South African Family Practice - Volume 58, Issue 1, 2016
Volume 58, Issue 1, 2016
Chemical and thermal ocular burns : a review of causes, clinical features and management protocol : reviewAuthor Khathutshelo MashigeSource: South African Family Practice 58, pp 1 –4 (2016) http://dx.doi.org/http://dx.doi.org/10.1080/20786190.2015.1085221More Less
Chemical and thermal ocular burns are among the most urgent ophthalmic emergencies, often resulting in permanent damage, and in some cases, blindness. These burns are the result of exposure to chemicals or radiant energy (thermal or ultraviolet). The most serious injuries are due to chemical burns by strong acid or bases. The purpose of managing these burns is to eliminate or limit the causative agent from penetrating the ocular structures by irrigation; and, promoting ocular surface healing through medical and surgical intervention. This review presents a current update on the causes of chemical and thermal ocular burns, their clinical features and the importance of appropriate and prompt treatment.
Author Gboyega A. OgunbanjoSource: South African Family Practice 58 (2016)More Less
Just when we emerged from the Ebola virus disease outbreak in West Africa, we are inundated by another viral disease outbreak with possible global spread. This time, it is not from Africa but from South America and specifically from two countries namely Brazil and Colombia. The Zika virus is a mosquito-borne virus disease first discovered in 1947 among rhesus monkeys from the Zika forest of Uganda, through a monitoring network of sylvatic yellow fever.
Expectations of hypertensive patients attending the GOPC of the University of Calabar Teaching Hospital, Calabar : researchSource: South African Family Practice 58, pp 5 –8 (2016) http://dx.doi.org/http://dx.doi.org/10.1080/20786190.2015.1078158More Less
Background: Hypertensive patients' expectations are a major determinant of treatment outcomes. This study was undertaken to determine the pattern of expectations of hypertensive patients as a basis for modification of the care given to them.
Methodology: This was a descriptive hospital study involving 260 hypertensive patients aged above 20 years, randomly selected. Study participants were engaged in patient-centred consultation during each visit. Their socio-demographic characteristics were collected using a semi-structured questionnaire, while the expectations of the hypertensive patients were also assessed. Their blood pressure was measured on three (3) occasions at two-monthly intervals. Data were analysed using SPSS version 20.0 and data were presented in tables.
Results: The majority of the respondents (161, 61.9%) were females while the males numbered 99 (38.1%). Most (219) of the respondents were older than 40 years and had some form of education. The majority of the respondents needed information on hypertension (85.3%), expected that the hypertensive medication they would be given would lower their blood pressure (88.5%), and expected a cure of their hypertension (70.4%). There were some respondents who did not have any expectations.
Conclusion: Hypertensive patients have varying illness expectations that can be explored using the patient-centred consultation strategy to improve treatment outcomes.
Author Jacky Van SchoorSource: South African Family Practice 58, pp 6 –10 (2016)More Less
Symptoms suggestive of acute urinary tract infections (UTIs) are common reasons why women consult a health professional. Antimicrobial agents are usually prescribed for the treatment of symptomatic UTIs seen in clinical practice. However, the extensive use of antimicrobial agents for community-acquired UTIs has resulted in the emergence of antimicrobial resistance. Increasing concern about the association between the use of antimicrobial agents and acquired antimicrobial resistance has highlighted the need for rational pharmacotherapy when treating UTIs. This article discusses currently recommended antimicrobial therapy for uncomplicated UTIs in women, UTIs during pregnancy and recurrent UTIs.
Factors affecting the implementation of nurse-initiated antiretroviral treatment in primary health care clinics of Limpopo Province, South Africa : researchSource: South African Family Practice 58, pp 9 –12 (2016) http://dx.doi.org/http://dx.doi.org/10.1080/20786190.2015.1114704More Less
Introduction: The implementation of nurse-initiated antiretroviral (ARV) treatment at primary health care clinics was introduced in 2010 as a response to lower the HIV prevalence rate in the community.
Aim: The aim of the study was to identify the factors affecting the implementation of nurse-initiated ARV treatment in primary health care clinics referring patients to Dr CN Phatudi Hospital, Limpopo Province.
Methodology: A qualitative study was conducted in 2013 with a purposeful sample of nurses from 12 clinics involved in the nurse-initiated antiretroviral treatment (NIMART) programme. Two free-attitude focus groups and two individual interviews were conducted (audio- and video-recorded whilst the researcher took field notes). These interviews were transcribed verbatim and analysed using the colour-coding as well as cut-and-paste methods.
