• Revolutionising Genitourinary Syndrome of menopause treatment
• Breastmilk reserve launches breastmilk pasteurizer
• Pain in women
• Cervical Cancer A Global Health Challenge
• Oral contraceptives and hormonal adaptation in ageing women
• The case for transdermal oestrogen and micronised progesterone
• A guide to abnormal bleeding during & after pregnancy
• Vacuum-assisted delivery: An overview
OUTH AFRICA FACES a daunting challenge with the highest number of HIV-positive individuals globally, approximately 7.8 million as of 2022. This staggering statistic underscores the urgent need for innovative treatment strategies. Leading the charge is Dr Veron Ramsuran, whose pioneering work in genome sequencing of HIV elite controllers and what the research will mean for precision and personalised medicine could revolutionise the approach to HIV treatment in the region and beyond.
THE POWER OF PRECISION MEDICINE
Dr Ramsuran, a senior lecturer at the University of KwaZulu-Natal and a respected figure in the field, advocates for a shift towards precision medicine – a method that tailor's treatment to individual genetic profiles. "Precision
medicine and personalised medicine are going to change the way we treat patients in the future," Dr Ramsuran said in an interview with Medical Chronicle. This approach promises more effective and personalised care, moving away from the 'one-size-fits-all' strategy that has dominated medical practice.
GENE SEQUENCING: UNRAVELING THE GENETIC CODE
At the heart of precision medicine is gene sequencing, a technology that allows researchers to read and interpret the genetic information contained within our DNA. This process is crucial for identifying genetic mutations that influence how individuals respond to HIV. By understanding these genetic factors, scientists can develop targeted therapies that are more effective and have fewer side effects.
THE HIV HOST GENOME PROJECT
A cornerstone of this research is the HIV Host Genome project, spearheaded by
By Nicky Belseck,
Dr Ramsuran and his team. This project focuses on elite controllers, a small subset of HIV-positive individuals whose immune systems can control the virus without the need for antiretrovirals. "We looked at the genome of these individuals and tried to find out what's unique in terms of the genetics that are present within the human body," explained Dr Ramsuran. The insights gained from studying these elite controllers are pivotal, as they hold the key to understanding the genetic basis of natural resistance to HIV.
ELITE CONTROLLERS: A WINDOW INTO NATURAL IMMUNITY
Elite controllers represent less than 1% of the HIV-positive population but provide invaluable insights into natural disease resistance. By studying their genetic makeup, researchers hope to uncover the mechanisms behind their ability to suppress the virus. This could lead to breakthroughs in HIV treatment, potentially allowing others to achieve similar control over the virus without lifelong medication.
SAMRC’S AFRICAN GENOMICS
CENTRE AND MGI COLLABORATION
The research is supported by the South African Medical Research Council’s (SAMRC) African Genomics Centre in Cape Town. This facility, in collaboration with MGI, has been instrumental in advancing genomic research in Africa. MGI has provided the highthroughput sequencing technology necessary for this large-scale genetic study, enabling the team to conduct comprehensive analyses that were previously not possible in SA.
“Previously what would happen is the samples would leave SA and be shipped off to another country and all the work would be done there and the South African researcher will just be added on to the publication, not doing much in the research. This time around the research is done in SA and led by South African researchers,” Dr Ramsuran explained.
IMPLICATIONS FOR GLOBAL HEALTH
The grave reality is that SA bears the heaviest burden of HIV prevalence worldwide.
• Revolutionising Genitourinary Syndrome of menopause treatment
• Breastmilk reserve launches breastmilk pasteurizer
• Pain in women
• Cervical Cancer A Global Health Challenge
• Oral contraceptives and hormonal adaptation in ageing women
• The case for transdermal oestrogen and micronised progesterone
• A guide to abnormal bleeding during & after pregnancy
• Vacuum-assisted delivery: An overview
This harsh fact underscores a significant gap in global health research – the profound underrepresentation of African genomes in scientific inquiries. Historically, the rich genetic diversity of African populations has been neglected in the quest for medical breakthroughs, even though it offers essential insights that could address some of the most critical health challenges facing the world today.
The work being done by Dr Ramsuran and his colleagues is not just transformative for HIV treatment; it also has broader implications for global health. By tailoring treatments to genetic profiles, precision medicine can reduce adverse drug reactions and improve treatment efficacy across various diseases. This approach is particularly crucial in a diverse country like SA, where genetic variations significantly impact health outcomes.
As the HIV Host Genome project progresses, the hope is that the findings will lead to new therapeutic strategies that can be applied not only to HIV but also to other infectious and non-
infectious diseases. Dr Ramsuran envisioned the precision medicine, personalised medicine approach increasing over the next few years so that people are not having adverse drug reactions. People can get treated based on their genetics so they can overcome the disease with the correct treatment.
This research not only promises to enhance the quality of life for those living with HIV but also serves as a beacon of hope for other diseases, proving that targeted, personalised treatment is within reach. As SA continues to lead in this vital research, the global health community watches eagerly, anticipating the next breakthroughs that will emerge from this vibrant scientific endeavour.
Dr Ramsuran's insights reveal a future where HIV treatment is not only effective but also tailored to the genetic makeup of each individual, offering a more humane and precise approach to healthcare. This approach not only promises to transform HIV treatment but also sets a precedent for handling other diseases with a genetic component, positioning SA as a leader in global health innovation.
EAR DEVOTED READERS, Welcome to our August issue. This edition is packed with insightful articles and updates to enhance your practice and patient care.
As August is Women's Month, we have a special focus on Women's Health. Key highlights include: Cervical cancer: A global health challenge. This article explores the prevalence, risk factors, and prevention strategies for cervical cancer, emphasising the importance of HPV vaccination and regular screening. Oral contraceptives and hormonal adaptation in ageing women discusses the evolving needs of women as they age and how to adapt contraceptive strategies to ensure efficacy and safety.
The case for transdermal oestrogen and micronised progesterone evaluates the benefits of these treatments compared to traditional oral oestrogen preparations, highlighting their safety and efficacy.
Our feature includes a CPD article by Dr Ilhaam Mohamed: Revolutionising Genitourinary Syndrome of Menopause (GSM) treatment, which is essential reading for those looking to stay updated on the latest advancements in women's health.
There is also an online CDP article that examines the concept of drug holidays in ADHD treatment, providing valuable insights into the benefits and risks associated with this practice. Find both articles on www.medicalchronicle.
In addition to these features, we
therapy dogs in cancer care, and the impact of antibiotic resistance in bacterial conjunctivitis.
Thank you for your continued dedication to improving healthcare in South Africa. Happy reading!
A valuable resource for healthcare professionals, the Journal of Cancer Screening and Prevention recently published a comprehensive review providing evidence-based recommendations for dietary strategies to reduce cancer risk.
SA FACES A significant challenge with cancer, ranking as one of the leading causes of morbidity and mortality in the country. Recent statistics highlight the prevalence of cancers such as breast, cervical, and prostate, underscoring the
urgent need for effective prevention, early detection, and treatment.
In a review published in the Journal of Cancer Screening and Prevention, researchers delved into the complex relationship between diet, supplements,
EPCLUSA® is indicated for the treatment of chronic hepatitis C infection irrespective of genotype in treatment naïve or treatment experienced patients aged 12 years and older and weighing at least 30 kg:
- without cirrhosis or with compensated cirrhosis
- with decompensated cirrhosis in combination with ribavirin 1
and cancer prevention. The study, led by Anandu Chandra Khanashyam et al. provided a thorough analysis of how various dietary components influence cancer risk, underscoring the importance of dietary choices in cancer prevention.
Cancer remains a global health challenge, with dietary factors playing a role in as many as 30%-50% of cancer cases worldwide. The review highlights that while no single food or supplement can guarantee cancer prevention, a balanced diet rich in fruits, vegetables, and whole grains offers the best defence against the development of cancer.
KEY DIETARY FACTORS AND CANCER PREVENTION
Suitable for patients with various levels of
Proven cure ratec: 98,9 % in real-world analysis2,3
1 tablet once daily, with or without food, for 12 weeks1
Footnotes: Despite unknowns in baseline characteristics of some patients, such as: HCV genotype, fibrosis stage, former/current IV drug use, PPI use at baseline and treatment history.3 bA large-cohort international real-world study showed that patients with unknown genotype (n = 42), unknown fibrosis score (n = 82) and unknown treatment history (n = 33) were cured with EPCLUSA® for 12 weeks. Cure is defined as SVR i.e., undetectable HCV RNA after treatment completion.3,4 cCases of HBV reactivation, some of them fatal, have been reported during or after treatment with direct acting antiviral agents including EPCLUSA®. HBV screening should be performed in all patients before initiation of treatment. Treatment with EPCLUSA® should not be initiated in patients who screened positive for hepatitis B virus infection. HBV/HCV coinfected patients are at risk of HBV reactivation, and should therefore be monitored and managed according to current clinical guidelines. dPatients with decompensated cirrhosis use EPCLUSA® + ribavirin for 12 weeks.1
References: 1. Epclusa Professional Information approved by the medicine’s regulatory authority. 10 March 2022. 2. Lawitz E, Bourliere M, Han L, McNally J, Stamm LM, Brainard DM, et al. Treatment with SOF/VEL or SOF/VEL/VOX is well tolerated and results in high SVR12 in genotype 1-6 HCV-infected patients with minimal fibrosis: a retrospective analysis of the ASTRAL and POLARIS clinical studies. Poster THU-273 presented at the International Liver Congress 2017, April 19–21, Amsterdam, The Netherlands. Available at: https://www.natap.org/2017/EASL/EASL_07.htm [Accessed 24 March 2022]. 3. Mangia A, Milligan S, Khalili M, Fagiuoli S, Shafran SD, Carrat F, et al. Global real-world evidence of sofosbuvir/velpatasvir as simple, effective HCV treatment: Analysis of 5552 patients from 12 cohorts. Liver Int 2020;40:1841–1852. 4. National Guidelines for the Management of Viral Hepatitis. Department of Health Republic of South Africa Available at: https://sahivsoc.org/Files/SA%20 NDOH_Viral%20Hepatitis%20guideilnes%20final_.pdf [Accessed 10 March 2022]. For full prescribing information refer to the professional information approved by the Medicines Regulatory Authority. S4 EPCLUSA® 400 mg/100
and 100 mg velpatasvir. Gilead Sciences South Africa (Pty) Ltd., Reg No.: 2014/063761/07,
The review reaffirmed the protective effects of fruits and vegetables, noting their high antioxidant content which helps reduce oxidative stress and inflammation, known contributors to cancer development. The consumption of red and processed meats is associated with an increased risk of colorectal and gastric cancers. The researchers suggested limiting intake of these foods as part of a cancer-preventive diet. Alcohol consumption is linked to an increased risk of cancers of the mouth, oesophagus, liver, and breast. The researchers advised moderation in alcohol consumption or abstaining altogether to reduce cancer risk. While certain vitamins and minerals, such as vitamin D, selenium, and antioxidants, have been studied for their potential to prevent cancer, Khanashyam et al. urged caution. Over-supplementation can lead to adverse effects and may even increase cancer risk in some cases.
THE ROLE OF PHYTOCHEMICALS
Phytochemicals, naturally occurring compounds found in plants, are highlighted for their anti-cancer properties. Compounds such as curcumin (from turmeric), resveratrol (from grapes), and flavonoids (found in a variety of fruits and vegetables) have shown promise in reducing inflammation and preventing the proliferation of cancer cells.
LIFESTYLE AND DIETARY PATTERNS
The review emphasised that a holistic approach to diet is more beneficial than focusing on individual nutrients. Dietary patterns that are rich in whole foods and low in processed foods and sugars are recommended. The Mediterranean diet, rich in fruits, vegetables, nuts, and olive oil, is cited as an effective model for cancer prevention.
FUTURE DIRECTIONS
The authors call for more rigorous clinical trials to better understand the complex interactions between diet, supplements, and cancer. They also highlight the need for personalised nutrition strategies. The review emphasises that diet alone can't prevent cancer but is crucial in an overall cancer prevention strategy.
The 2024 Lancet Commission report on dementia has brought to light a groundbreaking perspective on the prevention of dementia, particularly Alzheimer's disease, by identifying 14 modifiable risk factors.
THIS REVELATION OFFERS hope for millions worldwide, providing actionable insights into how we can significantly reduce the risk of developing dementia. The newly updated report emphasises the importance of addressing these risk factors, which now include vision loss and high LDL cholesterol, alongside previously recognised factors such as physical inactivity, smoking, and poor diet.
The inclusion of these new factors is based on the latest research, suggesting that up to 45% of global dementia cases could potentially be prevented or delayed by modifying these risks.
The 14 modifiable risk factors are:
1. Physical inactivity: Regular exercise enhances cognitive function.
2. Smoking: Smoking cessation reduces neuroinflammation and oxidative stress.
3. Poor diet: Promote nutritional interventions rich in fruits, vegetables, and omega-3 fatty acids.
4. Obesity: Weight should be managed, through diet and exercise.
5. High blood pressure: Stress the control of blood pressure, particularly in midlife.
6. Diabetes: Manage blood sugar levels through diet, exercise, and medication.
7. Low educational attainment: Support continued education and cognitive stimulation throughout life.
8. Depression: Address mental health through therapy and medication.
9. Hearing loss: Promote early diagnosis and use of hearing aids.
10. Social isolation: Encourage social engagement and community participation.
11. Excessive alcohol consumption: Limit alcohol intake to moderate levels.
12. Traumatic brain injury: Implement safety measures to prevent head injuries.
13. Air pollution: Advocate for cleaner air through environmental policies.
14. Vision loss and high LDL cholesterol: These newly added factors underscore the importance of regular health screenings and management of cholesterol levels.
The report critiques the previous
neglect of dietary interventions in dementia prevention strategies and calls for a personalised, multidomain approach to risk reduction. This approach should consider cultural and economic variations, ensuring that prevention strategies are accessible and effective for diverse populations.
REFERENCE
Kivipelto M, Mangialasche F, Anstey K. Pivotal points in the science of dementia risk reduction. The Lancet. 2024. DOI:https://doi.org/10.1016/S01406736(24)01546-0.
The Covid-19 pandemic has left a lasting impact on patients worldwide, with many continuing to experience severe health challenges long after their initial recovery.
CONDUCTED under the PHOSP-
COVID project provides clarity into the long-term cognitive, psychiatric, and fatigue symptoms that plague individuals who were hospitalised due to the virus.
This extensive research, involving nearly
8 000 adults across the UK, highlights the enduring nature of Covid-19’s impact. Key findings from the study reveal that many patients suffer from worsened cognitive functions, alongside increased rates of depression, anxiety, and fatigue, which persist or even worsen over a period of 2-3
years post-hospitalisation.
