The South African General Practitioner

The link between thyroid hormones and cutaneous squamous cell carcinoma

2024-06-04T09:44:52+00:00

This case study aims to improve clinical practice by highlighting hypothyroidism as a possible risk factor for the development of squamous cell carcinoma (SCC), particularly in people of colour. A 65-year-old Black female presented with generalised weakness and confusion. Examination revealed a left-sided oculomotor nerve palsy. Laboratory tests indicated central hypothyroidism with a CT brain scan showing a cystic lesion in the suprasellar region. Patient history revealed that a malignant growth had been excised from her left leg eight months earlier and biopsy results revealed SCC. This case study underlines the connection between hypothyroidism and SCC, emphasising the complex role of thyroid hormones in cancer development.

CPD Questionnaire (V05N02)

2024-06-24T09:08:11+00:00

CPD questionnaire

Unveiling the grip of opioid addiction in South Africa: a call for community-centred interventions

2024-04-14T07:42:22+00:00

In anticipation of the forthcoming rollout of opioid substitution therapy (OST), this paper discusses the nature of heroin, which is commonly referred to as whoonga or nyaope in South Africa, examining its addictive properties as a foundation for community interventions, including harm reduction. Analysing its chemical composition enables the classification of the main substance as an opioid. Identifying common cheaper adulterants added to produce or sell more product, to make it less potent or to mimic its effects and potentially increasing its desirability to consumers, helps to dispel misconceptions such as the inclusion of rat poison or antiretroviral agents, and aids in relevant treatment approaches and strategies. This paper further seeks to initiate crucial conversations to raise awareness of the drug and its effects. The emphasis is on psychoeducation as a foundational step in enabling communities to comprehend the complexities of opioid addiction, its pervasive grip on individuals, and the formidable obstacles to cessation. Such understanding fosters empathy and lays the groundwork for comprehensive and supportive care for individuals struggling with opioid addiction. Drawing from successful models in other countries, the paper supports proposals of expanding OST to the community and primary healthcare settings, involving primary healthcare nurses, clinical associates, and mental health professionals not only to increase access to treatment but also to enhance support for those affected by opioid addiction.

The days of small things

2024-05-31T10:08:13+00:00

In the 1970s, I did a weekly rural clinic in the Injasuti Valley in the Drakensberg mountains. The clinic was near the river and outside were some tall gum trees that quietly sang when the warm summer winds came sweeping down the valleys. There were usually some cattle slowly cropping the grass near the clinic while unperturbed goats would tug at the lower branches of a thorn tree under which the patients sat, discussing the affairs of the day. They were what the prophet Zechariah called “the days of small things”.

Impact of early vs. delayed initiation of dutasteride/tamsulosin combination therapy on the risk of acute urinary retention or BPH‑related surgery in LUTS/BPH patients with moderate‑to‑severe symptoms at risk of disease progression

2024-06-11T12:25:15+00:00

Purpose: To evaluate the effect of delayed start of combination therapy (CT) with dutasteride 0.5 mg and tamsulosin 0.4 mg on the risk of acute urinary retention or benign prostatic hyperplasia (BPH)-related surgery (AUR/S) in patients with moderate-to-severe lower urinary tract symptoms (LUTS) at risk of disease progression.

Methods: Using a time-to-event model based on pooled data from 10,238 patients from Phase III/IV dutasteride trials, clinical trial simulations (CTS) were performed to assess the risk of AUR/S up to 48 months in moderate-to-severe LUTS/ BPH patients following immediate and delayed start of CT for those not responding to tamsulosin monotherapy. Simulation scenarios (1 300 subjects/arm) were investigated, including immediate start (reference) and alternative delayed start (six scenarios 1–24 months). AUR/S incidence was described by Kaplan–Meier survival curves and analysed using log-rank test. The cumulative incidence of events as well as the relative and attributable risks were summarised stratified by treatment.