Results: Common themes that emerged from the individual and focus-group interviews were: (1) lack of resources, which included health care workers, drugs, stationery, telephones, poor training and inadequate workspace; (2) factors affecting treatment adherence, such as stigma, poverty, poor roads and the restrictions on the 'one pill' regime; (3) support from management and the visiting doctor and (4) nurses' work satisfaction.
Conclusion: Two of the themes that emerged acted as barriers to the implementation of the NIMART programme, namely: (1) lack of resources and (2) factors affecting treatment adherence. The two other themes enhanced the implementation of the NIMART programme, namely: (1) support visits and (2) nurses' work satisfaction.
Author R. Van RensburgSource: South African Family Practice 58, pp 11 –15 (2016)More Less
Acute pain is known to every person universally, and the management of pain is one of the biggest industries in the world today. There are many and varied options to achieve analgesia, but if not used for the correct indication, if not initiated effectively, or if the intervention causes unacceptable side-effects, it can lead to suboptimal pain relief and potentially dire outcomes. Knowledge of the pathways involved in pain perception, and how these pathways can be targeted with various modalities is required to obtain adequate analgesia. This article provides an overview of the available evidence-based therapeutic options for acute pain management.
HIV in acute care : a review of the burden of HIV-associated presentations to an Emergency Department : researchSource: South African Family Practice 58, pp 13 –17 (2016) http://dx.doi.org/http://dx.doi.org/10.1080/20786190.2015.1079027More Less
Objective: To determine the burden of human immunodeficiency virus (HIV) disease and co-infection on a district-level Emergency Department (ED) in KwaZulu-Natal.
Methods: A retrospective chart review was conducted of the case notes of adult medical patients who presented to the ED over a three-month period. Patients presenting with HIV disease and its complications were identified. Patient demographics, disease presentation and severity, investigations and procedures undertaken, and disposition of patients in the HIV-positive cohort were assessed.
Results: 428 of the 861 (49.7%) medical patients presenting to the ED were HIV positive. Some 37% of patients did not know their HIV status. In the HIV-positive cohort, the median age of presentation was 37 years, with almost equal male-to-female distribution. Of the patients seen, 57.5% were referred and 68% of patients presented after hours. In total, 80% of patients were triaged as yellow code. The predominant systems involved were the respiratory and central nervous systems, with pulmonary tuberculosis, community-acquired pneumonia and meningitis being the most common diagnoses. X-rays and laboratory testing were the most common investigations requested. Lumbar punctures, pleural paracentesis and pericardiocentesis were common emergency procedures performed. The majority (89.3%) of patients were admitted to the medical ward. Of the HIV-positive patients, 33% were on anti-retroviral therapy. ED mortality was 1.9%.
Conclusion: In South Africa, very little is known about the ED's ability to cope with the HIV epidemic. This study highlights the significant impact HIV places on the resources of an ED. Strengthening of the primary health care system with a more aggressive approach to HIV testing and ARV initiation may contribute positively to reducing the burden of HIV emergencies and co-morbidities presenting to the ED.
MeSH: Human Immunodeficiency virus (HIV); Emergency Department, South Africa, opportunistic infections; HIV testing
Author K. OuthoffSource: South African Family Practice 58, pp 16 –18 (2016)More Less
Cognitive enhancement involves the non-medical use of illicit and/or prescription drugs, such as agents prescribed for attention deficit/hyperactive disorder (ADHD) and narcolepsy, usually in order to stay awake and to counteract fatigue and loss of concentration, generally in the context of high workload and stress. Growing interest in taking prescription stimulant drugs for non-licensed purposes to improve academic, work and sporting performance has raised medical, ethical and regulatory issues.
Knowledge, awareness and readiness of private sector doctors practising in the Ethekweni and Ugu districts of KwaZulu-Natal province for the implementation of the National Health Insurance : researchAuthor S. Latiff-KhamissaSource: South African Family Practice 58, pp 18 –23 (2016) http://dx.doi.org/http://dx.doi.org/10.1080/20786190.2015.1123361More Less
Background: The proposed National Health Insurance (NHI) aims to improve quality of care and equity in healthcare financing for all South Africans. Successful implementation requires participation by stakeholders, such as private sector doctors who play an important role in healthcare delivery. A study was conducted to determine their knowledge, awareness and readiness for the implementation of the NHI.