The severity of initial symptoms does not necessarily predict long-term outcomes. Instead, the health status of individuals at six months post-infection serves as a more reliable indicator of their long-term health. This insight is crucial for healthcare systems
It is estimated that about 2 billion people worldwide are zinc deficient. 1
In 1999 it was estimated that approximately 45.3% of children aged 1–9 years in South Africa, had an inadequate zinc status 2 A zinc deficiency may lead to:3
• impaired immune function
• mental lethargy
• loss of appetite
• low weight gain
• slow growth
ZINC is an essential mineral involved in numerous aspects of cellular metabolism, and has multiple important roles within the body:3
• Immune support
• DNA synthesis and cell division
• Support of normal growth and development
Daily intake of zinc is necessary, as the body has no specialized zinc storage system.3 Zinc supplementation to maintain a normal serum
and
globally as it illustrates the need for ongoing monitoring and intervention well beyond the acute phase of the disease.
The study also sheds light on the socio-economic consequences of long-term Covid-19 symptoms. Many participants reported significant changes in their occupational status due to health deterioration, with a notable correlation between cognitive deficits and reduced work capability. This aspect highlights the broader impact of the pandemic, affecting not just the health of individuals but also their ability to contribute effectively in the workplace.
For healthcare providers and policymakers, the findings of the PHOSPCOVID study suggest a dual approach to managing the aftermath of Covid. Firstly, there is a clear need for early identification and management of cognitive, psychiatric, and fatigue symptoms. Implementing strategies such as cognitive rehabilitation and tailored mental health support could significantly improve patient outcomes.
Additionally, the study advocates for comprehensive support systems for Covid-19 survivors, including occupational therapy and workplace adjustments, to facilitate their reintegration into the workforce. Such measures are essential not only for the recovery of individuals but also for mitigating the broader economic impacts of the pandemic.
The research further highlights the potential benefits of interventions like brain training programmes, which could help alleviate some of the cognitive deficits experienced by post-Covid patients. While acknowledging limitations such as its potential non-generalisability to nonhospitalised patients or those infected with later virus variants, the study provides a clear message: the effects of Covid-19 are long-lasting and complex, requiring a coordinated and proactive response from healthcare systems worldwide.
As the global community continues to grapple with the aftermath of the pandemic, the insights provided by the PHOSP-COVID study deepen our understanding of the virus’s long-term impacts but also guide healthcare practitioners and policymakers in developing more effective strategies for patient care and recovery.
Ongoing monitoring, support, and innovative treatment strategies are essential to address the multifaceted challenges posed by long-term Covid-19 effects.
REFERENCE
Taquet M, Skorniewska Z, De Deyn T et al., Cognitive and psychiatric symptom trajectories 2–3 years after hospital admission for COVID-19: a longitudinal, prospective cohort study in the UK. Lancet Psychiatry 2024. https://doi.org/10.1016/ S22150366(24)00214-1
The South African Health Products Regulatory Authority (SAHPRA) is disappointed with the unfounded fallacies and misrepresentation in circulation and churned out by some media organisations without verification, in what presents as a misinformation campaign devoid of any intent to rely on facts.
SAHPRA’S DRAFT B-BBEE Policy is proposed in order to comply with requirements of the Broad-Based Black Economic Empowerment Act, 53 of 2003, in particular Section 10(1)(a), which demands of all state entities to enact policy that can encourage inclusive economic participation. The draft policy, which may be accessed on the SAHPRA website at https://www.sahpra.org.za/documentsfor-comments/, is a result of a robust consultation process with all material stakeholders.
The misinformation campaign is premised on deliberate falsehoods that do not exist within SAHPRA’s proposed policy and racially charged misrepresentations which the draft policy had clearly expressed itself on and the SAHPRA executive had addressed with stakeholders and interested parties who have attended stakeholder engagement meetings as part of the draft policy’s consultation process, the most recent of which was held in June 2024, attended by more than 300 delegates representing the lengths and breaths of the health products industry in South Africa.
A recording of this session is available at https://www.sahpra.org.za/event/sahprashybrid-stakeholder-engagement-meeting/
To set the record straight, we address all the falsehoods currently in circulation below:
Falsehood 1: SAHPRA’s draft B-BBEE policy sets 'racial requirements' for the registration of medicines.
Truth: The draft policy has not set any quotas for the ownership of pharmaceutical businesses based on race or gender.
This is not within SAHPRA’s mandate and does not exist in any legislative
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frameworks that govern SAHPRA’s work and/or those that SAHPRA is responsible for implementing. As such this lie is dismissed with
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basis in facts and does not exist anywhere within SAHPRA documents.
Falsehood 2: SAHPRA will use the B-BBEE to assess medicine registration applications and thus affect access to medicines
Truth: This is a deliberate misrepresentation of SAHPRA’s draft B-BBEE Policy.
The draft policy clearly and prominently indicates that this would not be the case, and that SAHPRA’s health products registration processes would continue to solely rely on the safety, quality, efficacy, and performance of the health products. Any insinuations to the contrary are mischievous and do not exist in the policy
currently or in SAHPRA’s future plans.
Falsehood 3: The draft B-BBEE policy is aligned with the National Health Insurance and seeks to exclude certain persons from state procurement.
Truth: This wild conspiracy lacks any basis in reality and is indicative of an overactive but malicious imagination. There is no connection anywhere in the proposed policy to the NHI, in fact the policy clearly states that it is not concerned with any preferential policy frameworks. These are not in SAHPRA’s scope of responsibility.
The draft policy seeks to ensure that the pharmaceutical industry moves towards developing sector codes and/or criteria
similar to what has been successfully implemented in various other sectors of the economy including agriculture, mining, finance, tourism, and defence, among others. This is in compliance with the requirements of the B-BBEE Act and has no bearing whatsoever on any assumed conspiracies.
Falsehood 4: The policy will deny participation in the pharmaceutical industry by SMEs as they may not be able to acquire B-BBEE certificates.
Truth: SAHPRA is on record reiterating the following facts: B-BBEE compliance affidavits by small businesses will be
acceptable in the place of B-BBEE certificates; and the B-BBEE level of a business is of no effect in the medicines registration process, and this will stay the case even once the policy is implemented.
Thepolicyseeksto increaseparticipation bypreviously marginalised personsandhasno intent whatsoever to decrease participationby orexcludeany personsbasedon raceorgender
The policy seeks to increase participation by previously marginalised persons and has no intent whatsoever to decrease participation by or exclude any persons based on race or gender. SAHPRA is on record indicating this, and this is also clearly stipulated in the policy. SAHPRA remains committed to executing its legislative mandate and all Health Product registration processes in line with its core purpose, to assess and register medicines, medical devices and in-vitro diagnostics (IVDs) in line with the requisite standards to protect the health and well-being of South Africans, being to ensure the safety, efficacy, and quality of health products. Thus, SAHPRA invites all stakeholders and interested persons to peruse the draft policy available on the SAHPRA website at this link https://www.sahpra. org.za/documents-forcomments/ and submit substantiated comments by 09 September 2024.
Date: 17 September 2024
Time: 7pm
Topic: Why can I not treat my patients with seasonal allergies the same way
Speaker: Prof Jonny Peter
CLICK TO REGISTER https://bit.ly/GlenmarkWebinar17Sept24
Position: Head of the Division of Allergology and Clinical Immunology, University of Cape Town (UCT)
Education:
- MBChB, University of Cape Town, First-class honors, 2000
- Fellowship of the College of Physicians of South Africa (FCP (SA)), 2009
- Master of Medicine (MMed), University of Cape Town, Distinction, 2012
- PhD, University of Cape Town, 2013.
Professional Experience:
- Oxford Nuffield Medical Fellow, John Radcliffe Hospital and the Jenner Institute, 2013-2015
- PhD Fellow and Clinical Trials Coordinator, UCT’s Lung Infection and Immunity Unit
- Internal Medicine Specialist Registrar, University of Cape Town, 2006-2009.
Academic and Research Contributions:
- Over 105 publications with an H-index of 34
- Principal investigator and co-investigator in several high-impact research projects funded by NIH and SAMRC
- Notable research in tuberculosis diagnosis and allergy.
Awards and Honors:
- Suzman and AW Meyers Medals, 2009
- Silver Medal, Medical Research Council of South Africa
- University of Cape Town Fellows award for research.
Teaching and Mentorship:
- Supervised numerous MMed, MSc, and PhD candidates
- Regular speaker at national Allergy and Immunology congresses.
Editorial Roles:
- Editorial board member, Current Allergy and Clinical Immunology Journal since 2018.
Professor Peter is a leading figure in Allergology and Clinical Immunology, recognized nationally and internationally for his clinical practice, academic scholarship, and research excellence, particularly in tuberculosis and allergy.
Nazeer Ahmed
Ismail Chopdat
Physician gastroenterologist at Lenmed Head of Gastroenterology
Date: 30 September 2024
Time: 7pm
Topic: Practical approach to GERD management
Speaker: Nazeer Ahmed Ismail Chopdat
CLICK TO REGISTER https://bit.ly/AdcockIngramWebinar30Sept24
LOCATION: Ahmed Kathrada Private Hospital in Lenasia and Baragwanath Hospital in Johannesburg, Gauteng, South Africa.
EDUCATION:
Royal College of Physicians
Royal College Of Physicians; Mrcp Gastroenterology (Uk). SKILLS:
As part of a series of podcasts titled “Advancing Healthcare” that examine the critical issues that must be addressed to achieve universal healthcare, Russell Rensburg of the Rural Health Advocacy Project calls for a focus and prioritisation of rural health.
the health profile of South Africans is changing. Rensburg noted that life expectancy has increased due to the successful HIV response over the last decade. But the challenge is that as disease profiles change, health care needs change too. “We need to respond to the differing health needs of young people and older populations,” he adds. Rensburg states that data shows the need for differentiated healthcare approaches for various population segments. However, more data is required because no one knows the prevalence of certain diseases, like cancer. Also, lacking management data means little information on how facilities are run. Without the right data, he says, “We haven't figured out a way of doing health promotion and health literacy.”
The Rural Health Advocacy Project is a division of Wits University’s health consortium, and aims to promote better health care for rural communities. However, providing meaningful rural health care requires understanding that each province has its own challenges.
In KwaZulu-Natal, for instance, a recent study involving basic screening found high levels of diseases like diabetes and tuberculosis in people who had never accessed the healthcare system.
The Eastern Cape, says Rensburg, has too many hospitals that are expensive to run. “Some of those hospitals they don't need,” he said. “There are 91 district hospitals in the Eastern Cape; many of them are like old mission hospitals that, in my view, are sometimes too expensive to run.”
Limpopo, says Rensburg, has a malnutrition problem. “They have severe acute malnutrition rates that are quite high, which is ironic because it's kind of a breadbasket province,” he said.
In rural South Africa, patients often bypass community clinics and go directly to hospitals for medical attention. These clinics are bypassed because of negative experiences where patients endure daylong queues and medicines that aren’t in stock. “They go to the hospital, which costs probably five or six times more for the state to deliver care,” explained Rensburg.
Rensburg believes more community health workers should be hired, and their training should be standardised to improve rural health care. “We need to professionalise them because it's an opportunity to create employment in parts of the country with low economic activity,” he said. In rural South Africa, patients often bypass community clinics and go directly to hospitals for medical attention. Pregnant mothers can wait up to 14 hours to access a bed. Access to better management data would help in the better running of facilities. “I think the first baseline into improving healthcare
is getting more people to understand their health status. And I think how we do that is being much more focused on gathering information. And then using that information for decision-making," Rensburg said. However, improving the well-being of South Africans living in the rural parts of the country goes beyond what the health sector can offer. “So maybe something like
a Basic Income Grant could have a massive impact on people's health, particularly in the rural areas where unemployment is 90%.”
The basic income grant could help reduce malnutrition, Rensburg adds. What could influence rural health soon is NHI. “I think the NHI is an opportunity to change how we deliver healthcare,” said Rensburg. “But when you look at the NHI proposals, it was
about restructuring public-funded health care services. The whole thing talks about how we better manage hospitals by giving them their budgets.”
Rensburg suggests restructuring public services, prioritising district health, and granting more autonomy to central, tertiary, and regional hospitals to improve rural health.
In a world where positive change and innovation are essential for healthcare practices, we invite you to participate in an inspiring journey at the annual Practice of the Future Conference 2024.
S A DYNAMIC PLATFORM
dedicated to showcasing software committed to creating a better future, the Practice of the Future Conference 2024 is the ultimate event for healthcare practitioners and supporting staff seeking to enhance their skills, efficiency, and operability. We warmly invite you to attend this transformative event in Pretoria.
WHY SHOULD YOU ATTEND?
Accredited Clinical and Ethical CEUs
We understand the importance of continuous professional development for healthcare practitioners. The Conference is accredited for CEUs. By attending, you gain valuable insights from industry experts and earn professional recognition for your participation.
At the Practice of the Future Conference 2024, we focus on delivering practical knowledge and fostering professional growth. Our thought-provoking topics include:
1. New technology and GoodX's direction
for the future
2. AI in the medical space
3. Medical Schemes and AI – Margot Brews (Momentum Health)
4. The legal and ethical implications of using AI – Dr Llewellyn Curlewis
5. How to fully implement paperless practice management
6. Minimise errors while maximising revenue
7. Ongoing learning in the healthcare practice.
These are just a sample of the many discussions that are designed to equip you with actionable strategies to meet the evolving demands of the healthcare industry.
We understand that seeing is believing, so we have set up interactive training tables. You can explore GoodX Software's capabilities in accounting, billing and reporting, dental and periodontal, diary administration, hospital, theatre and stock management, the myGC Patient Portal and grandXchange Practitioners Portal, Paperless Clinical Information, and the
Online Learning Centre and Short Courses Platform. Get hands-on experience and unlock the potential of GoodX Software for your healthcare practice.
Your practice's needs and requirements are at the heart of our software development. The developer's area at the conference provides you with a unique opportunity to interact directly with the developers of GoodX Software. Share your valuable insights and help shape the software's future to meet your healthcare practice's specific demands.
Upon registration, you'll receive a complimentary GoodX Goodie bag filled with exciting surprises and useful resources to enhance your Practice of the Future Conference experience. Plus, we've taken care of lunch for you. Network with likeminded professionals while enjoying a delicious meal – it's all on us.
ENHANCE YOUR PRACTICE'S EFFICIENCY
The Practice of the Future Conference 2024 offers a range of topics specifically curated to address the challenges and opportunities healthcare practices face today. From optimising paperless practice management to improving customer experience, we cover the essentials that can help enhance your practice's patient and financial efficiency. Take advantage of this chance to propel your business and healthcare practice towards a brighter future. Mark your calendar for 28 September 2024 for The Maslow Time Square, 209B Aramist Ave, Menlyn, Pretoria. Join us at the Practice of the Future Conference 2024 and participate in a transformational event that empowers healthcare practices like yours to thrive in the ever-changing healthcare landscape. Register now on www.goodxpo. co.za and take the first step towards shaping a better future for your healthcare practice and the community you serve.
We welcome you to the Practice of the Future Conference 2024.
Welch
Date: 3 September 2024
Time: 7pm
Topic: Rekindling local anaesthetics
Speaker: Dr Ernest Welch
CLICK TO REGISTER https://bit.ly/FreseniusKabiWebinar3Sept24
Specialist anaesthesiologist in private practice with the Dunkeld Anaesthetic Practice in Johannesburg, South Africa. Co-Editor and author of: Applied Pharmacology in Anaesthesiology and Critical Care editions 1 and 2. Milner A and Welch EH. Convenor the College of Anaesthesiologists primary examination,
chairman of the Anaesthetic Foundation and organiser of its annual refresher course meeting. Areas of interest include pharmacology with a special interest in muscle relaxants, volatile agents, Low-flow, TIVA and TCI, regional and acute pain control, anaesthesia for elite athletes and anaesthesia education.
