Asia Pacific Family Medicine - Latest Articles

Impact of carpal tunnel syndrome on the expectant woman's life

Zatel Rozali — 2012-01-30T00:00:00Z

IntroductionCarpal Tunnel Syndrome is known to be a common complication during pregnancy especially during the third Trimester. Aim: This article focuses on its impact to the third trimester pregnant mothers with CTS. Methods: Third trimester pregnant mothers with no other known risk factors for CTS, were interviewed and examined for a clinical diagnosis of CTS. The severity of CTS was assessed by means of symptoms severity and functionality using the Boston Carpal Tunnel Questionnaire. Results: Out of 333 third trimester pregnant mothers, 82 (24.6%) were clinically diagnosed with CTS. Malay race was found to have significant correlation with the diagnosis of CTS (p=0.024) and are two times more likely to get CTS during pregnancy (OR=2.26) compare to the non-Malays. Bilateral CTS was two times higher (n=58, 63.4%) than unilateral cases (n=30, 36.6%), however no significant correlation between the two was found with severity (p=0.284) or functional (p=0.906). The commonest complaint was numbness/ tingling during day time (n=63, 76.8%). Majority of the CTS cases were mild (n=66, 80.5%) and approximately one third (n=28, 34.1%) had affected hand functions. All symptoms related to pain was found to have significant correlation with severity (p=0.00, OR=12.23) and function (p=0.005, OR=5.01), whereas numbness and tingling does not (Severity, p=0.843, function, p=0.632). Conclusion: This study shows that even though CTS in third trimester pregnancy is prevalent, generally it would be mild. However, function can still be affected especially if patients complain of pain.

Can we bridge the gap? Knowledge and practices related to Diabetes Mellitus among general practitioners in a developing country: A cross sectional study

Prasad Katulanda — 2011-11-24T00:00:00Z

Background: Diabetes mellitus is becoming a serious public health problem in Sri Lanka and many other developing countries in the region. It is well known that effective management of diabetes reduces the incidence and progression of many diabetes related complications, thus it is important that General Practitioners (GPs) have sound knowledge and positive attitudes towards all aspects of its management. This study aims to assess knowledge, awareness and practices relating to management of Diabetes Mellitus among Sri Lankan GPs. Methods: A cross-sectional study was conducted among all 246 GPs registered with the Ceylon College of General Practitioners using a pre-validated self-administered questionnaire. Results: 205 responded to the questionnaire(response rate 83.3%). Their mean duration of practice was 28.7 ± 11.2 years. On average, each GP had 27 ± 25 diabetic-patient consultations per-week. 96% managed diabetic patients and 24% invariably sought specialist opinion. 99.2% used blood glucose to diagnose diabetes but correct diagnostic cut-off values were known by only 48.8%. Appropriate use of HbA1c and urine microalbumin was known by 15.2% and 39.2% respectively. 84% used HbA1c to monitor glyceamic control, while 90.4% relied on fasting blood glucose to monitor glyceamic control. Knowledge on target control levels was poor.Nearly 90% correctly selected the oral hypoglyceamic treatment for obese as well as thin type 2 diabetic patients. Knowledge on the management of diabetes in pregnancy was poor. Only 23.2% knew the correct threshold for starting lipid-lowering therapy. The concept of strict glycaemic control in preference to symptom control was appreciated only by 68%. The skills for comprehensive care in subjects with multiple risk factors were unsatisfactory. Conclusions: The study was done among experienced members of the only professional college dedicated to the specialty. However, we found that there is room for improvement in their knowledge and practices related to diabetes. We recommend continuing medical education and training programs to update GP's knowledge in order to improve health outcomes in this group of patients.

