The management of community-acquired pneumonia in adults at a rural regional hospital in KwaZulu Natal.

BACKGROUND: Pneumonia stands as a significant global contributor to mortality, particularly in South Africa, where it ranks as the second leading cause of death. The country's high prevalence of HIV infection compounds this issue, significantly increasing mortality rates associated with community-acquired pneumonia (CAP). OBJECTIVE: This study aimed to audit CAP patient management at a regional rural hospital in KwaZulu-Natal. METHOD: A retrospective review of patient files from September to December 2016 was undertaken. Data extraction from clinical files, conducted according to inclusion criteria, was transferred to a data collection sheet and analyzed using SPSS version 21. RESULTS: The review encompassed 124 patient files over four months, revealing that 117 (94.4%) patients were not managed by the Standard Treatment Guidelines and Essential Medicines List for South Africa. Of the patients admitted with CAP, 54% were HIV positive, and 49 (39.5%) patients succumbed to the illness. Notably, none of the patients underwent assessment using a severity score. CONCLUSION: The findings underscore a need for more adherence to South African guidelines for managing CAP among staff at the rural regional hospital. This leads to severe consequences, exemplified by the high mortality rate. Urgent intervention is required to incorporate severity assessment scores into pneumonia evaluations, thus enabling appropriate clinical management. CONTRIBUTION: This study sheds light on the significant impact of CAP within the South African hospital context, delineating critical gaps in clinical care and emphasizing the imperative to address clinical inertia.

Perioperative antithrombotic medication: An approach for the primary care clinician.

The primary care clinician faces many challenges and is often left to manage complex pathology because of resource constraints at higher levels of care. One of these complex conditions is the perioperative management of antithrombotic medication. This narrative review is focused on helping the clinician navigate the complex path and multiple guidelines related to the perioperative use of antithrombotic medication. Perioperative antithrombotic guidelines (American College of Chest Physicians, European Society of Regional Anaesthesia, and American Society of Regional Anesthesia) and relevant publications were identified by a PubMed search using the terms perioperative AND anticoagulants OR antithrombotics AND guideline. Issues relevant to clinical practice were identified, and attempts were made to explain any ambiguity that arose. Adhering to basic pharmacological principles and evidence-based guidelines allows for the safe usage of antithrombotics. Knowing when to stop, continue, bridge and restart antithrombotic medication prevents perioperative morbidity and mortality. Stopping antithrombotic medication too early can lead to thromboembolic complications associated with their primary disease process. Not stopping antithrombotic medication or stopping it too late can potentially cause life-threatening bleeding, haematomas and increased transfusion requirements.

Community voices from modern maternal waiting home users in Zambia.

Objective: This study aimed to understand community voices on factors influencing utilisation of MMWHs in Zambia. Methods: The study employed a mixed method study design in four selected health facilities across Zambia districts between January 2021 and December 2022. Purposeful sampling was used to select study participants using MMWH registers as the sampling frame for mothers who had utilised MMWHs and their spouses. Sampling of participants through face-to-face, in-depth interviews (IDIs) and focus group discussions (FGDs) was conducted to saturation in all targeted health facilities Data was transcribed verbatim and analysed thematically. Results: Results found that the comfortable state of the MMWHs, long distances to health facilities, fear of maternal complications, availability and positive attitudes of specialized health personnel, and the information on childcare provided were major factors. Spouses supported their partners using MMWHs due to the quality of care and the availability of modern equipment and furniture. However, some spouses indicated that utilisation of MMWHs has a bearing on a household's financial resources. Conclusion: MMWHs are a pivotal intervention in improving maternal outcomes. All health facilities had no maternal and newborn complications or deaths over the study period.

Developing an electronic portfolio of learning for family medicine training in South Africa.