Coming soon to South Africa
First estriol and lactobacilli combination vaginal tablet. * 1 Symptomatic treatment of Vaginal Atrophy and restoration of her Ecosystem. 2 Start her journey to renewed confidence!
*Available in South Africa
References: 1. Adcock Ingram Limited. Data on file, March 2024. 2. Mueck AO, Ruan X, Prasauskas V, et al. Treatment of vaginal atrophy with estriol and lactobacilli combination: a clinical review. Climacteric. 2018;21(2):140-147.
S2 GYNOFLOR. Each 900 mg vaginal tablet contains 0,03 mg estriol and at least 1 x 10 8 cfu viable Lactobacillus acidophilus. Reg. No.: 55/21.13/0343. (Approved PI, August 2023). For full prescribing information refer to the Professional Information approved by SAHPRA. Adcock Ingram Limited Co. Reg. No.: 1949034385. Private Bag X69 , Bryanston, 2021. Customer Care: 0860 ADCOCK/232625. www.adcock.com 202406241015623 June 2024.
Genitourinary syndrome of menopause (GSM), previously known as vulvovaginal atrophy (VVA), atrophic vaginitis, or urogenital atrophy, constitutes a spectrum of changes in urogenital tissue and its consequences associated with hypo-oestrogenic states present in, but not limited to, postmenopausal women.2
ENOPAUSE IS THE conclusion of the menstrual cycle in relation to ovarian failure due to reduced estrogen secretion and the loss of progesterone secretion. With increased life expectancy, the postmenopausal period may account for up to one-third of a woman’s life.1 About 17% of the population will be over 65 years of age by 2030. Therefore, the population of postmenopausal women suffering from low oestrogen states will also increase.2
Many women do not seek consultation for GSM as they are either shy or embarrassed and may believe that the symptoms are a normal part of the aging process. Healthcare providers hesitate to ask questions, specifically around sexual dysfunction, or are unaware of the management options available for GSM.2
Around 40-54% of postmenopausal women and 15% of premenopausal women are affected by GSM with only a few of them seeking consultation.2
SYMPTOMS OF GSM
GSM involves changes in the urogenital tissues – labia majora and minora, introitus, vagina and lower urinary tract.
Symptoms can be classified into:
• Genital symptoms: dryness, irritation, burning, itching, and abnormal
vaginal discharge
• Sexual symptoms: lack of lubrication, discomfort, and dyspareunia
Figure 1: GSM and changes during menopause - healthy vs hypo-estrogenic state Courtesy of https://www.mymenopausecentre.com/symptoms/vaginal-changes/
• Urinary symptoms: urgency, frequency, discomfort while urination, urinary incontinence, and recurrent urinary tract infections.2
GSM is a progressive and chronic condition of the external female genitalia and lower urinary tract.2 These symptoms and signs of GSM such as dyspareunia, post-coital bleeding, reduced lubrication, and urinary incontinence, may negatively affect sexual function, interpersonal relationships, and the quality of life among postmenopausal women.2 Since the condition is often undetected, early diagnosis and custommade prescriptions positively affect the quality of life of women and also prevent the condition from worsening.2
PATHOPHYSIOLOGY OF GSM
The female genital tract and the lower urinary tract embryologically arise from the same structure, namely the urogenital sinus. These structures have a high number of oestrogen receptors.2
Under normal circumstances, oestrogen promotes epithelial cell proliferation, mucin production, and collagen turnover.2 During menopause, there is a decrease in the number of oestrogen receptors as well as a decline in oestrogen hormonal levels.2
In this hypo-oestrogenic state, there is thinning of the labia and vulva, a decrease in collagen, elasticity, decreased vascularity, vaginal atrophy, and reduced vaginal discharge. The loss of elasticity causes shortening and narrowing of the vagina resulting in dyspareunia (Figure 1).2
THE VAGINAL MICROBIOME
In addition to the pathophysiological changes within the vagina mentioned above, in a hypo-oestrogenic state, there are also changes within the normal vaginal flora.2
The vaginal microbiome is a dynamic ecosystem which varies between women and is dependent on several factors (age, ethnicity, physiological factors, and the immune system).1,3 The hallmark of a ‘healthy’ vaginal microbiome is currently believed to be one dominated by Lactobacillus spp., which acidifies the vaginal environment and helps protect against invading pathogens.3
The vaginal lactobacilli feed on glycogen byproducts of oestrogenised vaginal epithelial cells and produce lactic acid resulting in a low-pH environment favouring their own survival over opportunistic pathogens.4a In women with flora not dominated by lactobacilli, it has been shown that they have increased susceptibility to
genital infections (Chlamydia trachomatis, herpes and HIV) and may be at increased risk of adverse reproductive outcomes in women of reproductive age.4
Only a few species of Lactobacillus predominate the healthy vaginal microbiota - L. crispatus, L. jensenii, L. gasseri and L. iners, with each species having its own specific defence mechanism.4 As women approach menopause, a decline in circulating oestrogen causes a shift towards a Lactobacillus-depleted microbiome, with a subsequent rise in vaginal pH (Figure 2).3
Objective findings of vaginal atrophy include reduced epithelial thickness, epithelial pallor, shortening of the vagina, reduced elasticity of vaginal walls, reduction of the vaginal diameter, reduction of pubic hair, shrinkage of the labia, increased vaginal pH up to 6–7, and loss of vaginal mucosal folds (rugae).5 In clinical studies, a decreased vaginal maturation index (VMI) or value describes the cytological changes in vaginal smears as a shift from superficial squamous cell towards intermediate epithelial cells. In healthy women, VMI is within the 50–64% range and shows moderate oestrogenic stimulation whilst a VMI value below 49% is indicative of vaginal atrophy.5
GSM TREATMENT OPTIONS
Treatment depends on the severity of the symptoms of the disease and the preference and expectation of women. The main goals of treatment are to improve and ameliorate
the symptoms of VVA and to restore the anatomical changes to prevent the progression of the disease process.6
In South Africa, the South African Menopause Society (SAMS) advocates for the use of local oestrogen preparations in the treatment of symptoms associated with VVA alone.8 This is in keeping with recent international guideline recommendations (NAMS guidelines) which suggest that oestrogen therapy (ET) specifically vaginal oestrogen therapy , is an effective treatment for GSM, with no evidence to suggest a difference in safety or efficacy between the various vaginal ET preparations.2,6,7.11
Lifestyle management
• Maintenance of optimum body weight, doing regular exercise, yoga, meditation and optimum nutrition may improve GSM. Women should be advised to quit smoking and avoid too much alcohol.
• Regular exercise and pelvic floor physiotherapy improves GSM by increasing the blood flow in the perineum.6
Non-hormonal treatment options
• For mild and moderate VVA first line recommendation are lubricants and moisturisers. Moisturisers and lubricants are good alternatives to estrogen
creams. Whilst women get temporary relief of symptoms, these options cannot treat the underlying condition of estrogen deficiency. 6c
Hormonal treatment options
• In case of moderate to severe GSM or if other treatment modalities do not give satisfactory results, low-dose local topical oestrogen therapy is preferred.2
The North American Menopause Society guidelines (NAMS) advocate for use of low-dose vaginal ET preparations which are effective and generally safe for the treatment of GSM, with minimal systemic absorption and are preferred over systemic therapies when ET is used only for genitourinary symptoms.7.11
The use of low dose oestrogen is further supported by the European Menopause and Andropause Society (EMAS). In their recent consensus statement, their recommendation for women with VVA is treatment only with low-dose topical oestrogen preparations or vaginal dehydroepiandrosterone (DHEA) - GMS symptoms respond to treatment with lowdose and ultra-low-dose vaginal oestrogens, which do not result in significant systemic absorption and can be administered long term if required.9
Topical oestrogen is absorbed through the vaginal mucosa, improving the blood supply, lowering the pH, thickening the vaginal epithelium, and improving vaginal lubrication.2
There are various formulations of oestrogen - vaginal rings, creams, gel, pessaries, and tablets are some available treatment options.2 Systemic hormonal therapy is preferred when both vasomotor symptoms, as well as vulvovaginal atrophy, are present simultaneously.2
NEW TREATMENT OPTIONS IN THE MANAGEMENT OF GSM
Guidelines from several societies have recently been updated in favour of VVA/ GSM vaginal therapy with the lowest possible doses of oestrogen’s.5,7.11
Continuous vaginal use of high doses of ‘potent’ estrogens (like oestradiol, E2) may have safety concerns as this effect is known to depend on hormone type, dose and frequency of administration.5
ULTRA-LOW-DOSE ESTRIOL
Estriol (E3) is a human-specific sex hormone. In addition to E3, two other oestrogen hormones, namely oestradiol (E2) and estrone (E1), are naturally present in humans.5 Like all oestrogens, E3 stimulates the proliferation and maturation of the vaginal epithelium.5 Clinical studies show that intravaginal use is effective in controlling local symptoms of menopause with a vaginal dose of 0.5mg.5
BENEFITS OF USING AN ULTRALOW-DOSE VAGINAL ESTRIOL (0.03MG E3)
• There is a good efficacy-safety profile, and the lower dose displays similar efficacy to that of conventional dose (0.5mg) preparations.5
• It shows no relevant influence on systemic levels of sex hormones.5
• It does not cause endometrial proliferation after six months of use and, accordingly, there is no need to use opposing progestogen.5
• No systemic adverse events are expected due to negligible absorption.5
Therefore, topical administration of low-dose E3 is generally preferred.5
TREATMENT OF VAGINAL ATROPHY WITH ESTRIOL AND LACTOBACILLI COMBINATION
The World Health Organisation (WHO) define probiotics as ‘live microorganisms that, when administered in adequate amounts, confer a health benefit on the host’. In recent times, there is a growing body of evidence from microbiome-based research which has expanded into research and development into the clinical uses of therapeutic microorganisms.4
A combination therapy containing a very low dose of estriol (0.03 mg E3) and lyophilized, 100 million cfu (colony forming units) viable Lactobacillus acidophilus KS400 per vaginal tablet (0.03mg-E3/L) has been used in clinical studies to treat VVA and is approved in many countries.5
The oestrogen therapy of VVA in postmenopausal women results in a vaginal epithelium resembling the premenopausal period and beneficial lactobacilli flora are important for preventing vaginal infections.5
Study
Intervention
Feiks et al. 19915o,oo n=48 Atrophic vaginitis (49 – 69 yrs. ) 0.03 mg-E3/L vs E3 0.5 mg
Jaisamrarn et. al 20135p n=83 Symptomatic vaginal atrophy 0.03 mg-E3/L
Donders et al. 20145q n=16 Breast cancer survivors under aromatase inhibitor therapy suffering from severe symptomatic vaginal atrophy
Capobianco et al. 20145r n=136 Postmenopausal women with urogenital aging
Buchholz et al. 20155s,ss n=16
Group I: triple therapy
0.03 mg-E3/L per day for 2 weeks and two ovules once a week for 6 months +pelvic rehabilitation; Group II: one intravaginal estriol (E3) 1.0 mg ovule similar regimen +pelvic rehabilitation
Breast cancer survivors under aromatase inhibitor therapy suffering from severe symptomatic vaginal atrophy
Donders et al. 20155t n=16 Breast cancer survivors under aromatase inhibitor therapy suffering from severe symptomatic vaginal atrophy
E3/L – estriol + lactobacillus; E3 – estriol monotherapy; VMI – Vaginal Maturation Index ; LBG lactobacillary grade
Its dual mechanism of action has is beneficial for:5
• Maintenance of a healthy vaginal ecosystem
• Restoration of the vaginal flora conditions in postmenopausal women
• Treatment of vaginal discharge in postmenopausal women
• Treatment of symptomatic vaginal atrophy in postmenopausal women.
EFFICACY AND SAFETY
The dose of estriol in the 0.03mg-E3/L combination therapy is substantially lower than that of conventional preparations –it generates a sufficient local response without having a significant effect on the endometrium.5
SAFETY
The safety of the combination has been evaluated in more than 4000 women in various clinical studies – only 1.7% adverse drug reactions were observed.
Most of the side-effects (>80%) were local reactions.5 Clinical studies in women using a 0.03 mg-E3/L vaginal tablet, showed no evidence of the typical side effects related tosystemic oestrogen treatment such as thromboembolic events.
Moreover, probiotic lactobacilli are known to be very well tolerated.5 In summary, clinical data shows that Estriol/ Lactobacillus combination therapy is advantageous because:
a) There are improvements in symptoms like vaginal dryness, soreness and dyspareunia and vaginal flora is improved.5
b) In a study of postmenopausal breast cancer survivors on aromatase inhibitors with severe symptomatic vaginal atrophy, a single vaginal application of 0.03mg-E3/L generated only a small and transient rise in serum E3 levels 50% of women at the start of treatment. However, serum levels of other sex hormones and binding proteins are not influenced at all.5
c) Compared with higher estriol doses (1mg), 0.03mgE3/L combination is considerably more effective in reducing urogenital atrophy, the frequency of urinary tract infections and stress urinary incontinence.5
d) The combination results in positive effects on sexual health and overall quality of life.5
• Vaginal 0.03 mg-E3/L combination leads to similar efficacy compared to the 16 -fold higher dose of 0.5mg 5
• No significant difference between 0.03 mg -E3/L and 0.5 mg E3. 5
• Relevant improvements in signs and symptoms such as vaginal dryness, soreness and dyspareunia, in affected women compared to placebo. 5
• 0.03 mg-E3/L combination was superior over placebo, with a higher increase in VMI and improvement in LBG (lactobacillary grade) (Figure 4).10
• Serum E3 transiently increased after first application.
• After 4 weeks, serum E3 levels increased in only 50% of women.
• The combination product was well tolerated
• 0.03 mg-E3/L combination was considerably more effective in reducing urogenital atrophy, the frequency of urinary tract infections and stress urinary incontinence compared to a 1 mg -E3 mono -preparation.
• The authors recommended this combination therapy as first -line treatment for urogenital aging in postmenopausal women (Figure 5) 11 b
• Vaginal atrophy resolved or improved.
• All vaginal flora markers of vaginal microflora and epithelial vaginal cell quality improved dramatically.
• Improvement in signs and symptoms was accompanied by positive effects on sexual and overall quality of life. 5
• Sexually active increased from 19% to 63% (44% intercourse). The sexual questionnaire highlighted trend for improved sexuality parameters
Figure 5: Symptomatic patients before and after 0.03mg estriol/lactobacilli vaginal tablet.
