Approach to chest pain and acute myocardial infarction.

Patient history, physical examination, 12-lead electrocardiogram (ECG) and cardiac biomarkers are key components of an effective chest pain assessment. The first priority is excluding serious chest pain syndromes, namely acute coronary syndromes (ACSs), aortic dissection, pulmonary embolism, cardiac tamponade and tension pneumothorax. On history, the mnemonic SOCRATES (Site Onset Character Radiation Association Time Exacerbating/relieving factor and Severity) helps differentiate cardiac from non-cardiac pain. On examination, evaluation of vital signs, evidence of murmurs, rubs, heart failure, tension pneumothoraces and chest infections are important. A 12-lead ECG should be interpreted within 10 minutes of first medical contact, specifically to identify ST elevation myocardial infarction (STEMI). High-sensitivity troponins improve the rapid rule-out of myocardial infarction (MI) and confirmation of non-ST elevation MI (NSTEMI). ACS (STEMI and NSTEMI/unstable anginapectoris (UAP)) result from acute destabilisation of coronary atheroma with resultant complete (STEMI) or subtotal (NSTEMI/UAP) thrombotic coronary occlusion. The management of STEMI patients includes providing urgent reperfusion: primary percutaneous coronary intervention(PPCI) if available, deliverable within 60 - 120 minutes, and fibrinolysis if PPCI is not available. Essential adjunctive therapies include antiplatelet therapy (aspirin, P2Y12 inhibitors), anticoagulation (heparin or low-molecular-weight heparin) and cardiac monitoring.

Impact of transthoracic echocardiography at district hospital level.

BACKGROUND: The use of and demand for echocardiography (ECHO) has increased worldwide. In developed countries, this has not translated into improved access outside tertiary centres. Previous studies have favoured the appropriate use of ECHO over its clinical impact, limiting generalisability to resource-constrained settings. OBJECTIVES: To assess the impact of an ECHO service at district hospital level in Cape Town, South Africa. METHODS: A prospective, cross-sectional study was performed. A total of 210 consecutive patients, referred to the ECHO clinic over a 5-month period, were recruited. Transthoracic ECHO was evaluated in terms of its indication, new information provided, correlation with the referring doctor's diagnosis and subsequent management plan. Impact included the escalation and de-escalation of treatment, as well as usefulness without a change in management. RESULTS: The results show that 83.8% of the patients' management was impacted on by echocardiography. Valvular lesions were the main indication. The most frequent contribution was information provided towards the diagnosis of heart failure and assessment after myocardial infarction. Of the echocardiograms, 56.2% confirmed the referring doctor's diagnosis, yet were still associated with a significant impact. The rational prescription of medication had the major impetus, followed by de-escalation of therapy and screening patients to determine referral to a tertiary facility. CONCLUSION: ECHO has a positive impact on patient management outside tertiary settings, where the definition of impact appears to be different. The value of a normal study, screening prior to upstream referral and usefulness irrespective of change have been established. This should alert policy makers against restriction of access to ECHO and promote training of personnel in its use.

A snapshot of noncommunicable disease profiles and their prescription costs at ten primary healthcare facilities in the in the western half of the Cape Town Metropole

Objectives: There has been a rapid increase in the prevalence of noncommunicable diseases globally. It is thought that this increase will have the greatest impact on developing countries; such as South Africa; where it will adversely affect quality of life and increase healthcare costs. This research was conducted to determine the disease profile and cost of treating patients at 10 facilities in the western half of the Cape Town Metropole.Design: An analytical; cross-sectional study was carried out in order to interpret the cost of the medication in relation to the patient disease profile. Setting and subjects: Data were collected from 10 facilities in the western half of the Cape Town Metropole over a three-month period.Outcome measure: The outcome measure was the disease profile of patients attending the facilities and the cost of prescriptions for these patients.Results: Most patient visits to the community health centres were to treat chronic diseases (82). The disease profile of patients was as follows: 58.96 had hypertension; 19.67 diabetes; 12.14 asthma and chronic obstructive pulmonary disease; and 21.80 arthritis. It was found that 65 of patients with a chronic condition had co-morbidities. The cost of prescriptions was significantly higher (p-value 0.001) for chronic conditions than for acute conditions. The number of comorbidities per patient also influenced the cost of the prescriptions.Conclusion: The results indicated that most of the adults attending public sector facilities in the western half of the Cape Town Metropole have chronic diseases and that the cost of treating these conditions is significantly greater than that of treating acute conditions. An integrated approach to the management of chronic diseases is important in low-resource settings for the efficient utilisation of limited resources

Assessment and evaluation in medical education

"Previous discussion has focused upon the educational process; specifically; the basis for ""good"" medical education; the methods of learning and teaching used and the relationship between undergraduate; postgraduate and life-long learning; continuing professional development. All these would appear to be; in the first instance; linear processes; with a beginning that commences with a specific teaching and learning activity and an end; often an end-point examination; hopefully testing how much we remember; apply and use. As part of any educational programme; assessment and evaluation feature frequently. The purpose of this article is to not only equip the reader with an understanding of the terminology used in assessment and evaluation; but to demonstrate that; as for many other aspects of medical education; the processes of assessment and evaluation bring cyclical and dynamic actions which can be used and built upon to improve the efficiency of the training model and even oneself."

Cefetamet pivoxil vs cefaclor in the treatment of acute otitis media in children.

74 children with acute otitis media (AOM) were entered into an observer-blind randomised multicentre general practice study to compare the efficacy and safety of the new third generation oral cephalosporin, cefetamet pivoxil, at a dose of 10 mg/kg twice daily with the efficacy and safety of cefaclor 10 mg/kg twice daily administered for 10 days. Of 36 evaluable patients in the cefaclor treatment group, 28 (78%) were cured, and a further 4 were improved, giving an overall efficacy rate (cure/improvement) of 89%. Of 36 evaluable patients in the cefetamet pivoxil treatment group, 31 (86%) were cured, and a further 4 were improved, giving an overall efficacy rate of 97%. Adverse events were reported in 4 patients: 1 cefaclor recipient and 3 patients in the cefetamet pivoxil treatment group. Diarrhoea, the most frequently observed adverse event, occurred in both treatment groups. The study results indicate that cefetamet pivoxil and cefaclor appear to have similar efficacy and safety in the treatment of AOM in children.