South African Family Practice

Health care is all about relationships

Indiran Govender — Tue, 05 Nov 2019 00:00:00 +0000

Dr Klaus von Pressentin previously wrote about relationship-centred patient care.¹ Undoubtedly this good, trusting, safe relationship will lead to good collaborative outcomes for both the doctor (a satisfying encounter) and the patient, with good clinical outcomes especially when it involves chronic conditions.

Burning issues in acute heart failure management

J A Ker, K Outhoff — Mon, 09 Dec 2019 10:01:54 +0000

In general, heart failure is the end-stage manifestation of cardiovascular disease and is an important and increasing cause of morbidity worldwide. Acute heart failure, whether of new onset or an exacerbation of chronic heart failure, causes sudden congestion, typically presenting as pulmonary oedema. The mortality associated with acute heart failure is extremely high. Potentially life-saving treatments and other burning issues are highlighted in this review.

Treating complexity in the older adult - the role of the geriatric giants

L Greenstein, A Abrahams, B Tipping — Tue, 05 Nov 2019 00:00:00 +0000

As people age, they accumulate medical conditions. Geriatric giants comprise a group of conditions that lead to significant mortality and morbidity and contribute to the complexity in treating geriatric patients. They are common and rarely occur in isolation. The 5 Is of geriatric giants are: iatrogenesis, immobility, instability, incontinence and impaired cognition. Consequences for the patient and their caregivers include loss of functional independence, institutionalisation and caregiver burnout. Primary care practitioners are often the first port of call for geriatric patients in South Africa and by asking a few key questions and performing a thorough examination; these conditions can be recognised early. Whilst there are often limitations to cure, the main aim is to maintain the older adult’s functional independence as much as possible, and by following an organised management approach to each of these conditions, the quality of life of patients can be improved.

An HIV-free generation: review of prevention strategies

I Moodley — Wed, 16 Oct 2019 00:00:00 +0000

Globally South Africa has the largest HIV epidemic, with an estimated 7.7 million people living with HIV (PLHIV). The burden of HIV in South Africa varies by age, gender and key population groups. Prevalence is highest among adults between the ages of 15 and 49 years and is higher among females than males. The prevalence rate also varies by province with the highest rates observed in KwaZulu-Natal, Free State, Eastern Cape, Mpumalanga and Northwest.

While greater access to anti-retroviral treatment (ART) has significantly reduced the number of deaths and new infections, the number of new infections is still relatively high, highlighting the need for prevention.

Initial prevention strategies focus on behavioural change through increased education and awareness to ensure safer sex, mainly through peer education, condom distribution and voluntary medical circumcision (VMMC), all of which are in place with varying degrees of success. More recently newer approaches are being considered such as pre-exposure prophylaxis (PrEP) and treatment as prevention (TasP). The major challenge is still behavioural change.

This review sets out to critically evaluate the current and newer approaches. Studies suggest that to achieve greater impact, rather than targeting the general population, prevention strategies should focus on vulnerable populations and in provinces with the highest HIV burden.

European osteoporosis pharmacological guidelines confirm current recommended treatment whilst answering important management questions

H De Wet — Tue, 05 Nov 2019 00:00:00 +0000

One in 3 women and 1 in 5 men over the age of 50 will sustain an osteoporotic fracture.¹ These fractures are often associated with significant morbidity and increased mortality.^1,2 The economic burden of osteoporotic fractures is enormous.¹ Fracture risk is much higher in the elderly than in younger people.² With an ever increasing life expectancy, the prevalence of fragility fractures can be expected to rise exponentially.¹ It is estimated that by 2050 there will be in excess of 5 million hip fractures globally.³ However, despite this high prevalence of osteoporosis, less than 20% of osteoporotic patients are assessed for fracture risk, screened for osteoporosis or initiated on appropriate secondary prevention including calcium or vitamin D supplementation.^1,2 A decline has been shown in both treatment initiation and adherence rates, especially in bisphosphonate treatment.^2,4 This has manifested in a higher incidence of hip fracture than what was projected in the United States, following a more than 10-year period of decline in hip fracture incidence.² Factors playing a role in sub-optimal treatment include a lack of disease awareness as well as uncertainty amongst treating physicians and patient fears. Physicians may be unsure regarding appropriate screening, identifying patients at high fracture risk, especially imminent fracture risk, appropriate treatment initiation and duration of treatment, as well as when to institute “drug holidays”. A further barrier to treatment initiation and adherence is patient concerns regarding route of administration, tolerability and fear of possible, although rare, side effects, such as osteonecrosis of the jaw (ONJ) and atypical femur fracture (AFF).^2,5

