (2012)More Less
Substance use disorders are highly prevalent in South Africa. General practitioners are often the first point of contact and play an essential role in correctly identifying the substance use problem. This article provides an overview of the importance of screening for and assessing substance use disorders and identifying the severity of the substance use disorder, so that the right level of management can be ensured. It also examines associated co-morbidities and provides a general overview of the management of substance use disorders.
Author J.A. KerSource: South African Family Practice 54, pp 409 –410 (2012)More Less
Beta blockers have been prescribed for the treatment of primary hypertension for a very long time. Currently, it is doubtful whether this is still a good idea. In fact, many are of the opinion that beta blockers should be relegated to a fourth-line drug, if used at all, for the treatment of hypertension. So what happened? Why the change of heart? Basically, two issues are driving this new view of beta blockers.
Author M.H. MotswalediSource: South African Family Practice 54, pp 411 –412 (2012)More Less
Atopic eczema is a chronic, relapsing inflammatory disease of the skin characterised by dryness and itching, with typical distribution on the elbows and knees in younger children and on the cubital and popliteal fossae in older children and adults. It can be classified as mild, moderate or severe.
Author E.D. NelSource: South African Family Practice 54, pp 414 –417 (2012)More Less
Gastro-oesophageal reflux is a normal physiological phenomenon that is frequently associated with regurgitation in infants. In general, it resolves by the age of one year. Some children are more likely to have persistent symptoms and develop complications, e.g. children with congenital abnormalities of the oesophagus, neurological impairment, and a family history of gastro-oesophageal reflux disease (GORD). Preliminary evidence suggests that GORD in infancy and childhood may be a precursor to adult GORD. GORD is reflux that is associated with troublesome symptoms or complications. These complications are categorised into oesophageal and extra-oesophageal difficulties. Diagnosis in most patients relies on a thorough history and physical examination. However, the symptoms in infants and young children are often atypical. Patients with significant symptoms require more extensive diagnostic assessment, such as contrast radiography, oesophagoscopy and oesophageal pH-metry. In most cases, parental reassurance and advice on feeding are sufficient. Thickened feeds reduce the frequency of regurgitation. Patients with complications require potent acid inhibition and occasionally anti-reflux surgery.
Hypertension, chronic kidney disease, atrial fibrillation and the newer anticoagulants : review articleAuthor B. RaynerSource: South African Family Practice 54, pp 418 –419 (2012)More Less
Atrial fibrillation (AF) is a common clinical condition that is associated with increased morbidity and mortality that mainly relates to an embolic stroke. Dominant risk factors for AF are advanced age and hypertension in the absence of mitral valve disease. In turn, hypertension and ageing are determinants of the congestive heart failure, hypertension, age, diabetes mellitus, prior stroke or transient ischaemic attack or thromboembolism (CHADS2) criteria for assessing the indication for anticoagulation. In addition, they are important risk factors for chronic kidney disease (CKD). In itself, CKD is an independent risk factor for AF and a higher risk of stroke. It is highly likely that a practitioner will encounter older patients with AF and concomitant hypertension and CKD that require anticoagulation therapy. Thus, it is essential for the practitioner to understand the risks and benefits of anticoagulation in older patients with AF, hypertension and CKD.
Author L.J. MathibeSource: South African Family Practice 54, pp 422 –423 (2012)More Less
Students often write messages on toilet walls. Some of these messages are derogatory, but some express their anguish, and reflect the challenges that they face while training. In this brief report, three messages, chosen from many which were written on public bathroom walls by medical students at one of the universities in South Africa, were analysed. A story of one brave medical student is also narrated. She chose not to express her emotions and ask for help, in the same way that many of her peers did.
The quality of specimens obtained by fine-needle aspiration biopsy : does training make a difference? : original researchSource: South African Family Practice 54, pp 425 –428 (2012)More Less
Background : The aim of this study was to determine the outcome of a one-hour training session on the correct technique of fine-needle aspiration biopsy (FNAB) by assessing adequacy of FNAB specimens received from clinicians at an academic hospital.
Method : Six clinicians were recruited and their FNABs assessed, six months prior to, and then again after, a one-hour training session in correct technique. Questionnaires were completed prior to the training session and after the subsequent six-month period, to determine the subjective assessment of the clinicians' perceived value of the training on their aspiration technique.
Results : Five of the clinicians had never received training in FNAB technique. The adequacy of the aspirates for all six clinicians did not improve, although this was not statistically significant. They performed a median of 15.5 FNABs in the six months prior to training, and 13.5 FNABs in the six-month follow-up period. Five of the six clinicians subjectively perceived the quality of the aspirates to have improved, and all six recommended the training session to their colleagues.