Family Resources Study: Part 1: Family Resources, Family Function and Caregiver Strain In Childhood Cancer

Avegeille Panganiban-Corales — 2011-10-31T00:00:00Z

Background: Severe illness can disrupt family life, cause family dysfunction, strain resources, and cause caregiver burden. The family's ability to cope with crises depends on their resources. This study sought to assess families of children with cancer in terms of family function-dysfunction, family caregiver strain and the adequacy of family resources using a new family resources assessment instrument. Methods: This is a cross-sectional study involving 90 Filipino family caregivers of children undergoing cancer treatment. This used a self-administered questionnaire composed of a new 12-item family resources questionnaire (SCREEM-RES) based on the SCREEM method of analysis, Family APGAR to assess family function-dysfunction; and Modified Caregiver Strain Index to assess strain in caring for the patient. Results: More than half of families were either moderately or severely dysfunctional. Close to half of caregivers were either predisposed to strain or experienced severe strain, majority disclosed that their families have inadequate economic resources; many also report inaccessibility to medical help in the community and insufficient educational resources to understand and care for their patients. Resources most often reported as adequate were: family's faith and religion; help from within the family and from health providers. SCREEM-RES showed to be reliable with Cronbach's alpha of 0.80. There is good inter-item correlation between items in each domain: 0.24-0.70. Internal consistency reliability for each domain was also good: 0.40-0.92. Using 2-point scoring system, Cronbach's alpha were slightly lower: full scale (0.70) and for each domain 0.26-.82. Results showed evidence of association between family resources and family function based on the family APGAR but none between family resources and caregiver strain and between family function and caregiver strain. Conclusion: Many Filipino families of children with cancer have inadequate resources, especially economic; and are moderately or severely dysfunctional. Many caregivers are predisposed to caregiver strain or are already experiencing severe strain. To provide appropriate care for these families, physicians should regularly assess family function, resources and strain experienced by caregivers. The SCREEM-RES questionnaire used in this study is a helpful and reliable instrument to assess adequacy of family resources.

Career shift phenomenon among doctors in Tacloban City, Philippines: Lessons for retention of health workers in developing countries

Meredith Labarda — 2011-10-06T00:00:00Z

Background: At the height of the global demand for nurses in the 1990s, a phenomenon of grave concern arose. A significant number of medical doctors in the Philippines shifted careers in order to seek work as nurses overseas. The obvious implications of such a trend require inquiry as to the reasons for it; hence, this cross-sectional study. The data in the study compared factors such as personal circumstances, job satisfaction/dissatisfaction, perceived benefits versus costs of the alternative job, and the role of social networks/linkages among doctors classified as career shifters and non-shifters.MethodologyA combined qualitative and quantitative method was utilized in the study. Data gathered came from sixty medical doctors practicing in three major hospitals in Tacloban City, Philippines, and from a special nursing school also located in the same city. Respondents were chosen through a non-probability sampling, specifically through a chain referral sampling owing to the controversial nature of the research. A set of pre-set criteria was used to qualify doctors as shifters and non-shifters. Cross-tabulation was carried out to highlight the differences between the two groups. Finally, the Wilcoxon-Mann-Whitney test was utilized to assess if these differences were significant. Results: Among the different factors investigated, results of the study indicated that the level of job satisfaction or dissatisfaction and certain socio-demographic factors such as age, length of medical practice, and having children to support, were significantly different among shifters and non-shifters at p ≤ 0.05. This suggested that such factors had a bearing on the intention to shift to a nursing career among physicians. Conclusion: Taken in the context of the medical profession, it was the level of job satisfaction/dissatisfaction that was the immediate antecedent in the intention to shift careers among medical doctors. Personal factors, specifically age, support of children, and the length of medical practice gained explanatory power when they were linked to job satisfaction or dissatisfaction. On the other hand, factors such as perceived benefits and costs of the alternative job and the impact of social networks did not differ between shifters and non-shifters. It would then indicate that efforts to address the issue of physician retention need to go beyond economic incentives and deal with other sources of satisfaction or dissatisfaction among practicing physicians. Since this was an exploratory study in a particular locale in central Philippines, similar studies in other parts of the country need to be done to gain better understanding of this phenomenon at a national level.

Treat-to-target approach in managing modifiable risk factors of patients with coronary heart disease in primary care in Singapore: what are the issues?