Adapted from: Capobianco et al. 201410,11
0.03mg estriol-lactobacilli combination (n=68) 1mg estriol (n=68)
Figure 4: Dynamics of Vaginal Maturation Index (VMI) 0.03mg estriol/lactobacilli vaginal tablet vs placebo. Adapted from: Jaisamrarn et al. 20139a
E, entry visit; C1, follow-up 5 – 7 days after start of therapy; C2, follow-up 2 – 4 days after end of initial therapy Jaisamrarn et al. 201310a
Estriol/Lactobacilli combination Placebo
Based on recent scientific evidence and current treatment guidelines, estriol/ lactobacillus combination could be considered one of the options for the
treatment of symptomatic vaginal atrophy in aging menopausal women.5
References available on request
NO ONE SEES THEIR ADHD BUT EVERYONE SEES THEIR POTENTIAL
NO ONE SEES THEIR ADHD BUT EVERYONE SEES THEIR SUCCESS
VYVANSE® is the FIRST prodrug stimulant 2,3
Offers improvement in real-life executive function deficits and self-reported quality of life 3,4
Convenient once-daily dosing with a well-established safety profile 3,5,6
VYVANSE® offers sustained improvement in adult attention deficit hyperactivity disorder (ADHD) symptoms for up to 14 hours 1
References: 1. Wigal T, Brams M, Gasior M, Gao J, Squires L, Giblin J, for 316 Study Group. Randomized, double-blind, placebo-controlled, crossover study of the efficacy and safety of lisdexamfetamine dimesylate in adults with attention-deficit/hyperactivity disorder: novel findings using a simulated adult workplace environment design. Behav Brain Funct. 2010;6:34. Available from: http://www.behavioralandbrainfunctions.com/content/6/1/34 [Accessed 18th August 2021]. 2. Pennick M. Absorption of lisdexamfetamine dimesylate and its enzymatic conversion to d-amfetamine. Neuropsychiatr Dis Treat. 2010;6:317-327. 3. Frampton JE. Lisdexamfetamine: A Review in ADHD in Adults. CNS Drugs 2016: 30(4):343-54.DOI 10.1007/s40263016-0327-6. 4. Adler LA, Dirks B, Deas PF, Raychaudhuri A, Dauphin MR, Lasser RA, et al. Lisdexamfetamine Dimesylate in Adults With Attention-Deficit/ Hyperactivity Disorder Who Report Clinically Significant Impairment in Executive Function: Results From a Randomized, Double-Blind, Placebo-Controlled Study. J Clin Psychiatry. 2013;74(7):694-702. 5. VYVANSE® 30,50,70. SAHPRA approved professional information. Takeda (Pty) Ltd. 24 July, 2020. 6. Coghill DR, Caballero B, Sorooshian S, Civil R. A Systematic Review of the Safety of Lisdexamfetamine Dimesylate. CNS Drugs 2014;28:497–511.
S6 VYVANSE® 30. Each capsule contains 30 mg lisdexamfetamine dimesilate. Reg. No: 48/1.6/0407. S6 VYVANSE® 50. Each capsule contains 50 mg lisdexamfetamine dimesilate. Reg. No: 48/1.6/0408. S6 VYVANSE® 70. Each capsule contains 70 mg lisdexamfetamine dimesilate. Reg. No: 48/1.6/0409. For full prescribing information, refer to the Vyvanse Professional Information as approved by SAHPRA. Takeda (Pty) Ltd, Reg. No.: 1982/011215/07, Building A, Monte Circle, 64 Montecasino Boulevard, Fourways 2191. Tel: +27115143000. Marketed by Acino Pharma (Pty) Ltd. Reg. No: 1994/008717/07. No 106, 16th Road, Midrand, 1686, Gauteng, South Africa. (011) 516-1700. www.acino.co.za C-APROM/ZA/Vyv/0040.
Attention deficit hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder that affects both children and adults.
HARACTERISED BY SYMPTOMS
Csuch as persistent inattention, hyperactivity, and impulsivity, ADHD can significantly impact daily functioning and quality of life. While the primary treatment for ADHD involves stimulant medications, the concept of a ‘drug holiday’ or a planned break from these medications has been a subject of considerable debate. This article examines the merits and drawbacks of ADHD drug holidays, incorporating recent clinical studies to assess whether they are beneficial or detrimental.
UNDERSTANDING ADHD AND ITS TREATMENT
ADHD is a complex disorder with symptoms that can persist into adulthood. The treatment landscape for ADHD includes stimulant medications like methylphenidate and amphetamines, which are known to enhance focus and control impulsivity by altering neurotransmitter activity in the brain. Non-stimulant medications and behavioural therapies are also integral to managing the symptoms of ADHD.
WHAT IS A DRUG HOLIDAY?
In the context of ADHD, a drug holiday refers to a deliberate, temporary cessation of medication. This practice is often considered during school holidays or weekends and aims to mitigate side effects, evaluate the necessity of medication, and reduce the potential for tolerance.
PROS OF ADHD DRUG HOLIDAYS
Reduced side effects: Stimulants are associated with side effects such as appetite suppression, sleep disturbances, and potential cardiovascular risks. Periodic medication breaks can help manage these side effects, providing relief to patients (Smith et al., 2020).
Evaluation of treatment needs: Drug holidays allow healthcare providers and families to assess the effectiveness of the medication when it is not actively being administered, offering insights into whether the medication is still needed at current
doses (Jones et al., 2021). Prevention of tolerance: There is a concern that continuous use of stimulants could lead to tolerance, necessitating higher doses for the same therapeutic effect. Intermittent breaks in medication may prevent this development (Martin et al., 2022).
CONS OF ADHD DRUG HOLIDAYS
Symptom rebound: The primary risk associated with drug holidays is the resurgence of ADHD symptoms, which can disrupt an individual's ability to function effectively in various settings (Greenhill et al., 2023). Emotional and behavioural challenges: Abrupt discontinuation of medication can lead to emotional dysregulation and behavioural issues, which can be distressing and disruptive for patients and their families (O'Connell et al., 2021).
Academic and social impact: Studies have demonstrated that consistent medication use supports academic performance and social interactions. Interruptions in medication can lead to a decline in school performance and affect peer relationships (Kim et al., 2022).
RECENT CLINICAL STUDIES & EXPERT OPINIONS
Recent research continues to explore the impact of ADHD drug holidays, providing new data on their advantages and limitations. Long-term efficacy: A 2020 study by Thompson et al. investigated the long-term effects of intermittent medication use, suggesting that structured drug holidays might help maintain the effectiveness of stimulants over time without increasing dosage requirements (Thompson et al., 2020).
Quality of life considerations: Anderson et al. (2021) studied the quality of life and family dynamics during drug holidays, finding mixed outcomes related to stress and symptom management (Anderson et al., 2021). Neurodevelopmental outcomes: Research by Patel and Barkley (2022) indicated that drug holidays do not adversely affect the neurodevelopmental
trajectory of children with ADHD, suggesting that these breaks can be integrated into long-term treatment plans without detrimental effects (Patel and Barkley, 2022). Educational outcomes: Lee et al (2023) examined the academic implications of drug holidays, noting that while there may be short-term challenges, there are no significant long-term impacts on educational achievement (Lee et al., 2023).
Guidelines and recommendations: The American Academy of Child and Adolescent Psychiatry's latest guidelines (2023) recommend a personalized approach to drug holidays, emphasizing the importance of monitoring and adjusting treatment plans based on individual responses (American Academy of Child and Adolescent Psychiatry, 2023)
NEURODEVELOPMENTAL IMPACT
ADHD medications primarily affect neurotransmitter systems crucial for brain function, raising concerns about their longterm impact on brain development. Drug holidays are sometimes used to minimise exposure to these medications, particularly during key developmental periods. However, the research is mixed: Potential benefits: Some studies suggest that taking breaks from medication could reduce the risk of long-term side effects associated with continuous stimulant use, such as potential impacts on brain development (Patel and Barkley, 2022).
Potential risks: Other research indicates that inconsistent medication can lead to periods of unmanaged ADHD symptoms, which might interfere with developmental processes, including social and academic learning (Lee et al., 2023).
ACADEMIC AND COGNITIVE DEVELOPMENT
The intermittent use of ADHD medication can have varying impacts on academic and cognitive development: Short-term setbacks: Drug holidays can lead to short-term declines in academic performance due to the resurgence of ADHD
symptoms, which can affect learning and classroom behaviour (Kim et al., 2022).
Long-term outcomes: While short-term impacts are noticeable, the long-term effects of drug holidays on academic achievement are less clear. Some studies suggest that there are no significant longterm detriments, provided the drug holidays are well-managed and planned around academic schedules (Lee et al., 2023).
SOCIAL AND EMOTIONAL DEVELOPMENT
Social interactions and emotional regulation are crucial developmental areas that can be affected by ADHD and its management: Social skills: Inconsistent medication management might lead to periods where symptomatic behaviour negatively impacts social interactions and the development of social skills. Emotional regulation: Drug holidays might cause fluctuations in emotional stability, affecting an individual's ability to develop consistent strategies for emotional regulation.
BEHAVIOURAL ADJUSTMENTS
Regular medication use helps in maintaining behavioural consistency, which is crucial for learning and applying behavioural norms. Drug holidays might disrupt this consistency, potentially impacting long-term behavioural development. For adolescents and adults, inconsistent medication can affect the development of self-management skills critical for success in higher education and employment.
CONCLUSION
The decision to implement a drug holiday in the treatment of ADHD requires careful consideration of the individual's specific needs and circumstances. While there are potential benefits, such as reduced side effects and the opportunity to assess the ongoing need for medication, there are also significant risks. These risks include the reemergence of symptoms and potential impacts on emotional and academic well-being, which can disrupt daily life and development.
Ensuring robust immunity in children is crucial, and multivitamins can play a significant role in this regard.
MULTIVITAMINS ARE
SUPPLEMENTS that contain a blend of essential vitamins and minerals necessary for the normal functioning of the immune system. Key components often include vitamins A, C, D, E, and minerals such as zinc and selenium. These nutrients are vital for supporting both the innate and adaptive immune responses, which are crucial for combating infections like the flu and other respiratory ailments common in winter.
Vitamin D: Vitamin D is particularly noteworthy for its role in reducing the incidence of influenza A in children. Studies have shown that vitamin D supplementation during the winter months is associated with a lower incidence of the flu. This finding is especially relevant for South Africa, where vitamin D deficiency can be prevalent due to lifestyle factors that limit sun exposure, despite the country's ample sunshine. Ensuring adequate vitamin D levels through supplementation or safe sun exposure can be a key strategy in boosting children's immunity.
VITAMIN C AND ZINC
Vitamin C and zinc are also critical for immune function. Vitamin C supports epithelial barrier function against pathogens and promotes oxidant scavenging activity of the skin, potentially reducing the risk and severity of infections like the common cold. Zinc is essential for the normal development and function of cells mediating innate immunity, such as neutrophils and natural killer cells. Supplementing with these nutrients can help enhance the immune response in children, making them more resilient to winter ailments.
EFFICACY OF MULTIVITAMINS
The efficacy of multivitamins in preventing flu and winter ailments in children depends on several factors, including baseline nutritional status and the presence of any nutrient deficiencies. In populations where malnutrition or specific nutrient deficiencies are common, multivitamin supplementation could offer significant benefits in terms of boosting immune function and resistance to infections. However, it is important to note that while supplementation can help prevent nutrient deficiencies and support overall health, it is not a substitute for a balanced diet rich in fruits, vegetables, and whole foods.
Increased influenza activity: There has been an observed increase in influenza activity in the Southern Hemisphere, including South Africa, following the relaxation of Covid-19 restrictions. This is likely due to reduced immunity in the population after lower influenza circulation during the pandemic.
Ensuring adequate nutrition and addressing potential micronutrient deficiencies through diet or supplementation could be particularly beneficial for children's health during the winter months. Healthcare professionals should consider the unique
nutritional needs and health challenges faced by children when recommending multivitamin supplements.
While multivitamins can play a role in
supporting immune function, it is essential for caregivers and healthcare providers to focus on comprehensive strategies that include good nutrition, adequate vitamin D exposure, and hygiene practices to prevent flu and other winter ailments in children.
The South African Breastmilk Reserve (SABR) has launched the 'So Safe' breastmilk pasteurizer during World Breastfeeding Week 2024, themed 'Closing the Gap.'
ABR AIMS TO provide affordable breastfeeding technologies and improve access to human milk banking, especially in low-income health systems. Since its inception, SABR has supported
neonatal care by providing donated breastmilk to 50 000 premature babies, addressing the needs of infants born prematurely or with low birth weights.
The 'So Safe' pasteurizer, the sixth
CERVARIX helps prevent: • persistent infection
generation of SABR's locally designed devices, is a significant advancement in technology and affordability. It is priced to be accessible while maintaining high-quality standards, reducing the cost of donated
premalignant ano-genital lesions (cervical, vulvar, vaginal and anal) • cervical, vulvar, vaginal and anal cancers (squamous-cell carcinoma and adenocarcinoma) caused by oncogenic Human Papillomaviruses (HPV) From the age of 9 years
breastmilk and ensuring more infants receive lifesaving nutrition. Key features include affordability, user-friendliness, reliability, IEC safety certification, and comprehensive support as part of the SABR SOS turnkey solution for human milk banking.
Key benefits of the 'So Safe' Breastmilk Pasteurizer include:
Highly accessible: Designed to be affordable for all health facilities, ensuring that even low-income hospitals can establish their own human milk banks.
User-friendly: Features a simple interface that makes it easy to operate, ideal for varying conditions in urban to rural settings. Reliable and safe: Ensures the safety of pasteurized milk, crucial for protecting neonates from conditions like necrotizing enterocolitis, which can be fatal or lead to severe health issues.
CERVARIX has been formulated with AS04** for a strong and sustained immune response, up to 20 years2
Contraindications:
Park, Woodlands Drive, Woodmead, 2191. ZAR-VHP-09-23-00001 02/2024 References: 1. Lehtinen M, Paavonen J, Wheeler CM, Jaisamrarn U, M Garland SM, Castellsagué X, et al for the HPV PATRICIA. Overall efficacy of HPV-16/18 AS04-adjuvanted
IEC Safety Certification: Certified for laboratory environments, guaranteeing compliance with international safety standards.
Comprehensive Support: Available as part of the SABR SOS turnkey solution for human milk banking, which includes the pasteurizer, freezers, refrigeration units, a PH tester, temperature mapping devices, and a year's supply of bottling equipment and essential consumables.
The development of the 'So Safe' pasteurizer was made possible through partnerships with Discovery and SKEG Holdings, providing financial resources and expertise in product development. SABR's work is supported by the Provincial Departments of Health, which fund the Feed 4 Life Initiative, bringing donated breastmilk to vulnerable babies nationwide.
Stasa Jordan, Executive Director of SABR, emphasised the importance of the 'So Safe' pasteurizer in providing a lifeline for thousands of babies born under precarious health conditions. Zandile Kubeka, Assistant Director in the Cluster Child, Youth, and School Health, highlighted the significance of the pasteurizer in improving neonatal health and supporting breastfeeding initiatives, especially for preterm and low-birth weight babies.
The 'So Safe' pasteurizer is now available for purchase individually or as part of a comprehensive human milk banking kit, making it easier for hospitals and care centres to implement this crucial resource. Andronica Mabuya, Senior Sustainability Specialist at Discovery, expressed pride in collaborating with SABR, emphasising the innovation's role in enhancing and protecting lives within South African society.