Conclusion : No improvement was noted after training, but the number of FNABs performed per clinician was suboptimal. Previous studies have shown that clinicians performing relatively few aspirates perform poorly, even if they have received adequate training. The fact that all six would recommend the training session to colleagues is encouraging, and the authors recommend that formal training in FNAB technique should be included in the undergraduate medical curriculum.
The relationship of overweight and obesity to the motor performance of children living in South Africa : original researchSource: South African Family Practice 54, pp 429 –435 (2012)More Less
Objectives : This study aimed to determine the relationship between overweight and obesity and the motor performance of nine- to 13-year-old South African children.
Design : The study used a one-way cross-sectional design based on baseline measurements.
Settings and subjects : The research group comprised 280 Grade 4, 5 and 6 learners (128 boys and 152 girls) from two schools that represented a distribution of socio-economic status, race and gender.
Outcome measures : Anthropometric [(body mass index (BMI) and fat percentage] and motor performance measurements (fine manual control, manual coordination, body coordination and strength and agility) were obtained by means of the Fitnessgram and the Bruininks-Oseretsky Test of Motor Proficiency-II. International age-specific cut-off points were used to classify the children's body composition as normal weight, overweight or obese. Data were analysed by means of descriptive statistics, correlation matrices and analysis of variance, followed by a Tukey post hoc analysis.
Results : The results showed that running speed and agility decreased significantly with an increase in BMI. Muscular strength also decreased significantly with a smaller practical significance, while fine manual control, manual coordination, and body coordination showed the weakest relationship to BMI. Analysis of variance showed significant relationships between BMI and running speed and agility (p-value < 0.05). These relationships were influenced differently by gender and ethnicity.
Conclusion : The motor performance of young South African children was negatively influenced by overweight and obesity. Intervention strategies are recommended to reduce the consequences of overweight and obesity in the overall development of such children.
Patients with type 2 diabetes and difficulties associated with initiation of insulin therapy in a public health clinic in Durban : original researchSource: South African Family Practice 54, pp 436 –440 (2012)More Less
Objectives : Many patients with type 2 diabetes are uncontrolled on maximum oral treatment. The early introduction of insulin can lower diabetes-related complications. The purpose of this study was to explore the reasons behind a perceived reluctance of patients with type 2 diabetes to commence insulin therapy despite objective evidence for the augmentation of oral treatment with insulin. Secondary objectives were to review the demographic data of these patients, to review the patients' knowledge of their disease and of insulin and to compare the knowledge and difficulties of those who agreed to be initiated on insulin with that of those who refused.
Design : The study used an observational analytical design. All uncontrolled patients with type 2 diabetes on maximum oral therapy were interviewed using face-to-face interviews with open- and closed-ended questions.
Setting and subjects : The study was conducted over a three-month period at the Phoenix Community Health Centre, a state-run institution, in Durban, KwaZulu-Natal.
Outcome measures : The education level of the patients, their knowledge of the disease, understanding of insulin, family support and fear of needles and pain were notable outcome measures.
Results : Fifty-nine patients were enrolled in the study. The mean haemoglobin A1c was 9.6. Level of academic education was not associated with a willingness to start insulin therapy (p-value = 0.426). Forty-seven per cent of the patients had no understanding of insulin. Forty-four per cent of the patients were willing to initiate insulin therapy and 55% refused. There was no significant difference in knowledge score between those who accepted and refused insulin therapy (p-value = 0.554). Seventy-nine per cent of patients were afraid of the pain associated with injections.
Conclusion : As a fear of injections and needles was the only significant factor that was associated with the refusal to initiate insulin therapy (p-value < 0.001), health professionals need to address this during patient education, so as to initiate insulin treatment successfully and timeously.
Source: South African Family Practice 54, pp 441 –446 (2012)More Less
Background : Families living with mental illness are a vulnerable group in the community. In the African culture, it is accepted that families are embedded safely in a community. In accordance with the principles of Ubuntu, people with mental illness should be well supported and cared for by their families and the wider community. Traditionally, people with mental illness are institutionalised, out of sight of the family and the general population. However, the deinstitutionalisation of mental health services has changed the structure and mode of caring for people with mental illness. The family and community are now regarded as the dominant care givers and providers.
Method : A qualitative grounded theory method was used.