Integrating services for impact and sustainability: a proof-of-concept project in KwaZulu-Natal, South Africa

J Lyn Haskins, Sifiso A Phakathi, Merridy Grant, Christiane M Horwood — Mon, 09 Dec 2019 11:56:51 +0000

Background: Integration of services in primary health care settings can provide mother/baby pairs with all required services at one visit. This study aimed to evaluate a proof of concept, quality improvement (QI) intervention to strengthen well-child service provision and integration with maternal health services in five rural clinics in KwaZulu-Natal, South Africa.

Methods: Quantitative cross-sectional surveys were conducted among mothers bringing their child for well-child services, before and after implementation of the intervention. Exit interviews and reviews of the child’s Road to Health Booklet (RTHB) were conducted to determine services provided at the visit, and the time spent in the clinic was observed and recorded.

Results: A total of 413 exit interviews and record reviews were conducted (123 at baseline and 290 at follow-up). At follow-up, significantly more mothers were tested for HIV during the well-child visit (9.2% vs. 22.6%; p = 0.045) and significantly more mothers received ART (3.7% vs. 35.5%; p = 0.010). However, coverage of growth-monitoring services remained low and there was no difference in infant feeding advice provided to mothers at baseline and follow-up (49.5% vs. 49.7%; p = 0.996). More mothers interacted with a registered nurse at follow-up than at baseline (35.8% vs. 80.7%; p = 0.032).

Conclusions: Over the implementation period of the QI intervention, improvement was shown in coverage and quality of some maternal health and HIV services, but there was no improvement in growth monitoring. This suggests that QI has the potential to improve integration of service delivery, but this was a small study and further research is recommended.

The full article is available at https://doi.org/10.1080/20786190.2019.1656435

Profile of adult patients admitted with drug-induced liver injury at a district hospital in Pietermaritzburg, KwaZulu-Natal

K Naicker, S Rangiah — Mon, 09 Dec 2019 12:13:27 +0000

Background: Drug-induced liver injury (DILI) can be prevented if diagnosed and treated timeously. The identification and primary prevention of DILI risk factors presents the rational means of reducing hospital costs and mortality.

Methods: A retrospective chart review was conducted of clinical in-patient records of all adult patients admitted to Northdale Hospital (NDH) with a diagnosis of DILI. Patients with pre-existing liver disease were excluded.

Results: A total of 95 patient files with DILI were reviewed. The burden of DILI at NDH over the two-year period was 0.19%. The average age was 38 years, with a slightly higher female preponderance (62.1%). A lower serum albumin level (mean 21.35 g/dl) was significantly associated with DILI (p < 0.001). Forty-six patients had a history of alcohol consumption, which increased the risk of DILI (OR 2.1). Of the patients reviewed, 62 (65%) were on antiretroviral therapy (ART) whereas 41 (43%) were on tuberculosis treatment (TBT) at presentation. The most common co-morbidities associated with DILI were HIV (75.7%), TB (43.2%), renal disease (34.7%) and malnutrition (31.6%). The most common hepatotoxins, apart from ART and TBT, were paracetamol (46.3%), cotrimoxazole (32.6%), alcohol (48.4%) and traditional medication (27.4%).

Conclusion: This study demonstrated associations with the development of DILI and being female gender, younger age group, hypoalbuminaemia and renal failure. The use of alcohol, traditional medication and the overzealous use and prescription of paracetamol to patients who present with DILI is concerning. The case fatality rate of 14.7% demonstrates the importance of identifying these potential risk factors timeously.