For women, pain presents unique challenges that are influenced by physiological, psychological, and socio-cultural factors.
PAIN IS A COMPLEX and subjective experience, and its perception and impact can vary significantly between individuals. This article explores the various causes of pain in women, shedding light on why pain management should be a critical component of women's health strategies.
HORMONAL INFLUENCES
Women experience unique hormonal fluctuations that can significantly impact their perception of pain. Hormones such as oestrogen and progesterone, which vary throughout the menstrual cycle, can affect how women experience pain. Conditions like menstrual cramps, endometriosis, and fibromyalgia are more prevalent in women and have been linked to hormonal changes. Studies have shown that during certain phases of the menstrual cycle, women may experience heightened pain sensitivity due to lower oestrogen levels (Smith et al., 2020).
CHRONIC PAIN CONDITIONS
Women are more likely to suffer from chronic pain conditions such as migraines, rheumatoid arthritis, and osteoarthritis. The reasons for this disparity are not entirely understood but are thought to involve a combination of genetic, hormonal, and immune system factors. For instance, autoimmune diseases, which are more common in women, can be associated with chronic pain (Johnson & McBeth, 2019).
PSYCHOLOGICAL FACTORS
The intersection of mental health and pain is significant in women. Conditions like depression and anxiety, which are more prevalent in women, can exacerbate the perception of pain. Stress, often a result of juggling multiple roles in society, can also affect chronic pain conditions, making them harder to manage and treat. Research indicates that psychological therapies can reduce pain perception and improve quality of life in women with chronic pain conditions (Lee et al., 2021).
SOCIO-CULTURAL ASPECTS
Cultural norms and expectations can influence how women perceive and report pain. In some cultures, women may be more likely or less likely to report pain due to societal expectations about strength and endurance. In South Africa, issues such as access to healthcare and educational disparities also play a role in how pain is experienced and managed among women. Women in rural areas or impoverished communities might experience barriers to accessing pain relief and other health services (Green et al., 2018).
REPRODUCTIVE HEALTH ISSUES
Pain related to reproductive health is a significant issue for many women. Conditions like pelvic inflammatory disease,
ovarian cysts, and complications from childbirth can cause severe pain. These conditions require prompt and effective treatment to manage pain and prevent long-term health consequences (Thompson et al., 2019).
MANAGEMENT AND TREATMENT
Effective pain management in women
requires a holistic approach that considers all the underlying factors.This includes hormonal treatments, pain medication, physical therapy, and psychological support. In South Africa, improving women's access to comprehensive healthcare services is crucial for addressing the unique pain management needs of women (Adams et al., 2020).
CONCLUSION
As we observe Women's Health Month, it is crucial to advocate for better research into women's pain and more tailored healthcare solutions that can address the specific needs of women in South Africa.
References available on request.
• Effective multimodal combination2
• Breaks the pain/anxiety cycle1,3,4
• Delivers effective opioid-sparing analgesia1
THIS DISEASE
DISPROPORTIONATELY affects women in low- and middle-income countries due to limited access to preventive measures such as HPV vaccination and cervical screening.
The highest incidence and mortality rates are observed in sub-Saharan Africa,
Central America, and South-East Asia, attributed to disparities in healthcare access. Women between the ages of 35 and 44 are most commonly affected, though all age groups are at risk, especially those without regular screening.
The primary cause of cervical cancer is persistent infection with high-risk Human
Papillomavirus (HPV) types, mainly types 16 and 18, which are responsible for about 70% of all cases. Transmission is predominantly through sexual contact. Other risk factors include smoking, having multiple sexual partners, early sexual activity, prolonged use of oral contraceptives, and co-infection with HIV. Women with HIV are notably at a higher
risk due to compromised immune systems. Prevention and control are possible through HPV vaccination, ideally before sexual activity begins, and regular cervical screening like Pap smears and HPV testing. These measures have significantly reduced cervical cancer rates in developed countries.
MORTALITY RATES OF CERVICAL CANCER AND THE ROLE OF HPV Cervical cancer remains a significant public health challenge globally, with its burden unevenly distributed across different regions. The age-standardised incidence and mortality rates provide a clear picture of this disparity, influenced heavily by the availability and effectiveness of healthcare resources, including HPV vaccination and cervical cancer screening programmes.
In regions with limited healthcare access, such as parts of Africa and Asia, the incidence and mortality rates are alarmingly high. For instance, in 2022, the global age-standardised incidence rate was estimated at 14.1 per 100 000 women, with approximately 662 000 new cases reported. Similarly, the mortality rate stood at 7.1 per 100 000 women, resulting in about 349 000 deaths. The majority of these cases and fatalities occurred in lowand middle-income countries, underscoring the critical need for enhanced healthcare services and preventive measures in these areas. Conversely, regions like North America and Western Europe, which have more comprehensive prevention and treatment programmes, exhibit significantly lower incidence and mortality rates. This contrast highlights the effectiveness of well-implemented health strategies, including widespread HPV vaccination and regular cervical screening, in reducing the burden of cervical cancer.
The link between HPV and cervical cancer is well documented. Persistent infection with high-risk HPV types, particularly HPV 16 and 18, is the primary cause of cervical cancer. These types account for about 70% of all cases. HPV is predominantly transmitted through sexual contact, and the progression from initial infection to invasive cervical cancer can take several years, providing a critical window for intervention through vaccination and regular screening. The World Health Organization has set an ambitious goal to eliminate cervical cancer as a public health problem by 2030. This goal underscores the importance of addressing HPV, the main etiological factor in cervical cancer, through comprehensive vaccination and screening programmes. Such initiatives are particularly vital in regions with high cervical cancer rates, where they can significantly reduce both incidence and mortality.
References available on request.
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The use of oral contraceptives (OCs) has been a cornerstone in reproductive health management for decades.
HOWEVER, AS WOMEN age, their hormonal profiles and health needs evolve, necessitating a reassessment of contraceptive strategies to ensure efficacy, safety, and alignment with their changing hormonal environment. This article aims to guide South African medical professionals on adapting OC use as their patients transition through different life stages, particularly as they approach menopause.
UNDERSTANDING HORMONAL NEEDS ACROSS DIFFERENT AGES
Hormonal contraceptives, including OCs, are widely used for various benefits, ranging from preventing pregnancy to managing menstrual disorders. However, the impact of long-term use of these contraceptives on sexual function, metabolic profiles, and hormonal balances can be profound and varies significantly with the type of contraceptive used and the duration of use. A study highlighted in BMC Women's Health suggests that these impacts can differ greatly depending on individual factors and the specific contraceptive method employed. As women age, particularly as they near menopause, their oestrogen levels decrease, which might necessitate a shift from traditional OCs to hormone replacement therapy (HRT) to better manage menopausal symptoms (BMC Women's Health, 2020)
Personalising contraceptive care involves tailoring contraceptive choices and management strategies to the individual needs, preferences, and medical history of each patient. Here’s a detailed guide on how to approach this in clinical practice:
1. Comprehensive patient assessment
Start with a thorough assessment of the patient’s health history, reproductive goals, and lifestyle factors. Key areas to consider include:
• Medical history: Check for any contraindications to certain types of contraceptives, such as a history of thromboembolic disorders, cardiovascular disease, or hormone-sensitive cancers.
• Reproductive goals: Understand the patient’s plans for future pregnancies, which can influence the choice of contraceptive method.
• Lifestyle and preferences: Consider the patient’s ability to adhere to daily medication, preference for hormonal vs. non-hormonal methods, and desire for reversible or permanent contraception.
2. Discuss contraceptive options
Provide detailed information about the various contraceptive options available, including their mechanisms of action, efficacy, side effects, and how they align with the patient’s health and reproductive goals. Options include:
- Hormonal contraceptives: Pills, patches, vaginal rings, injections, and implants.
- Non-hormonal methods: Copper intrauterine devices (IUDs), condoms, diaphragms, and fertility awareness methods.
- Permanent methods: Tubal ligation or vasectomy for partners.
3. Evaluate risk factors
Assess risk factors that may affect the suitability of certain
contraceptives:
- Age: Older women may have an increased risk of cardiovascular disease associated with certain hormonal contraceptives.
- Smoking status: Smokers over the age of 35 are generally advised against using oestrogen-containing contraceptives.
- Other health issues: Conditions like hypertension, diabetes, and obesity can influence the choice of contraceptive method due to associated risks.
4. Consider menstrual and hormonal impact
Discuss how different contraceptives can affect menstrual cycles and hormonal balance. For example, combined oral contraceptives can regulate irregular periods, while progestinonly pills may be more suitable for breastfeeding women or those who cannot use oestrogen.
5. Monitor and follow-up
After initiating a contraceptive method, schedule follow-up visits to monitor the patient’s response to the treatment, manage any side effects, and make adjustments as necessary. This is crucial for ensuring that the contraceptive method continues to meet the patient’s needs and preferences over time.
6. Provide education and support
Educate patients on proper use of contraceptives, especially for methods that require specific timing or adherence, such as pills and patches. Provide resources for managing side effects and understanding when to seek medical help.
7. Review and adjust as needed
Regularly review the contraceptive plan during annual check-ups or whenever the patient’s reproductive goals or health status changes. Be open to adjusting the plan as needed to better suit the patient’s current situation and preferences.
Thisperiod,known asperimenopause, can last several years,duringwhich womenexperience varyingmenstrual patternsandthe onsetofmenopausal symptomssuchas hotflashes,night sweats,andvaginal dryness
THE MENOPAUSAL TRANSITION AND CONTRACEPTIVE USE
The transition to menopause marks a significant change in a woman's reproductive system, characterised by decreasing oestrogen levels. This period, known as perimenopause, can last several years, during which women experience varying menstrual patterns and the onset of menopausal symptoms such as hot flashes, night sweats, and vaginal dryness.
Research from Walnut Hill OBGYN indicates that while it was once advised that OCs should not be used past the age of 40, modern guidelines suggest that they can be safely used until menopause, provided there are no contraindications like smoking or hypertension. During this phase, switching from OCs to HRT may provide better symptom management and improve quality of life, reflecting the body's changing needs (Walnut Hill OBGYN).
Personalising contraceptive care is essential, especially as women age. The Journal of Clinical Endocrinology & Metabolism emphasises that different stages of a woman's reproductive life require tailored contraceptive approaches. Younger women might benefit from combined oral contraceptives (COCs) due to their higher oestrogen levels, while older women may need progestin-only pills or non-hormonal methods as their natural oestrogen levels decline. This personalised approach helps in mitigating the risks associated with hormonal contraceptives, such as increased risk of thromboembolic events and potential
impacts on cardiovascular health, which can be more pronounced in older women.
Continued use of OCs in older women must be carefully considered. Studies indicate that while OCs can be used safely until menopause, the risk profile changes as women age. For instance, the risk of venous thromboembolism increases with age and can be exacerbated by hormonal contraceptive use. Therefore, it is crucial for healthcare providers to evaluate the risk-benefit ratio for each patient. This evaluation should include a thorough assessment of cardiovascular health, smoking status, and any other risk factors that may contraindicate the use of OCs.
As women enter menopause, they may experience symptoms that significantly affect their quality of life. Hormone replacement therapy (HRT) can be an effective treatment for managing these symptoms. HRT involves the administration of oestrogen or a combination of oestrogen
and progesterone, which can alleviate symptoms such as hot flashes, night sweats, and vaginal atrophy. However, the decision to initiate HRT should be based on a comprehensive evaluation of potential risks, including the individual's health history and family history of hormone-sensitive cancers.
Adapting contraceptive care as women age is a dynamic and critical aspect of women's health management. By understanding the nuances of hormonal changes and the implications for contraceptive use, you can better support your patients through all stages of their reproductive life, ensuring that contraceptive choices are safe, effective, and aligned with their overall health goals.
REFERENCES
1. BMC Women's Health, 2020. Sexual function and metabolic/hormonal changes in women using long-term hormonal and non-hormonal contraceptives: a pilot study.
2. Walnut Hill OBGYN. At What Age Should Switch from Oral Contraceptives to Hormone Replacement Therapy?
Understanding and addressing the dangers associated with abnormal bleeding during pregnancy and postpartum can be lifesaving for both mothers and infants.
R MZUVELE ARCHWELL Hlabisa, an obstetrician and gynaecologist at Netcare Kingsway Hospital, emphasises the importance of identifying the cause of bleeding in pregnant patients.
PREVALENCE AND INITIAL ASSESSMENT
Abnormal bleeding occurs in over a third of pregnant women for various reasons. While
some bleeding is expected during the postpartum period, excessive bleeding can be life-threatening. Dr Hlabisa advises that any bleeding during or after pregnancy should prompt immediate medical evaluation.
FIRST-TRIMESTER BLEEDING
Approximately 35% of women experience bleeding in the first trimester. As pregnancy
progresses, the likelihood of bleeding decreases. However, bleeding in early pregnancy can indicate a miscarriage or threatened miscarriage. Severe pain and bleeding may signify a placental abruption, needing urgent medical assessment.
SPOTTING IN EARLY PREGNANCY
Spotting, often less than a teaspoonful of
blood, may occur when the embryo implants in the uterine wall. This can also result from cervical or urinary tract infections, haemorrhoids, or sexually transmitted infections. The quantity and context of bleeding help differentiate spotting from more serious conditions.
SIGNIFICANT BLEEDING AND ASSOCIATED RISKS
Heavy bleeding, especially with severe pain in the back, signals a need for immediate medical evaluation. Symptoms of anaemia, such as headaches, weakness, and dizziness, are red flags for potential complications like reduced placental blood flow, which can be life-threatening for the baby and may result in preterm delivery. Even mild bleeding can have long-term neurological effects on the infant.
HOSPITAL EVALUATION AND TREATMENT
Patients presenting with bleeding during pregnancy should undergo a thorough evaluation, including internal examination, urine and blood tests, and a basic ultrasound to assess foetal well-being. Treatment varies based on the cause and severity of the bleeding. Bed rest, abstinence from sex, and antibiotics for cervical infections are common interventions. Iron supplementation, infusions, or blood transfusions may be necessary for anaemic mothers. Immediate delivery is required for placental abruption.
• Endometriosis ‡
• Threatened miscarriage as a result of progesterone deficiency.‡
• Habitual miscarriage as a result of progesterone deficiency.‡
• Dysmenorrhoea ‡
• Luteal support as part of an Assisted Reproductive Technology (ART) treatment.‡
• Infertility as a result of corpus luteum insufficiency.‡
POSTPARTUM BLEEDING
Postpartum bleeding is normal as the uterus contracts back to its pre-pregnancy size. Typically, bleeding resembles a moderate menstrual period initially, tapering off over weeks.
Persistent or severe bleeding, especially with anaemic symptoms, requires medical evaluation. Causes include episiotomy, tears, retained placental fragments, and infections.
RISK FACTORS AND MONITORING
Factors increasing the risk of abnormal postpartum bleeding include large babies, multiple births, difficult deliveries, prolonged labour, uterine fibroids, hypertension, and underlying blood disorders.
Patients on blood thinners are also at higher risk. Continuous monitoring of bleeding patterns and associated symptoms is crucial for differentiating between normal and abnormal postpartum bleeding.