Methods: A cross-sectional descriptive study was carried out by administering close-ended anonymous questionnaires to private sector doctors in the South region of KwaZulu-Natal. Data were analysed using SPSS version 15.0.
Results: The response rate was 70%; the majority were male with 56% of respondents in the age group 41-60 years. Over 68% had satisfactory knowledge about NHI, whilst 24 (3%) had good knowledge (p < 0.05); doctors with satisfactory knowledge indicated their preference for NHI information via circulars and newspapers. Some 64% believed that they have the necessary skills to implement the NHI, but are not completely ready regarding infrastructure and resources.
Conclusions: The majority have satisfactory knowledge, awareness and believe they have the necessary skills to participate in the NHI. However, the government needs to increase knowledge and awareness, and to improve infrastructure and resources in order for effective implementation of the NHI.
Author G.L. MuntinghSource: South African Family Practice 58, pp 19 –26 (2016)More Less
Chronic obstructive pulmonary disease (COPD) is characterised by chronically poor air flow. Typically, it worsens over time. The main symptoms include shortness of breath, coughing and sputum production. Most people with chronic bronchitis have COPD. Tobacco smoking is the most common cause of COPD. A number of other factors, such as air pollution and genetics, play a smaller role. One of the common sources of air pollution is poorly vented cooking and heating fires in the developing world. Longterm exposure to these irritants causes an inflammatory response in the lungs, resulting in narrowing of the small airways and breakdown of the lung tissue, leading to emphysema. Genetic involvement, i.e. alpha-1 antitrypsin deficiency, is now a recognised cause. The diagnosis is based on poor air flow, as measured by lung function tests. In contrast to asthma, the air flow reduction does not improve significantly with the administration of a bronchodilator. COPD can be prevented by reducing exposure to known environmental risk factors. This includes an effort to decrease the rate of smoking and to improve indoor and outdoor air quality. COPD treatment includes stopping smoking, vaccinations, rehabilitation, and often inhaled bronchodilators and steroids. Some people may benefit from long-term oxygen therapy or lung transplantation. Increased use of medication and hospitalisation may be needed in those who have periods of acute worsening. Worldwide, COPD affects 329 million people, or nearly 5% of the population. In 2013, it resulted in 2.9 million deaths, up from 2.4 million deaths in 1990. The number of deaths is projected to increase owing to higher smoking rates and an ageing population in many countries. New treatments are also emerging very slowly.
Source: South African Family Practice 58, pp 24 –27 (2016) http://dx.doi.org/http://dx.doi.org/10.1080/20786190.2015.1078156More Less
Background: Poor nutritional status has been shown to be associated with a significant decline in lung function in patients with cystic fibrosis. There are few data published on the lung function decline and the effects of nutritional status in cystic fibrosis (CF) in South Africa.
Aim: To assess anthropometric parameters (weight, height, body mass index Z-score) in relation to lung function parameters in CF patients.
Methodology: A retrospective chart review of clinical records of participants over the age of five years attending the CF clinic at Steve Biko Academic Hospital from 2005 to 2010.
Results: Twenty files were reviewed for lung function, anthropometric measurements, gender and CF-causing mutations. For anthropometric measurements the average changes were -0.8, -0.5 and 2.0 for weight, BMI and height Z-scores, respectively. A decline in FEV1 of -25.3 (95% CI 39.4; -13.3) over the five-year period was noted, with an average decline of 5.3% per year. For FEF25-75, the average change was -22.4 (95% CI-34.6; -10.2) with a decline of 4.5% per year. Using multivariate analysis, the FEV1 was found to be significantly influenced by: age -3.96 (95% CI -7.4; -0.5); p = 0.03, weight 1.8 (95% CI -3.4; -0.9); p = 0.04, BMI Z-score 4.3 (95% CI 5.3; 23.3); p = 0.02 and gender (p = 0.02). The FEF25-75 was significantly influenced by BMI Z-score and gender.
Conclusion: The average lung function decline per year for FEV1 was higher than that seen in developed countries. The decline in FEV1 was related to gender, age, weight and BMI. The decline in FEF25-75 was affected only by BMI Z-score and gender.