Ngiap Chuan Tan — 2011-09-22T00:00:00Z

Background: The key management strategy for established coronary heart disease (CHD) patients is to control the underlying risk factors. Further complications will be reduced when these risk factors are treated-to-target (TTT) as recommended by clinical practice guidelines. These targets include blood pressure (BP) lower than 130/80 mm Hg and LDL-cholesterol of less than 2.6 mmol/L and for those with type 2 diabetes mellitus (DM), HBA1c less than 7%. This article aimed to explore the issues affecting this approach from both the patients' and primary care physicians' (PCP) perspectives. Methods: The study involved triangulation of research methods to determine the findings. Part A: focus group discussions to collect qualitative data from patients with CHD and from PCPs who were managing them in primary care. Part B: A subsequent questionnaire survey to determine the extent of their awareness of treatment targets for modifiable risk factors. Results: CHD patients had variable awareness of the modifiable risk factors for CHD due to poor concordance between the PCPs' approach in managing the CHD patients and the latter's reception of information. 46% of participants knew their targets of BP control correctly; 11% of them were correct in stating their target for LDL-cholesterol control. Amongst these participants with DM (n = 146), 27% of them were correct in indicating their target of diabetic control. Conclusions: Communication and practice barriers exist which hinder the treat-to-target approach in mitigating the risk factors for CHD patients. Incorporating this approach in routine clinical practice by PCPs has greater potential to achieve treatment targets for patients.

Working towards decreasing infant mortality in developing countries through a change in the medical curriculum

Iffat Zaman — 2011-08-28T00:00:00Z

Background: High infant and maternal mortality rates are one of the biggest health issues in Pakistan. Although these rates are given high priority at the national level (Millennium Development Goals 4 and 5, respectively), there has been no significant decrease in them so far. We hypothesize that this lack of success is because the undergraduate curriculum in Pakistan does not match local needs. Currently, the Pakistani medical curriculum deals with issues in maternal and child morbidity and mortality according to Western textbooks. Moreover, these are taught disjointedly through various departments. We undertook curriculum revision to sensitize medical students to maternal and infant mortality issues important in the Pakistani context and educate them about ways to reduce the same through an integrated teaching approach. Methods: The major determinants of infant mortality in underdeveloped countries were identified through a literature review covering international research produced over the last 10 years and the Pakistan Demographic Health Survey 2006-07. An interdisciplinary maternal and child health module team was created by the Medical Education Department at Shifa College of Medicine. The curriculum was developed based on the role of identified determinants in infant and maternal mortality. It was delivered by an integrated team without any subject boundaries. Students' knowledge, skills, and attitudes were assessed by multiple modalities and the module itself by student feedback using questionnaires and focus group discussions. Results: Assessment and feedback demonstrated that the students had developed a thorough understanding of the complexity of factors that contribute to infant mortality. Students also demonstrated knowledge and skill in counseling, antenatal care, and care of newborns and infants. Conclusions: A carefully designed integrated curriculum can help sensitize undergraduate medical students and equip them to identify and address complex issues related to maternal and infant mortality in underdeveloped countries.

Predictors of switching from beta-blockers to other anti-hypertensive drugs: a review of records of 19,177 Chinese patients seen in Public Primary Care Clinics in the New Territory East, Hong Kong

Martin Wong — 2011-07-27T00:00:00Z

Background: Beta-blocker drugs are commonly used in family practice and studies showed that they were the most popularly prescribed medications among all antihypertensive agents. This study aimed to identify the factors associated with medication switching from a beta-blocker to another antihypertensive drug among Chinese patients. Methods: We used a validated database which consisted of the demographic and clinical information of all Chinese patients prescribed a beta-blocker from any public, family practice clinics between 01 Jan 2004 to 30 June 2007 in one large Territory of Hong Kong. The proportion of patients switched from beta-blockers to another antihypertensive agent 180 days within their first prescription was studied, and the factors associated with medication switching were evaluated by using multivariate regression analyses. Results: From 19,177 eligible subjects with a mean age of 59.1 years, 763 (4.0%) were switched from their beta-blockers within 180 days of commencing therapy. A binary logistic regression model used medication switching as the outcome variable and controlled for age, gender, socioeconomic status, clinic setting (general out-patient clinics, family medicine specialist clinic or staff clinics), district of residence, visit type (new vs. follow-up attendance), the number of concomitant co-morbidities, and the calendar year of prescription. It was found that older patients (age 50-59 years: adjusted odds ratio [AOR] 1.38, 95% C.I. 1.12-1.70; p = 0.002; age 60-69 years: AOR 1.63 95% C.I. 1.30-2.04, p < 0.001; age ≥ 70 years: AOR 1.82, 95% C.I. 1.46-2.26, p < 0.001; referent age < 50 years) and new visitors (AOR 0.57, 95% C.I. 0.48-0.68, p < 0.001) were more likely to have their medication switched. Conclusions: Closer monitoring of the medication taking behavior among the older patients and the new clinic visitors prescribed a beta-blocker is warranted. Future studies should evaluate the reasons of drug switching.