The full article is available at https://doi.org/10.1080/20786190.2019.1657323

An assessment of erectile dysfunction among male diabetics attending Temba Community Health Centre, Pretoria

T Bongongo, J V Ndimande, J Tumbo — Mon, 09 Dec 2019 12:26:46 +0000

Introduction: Erectile dysfunction is common among men with diabetic mellitus and has a negative effect on their quality of life. The proportion of male diabetics who disclosed their problematic sexual performance was increasing at Temba Community Health Centre (CHC), which motivated a survey that was conducted from April 2015 till April 2016.

Aim: Assessment of erectile dysfunction among male diabetics attending Temba Community Health Centre.

Setting: Temba Community Health Centre, Pretoria, South Africa.

Method: A cross-sectional survey was conducted using a piloted, structured questionnaire adapted from the International Index of Erectile dysfunction (IIRF-5) questionnaire. Convenience sampling was used to select 191 participants.

Result: From the selected sample, 97.3% of male diabetics were suffering from erectile dysfunction. Among them, 120 (62.8%) were between 41 and 60 years of age, 96 (50.2%) were employed, 81 (42.4%) had a secondary level of education and 84 (44.4%) were married. The duration of diagnosed diabetes varied between 2 months and 564 months (42 years). Hypertension and HIV, as co-morbidities, affected 12.7% of the participants and 56% of participants consulted primarily for erectile dysfunction, not knowing that it was a complication of diabetes mellitus.

Conclusion: The assessment of erectile dysfunction among male diabetics attending Temba CHC in Pretoria showed that more than two-thirds of the selected sample of patients suffered from erectile dysfunction, from a mild to a severe form of the condition. Most of those participating were between 41 and 60 years old, half of them were married, have a secondary level of education and were unaware that erectile dysfunction is a complication of diabetes mellitus.

The full article is available at https://doi.org/10.1080/20786190.2019.1658935

Factors associated with physical activity amongst patients with hypertension in two community health centres in uMgungundlovu health district, KwaZulu-Natal, 2018

S W Mbambo, B Tlou, T P Dlungwane — Mon, 09 Dec 2019 12:43:00 +0000

Background: Hypertension (HPT) is a global public health challenge. It predisposes to cardiovascular diseases, kidney diseases and disability as well as contributing to high death rates. HPT is increasing tremendously in sub-Saharan Africa with HPT-related mortality risk having increased by 25% in less than 10 years in South Africa. Physical activity is a cost-effective way of reducing, controlling and preventing hypertension. The aim of the study was to establish the level of physical activity, and factors associated with physical activity, amongst patients with hypertension, in two community health centres in uMgungundlovu Health District, KwaZulu-Natal, 2018.

Methods: An observational, cross-sectional descriptive study with an analytic component was implemented. Data were collected utilising an interviewer-administered questionnaire. Frequency distribution tables and the chi-square test were used in the analysis of data. A p-value less than 0.05 was deemed statistically significant.

Results: A total of 374 questionnaires were administered of which 373 were adequately completed, yielding a response rate of 99.7%. The results showed that 39.1% were highly physical active, 32.4% were moderately physical active and 28.4% had low physical activity. Age, marital status, employment status and level of education were significantly associated with physical activity. Major barriers to physical activity included health problems and having no time to exercise. Health-related reasons were reported to be the major motivator towards physical activity.

Conclusion: Over a third of the participants presented with high levels of physical activity. Health education should focus on promoting physical activity for HPT clients.

The full article is available at https://doi.org/10.1080/20786190.2019.1664085

An evaluation of male learners’ knowledge, attitudes and practices regarding sexual and reproductive health in rural northern KwaZulu-Natal province

Mampho Mochaoa Rogers, Gloria Mfeka-Nkabinde, Andrew Ross — Mon, 09 Dec 2019 12:58:37 +0000

Background: With a disparate HIV prevalence among young men and women, high rates of teenage pregnancies and a lack of responsible fatherhood, issues of reproductive health among young people need to be urgently addressed. The aim of this research was to assess the knowledge, attitudes and practices regarding sexual and reproductive health among young men in the Bethesda Hospital catchment area of northern KwaZulu-Natal province.