Results: Survival curves for patients starting CT at month 1 and 3 did not differ from those who initiated CT immediately. By contrast, significant differences (p < 0.001) were observed when switch to CT occurs ≥ 6 months from the initial treatment. At month 48, AUR/S incidence was 4.6% vs 9.5%, 11.0% and 11.3% in patients receiving immediate CT vs. switchers after 6, 12 and 24 months, respectively.

Conclusions: Start of CT before month 6 appears to significantly reduce the risk of AUR/S compared with delayed start by ≥ 6 months. This has implications for the treatment algorithm for men with LUTS/BPH at risk of disease progression.

Prostate safety events during testosterone replacement therapy in men with hypogonadism - a randomized clinical trial

2024-06-19T07:24:57+00:00

Importance: The effect of testosterone replacement therapy (TRT) on the risk of prostate cancer and other adverse prostate events is unknown.

Objective: To compare the effect of TRT vs placebo on the incidences of high-grade prostate cancers (Gleason score >4 + 3), any prostate cancer, acute urinary retention, invasive prostate procedures, and pharmacologic treatment for lower urinary tract symptoms in men with hypogonadism.

Design, setting, and participants: This placebo-controlled, double-blind randomized clinical trial enrolled 5246 men (aged 45-80 years) from 316 US trial sites who had 2 testosterone concentrations less than 300 ng/dL, hypogonadal symptoms, and cardiovascular disease (CVD) or increased CVD risk. Men with prostate-specific antigen (PSA) concentrations greater than 3.0 ng/mL and International Prostate Symptom Score (IPSS) greater than 19 were excluded. Enrollment took place between May 23, 2018, and February 1, 2022, and end-of-study visits were conducted between May 31, 2022, and January 19, 2023.

Intervention: Participants were randomized, with stratification for prior CVD, to topical 1.62% testosterone gel or placebo. Main outcomes and measures: The primary prostate safety end point was the incidence of adjudicated high-grade prostate cancer. Secondary end points included incidence of any adjudicated prostate cancer, acute urinary retention, invasive prostate surgical procedure, prostate biopsy, and new pharmacologic treatment. Intervention effect was analyzed using a discrete-time proportional hazards model.

Results: A total of 5204 men (mean [SD] age, 63.3 [7.9] years) were analyzed. At baseline, the mean (SD) PSA concentration was 0.92 (0.67) ng/mL, and the mean (SD) IPSS was 7.1 (5.6). The mean (SD) treatment duration as 21.8 (14.2) months in the TRT group and 21.6 (14.0) months in the placebo group. During 14 304 person-years of follow-up, the incidence of high-grade prostate cancer (5 of 2 596 [0.19%] in the TRT group vs 3 of 2 602 [0.12%] in the placebo group; hazard ratio, 1.62; 95% CI, 0.39-6.77; p = .51) did not differ significantly between groups; the incidences of any prostate cancer, acute urinary retention, invasive surgical procedures, prostate biopsy, and new pharmacologic treatment also did not differ significantly. Change in IPSS did not differ between groups. The PSA concentrations increased more in testosterone-treated than placebo-treated men.

Conclusions and relevance: In a population of middle-aged and older men with hypogonadism, carefully evaluated to exclude those at high risk of prostate cancer, the incidences of high-grade or any prostate cancer and other prostate events were low and did not differ significantly between testosterone- and placebo-treated men. The study’s findings may facilitate a more informed appraisal of the potential risks of TRT.