Author A. MaraisSource: South African Family Practice 58, pp 27 –30 (2016)More Less
Gastro-oesophageal reflux disease (GORD) is a common condition worldwide. It is characterised by numerous upper gastrointestinal tract symptoms, but patients mainly present with heartburn and regurgitation. Various causes have been linked to the pathophysiology of GORD. Some of them are well known, while others are less frequently implicated. Oesophageal inflammation is the result of the inadequately managed suppression of gastric acid caused by the retrograde flow from the stomach through the lower oesophageal sphincter, which may result in complications, including stricture formation, Barrett's oesophagus, erosive oesophagitis and adenocarcinoma. The incidence per region and country varies significantly, and is dependent on the population demographics. GORD is responsible for an impaired general health score in affected individuals, and has a negative impact on economic productivity in society. Treatment may range from unscheduled self-medication to complicated laparoscopic surgery. This article describes some of the associated factors, revised definitions and the role of surgery in the management of GORD.
Source: South African Family Practice 58, pp 28 –29 (2016) http://dx.doi.org/http://dx.doi.org/10.1080/20786190.2015.1085224More Less
The international #1WordforFamilyMedicine initiative serves to explore the identity of family physicians and allows the international Family Medicine community to collaborate on advocating the discipline. South African family physicians provided 42 responses via a social media and online survey. Two "word cloud" images were created based on two icons recognised as being truly South African around the world - the national flag and former president Nelson Mandela. The #1WorldforFamilyMedicine initiative was promoted by the World Organization of Family Doctors across the globe to help celebrate World Family Doctor Day on 19 May 2015. To date, over 70 images have been created in 50 different countries on six continents. The images represent family physicians' love for their profession and the community they serve. It is hoped that this initiative will help to inspire current and future Family Medicine and primary care providers.
Source: South African Family Practice 58, pp 30 –31 (2016) http://dx.doi.org/http://dx.doi.org/10.1080/20786190.2015.1083718More Less
South Africa faces numerous challenges in healthcare, with the result that communities in many rural provinces are grossly underserved. These problems are compounded when doctors are unable to communicate with their patients. IsiZulu is spoken by most people in KwaZulu-Natal. Older and rural patients often present as monolingual isiZulu speakers. The need and ability to speak an indigenous language is emphasised in communication, identified as a core competency for doctors. The benefits of language-concordant health care have been documented, and policies at national, regional and institutional level provide for language diversity. As first-language English users, medical students have to be trained to become competent in speaking isiZulu. This mixed-method study assessed the knowledge, attitudes and perceptions of third-year students who had received isiZulu-training during their first year at the University of KwaZulu-Natal. The results indicated an improvement in students' communicative competence. In general, positive attitudes were held by the students towards the language, but there was a perceived need for additional input in order for the students to become competent.
The role of proprotein convertase subtilisin/kexin type 9 inhibitors in managing cardiovascular risk : reviewSource: South African Family Practice 58, pp 31 –34 (2016)More Less
Hypercholesterolaemia and dyslipidaemia, marked by decreased levels of high-density lipoprotein and elevated levels of lowdensity lipoprotein (LDL), increase the risk of cardiovascular disease. Familial hypercholesterolaemia (FH), diagnosed based on the clinical features seen in patients with a positive family history, constitutes a heritable disorder involving a single gene. FH can exist in either the heterozygous or homozygous form, and may be differentiated based on clinical features and genetic studies. A novel drug target, proprotein convertase subtilisin/kexin type 9 (PCSK9), has resulted in the development and subsequent approval of new, targeted monoclonal antibodies in the treatment of FH. Targeting PCSK9 with monoclonal antibodies, i.e. evolocumab and alirocumab, inhibits the degradation of LDL receptors, and against a background of optimised statin therapy, increases the life expectancy of patients with hypercholesterolaemia by reducing the incidence and severity of coronary artery disease.
Strengthening primary health care through primary care doctors : the design of a new national Postgraduate Diploma in Family Medicine : reportSource: South African Family Practice 58, pp 32 –36 (2016) http://dx.doi.org/http://dx.doi.org/10.1080/20786190.2015.1083719More Less
Strengthening primary health care is a national priority in South Africa, in order to improve quality of care and health outcomes, reduce inequity and to pave the way for National Health Insurance. The World Health Organization and World Health Assembly both recommend the inclusion of a primary care doctor with postgraduate training in Family Medicine in the primary healthcare team. Currently, medical practitioners without postgraduate training, and those who may need re-orientating and upskilling for the future re-engineered primary care system, are the largest pool of doctors in South Africa. Most of these doctors are of an age and at a stage in their careers where it is unlikely that they will train to be a family physician.