Workplace-based assessment has become increasingly crucial in the postgraduate training of specialists in South Africa, particularly for family physicians. The development of a Portfolio of Learning (PoL) has been a central focus within the discipline of family medicine for over a decade. Initially, a paper-based portfolio was adopted to collect evidence of learning for 50 out of 85 agreed exit-level outcomes. Stellenbosch University led the conversion of this portfolio into an electronic format, known as e-PoL, utilising Scorion software. The e-PoL was successfully implemented in the Western and Eastern Cape regions and was subsequently adopted nationally under the coordination of the South African Academy of Family Physicians. In 2023, the e-PoL underwent a redesign to gather evidence of learning for 22 entrustable professional activities (EPAs). Key insights from this development process underscore the importance of the PoL in supporting assessment-for-learning rather than merely assessment-of-learning. This necessitates features for feedback and interaction, ensuring that the PoL functions beyond a mere repository of forms. Additionally, the e-PoL should facilitate triangulation, aggregation, and saturation of data points to effectively measure EPAs. Furthermore, the PoL has not only documented learning but has also played a pivotal role in guiding the development of clinical training by explicitly outlining expectations for both registrars and supervisors. While the initial design and development costs are significant, operational costs become affordable when shared across all training programmes.

Mastering your fellowship: Part 4, 2024.

The 'Mastering your Fellowship' series provides examples of the question format encountered in the written and clinical examinations for the Fellowship of the College of Family Physicians of South Africa (FCFP [SA]) examination. The series is aimed at helping family medicine registrars prepare for this examination. Model answers are available online.

Mastering your fellowship: Part 2, 2024.

The 'Mastering your Fellowship' series provides examples of the question format encountered in the written and clinical examinations, Part A of the Fellowship of the College of Family Physicians of South Africa (FCFP [SA]) examination. The series is aimed at helping family medicine registrars prepare for this examination.

Health budget cuts will be paid for by the most vulnerable.

No abstract available.

Development of entrustable professional activities for family medicine in South Africa.

South Africa is undergoing a significant shift towards implementing enhanced workplace-based assessment methodologies across various specialist training programmes, including family medicine. This paradigm involves the evaluation of Entrustable Professional Activities (EPAs) through comprehensive portfolios of evidence, which a local and national clinical competency committee then assesses. The initial phase of this transformative journey entails the meticulous development of EPAs rooted in discrete units of work. Each EPA delineates the registrar's level of entrustment for autonomous practice, along with the specific supervision requirements. This concise report details the collaborative effort within the discipline of family medicine in South Africa, culminating in the consensus formation of 22 meticulously crafted EPAs for postgraduate family medicine training. The article intricately outlines the systematic structuring and rationale behind the EPAs, elucidating the iterative process employed in their development. Notably, this marks a groundbreaking milestone as the first comprehensive documentation of EPAs nationally for family medicine training in Africa.

The Impact of Regular Screening and Lifestyle Modification on Cardiovascular Disease Risk Factors in South African Women Living With HIV.

BACKGROUND: The Integration of cardiovascular disease SCreening and prevention in the HIV MAnagement plan for women of reproductive age study set out to determine the effectiveness of screening and lifestyle modification in modifying cardiovascular disease (CVD) risk factors in women living with HIV (WLHIV). METHODS: In this prospective, quasiexperimental, intervention study, WLHIV aged 18-<50 years were enrolled from 2 clinics (intervention [I-arm]) and (control arms [C-arm]) in Umlazi, South Africa, between November 2018 and May 2019. Women in the I-arm received lifestyle modification advice on diet, physical activity, alcohol use, and smoking cessation and underwent annual screening for CVD risk. The CVD risk factors were assessed through standardized questionnaires and clinical and laboratory procedures at baseline and at end of 3 years of follow-up. Prevalence of metabolic syndrome and other CVD indices were compared between arms at end-of-study (EOS). RESULTS: Total of 269 WLHIV (149 I-arm and 120 C-arm) with a mean ± SD age of 36 ± 1 years were included in the EOS analyses after 32 ± 2 months of follow-up. The metabolic syndrome prevalence at EOS was 16.8% (25/149) in the I-arm and 24% (24/120) in the C-arm (risk ratio 0.9; 95% CI: 0.5 to 1.1; P 0.86). Proportion of women with fasting blood glucose >5.6 mmol/L in the I-arm and C-arm were 2.7% (4/149) and 13.3% (16/120) respectively (risk ratio 0.2; 95% CI: 0.069 to 0.646; P < 0.01). High-density lipoprotein improved with the intervention arm from baseline to EOS (95% CI: -0.157 to -0.034; P < 0.05). CONCLUSIONS: Although there was no significant difference in the prevalence of metabolic syndrome between study arms, we observed decreased blood glucose levels in the I-arm compared with the C-arm and improved high-density lipoprotein within the I-arm, following lifestyle modification and regular screening for CVD risk factors in WLHIV.