Results : This article discusses research in progress that demonstrates how families in the community experienced stigma and isolation in the community, as well as crime. There was little support from the community in assisting families to shoulder their burden of care. In this article, we reflect on the possibility that the spirit of Ubuntu may well assist families living with mental illness, despite the burden that communities have to shoulder when fulfilling their own family obligations.
Conclusion : In a community in which Ubuntu is the underpinning life philosophy and way of life, these values could be reinstated and revived to promote the survival and recovery of families living with mental illness in the community, and to reintroduce humanness in the community.
Knowledge of cardiopulmonary resuscitation of clinicians at a South African tertiary hospital : original researchSource: South African Family Practice 54, pp 447 –454 (2012)More Less
Objectives : The objectives of this study were to assess clinicians' knowledge about evaluating possible cardiac arrest patients and recognising cardiac arrest, to assess clinicians' knowledge about appropriate decisions and actions during cardiopulmonary resuscitation (CPR), and to determine which advanced life support courses had been undertaken and whether they were still valid.
Design : This was a descriptive, cross-sectional survey.
Setting and subjects : The subjects were doctors who worked in clinical disciplines at a South African tertiary hospital. Using convenience sampling, doctors from each clinical discipline were invited to participate. Those who consented were included, until a sample of 100 was obtained.
Outcome measures : A self-administered, closed-ended questionnaire that was based on the course content of the American Heart Association (AHA) Basic Life Support (BLS) course was used. The minimum score of 84%, benchmarked against the AHA BLS course, was used to define adequate knowledge.
Results : One hundred doctors participated. None of the participants showed adequate knowledge. The mean total score was 35.1% (95% CI: 31.7; 38.6). The mean adult CPR score was 40.6% (95% CI: 37.4; 45.6). The mean paediatric CPR score was 36.6% (95% CI: 37.0; 41.6).
Conclusion : The participants' knowledge of resuscitation was poor. This raises considerable concern about the effectiveness of the CPR that is performed. This study highlights the need for adequate training of clinicians in the skill of resuscitation and the importance of developing appropriate CPR training programmes that are accessible, innovative and inexpensive.
Source: South African Family Practice 54, pp 455 –458 (2012)More Less
Background : The aim of this study was to determine the ocular manifestations of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) among the study population.
Method : A cross-sectional descriptive study was conducted among HIV-AIDS patients at the Federal Medical Centre, Owo, Nigeria. Ethics clearance was obtained from the ethics review committee of the hospital. Informed consent was obtained from all the respondents. This study was conducted over a period of nine months, from October 2010-June 2011, at the medical outpatient centre and the eye clinic of the hospital. The obtained information included the socio-demographics of the respondents, World Health Organization clinical stage of AIDS, CD4 count, duration of HIV-positive status, history of ocular problems and the treatment sought.
Results : A total of 112 consenting respondents participated in this study. Not many respondents (36, 32.1%) were aware of eye complications that relate to HIV-AIDS. Most informed respondents had been enlightened by health workers (20, 55.6%). Few respondents (16, 14.3%) had HIV-AIDS ocular manifestations. Squamous cell carcinoma was the most common ocular manifestation.
Conclusion : Efforts should be made to promote the ocular health of HIV-AIDS patients to prevent blinding ocular manifestation.
Source: South African Family Practice 54, pp 459 –462 (2012)More Less
Pyogenic liver abscess is a major visceral abscess that may pose a diagnostic dilemma in a febrile child with prominent extra-abdominal symptoms. We present a case of a well-nourished, immunocompetent four-year-old girl who had none of the common predispositions to a liver abscess. Hence, in this unusual setting, pyogenic liver abscess was not considered at the initial assessment, until closer evaluation and futile efforts to drain a seemingly large "pleural effusion" eventually revealed the diagnosis, which was confirmed by imaging. She underwent ultrasound-guided percutaneous drainage of the pyogenic liver abscess to avert the sequelae of this potentially fatal disorder. This underscores the need to think laterally when considering differential diagnoses for the sick child.
Author David E. WhittakerSource: South African Family Practice 54 (2012)More Less
In conversation with colleagues at the 2012 Family Practitioners Conference, I learned that in South Africa, family medicine has been completely transformed and is now aligned with the needs of the people of sub-Saharan Africa. The family physician is now the African family physician (AFP) and has a job description in accordance with the primary healthcare approach. My colleagues were keen to impress on me just how different things are now: "It's all changed," said one. "It's different now," said another, referring to registrar training, while in a workshop, a third declared that "Family medicine got it wrong". Affronted by such summary relegation to family medicine's Jurassic Park, I looked into some of these changes.