This article reports on a national process to design a Postgraduate Diploma in Family Medicine which will meet the learning needs of primary care doctors in both the public and private sectors as they prepare for the future.
A year-long process included two national stakeholder workshops, a survey of learning needs and two additional expert workshops before consensus could be reached on the design of the new diploma programme.
The future roles and competencies required of primary care doctors, learning outcomes congruent with these roles, and an educational design, which could be delivered at scale commensurate with the national need by all of the relevant higher education institutions, were envisaged during this process.
The design of this diploma, presented here, will now be developed into a revised or new programme by the higher education institutions, and implemented from 2016 onwards.
Author Heidi SiebertSource: South African Family Practice 58, pp 35 –38 (2016)More Less
The concept of using a patient's own blood or components thereof (autologous), to enhance the physiological process of healing has been in place for many years. Autologous platelet-rich plasma (PRP) has been used for both soft tissue and bone healing and rejuvenation. PRP has also been used in orthopaedics for bone, tendon and muscle injuries, dentistry for dental implants, dermatology for wound healing, and in pathological conditions such as alopecia aereata. However, more recently, it has been used in the fast-growing field of aesthetic and anti-ageing medicine for skin rejuvenation. PRP seems like a logical, safe, relatively, cheap and easy procedure, but is this the case? Although safety and improved short-term outcomes for orthopaedic indications have been demonstrated in a few reviews, long-term improvement has not been demonstrated. Randomised controlled trials in dermatology and aesthetic indications are sparse, but show promise for alopecia areata and skin rejuvenation.
Utilisation of staff clinic facility in a Northwest Nigeria hospital : emerging challenges for the National Health Insurance Scheme : researchSource: South African Family Practice 58, pp 37 –41 (2016) http://dx.doi.org/http://dx.doi.org/10.1080/20786190.2015.1079014More Less
Background: The health status of workers and their families affects workplace productivity. The National Health Insurance Scheme (NHIS) objective of improving healthcare accessibility to Nigerians has increased service utilisation but may pose new challenges to existing facilities. This study was undertaken to describe the pattern of clinic utilisation, disease entities of subjects, use of the excused-duty certificate and identify points of delay.
Methods: A prospective cross-sectional study of 352 subjects randomly selected over 6 weeks among patients attending the Aminu Kano Teaching Hospital Staff clinic.
Results: Most subjects (307, 87.2%) had insurance and were predominantly (227, 64.5%) dependants. Most subjects (190, 55%) had used the clinic once to three times in the preceding 12 weeks and were predominantly (85, 24.2%) hospital attendants. Infectious disease (204, 58%) was the commonest reason for the clinical encounter. Their mean waiting and consultation times were 77.3 (SD ± 43) and 9.6 (SD ± 4.5) minutes respectively. Only 52 (14.8%) subjects were seen within 30 minutes of clinic arrival. Only a few subjects (3, 0.9%) had received an excuse-duty certificate in the preceding 12 weeks, mainly for malaria.
Conclusion: High clinic utilisation and acute infectious disease burden are major challenges for the clinic, while prolonged clinic waiting time was suffered by clinic users. Prolonged waiting time may affect workplace availability and productivity. Proactive improvements in the causal factors for prolonged clinic waiting time may be required.
Source: South African Family Practice 58, pp 39 –45 (2016)More Less
Venous thromboembolism (VTE) encompasses two vascular conditions that are of significant importance, namely deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT is also the most common cause of PE. Medical and surgical patients, and individuals who are at increased risk of developing VTE through a variety of factors, require adequate thromboprophylaxis. Primary and secondary prevention, as well as the definitive treatment of VTE, are accomplished through the use of a variety of anticoagulant drugs. This article attempts to provide an overview of VTE, and its prevention and treatment.
Source: South African Family Practice 58, pp 52 –53 (2016)More Less
The series, "Mastering your Fellowship", provides examples of the question format encountered in the written examination, Part A of the FCFP(SA) examination. The series aims to help Family Medicine registrars prepare for this examination. Model answers are available online.