Paradigms of family medicine: bridging traditions with new concepts; meeting the challenge of being the good doctor from 2011

John Murtagh — 2011-07-16T00:00:00Z

This is the paper for the Wes Fabb Oration for the WONCA Asia Pacific Regional Conference 2011. This paper will review the case for the important role of the family physician/general practitioner in worldwide health care as determined by the WHO. The importance of continuing care is highlighted. The features of a good doctor will be defined and the process of meeting this challenge for excellence of care is presented.

Cultural Aspects of Primary Healthcare in India: A case-based analysis

Roger Worthington — 2011-06-16T00:00:00Z

Delivering quality primary care to large populations is always challenging, and that is certainly the case in India. While the sheer magnitude of patients can create difficulties, not all challenges are about logistics. Sometimes patient health-seeking behaviour leads to delays in obtaining medical help for reasons that have more to do with culture, social practice and religious belief. When primary care is accessed via busy state-run outpatient departments there is often little time for the physician to investigate causes behind a patient's condition, and these factors can adversely affect patient outcomes. We consider the case of a woman with somatic symptoms seemingly triggered by psychological stresses associated with social norms and familial cultural expectations. These expectations conflict with her personal and professional aspirations, and although she eventually receives psychiatric help and her problems are addressed, initially, psycho-social factors underlying her condition posed a hurdle in terms of accessing appropriate medical care. While for many people culture, belief and social norms exert a stabilising, positive influence, in situations where someone's personal expectations differ significantly from accepted social norms, individual autonomy can be directly challenged, and in which case, something has to give. The result of such challenges can negatively impact on health and well-being, and for patients with immature defence mechanisms for dealing with inner conflict, such an experience can be damaging and ensuing somatic disturbances are often difficult to treat. Patients with culture-bound symptoms are not uncommon within primary care in India or in other Asian countries and communities. We argue that such cases need to be properly understood if satisfactory patient outcomes are to be achieved. While some causes are structural, having to do with how healthcare is accessed and delivered, others are about cultural values, social practices and beliefs. We note how some young adult women are adversely affected and discuss some of the ethical issues that arise.

In a free healthcare system, why do men not consult for lower urinary tract symptoms (LUTS)?

U Chong Lai — 2011-06-08T00:00:00Z

Background: The prevalence of lower urinary tract symptoms (LUTS) varies among different populations but the rate of seeking medical advice is consistently low. Little is known about the reasons for this low rate. In the city of Macau, China, primary healthcare is free and easily accessible to all citizens. We aim to study the patients' rate of consulting for LUTS and their reasons for not consulting under a free healthcare system.MethodA convenience sample of 549 male patients aged 40-85 years in a government health centre filled in the International Prostate Symptoms Scale (IPSS) questionnaire. They were also asked if they had consulted doctors for LUTS, and if not, why not.ResultOf the whole sample, 64 men (11.7%) had ever consulted doctors for LUTS. Of 145 with moderate to severe LUTS, 35 (24.1%) consulted. Of 73 who were dissatisfied with their quality of life, 22 (30.1%) consulted. Regarding the symptoms as normal or not problematic was the main reason for not consulting. Advancing age and duration of symptoms were the significant factors for consulting. Conclusion: Primary care doctors could help many of LUTS patients by sensitively initiating the discussion when these patients consult for other problems.