Mastering your fellowship: Part 1, 2024.

The series, 'Mastering your Fellowship', provides examples of the question formats encountered in the written and clinical examinations, Part A of the Fellowship of the College of Family Physicians (South Africa) (FCFP [SA]) examination. The series is aimed at helping family medicine registrars (and their supervisors) in preparing for this examination.

The Influence of HIV Status on Acute Appendicitis: A Retrospective Study from South Africa.

BACKGROUND: Despite the human immunodeficiency virus (HIV) being the most common comorbidity in South African surgical patients, its impact on appendicitis has not been well-described. We aimed to determine HIV status' influence on patients' presentation, assessment, management and outcomes with acute appendicitis. METHODS: The retrospective chart review included all patients aged 12 years and older who were HIV-positive or HIV-negative and presented with acute appendicitis between 1 January 2013 and 31 December 2019. The primary outcome measure was survival to discharge. Secondary outcomes included analysis of the presentation (vital signs), assessment (biochemical, inflammatory markers) and management (intraoperative anatomical severity grading, length of hospital stay). RESULTS: Of the 1096 patients with appendicitis, 196 (17.9%) were HIV-positive, and CD4 counts were available for 159. The median age was 23 years, with the HIV-positive patients being older and HIV-negative group having more males (58.7%). While the HIV-positive patients had a longer median length of hospital stay, there was no statistically significant difference in the two groups' incidence of high-grade appendicitis (p = 0.670). The HIV-positive patients had a higher median shock index (OR 7.65; 95% [CI 2.042-28.64]) than their HIV-negative counterparts. HIV-positivity had a significant association with mortality (OR 9.56; 95% CI [1.68-179.39]), and of the seven HIV-positive patients who died, 66.7% (n = 4) had a CD4 < 200 cells/mm3 (OR 8.6; 95% CI [1.6-63.9]). CONCLUSION: HIV-positive patients, those with CD4 < 200 cells/mm3 or not on ART, have increased mortality risk and may benefit from increased perioperative surveillance. Patients with an unknown HIV status in a high-prevalence population should be offered HIV testing to risk stratify more accurately.

A single-centred retrospective observational analysis on mortality trends during the COVID-19 pandemic.

BACKGROUND: South Africa experienced high mortality during the COVID-19 pandemic. Resources were limited, particularly at the district hospital (DH) level. Overwhelmed healthcare facilities and a lack of research at a primary care level made the management of patients with COVID-19 challenging. The objective of this study was to describe the in-hospital mortality trends among individuals with COVID-19 at a DH in South Africa. METHODS: Retrospective observational analysis of all adults who demised in hospital from COVID-19 between 01 March 2020 and 31 August 2021 at a DH in South Africa. Variables analysed included: background history, clinical presentation, investigations and management. RESULTS: Of the 328 participants who demised in hospital, 60.1% were female, 66.5% were older than 60 and 59.6% were of black African descent. Hypertension and diabetes mellitus were the most common comorbidities (61.3% and 47.6%, respectively). The most common symptoms were dyspnoea (83.8%) and cough (70.1%). 'Ground-glass' features on admission chest X-rays were visible in 90.0% of participants, and 82.8% had arterial oxygen saturations less than 95% on admission. Renal impairment was the most common complication present on admission (63.7%). The median duration of admission before death was four days (interquartile range [IQR]: 1.5-8). The overall crude fatality rate was 15.3%, with the highest crude fatality rate found in wave two (33.0%). CONCLUSION: Older participants with uncontrolled comorbidities were most likely to demise from COVID-19. Wave two (characterised by the 'Beta' variant) had the highest mortality rate.Contribution: This study provides insight into the risk factors associated with death in a resource-constrained environment.

Quality of care of patients with type 2 diabetes mellitus at a public sector district hospital.