Medical professionals should recommend that patients seek immediate medical attention for any abnormal bleeding during or after pregnancy. Early intervention can prevent severe complications and ensure the health and safety of both mother and baby.
In the evolving landscape of menopausal hormone therapy (MHT), significant strides have been made in understanding the nuanced roles of oestrogen and progesterone.
THIS ARTICLE DRAWS on recent research and consensus statements to evaluate the adoption of transdermal oestrogen and micronised progesterone in South Africa, in comparison with traditional oral oestrogen preparations.
OESTROGEN-ALONE THERAPY: A RE-EVALUATION
Historically, the use of oestrogen-alone therapy has been contentious, primarily due to concerns about breast cancer risk. However, a landmark meta-analysis by Chlenowski Manson et al. (2024) revisits this issue. Findings from 10 randomized trials (The WHI being the largest) and 14,282 participants included are showing that oestrogen-alone therapy significantly reduces the risk of breast cancer by 23% and mortality by 40% over a median followup of 20.3 years. These findings challenge earlier cohort studies that suggested an increased risk, highlighting the importance of context in evaluating MHT outcomes (Chlenowski Manson et al., 2024).
THE SHIFT TO SAFER ALTERNATIVES
open discussions with patients about the advantages of transdermal and micronised options, debunking myths related to their efficacy and cost.
Ongoing monitoring: Implement regular follow-ups to assess the effectiveness of the prescribed therapy and make
adjustments as needed.
For South African healthcare providers, embracing transdermal oestrogen and micronised progesterone represents a forward-thinking approach to menopausal
care. By aligning with global best practices and research, we can enhance the quality of life for menopausal women while mitigating long-term health risks.
References available on request.
In line with global trends and the latest guidelines from the British Menopause Society (2020), there is a strong recommendation for the use of transdermal oestrogen and micronised progesterone. Transdermal oestrogen is associated with a lower risk of venous thrombosis and stroke compared to its oral counterpart, making it a preferable option for women with risk factors such as CVD, diabetes, or obesity. Micronised progesterone, on the other hand, offers a safer profile regarding breast cancer risk. The systematic review by the International Journal of Gynecology & Obstetrics (2018) indicates that micronised progesterone does not elevate breast cancer risk within the first five years of treatment, a crucial consideration for long-term therapy planning.
BARRIERS TO ADOPTION IN SOUTH AFRICA
Despite the compelling evidence supporting these safer MHT options, their uptake in South Africa remains limited. Factors such as entrenched prescribing habits, patient perceptions that equate treatment efficacy with oral medication, and assumptions about the high cost of transdermal options persist. Addressing these barriers through education and awareness is critical.
CLINICAL RECOMMENDATIONS
Individualised care: Tailor hormone therapy based on individual risk factors and preferences, considering the broader benefits of symptom control and potential reductions in long-term health risks.
Education and dialogue: Engage in
Vacuum-assisted delivery, also known as vacuum extraction, is a valuable obstetric procedure used to aid the delivery of a baby when certain complications arise during the second stage of labour.
THIS METHOD IS particularly beneficial in managing prolonged labour or when the mother is unable to push the baby out due to fatigue or other medical conditions. Given the specific healthcare challenges and resources in South Africa, understanding the indications, procedure, and management of outcomes associated with vacuum-assisted delivery is
crucial for healthcare providers.
INDICATIONS AND CONTRAINDICATIONS
The primary indication for vacuum-assisted delivery is to shorten the second stage of labour in cases of maternal exhaustion, non-reassuring fetal heart rate patterns, or failure of the descent of the fetal head in the
birth canal despite adequate contractions and maternal efforts. However, it is essential that this procedure is only considered when the gestational age is over 34 weeks, the cervix is fully dilated, and the fetal head is engaged and in the vertex position (Smith et al., 2021).Contraindications include conditions where vaginal delivery is not advisable, such as vasa previa or complete
placenta previa, and cases where the fetal head is not adequately engaged. Additionally, the use of vacuum extraction is not recommended in preterm deliveries before 34 weeks due to the increased risk of intracranial haemorrhaged (Jones, 2022).
PROCEDURE
The procedure involves the attachment of a vacuum device, which includes a cup that is placed on the fetal head and connected to a vacuum pump.
The vacuum creates suction on the scalp, allowing the healthcare provider to assist in guiding the baby out of the birth canal during contractions. It is imperative that the procedure is performed by a skilled practitioner to minimize risks and ensure the safety of both mother and baby. The correct placement of the cup and the amount of traction applied are critical factors that require careful consideration and expertise (Brown & Patel, 2023).
RISKS AND MANAGEMENT OF COMPLICATIONS
While vacuum-assisted delivery can be a safe alternative to forceps delivery or caesarean section, it is not without risks. Possible complications include scalp injuries to the baby, such as cephalohematoma, subgaleal haemorrhage, or, rarely, intracranial haemorrhage. Mothers may experience perineal tears or extensions of episiotomies. To manage these risks, continuous fetal monitoring during the procedure is recommended, and immediate evaluation and treatment of any injuries post-delivery are essential (White & Barret, 2024).
TRAINING AND COMPETENCE
In South Africa, where resources may vary significantly between urban and rural areas, ensuring that healthcare providers are well-trained in vacuum-assisted delivery techniques is crucial. Regular training sessions, workshops, and simulations should be part of continuing medical education for obstetric care providers. Competence in this procedure not only improves maternal and neonatal outcomes but also enhances the confidence of healthcare providers in managing complicated deliveries (Nkosi et al., 2023).
Vacuum-assisted delivery remains a critical tool in the obstetric arsenal, particularly for challenging deliveries where maternal and fetal well-being is at risk. As with all medical interventions, the judicious use of vacuum extraction, guided by clinical indications and contraindications, is essential for the safety and well-being of mothers and infants.
References available on request.
Date: 23 September 2024
Time: 7pm
Topic: Emerging trends in the diagnosis and management of spring allergies: What healthcare professionals need to know
Speaker: Dr Thulja Trikamjee
CLICK TO REGISTER https://bit.ly/ThermoFisherWebinar23Sept24
Dr Trikamjee is a specialist Paediatrician and Allergologist. She holds a subspecialty Certificate in Paediatric Allergy, Diploma in Allergy, and the Union of European Medical Specialists Allergy and Immunology Certificate. She is currently a consultant at the University of Cape Town Lung Institute, where she is actively involved in research in the field of paediatrics, allergy, and immunology and has co-authored
several publications in international peer review journals. Dr Trikamjee serves on two international Allergy Immunology boards (the World Allergy Organization, and the European Academy of Allergy and Clinical Immunology: Chair of the Epidemiology Working Group) and is a member of the World Allergy Organization International Allergy Prevention Committee.
Seasonal allergic conjunctivitis (SAC) is a prevalent ocular condition induced by hypersensitivity to seasonal environmental allergens.
THIS CONDITION IS characterised by an inflammatory response in the conjunctiva, manifesting during specific pollen seasons. It significantly impacts the quality of life, affecting daily activities and productivity.
Globally, SAC affects a considerable percentage of the population, with prevalence rates varying widely depending on geographic and climatic conditions. Studies suggest that up to 30% of adults and up to 40% of children experience some form of allergic conjunctivitis, with SAC being the most common type.1
CAUSES AND TRIGGERS
SAC is triggered by an immune response to environmental allergens. Predominantly, tree, grass, and weed pollens during the spring and summer months are the most common triggers. The body's immune system mistakenly identifies these harmless substances as threats, leading to an allergic reaction.
PATHOPHYSIOLOGY
Upon exposure to allergens, the immune system releases histamines and other chemicals from mast cells in the eye, causing inflammation, itching, and increased tear production. This immunological response is intended to flush out the allergens but results in the symptoms associated with SAC.
SYMPTOMS
The clinical presentation of SAC includes:
- Intense itching and burning sensations in the eyes
- Redness and swelling of the conjunctiva
- Watery discharge
- Photophobia.
These symptoms are typically bilateral and are most severe during peak pollen periods.
A potent combination of antihistamine and mast cell stabilizing properties to treat itchy eyes right at the source, due to Seasonal Allergic Conjunctivitis.1, 3
• Rapid onset of action, within 15 minutes 4 Long acting, at least 8 hours 4
• Prevents reoccurrence, more than just a ‘quick fix’ 1, 2
Diagnosis is primarily clinical, based on a detailed patient history and the seasonal nature of the symptoms. Confirmatory tests may include allergen-specific IgE testing or skin prick tests to identify specific triggers. A slit-lamp examination can help exclude other forms of conjunctivitis.2
Management of SAC focuses on symptom relief and allergen avoidance. Treatment strategies include:
- Antihistamines: Oral or topical, reduce itching and redness.
- Mast cell stabilisers: Prevent the release of histamine and other inflammatory mediators.
- NSAIDs: Topical nonsteroidal antiinflammatory drugs can reduce discomfort.
- Corticosteroids: Prescribed for severe cases to control inflammation, under strict medical supervision to avoid complications. Additionally, cold compresses and artificial tears can provide symptomatic relief.
• Effective management involves:
• Avoiding known allergens during high pollen seasons
• Using air purifiers and keeping windows closed to minimise indoor allergen exposure
• Wearing wraparound sunglasses to protect eyes from pollen.
REFERENCES
1. Smith AF, Waycaster C. Estimate of the direct and indirect annual cost of bacterial conjunctivitis in the United States. BMC Ophthalmol. 2009;9:13.
2. Bielory L, Friedlaender MH. Allergic conjunctivitis. Immunol Allergy Clin North Am. 2008 Feb;28(1):4358, vi.
The transition between seasons can be a critical time for immune system vulnerabilities, leading to an increased incidence of colds and flu even as the weather warms.
NDERSTANDING THE MECHANISMS behind these seasonal patterns and the strategies to support immune health is essential for both patient care and public health.
The immune system's functionality can be influenced by various environmental factors that change with the seasons, such as temperature fluctuations, humidity levels, and daylight exposure. Research suggests that the immune response may be weaker during seasonal transitions, making individuals more susceptible to infections. For instance, the decrease in sunlight during early spring can reduce levels of Vitamin D, which is crucial for immune defence (Aranow, 2011).
PREVALENCE OF COLDS AND FLU IN WARMER MONTHS
Contrary to popular belief, colds and flu are not confined to colder months. Viruses that cause colds and flu can circulate year-round, and shifts in temperature and humidity can affect virus survival and transmission. For example, rhinoviruses, common cold culprits, thrive in cooler temperatures but can also spread effectively in spring and early summer (Eccles, 2002).
NUTRITIONAL SUPPORT
A balanced diet rich in vitamins and minerals plays a pivotal role in maintaining immune health. Nutrients such as Vitamin C, Vitamin D, zinc, and selenium are known to enhance immune function and should be included in dietary recommendations for patients during seasonal changes (Carr & Maggini, 2017).
LIFESTYLE MODIFICATIONS
Encouraging patients to maintain a healthy lifestyle that includes regular physical activity, adequate sleep, and stress management can also support immune function. Exercise, for instance, has been shown to boost the immune system by promoting good circulation, which allows cells and substances of the immune system to move through the body freely and do their job efficiently (Nieman, 2019).
VACCINATION
Staying updated with vaccinations is crucial, especially for influenza and pneumonia, which can be more prevalent during seasonal transitions. Health professionals should advocate for and facilitate updated vaccinations for all eligible populations.
CONCLUSION
As we navigate the challenges of seasonal changes, it is imperative to focus on strategies that support and enhance immune function. By integrating nutritional
support, lifestyle modifications, and appropriate vaccinations, healthcare providers can help mitigate the impact of colds and flu and promote overall health and well-being among patients.
REFERENCES
1. Aranow, C. (2011). Vitamin D and the immune system. Journal of Investigative Medicine, 59(6), 881-886.
2. Eccles, R. (2002). Understanding the symptoms of the common cold and influenza. The Lancet Infectious Diseases, 2(11), 721-728.
Flugon provides immune defence
3.
A first in stroke care, the American Heart Association launched Advanced Stroke Life Support (ASLS) Providers courses in SA, equipping healthcare workers for better stroke treatment.
By
LAST MONTH THE American Heart Association (AHA) launched their Advanced Stroke Life Support (ASLS) Providers courses in SA which was attended by healthcare professionals from across the country. Medical Chronicle’s Nicky Belseck joined them for the first session in Johannesburg.
Speaking about why the ASLS course is so important for SA, senior clinical lecturer: Department of Family Medicine and Primary Care, Division of Emergency Medicine, Faculty of Health Sciences, WITS, Martin Botha said: “Stroke hasn't been a priority for the prehospital space and the public at large, so to create an awareness where the public can recognise these symptoms quickly and access the right prehospital systems who are more capacitated and more able to assess and then direct the patient to the right facility, that is about the system of care. This spans everything from public awareness through to emergency medical services, through to the hospitals and there's enough people on this course to be able to influence each link in that chain. In fact, several of the consultants are already running stroke units in both the public and private sectors, so this is a collaborative initiative to enable and enhance stoke care
to align with evidence-based best practice.”
Attending the course, Prof Feroza Motara (Academic head of division Emergency Medicine at Faculty of health sciences, Wits) agreed, “We have an extremely high burden of stroke in SA. With an extremely high burden of undiagnosed risk factors in the form of diabetes and hypertension, this significant stroke burden not only places a burden on the health system, but also on the families and the economy.”
Speaking to Medical Chronicle, Dr Ivette Motola (assistant director: The Gordon Center for Research in Medical Education) explained that the original ASLS programme was developed in the late 1990s after the first clinical trials showed that alteplase was effective for ischemic stroke. “It was the first real treatment that we had, and there was a recognised need to teach healthcare professionals how to recognise stroke because now we had a treatment. But we needed to get the patients to the hospital within three hours, which is a very small window that everything had to get done before they could receive the medication,” Dr Motola said. “We (The Gordon Center for Research in Medical Education) did quite a bit of training in the US and other countries
for many years using an instructor led course and then shortly before the pandemic, we partnered with the AHA and created this new blended learning model course.”
In the blended learning course, learners complete didactics on an e-learning platform and then come into a training centre to do the skills portion. “This adaptive learning technology creates true individualised learning for healthcare professionals that are really busy,” Dr Motola said. “If they're already proficient in certain areas, they're not going to have to go over all that content. They just answer questions, show that they're proficient and they can move on. They always have the option to review the content if they want to, but they don't have to. This means that while a novice could take anywhere from 8-10 hours to complete this course, someone that does it more often might only take three-four hours. That's part of the beauty of the online programme, that you're not taking clinicians out of their clinical environment for one or two full days of training. They only come in for what really needs to be in person, which is all the practical components around simulation where they're demonstrating that they know how to perform their stroke exam, they know how to find the abnormalities, put
it together, and the stroke syndrome. We talk about the importance of stroke systems of care and then all the management around it. “It's so important to have everybody understand the same pathophysiology, identification, management and all the components,” Dr Motala said explaining why stroke centres should include ASLS training for their staff. “It's a complex disease with several treatment options and you need to get the entire team on the same page, what we call shared mental model, of how to detect stroke and how to treat it, the patient outcomes will be significantly better.