Methods: This observational, descriptive cross-sectional study was conducted at six randomly selected high schools within the uMkhanyakude district. All grade 12 male learners ≥ 18 years completed a questionnaire regarding their reproductive health knowledge, attitudes and practices.

Results: A total of 279 learners participated in the study with a median age of 20.2 years and a mean knowledge score of 63.8%. Only 28.3% of the learners showed good or excellent knowledge on basic sexual and reproductive health questions; 50.9% believed that girls say ‘no’ to sex when they mean ‘yes’, and 46.2% believed that girls were sexually aroused when dominated by a man. Some 156 (55.9%) of those who were sexually active did not know their current sexual partner’s HIV status. There were significant associations between being brought up in a female-headed family and early sexual debut but not between early sexual debut and paternalistic attitudes to women.

Discussion and conclusions: Basic sexual and reproductive health knowledge among the majority of participants was adequate. Patriarchal attitudes of sexual domination were prominent, and these are probably influenced by sociocultural belief systems of traditional masculinity, which are defined and dominated by men. This perpetuates gender inequality and contributes to poor sexual and reproductive health outcomes. Poor health-seeking behaviour and attitude relating to sexually transmitted infections (STIs), and having concurrent multiple sexual partners, puts them and their sexual partners at risk of HIV/AIDS acquisition. Strategies need to be developed to enhance socially acceptable and comprehensive sexual and reproductive health education and services among young men in this area, foster positive attitudes towards women and encourage gender-equal relationships.

The full article is available at https://doi.org/10.1080/20786190.2019.1664539

A profile of Caesarean sections performed at a district hospital in Tshwane, South Africa

I Govender, C Steyn, O Maphash, A T Abdulrazak — Mon, 09 Dec 2019 13:10:51 +0000

Introduction: Caesarean section (CS) is a common obstetric procedure that prevents neonatal and maternal death when performed correctly if indicated; however, CS can give rise to complications that lead to maternal and perinatal morbidity and mortality. Rates of CS are increasing worldwide, although the World Health Organization (WHO) has indicated an ideal rate of 5–15%. South African CS rates are higher than the ideal.

Methods: Maternity records of 2015 were reviewed at Odi District Hospital (ODH) to assess whether ODH complies with the ideal CS rate. In this study, extracted data include date and time of CS, maternal age, parity, gestational age, total number of previous CSs, elective or emergency, indications, anaesthesia used and registration of the surgeon.

Results: There were 3 336 deliveries and 1 064 CSs (32%). The majority of women were aged from 19 to 34 years (59%), 72.8% were multiparous and 54% between 37–39 weeks’ gestation. The most common (40.1%) overall and emergency indication was foetal distress. Most CSs were emergencies (61.70%). Most elective CSs were because of a previous CS and spinal anaesthesia was used in 91.73%. Medical officers performed most of the CSs (79.0%) during working hours. The CS rate of 32% was significantly higher than the ideal 5–15% and higher than in other sub-Saharan countries with similar maternal characteristics. Indications for emergency and elective CSs were similar to previous research.

Conclusion: The Caesarean section rate at ODH is higher than the recommended rate. Potential CSs therefore need to be evaluated more intensely to assess the true need for surgical intervention.

The full article is available at https://doi.org/10.1080/20786190.2019.1671655

The quality of feedback from outpatient departments at referral hospitals to the primary care providers in the Western Cape: a descriptive survey

Mon, 09 Dec 2019 13:26:38 +0000

Background: Coordinating care for patients is a key characteristic of effective primary care. Family physicians in the Western Cape formed a research network to enable them to perform practical research on key questions from clinical practice. The initial question selected by the network focused on evaluating the quality of referrals to and feedback from outpatient departments at referral hospitals to primary care providers in the Western Cape.