BACKGROUND: Globally, diabetes mellitus (DM) remains one of the leading causes of mortality, with approximately 2 million deaths in 2019, the condition also contributes significantly to adverse health conditions and costs. The study aimed to describe the quality of care (QOC) rendered to patients with type 2 DM (T2DM) seeking care at Wentworth Hospital (WWH), a district hospital in KwaZulu-Natal province, South Africa. METHODS: A descriptive cross-sectional design was used, and all patients living with T2DM on treatment who had accessed care for at least 1 year were included. Data were collected through structured exit interviews, and their clinical data were extracted from their medical records. Their knowledge, attitudes and practices were assessed using a 5-point Likert scale. RESULTS: The mean age (standard deviation [s.d.]) was 59 (13.0) years and most (65.3%) were female, of African (30.0%) and Indian (38.6%) descent, with two-thirds (69.4%) obtaining a secondary school education. Their mean glycated haemoglobin (HbA1c) (s.d.) was 8.6 (2.4%). Over 82% had one or more comorbidity, while 30% had at least one DM-related complication. Generally, participants were pleased with the care received, but their knowledge and practices related to their T2DM was suboptimal. CONCLUSION: This study indicates that the QOC was suboptimal due to poor efficacy indicators, poor knowledge and lack of adequate lifestyle measures, despite the frequency of medical practitioner reviews.Contributions: This study identified gaps in QOC and will aid South African public sector policy-makers in devising quality improvement initiatives.

Mastering Your fellowship: Part 4, 2023.

The 'Mastering your Fellowship' series provides examples of the question format encountered in the written and clinical examinations, Part A of the Fellowship of the College of Family Physicians of South Africa (FCFP [SA]) examination. The series is aimed at helping family medicine registrars prepare for this examination.

The pearls and pitfalls of setting high-quality multiple choice questions for clinical medicine.

Multiple choice question (MCQ) examinations have become extremely popular for testing applied knowledge in the basic and clinical sciences. When setting MCQ examinations, assessors need to understand the measures that improve validity and reliability so that the examination accurately reflects the candidate's ability. This continuing medical education unit will cover the essentials of blueprinting an exam, constructing high-quality MCQs and post hoc vetting of the exam. It is hoped that academics involved in assessments use the content provided to improve their skills in setting high-quality MCQs.

Mastering your fellowship: Part 3, 2023.

The series, 'Mastering your Fellowship', provides examples of the question formats encountered in the written and clinical examinations, Part A of the Fellowship of the College of Family Physicians of South Africa (FCFP [SA]) examination. The series is aimed at helping family medicine registrars (and their supervisors) in preparing for this examination.

Mastering your fellowship: Part 2, 2023.

No abstract available.

Developing entrustable professional activities for family medicine training in South Africa.

Workplace-based assessment (WPBA) is becoming part of high-stake assessments in specialist training. Entrustable professional activities (EPAs) are a recent addition to WPBA. This is the first South African publication on developing EPAs for postgraduate family medicine training. An EPA is a unit of practice, observable in the workplace, constituting several tasks with underlying knowledge, skills and professional behaviours. Entrustable professional activities allow for entrustable decisions regarding competence in a described work context. A national workgroup representing all nine postgraduate training programmes in South Africa has developed 19 EPAs. This new concept needs change management to understand the theory and practice of EPAs. Family medicine departments with large clinical workloads are small, necessitating navigating logistical issues to develop EPAs. It has unmasked existing workplace learning and assessment challenges.Contribution: This article contributes new thinking to developing EPAs for family medicine in an effort to understand more authentic WPBA nationally.

Improving service provision through change management.

The change agent role of the family physician is often a daunting task with very little guidance on how to approach change leadership in the current fellowship curriculum. This continuing medical education resource will utilise the theory of change and provide some guidance to taking on this task in the workplace. The approach can be used in healthcare, the community, academia, and research projects. The resource will outline a systematic approach to developing a logic-based strategy for outcomes. The process will be unpacked, the evaluation method outlined, and strategies for ensuring the sustainability of the changing culture will be discussed.

Mastering Your Fellowship: Part 1, 2023.

The series 'Mastering your Fellowship' provides examples of the question formats encountered in the written and clinical examinations, Part A of the Fellowship of the College of Family Physicians of South Africa (FCFP [SA]) examination. The series is aimed at helping family medicine registrars (and their supervisors) in preparing for this examination.