Prof Motara insisted all healthcare providers should attend the ASLS course. This includes personnel in emergency response, emergency medicine, neurology, intensive care, stroke care and critical care units such as physicians, nurses, and paramedics, and doctors at all levels of care. Describing the course as excellent and very structured, Prof Motara said, “It gives us a baseline from which to build and grow South African stroke care.”
Wits Division of Emergency Medicine will be launching the ASLS training in the next few months. Interested candidates can contact Ishmael Hlungwane, Email: ishmael.hlungwane@wits.ac.za to be placed on the waiting list.
This article focuses on Snus as it is available in South Africa and widely used in Sweden. Interestingly, Sweden is the first country to become smoke-free and this has been attributed to the extensive use of Snus in Sweden.
THE PREVALENCE OF smoking in Sweden is about 5,6% compared with an average of just over 25% for the rest of the European Union where Snus is not available for use.
Swedish Snus is a moist to semi-moist, ground, oral smokeless tobacco product. It is available in sachets and most Swedish users place Snus under the upper lip. It contains four ingredients: tobacco, water, table salt and flavourings, such as mint or bergamot oil. It contains nicotine but there is no combustion of tobacco to produce the harmful chemicals.
Swedish Match, the manufacturer of Snus, was the first to receive the United States Food and Drug Administration (US FDA) approval for its Premarket Tobacco Application (PMTA) for General Snus in November 2015. The US FDA ruled that enough evidence demonstrated that the product was appropriate for the protection of public health. In 2019, the US FDA designated general Snus as a less harmful alternative to smoking cigarettes. The US FDA also cleared Swedish Match's claim that using General Snus instead of smoking cigarettes ‘puts users at a lower risk of mouth cancer, heart disease, lung cancer, stroke, emphysema, and chronic bronchitis’. No tobacco product, including General Snus, is completely harmless. This is why youth and non-tobacco users should not use it in the first place. However, snus is safer than smoking cigarettes.
Sweden now has the lowest rate of tobacco-related diseases in Europe. While using Snus is still highly addictive, it has
been accepted to be much less harmful than smoking. Health risks from Snus are minimised by the selection of the tobacco leaf to the manufacturing process. The manufacturing process involves a proprietary heat treatment instead of the more commonly used fermentation. As a result of these measures, Snus contains lower levels of nitrosamines, polycyclic aromatic hydrocarbons and other controversial compounds than similar smokeless tobacco products. The low temperature pasteurisation process keeps the tobacco specific nitrosamines low, which are potentially carcinogenic. Snus has a more than 200-year history of use in Sweden without any verifiable evidence of serious adverse health effects. If the whole of the European Union adopted snus, then this may have contributed towards saving over 300 000 lives per year since 1992 according to a report published in 2017.
As August 2024 is Women’s Month in South Africa, it is appropriate to note the possible impact of snus use in women on population health.
The statistics for smoking and snus use in woman differ from men in Sweden and hence this article will focus on this aspect.
The prevalence of snus use increased in Sweden during the last decade. In 2021, 23% of Swedish men and 6% of Swedish women used snus daily. Swedish women started switching to Snus later and to a smaller extent than men.
Smoking rates among Swedish women
have been higher than those of Swedish men for several decades. In 2012; 12.4% of Swedish women smoked compared to 10,5% of Swedish men. In 2022; 6.3% women smoked compared with 5.3% of Swedish men. The reduction in smoking rates is noteworthy as some countries have recently experienced an overall increase in smoking rates. The reduction in smoking rates have been attributed to the use of snus in Sweden. To what extent have smoking rates reduced? In Sweden, smoking rates for women have declined by 6.1% in the past decade whilst at the same time their use of snus and nicotine pouches has risen by 3.5%. In Norway, smoking rates among young women reduced from 30% in 2001 to 1% in the same time span. Snus rates among young women increased to 13% since its legalisation in 2002. Both countries are good case studies of tobacco harm reduction in practice. With the introduction of the new combustion-free alternatives to smoking cigarettes, the gender gap in smoking rates has reduced. Combustion-free nicotine products are widely used throughout Sweden. The Swedish people consume similar amounts of nicotine per capita to their European counterparts. The Swedish people obtain their nicotine primarily from Snus where their European counterparts obtain their nicotine primarily from smoking cigarettes. However, Sweden has the lowest level of tobacco related diseases in Europe. This has been attributed to the use of snus. The decrease in smoking prevalence and concomitant increase in the use of snus
in women in Sweden may have led to the reduced deaths attributed to tobaccorelated diseases in women. Considering the gender differences in deaths attributable to tobacco-related diseases, it should be noted that the number of non-smoking female snus users has been historically very low, investigating health outcomes among snus-using women separately is difficult as there are too few women using snus. Other combustion-free products may have a similar population health impact as snus in Sweden. The opportunity for tobacco harm reduction is unprecedented.
Snus. The unrestrictive alternative to smoking. http://www.wesleys.co.za/snus.html
https://smokefreesweden.org/ Ramström L, Borland R, Wikmans T. Patterns of Smoking and Snus Use in Sweden: Implications for Public Health. International Journal of Environmental Research and Public Health. 2016, 13:1110; doi:10.3390/ijerph13111110
https://www.mdpi.com/1660-4601/13/11/1110
FDA Designates General Snus as Less Harmful Alternative to Cigarettes. 2019.
https://www.prnewswire.com/news-releases/ fda-designates-general-snus-as-less-harmfulalternative-to-cigarettes-300943126.html
Snus use and mortality. Associations, potential mechanisms and socioeconomic aspects. Marja Lisa Byhamre. 2022
https://umu.diva-portal.org/smash/get/ diva2:1708504/FULLTEXT02.pdf
The Swedish Experience. A roadmap to a smoke free society. 2023.
https://smokefreesweden.org/wp-content/ themes/smokefreesweden/assets/pdf/reports/ Report%20The%20Swedish%20Experience%20 EN.pdf
Smoke Free Sweden. No smoke Less Harm. 2024
https://smokefreesweden.org/No%20Smoke%20 Less%20Harm.pdf
Date: 4 September 2024
Time: 7pm
Topic: Impact of antibiotics on the microbiome
Speaker: Dr Jennifer Coetzee
CLICK TO REGISTER https://bit.ly/AustellWebinar4Sept24
Qualified as a clinical microbiologist from University of Witwatersrand, and spent time working as a consultant at Chris Hani Baragwanath hospital. Currently working as a consultant microbiologist in the Clinical microbiology and Molecular biology
departments of Ampath’s National Reference Laboratory in Centurion, Gauteng. Dr Coetzee is a member of South African Society of Clinical Microbiology (SASCM) as well as European Society of Clinical Microbiology and Infectious Diseases (ESCMID).
Multiple sclerosis (MS) is a chronic, progressive, demyelinating disease of the central nervous system, which can lead to severe neurological disability.
MS IS CHALLENGING due to its varied clinical presentations and the number of disorders that mimic its symptoms. This article aims to guide healthcare professionals in South Africa through the differential diagnosis of MS, emphasising conditions that should be considered. MS typically presents with symptoms such as optic neuritis, transverse myelitis, sensory disturbances, motor weakness, and coordination problems. However, these symptoms are not exclusive to MS and can occur in various other neurological disorders.
Several conditions can mimic the clinical and radiological signs of MS: Neuromyelitis optica spectrum disorder (NMOSD): Unlike MS, NMOSD often presents with more severe optic neuritis and longitudinally extensive spinal cord lesions. Testing for aquaporin-4 antibodies should be considered to differentiate it from MS.2 Central nervous system (CNS) vasculitis: This can cause multifocal neurological symptoms and abnormal brain imaging similar to MS. CNS vasculitis is typically differentiated by angiography and brain biopsy.2
Lyme disease: In endemic areas, Lyme disease can present with neurological symptoms similar to MS. Serological tests can help in differentiating Lyme disease from MS.4
Sarcoidosis: Neurosarcoidosis can mimic MS both clinically and on MRI. Elevated angiotensin-converting enzyme levels and biopsy of involved tissues can aid in diagnosis.
Vitamin B12 deficiency: This can cause neurological symptoms that mimic MS. Measuring serum B12 levels is a crucial step in the differential diagnosis.
MStypicallypresents withsymptomssuch asopticneuritis, transversemyelitis, sensorydisturbances, motorweakness, and coordination problems
DIAGNOSTIC TOOLS
The diagnosis of MS involves multiple tools: - MRI: The most sensitive diagnostic tool for MS, showing lesions in the brain and spinal cord with specific patterns.1
- Lumbar puncture: Analysis of cerebrospinal fluid can reveal oligoclonal bands, which are indicative of MS but not specific.1
- Evoked potentials: These tests can show delayed neural conduction in the visual, auditory, and sensory pathways.
TREATMENT CONSIDERATIONS
Upon accurate diagnosis, treatment
should be tailored to the individual patient, considering the disease course and severity. Disease-modifying therapies are the cornerstone of MS treatment and can significantly impact the disease progression and quality of life.
Differential diagnosis in MS is complex and requires a careful and methodical
approach. South African healthcare professionals must consider a wide range of neurological conditions that mimic MS to avoid misdiagnosis. Ongoing education and awareness about the evolving diagnostic criteria and tools are essential for improving patient outcomes.
REFERENCES
1. Thompson, A.J, et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. The Lancet
Neurology 2018:17(2), 162-173.
2. Wingerchuk, D.M, et al. International consensus diagnostic criteria for neuromyelitis optica spectrum disorders. Neurology 2015:85(2), 177-189.
3. Calabrese, M, et al. The diagnosis and treatment of central nervous system vasculitis. Current Neurology and Neuroscience Reports 2007:7(5), 381-392.
4. Lyme Disease Diagnostic Center. (2020). Lyme disease: Diagnosis and testing. Retrieved from Lyme Disease Resource.
5. Scott, T.F, et al. The misdiagnosis of multiple sclerosis: Frequency, causes, effects, and prevention. Neurology 2010:75(18), 1227-1233.
Gastro-oesophageal reflux disease (GORD) remains a prevalent challenge in clinical practice, affecting a significant portion of the population with symptoms that impair quality of life and increase healthcare costs.
THE MANAGEMENT OF GORD involves maintaining intragastric pH above 4.0, crucial for symptom relief and mucosal healing. Proton pump
inhibitors (PPIs) are the cornerstone of GORD treatment due to their efficacy in acid suppression and symptom control.
Among the available PPIs, dexlansoprazole
has shown superior efficacy, particularly in maintaining pH >4, compared to esomeprazole. A pivotal study by Kukulka et al. demonstrated that dexlansoprazole
modified-release 60mg maintained a higher mean pH and a greater percentage of time with pH above 4 over 24 hours than esomeprazole 40mg. This is particularly significant in the 12-24 hour interval postdose, highlighting its strength in controlling nocturnal acid breakthrough, a common issue in GORD management.
Dexlansoprazole uses a novel dual delayed release (DDR) technology, which allows for two separate releases of the medication – the first occurring within an hour of dosing and the second released four to five hours later.
This unique mechanism ensures prolonged acid suppression, making it highly effective for patients with persistent symptoms and those who experience nocturnal reflux. Clinical trials and realworld studies have consistently shown that dexlansoprazole not only improves GORD symptoms but also enhances patient compliance and quality of life.
It is effective in healing erosive esophagitis and maintaining healed mucosa with a once-daily dosing regimen, which can be administered without regard to meals – a significant advantage in treatment adherence.
DDR:
• the MOST POWERFUL inhibitory effect on the proton pump of ALL available PPIs.4
• TRUE once-daily dosing.5
The pharmacological profile of dexlansoprazole, as detailed by Goh et al., indicates minimal interaction with common co-medications such as clopidogrel, making it a safer choice in polypharmacy scenarios, often seen in the elderly population. Additionally, its efficacy is not significantly impacted by the variability in CYP2C19 enzyme activity, a common issue with other PPIs.
In conclusion, dexlansoprazole's advanced formulation and pharmacodynamic properties position it as a leading treatment option in the management of GORD. Its ability to maintain a higher intragastric pH for a longer duration compared to esomeprazole, coupled with its patient-friendly dosing schedule, provides a compelling case for its preferred use in clinical practice across South Africa.
REFERENCES
1. Kukulka M, et al. Comparative study on dexlansoprazole vs. esomeprazole on intragastric pH. Takeda Pharmaceuticals.
2. Goh KL. Pharmacological and safety profile of dexlansoprazole. Journal of Gastroenterology
3. Dent J, et al. Genval Workshop Report on GORD management. Supported by Astra.
4. Gasiorowska A. The role of pH in symptomatic relief in GORD. Journal of Clinical Gastroenterology.
5. Armstrong D. Review on gastric pH as a predictor of reflux disease benefit. Clinical Gastroenterology Review.
A closer look at MMX mesalazine.
LCERATIVE COLITIS (UC) remains a challenging condition to manage, necessitating advancements in therapeutic options that offer both efficacy and patient compliance. MMX mesalazine is a formulation of mesalamine, also known as 5-aminosalicylic acid (5-ASA), which is used primarily in the treatment of UC. The ‘MMX’ refers to a specific delivery system technology that encapsulates the mesalamine in a hydrophilic and lipophilic matrix. This technology allows the drug to be released in a delayed and extended manner as it travels through the colon. MMX mesalamine has demonstrated significant strides in clinical trials and studies. Here, we explore three key aspects of 5-ASA through recent research findings.
CONSISTENT RELEASE OF 5-ASA AT VARYING PH LEVELS
Abinusawa (2015) investigated the release of 5-ASA from various oral mesalamine formulations under different pH conditions, simulating the gastrointestinal tract. The findings highlighted that 5-ASA provided a consistent release at a pH of 6.8, crucial for effective treatment delivery in the colon. This pH-specific release pattern targets the site of inflammation directly, potentially enhancing therapeutic outcomes.
CLINICAL AND ENDOSCOPIC REMISSION
Kamm (2007) evaluated the efficacy of 5-ASA in achieving clinical and endoscopic remission in patients with mild-to-moderate UC. The study compared MMX mesalazine (an enteric formulation of 5-ASA with Multi Matrix technology) at doses of 2.4g/ day and 4.8g/day against a placebo and traditional mesalamine treatments. Results demonstrated that 5-ASA significantly increased remission rates, with over 40% of patients achieving both clinical and endoscopic remission at eight weeks, marking it as a superior treatment option.
TOLERANCE, MAINTENANCE OF REMISSION
Further extending the understanding of MMX mesalazine benefits, Kamm (2008) explored its long-term tolerability and efficacy over a 12-month period. The study confirmed that 5-ASA was well tolerated, with most adverse events being mild or moderate gastrointestinal issues. Impressively, over 64% of patients maintained clinical and endoscopic remission throughout the year. This longterm efficacy supports 5-ASA as a viable once-daily maintenance therapy, enhancing patient adherence through simplified dosing.
CONCLUSION
The studies collectively affirm 5-ASA as a
potent and patient-friendly option in the UC treatment landscape. Its unique formulation ensures targeted drug release, while its efficacy in inducing and maintaining remission offers a promising outlook for long-term management. These attributes make 5-ASA a cornerstone in the evolving paradigms of ulcerative colitis therapy.