Methods: A descriptive survey combined quantitative data collected from the medical records with quantitative and qualitative data collected from the patients by questionnaire. Family physicians collected data on consecutive patients who had attended outpatient appointments in the last three months. Data were analysed using the Statistical Package for the Social Sciences.

Results: Seven family physicians submitted data on 141 patients (41% male, 59% female; 46% metropolitan, 54% rural). Referrals were to district (18%), regional (28%) and tertiary hospitals (51%). Referral letters were predominantly biomedical. Written feedback was available in 39% of patients. In 32% of patients, doctors spent time obtaining feedback; the patient was the main source of information in 53% of cases, although many patients did not know what the hospital doctor thought was wrong (36%). The quality of referrals differed significantly by district and type of practitioner, while feedback differed significantly by level of hospital.

Conclusion: Primary care providers did not obtain reliable feedback on specialist consultations at referral hospital outpatients. Attention must be given to barriers to care as well as communication, coordination and relationships across the primary–secondary interface.

The full article is available at https://doi.org/10.1080/20786190.2019.1676021

The potential impact of dietary supplement adulteration on patient assessment and treatment from a healthcare provider’s perspective

Gary Gabriels, Mohamed Irhuma — Mon, 09 Dec 2019 10:56:02 +0000

Dietary supplements have been manufactured and supplied to the market with the objective of enhancing the overall health of the general population and optimising the performance of athletes. The perceived intention of dietary supplementation is to increase the nutritional content of a normal diet, and to fill a dietary need and/or presumed deficiency. The usage and popularity of dietary supplements, however, raises concerns from a health benefit and risk perspective. Moreover, safety and efficacy of these supplements have generally not been established by the Medicines Regulatory Authorities, both nationally and internationally. The exponential increase in supplement sales can, however, be attributed to aggressive marketing by manufacturers, rather than the development of more effective nutritional supplements. These supplements may contain adulterated substances that may potentially have harmful short- and long-term health consequences for the patient. In addition, a large spectrum of drug interactions may render the use of such supplements risky, without proper medical and scientific assessment.

The full article is available at https://doi.org/10.1080/20786190.2019.1609757

Improving the quality of clinical training in the workplace: implementing formative assessment visits

Robert Mash, Zelra Malan, Julia Blitz, Jill Edwards — Mon, 09 Dec 2019 11:36:25 +0000

Family physicians have a key role to play in strengthening district health services in South Africa. There are a number of barriers to the supply of these specialists in family medicine, one of which is the quality of workplace-based training and low pass rate in the national exit examination. The South African Academy of Family Physicians in collaboration with the Royal College of General Practitioners has adopted a short course to train clinical trainers and a process of formative assessment visits (FAVs) for clinical trainers in the workplace. Training programmes have struggled to implement the FAVs and this article reports on the experience at Stellenbosch University and the issues identified. Clinical trainers who participated in FAVs mostly set developmental goals for themselves that focused on improving the learning environment and consolidating personal skills in training and assessment. The FAVs were beneficial for the family physician trainers, their managers and the academic family physicians at the university. The tools and process for conducting the FAVs may be of value to other programmes.

The full article is available at https://doi.org/10.1080/20786190.2019.1647639

Mastering your fellowship (Online)

Klaus B von Pressentin, Mergan Naidoo, Tasleem Ras, Michelle Torlutter — Mon, 09 Dec 2019 10:24:13 +0000

The series, “Mastering your Fellowship”, provides examples of the question format encountered in the written and clinical examinations, Part A of the FCFP (SA) examination. The series is aimed at helping family medicine registrars prepare for this examination. Model answers are available online.

The spiritual construction of depression

Chris Ellis — Tue, 15 Oct 2019 00:00:00 +0000

“We have a preponderance of psychiatric treatments that now ignore the heart and soul of what it is to be human” - Robert A Berezin

In general practice we often see the classical features of depression in our patients. These are the ones laid out in the box that has been promulgated by the DSM V. We know that not everyone fits into these boxes for classification and there is a penumbra of feelings and emotions that occur around the classic features. They are the shadows of the shadows and the more indistinct symptoms that surround the core of central darkness.