Trial registration: ClinicalTrials.gov Identifier: NCT03518034

Direct oral anticoagulants: the available agents and practical considerations

2024-05-31T10:31:10+00:00

Thrombosis remains one of the leading causes of death in the world, and South Africa is no exception. In addition, as the population across the globe is ageing, the burden of stroke due to cardiovascular disease and atrial fibrillation (AF) is proliferating exponentially. Infection with HIV, which is prevalent in Africa, contributes significantly to the risk of both venous and arterial thrombosis. Anticoagulation can prevent thrombotic events but careful consideration of the choice of drug is needed to ensure efficacy and safety in the multifaceted anticoagulation drug arena. Although warfarin is still widely used, the direct oral anticoagulants (DOACs) are becoming the agents of choice for acute and chronic anticoagulation. The DOACs are a group of individual drugs, and choice of agent, and even dose, will depend on therapeutic indication, renal and liver function, age, body weight, comorbidities, previous medical history and concomitant medication. In this article the key pharmacological characteristics, indications and contraindications of the available DOACs in South Africa are summarised with the aim to assist with choosing the right anticoagulant, for the right patient, at the right dose, for the right duration.

Assessing the clinical impact of sodium-glucose cotransporter type 2 (SGLT2)- inhibitors in treating heart failure with reduced ejection fraction

2024-05-06T05:40:59+00:00

Heart failure with reduced ejection fraction (HFrEF), often considered life-threatening, presents a significant risk to patient health. Guideline-directed medical therapy (GDMT), comprising a four-drug regimen, is currently widely recommended to optimise patient outcomes. This article seeks to elucidate the absolute benefits of SGLT2-inhibitors in the management of HFrEF and their integration into GDMT protocols.

Self-reported practices and learning needs of private general practitioners during the pandemic in South Africa

2024-04-09T10:01:48+00:00

Background: General practitioners (GPs) are the first contact when seeking medical treatment for any symptom. However, their clinical practices and learning needs in the pandemic remain unknown in South Africa. We aimed to evaluate private GP practices and learning needs during the pandemic in South Africa. The objectives described and determined participant characteristics, skills, and roles and identified gaps.

Methods: The online survey conducted a cross-sectional descriptive study of private general GPs in South Africa between 30 June and 30 July 2021. Overall, 7 782 subscribed to the e-mail marketing network, which conducted a single-stage cluster sampling. A validated data collection tool and COVID-19 scorecard on the Likert scale were utilised. Data analyses used R and R Studio (v 2021.09.0+351) (R Core Team, 2019) and Microsoft Excel (v 2019).

Results: Respondents completed 88 questionnaires (40 males, 48 females, median age 47 years). The median clinical practice was 60%. The best-performing domain was medical products and technologies, at 69% (n = 61). The lowest was service delivery, at 47% (n = 41). Most reported training and practice in administration, communication, consultation, women’s health, and emergencies. Most did not practice obstetrics and paediatrics and lacked forensic medicine training and skills. Significant GP roles were competent clinician, capacity builder, and critical thinker. The minors were collaborators, community advocates, and the slightest change agents.

Conclusion: Most private GPs are trained in most disciplines with limited exposure to forensic medicine. Similarly, most competencies are performed except as change agents. However, gaps exist in obstetrics, paediatrics, and forensic medicine skills. Further research is recommended.

Acne vulgaris and variants

2024-05-22T08:26:24+00:00

Acne vulgaris is a multifactorial, inflammatory disease of the pilosebaceous unit (comprising the hair follicle and sebaceous gland), primarily involving the face, chest, and back. It is a chronic disease with a potentially severe impact on the quality of life and self-image of all age groups affected. It has been associated with increased rates of anxiety, depression, and suicidal ideation. Therefore, clinicians must be well informed on the pathogenesis, clinical diagnosis, grading of severity, treatment algorithm, and pharmacology of the medications used for acne.

Second victim syndrome: bridging compassion and healing in healthcare

2024-05-06T05:36:14+00:00

In the intricate healthcare landscape, where compassion merges with complex medical decisions and procedures, second victim syndrome may lurk unnoticed and unaddressed.¹ The psychological distress and emotional turmoil experienced by healthcare professionals after being involved in adverse patient events and near-misses remain largely silent, haunting healthcare professionals and leaving them vulnerable to subsequent health issues.² This editorial delves into this second victim syndrome, shedding light on its profound impact, particularly in the context of medical malpractice and litigation, and exploring the potential of mindfulness in nurturing healing and resilience.