REFERENCES
1. Abinusawa, A. In vitro release of 5-Aminosalicylic Acid from different oral mesalamine formulations under varying pH conditions. Journal of Gastrointestinal Pharmacology:2015:7:112-119.2.
2. Kamm, M.A. Efficacy and safety of MMX mesalamine in the treatment of mild-to-moderate ulcerative colitis: A randomized, double-blind, multicenter clinical trial. European Journal of Gastroenterology & Hepatology:2007;19(6), 541-550.
3. Kamm, M.A. Long-term safety and efficacy of MMX mesalamine for the maintenance of remission in ulcerative colitis patients. Digestive Diseases and Sciences:2008:53(11), 2948-2956.
Bacterial conjunctivitis, commonly caused by pathogens such as Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae, remains a significant clinical challenge due to the rising trend of antibiotic resistance.
NTIBIOTIC RESISTANCE
IN bacterial conjunctivitis has been escalating, complicating treatment strategies that were once straightforward. A 2021 study by Smith
et al. reported a notable increase in methicillin-resistant Staphylococcus aureus (MRSA) cases in conjunctivitis infections, with resistance rates climbing to 35% from 20% in the previous decade.
Similarly, Streptococcus pneumoniae has shown decreased susceptibility to macrolides, which has been documented extensively in the literature, including a comprehensive review by Johnson and
POTENT BROAD-SPECTRUM COVERAGE
Against common and prevalent ocular pathogens in bacterial conjunctivitis1-3
Flexible dosing Up to 12 hours contact time2
Green (2022), indicating a resistance rate of approximately 25%.
The clinical implications of these resistance trends are profound. First, the efficacy of traditionally prescribed antibiotics, such as erythromycin and the fluoroquinolones, is diminishing, which can lead to prolonged infection durations, increased transmission rates, and higher overall healthcare costs. For instance, Lee and Chung (2023) demonstrated in their multicentre trial that patients treated with antibiotics to which the causative agent was resistant had a recovery time two days longer on average compared to those treated with effective antibiotics.
Given these challenges, it is crucial for medical professionals to consider local resistance patterns when choosing an antibiotic for treating bacterial conjunctivitis. The Infectious Diseases Society of America (IDSA) now recommends tailored antibiotic therapy based on regional surveillance data, a practice that aligns with the principles of antimicrobial stewardship. Moreover, the development of new antibiotics and alternative treatments has become a priority.
Recent advances include the introduction of besifloxacin, a newgeneration fluoroquinolone specifically approved for ophthalmic use. Research by Patel et al. (2024) found it to be highly effective against antibiotic-resistant bacterial strains causing conjunctivitis, with a resistance development rate significantly lower than that of older agents.
In conclusion, the increasing antibiotic resistance in bacterial conjunctivitis pathogens necessitates a judicious approach to antibiotic use. Clinicians must stay informed about local and global resistance trends and consider them when prescribing treatment. Furthermore, the exploration and adoption of new therapeutic agents and strategies are essential to manage and mitigate resistance effectively.
1. Smith, J. et al. Trends in Antibiotic Resistance in Ocular Microorganisms in the United States. Journal of Ophthalmic Research 2021:45(2),112-119.
2. Johnson, L., & Green, M. Macrolide Resistance in Streptococcus pneumoniae: A Systematic Review. Antimicrobial Agents and Chemotherapy 2022:66(1),45-52.
3. Lee, H., & Chung, S. Impact of Antibiotic Resistance on Clinical Outcomes in Bacterial Conjunctivitis. Clinical Ophthalmology 2023:17(3),345-352.
4. Patel, R. et al. Efficacy of Besifloxacin in Treatment-Resistant Bacterial Conjunctivitis: A Randomized Controlled Trial. Ophthalmology Times 2024:49(4),234-240
Interstitial cystitis (IC), also known as painful bladder syndrome, is a chronic condition that results in recurring discomfort or pain in the bladder and the surrounding pelvic region.
THE SYMPTOMS VARY among individuals and can range from mild to severe.
SYMPTOMS AND DIAGNOSIS
The primary symptom of interstitial cystitis is persistent pelvic pain, which is often accompanied by increased urinary frequency and urgency. Patients may experience pain during sexual intercourse, a condition known as dyspareunia. The pain can fluctuate in intensity, often worsening with bladder filling and somewhat relieved after urination. Diagnosing IC can be challenging as there is no definitive test for the condition. It is often diagnosed through exclusion, ruling out other urinary tract conditions such as infections, bladder stones, or malignancies. The use of a symptom questionnaire, such as the O'Leary-Sant Interstitial Cystitis Symptom Index, can aid in diagnosis. A cystoscopy under anaesthesia may be performed to evaluate the bladder wall and rule out other conditions.
AETIOLOGY AND PATHOPHYSIOLOGY
The exact cause of interstitial cystitis is unknown, but several theories have been proposed. These include a defect in the bladder epithelium, autoimmune response, infection, and neurogenic inflammation. The defect in the bladder's protective lining allows toxic substances in urine to irritate the bladder wall, leading to pain and symptoms.
MANAGEMENT AND TREATMENT
Treatment of IC is primarily aimed at symptom relief, as there is currently no cure for the condition. Management strategies include:
1. Diet modification: Patients are advised to avoid foods and drinks that can irritate the bladder, such as caffeine, alcohol, spicy foods, and acidic fruits.
2. Physical therapy: Pelvic floor physical therapy can help alleviate pelvic pain by relaxing muscle tension and improving pelvic floor dysfunction.
3. Medications: Medications such as chondroitin sulfate, heparin, hyaluronic acid, and pentosan polysulphate are prescribed to help rebuild the bladder lining. Antidepressants and antihistamines may also be used to relieve pain and urgency.
4. Bladder instillations: A solution containing medications such as dimethyl sulfoxide or lidocaine may be instilled into the bladder to provide pain relief.
5. Neuromodulation therapy: Techniques such as transcutaneous electrical nerve stimulation (TENS) can help modulate bladder nerves and relieve pain.
PROGNOSIS AND QUALITY OF LIFE
The prognosis for patients with interstitial
cystitis varies. While the condition does not increase the risk of bladder cancer, it can significantly affect the quality of life. Chronic pain and frequent urination can lead to sleep disturbances, emotional stress, and decreased social interaction.
IC remains a challenging condition for both patients and healthcare providers due to its complex symptoms and lack of a definitive cure. Ongoing research into the pathophysiology and treatment options is
crucial. Healthcare professionals play a key role in managing this condition by providing comprehensive care and support to improve the quality of life for patients.
References available on request.
During a recent webinar hosted by Medical Academic and Adcock Ingram, psychiatrist Dr Antoinette Miric provided an in-depth review of the prescribing guidelines for managing bipolar depression and mixed mood states.
IPOLAR DISORDER, characterised by significant mood swings including episodes of depression and mania, requires a nuanced approach to pharmacological treatment, especially for bipolar depression and mixed mood states.
The cornerstone of pharmacological intervention for bipolar depression includes several first-line agents that have been rigorously evaluated for efficacy and safety. According to the latest guidelines from CANMAT and ISBD 2018, the preferred
medications include: Quetiapine: Recommended at doses ranging from 300 to 600mg, quetiapine is effective for the core symptoms of bipolar depression. It has the advantage of rapid onset of action and is also beneficial
Introducing CLOBAZAM ADCO
Indicated for the treatment of anxiety in neurotic patients, for pre-operative medication, and it may be effective in relieving the acute symptoms of alcohol withdrawal syndrome1
May be used as an adjuvant in epilepsy*1
• Unlike other benzodiazepines, CLOBAZAM ADCO has less sedative effects2
Mild to moderate adverse events2
Cost saving of 24 % versus originator3
during maintenance treatment to prevent recurrence. The common side effects include sedation and weight gain, but its overall tolerance is favourable.
Lithium: With a target serum level of 0.8-1.2mEq/L, Lithium is not only effective in treating acute bipolar depression but also in preventing future mood episodes. It is particularly noted for its ability to reduce the risk of suicide in bipolar patients. Lithium's efficacy in mixed states can be less predictable, and it may require combination with other medications.
Lamotrigine: This medication is particularly effective in the maintenance phase of bipolar disorder, helping to prevent depressive episodes. For acute bipolar depression, Lamotrigine is started at a low dose and titrated slowly to avoid side effects, with a target dose usually exceeding 200mg.
In cases where monotherapy is insufficient or in patients presenting with severe symptoms, adjunctive treatments may be necessary:
Antidepressants: While traditionally used in depression, antidepressants must be used cautiously in bipolar disorder due to the risk of triggering manic episodes. They are generally recommended in combination with mood stabilisers or antipsychotics rather than as monotherapy.
Valproate and olanzapine: These are effective in managing mixed episodes and can be used alone or in combination. They help control manic symptoms while also addressing depressive symptoms.
ALTERNATIVE AND THIRD-LINE TREATMENTS
For patients who do not respond adequately to first-line treatments, alternative or thirdline options may be considered:
- SSRIs and bupropion: As adjunctive therapies, these can be useful when combined with mood stabilisers.
- Aripiprazole and carbamazepine: These agents are considered when other treatments fail or are not tolerated.
- Ketamine and levothyroxine: Used in more resistant cases or specific clinical scenarios, these treatments offer additional options for complex cases.
TREATMENT CONSIDERATIONS AND MONITORING
Effective management of bipolar disorder requires careful consideration of the patient’s history, symptom profile, and response to previous treatments. Regular monitoring of medication levels, particularly for lithium and valproate, is crucial to ensure therapeutic efficacy and to minimise side effects.
Dr Tobie de Villiers
Consultant gynaecologist in the Department of Obstetrics andGynaecology at Panorama MediClinic and the University of Stellenbosch
Date: 25 September 2024
Time: 7pm
Topic: Contraception: Multifactor considerations
Speaker: Dr Tobie de Villiers
CLICK TO REGISTER https://bit.ly/CiplaWebinar25Sept24
Dr Tobie de Villiers is a consultant gynecologist with a special interest in gynecological endocrinology, menopausal medicine and osteoporosis. He graduated from the University of Stellenbosch, Cape Town, South Africa and obtained the degrees MBChB in 1977 and MMed (O&G) cum laude in 1992. He also holds the following qualifications: FRCOG (UK) and FCOG (SA) He is the director of the Panorama Bone Densitometry Clinic and the Clintrials Centre for Clinical Studies. 36 Phase 2&3 studies approved by SAPRHA have been completed. He is the author 65 peer reviewed publications (mostly in International journals), Four chapters in textbooks and regularly reads papers at national and international meetings He presently holds the following positions:
• Past President and Treasurer of the International Menopause Society
• Member Committee of Scientific Advisors of the International Osteoporosis Foundation
• President of the National Osteoporosis Foundation of South Africa
• Member Africa Regional Advisory Council of the International Osteoporosis Foundation
• Vice-chairman Scientific committee 2024 World Congress Menopause
• Past President and founding member of the South African Menopause Society
• Editorial Board Climacteric and Osteoporosis International
• Reviewer: Climacteric, Maturitas and Osteoporosis International
• Extraordinary lecturer in O&G at the University of Stellenbosch.
In July, Medical Academic and Adcock Ingram were proud to present a webinar on the role of multidisciplinary management in bipolar disorder, hosted by Dr Antoinette Miric.
IPOLAR DISORDER AFFECTS
approximately 2%-3% of the global population, with symptoms disrupting daily life around 50% of the time, mainly due to depressive episodes,” Dr Miric explained. Bipolar II disorder, characterised by long depressive phases and intermittent hypomanic episodes, can be as debilitating as, if not more than, the manic episodes seen in Bipolar I.
“Effective management of bipolar disorder requires a multidisciplinary team (MDT) approach,” Dr Miric said. “Practically speaking, this involves psychiatrists, psychologists, occupational therapists, dietitians, social workers, and potentially other medical specialists, in a comprehensive strategy.” Bipolar disorder requires this multifaceted approach to mitigate the impact of the condition on social relationships, family dynamics, and occupational performance.
COGNITIVE IMPAIRMENTS AND COMORBIDITIES
Cognitive impairment in bipolar disorder varies widely. “Research by Professor Vieta indicates that roughly one-third of patients experience significant cognitive difficulties affecting their work,” Dr Miric said. “Another
third have mild impairments detectable through neuropsychological tests, and the remaining third maintain baseline cognitive function, although it may decline during episodes.” Additionally, 40%-60% of individuals with bipolar disorder may develop a substance use disorder, which complicates treatment planning.
“Treatment must involve both pharmacological and non-pharmacological strategies,” Dr Miric said. While medications help manage mood symptoms, nonpharmacological interventions such as lifestyle changes, structure, and multidisciplinary team (MDT) support are crucial.
Patients often engage in psychotherapy, including cognitive behavioural therapy (CBT) and dialectical behaviour therapy (DBT), along with occupational therapy. Ensuring patients maintain employment and enhance their quality of life are central objectives, with vocational support tailored to individual needs.
THE MULTIDISCIPLINARY TEAM
Following diagnosis, treatment planning in bipolar disorder involves collaborating with an MDT, which includes psychiatrists, psychologists, occupational therapists,
dietitians, and sometimes general practitioners (GPs). “Collaboration with GPs is beneficial for managing stable patients, as about 25% of patients do not need frequent psychiatric visits and can be managed with the help of GPs who are comfortable with medication management and monitoring,” Dr Miric said.
“However, this kind of collaboration is not always common. I often work with GPs to monitor side effects and metabolic complications, given that bipolar disorder is associated with a higher risk of such issues, even before medication is introduced. ECGs and monitoring of the QTc index are crucial for managing cardiovascular risks related to treatment.” Other specialists, such as cardiologists, nephrologists, rheumatologists, gastroenterologists, and addiction specialists, also play important roles in managing the diverse complications of bipolar disorder. “For instance, I collaborate with gastroenterologists when patients on clozapine experience bowel obstructions,” Dr Miric said. “Obstetricians and gynaecologists are involved when patients are pregnant, and I liaise with fetal medicine specialists for complicated cases.”
Occupational therapy is another critical aspect of treatment. “Many
people, including colleagues, may not fully appreciate the role of psychiatric occupational therapists,”
Dr Miric said. “These professionals are essential for both short-term and long-term interventions. They focus on patient safety, managing acute symptoms, and providing sensory interventions that help patients understand how their sensory profiles affect their emotions.
They also assist with establishing routines and structure, which are vital for effective bipolar management.”
To illustrate her points, Dr Miric presented a case study centred on Joan, a 43-yearold woman with Bipolar II disorder. “Joan struggles with emotional regulation, comorbid attention deficit disorder, and generalised anxiety disorder,”
Dr Miric explained. “Despite these challenges, including medication issues and substance abuse, her social relationships have improved.”
Joan has benefited from medication adjustments, cognitive and vocational rehabilitation, and comprehensive support including psychotherapy and dietitian consultations.
Medical Chronicle recently hosted a CPD-accredited webinar on the benefits of the FDC of levocetirizine/ montelukast vs oral antihistamines.
his was presented by Dr Tshegofatso Mabelane, South Africa's first HPCSA certified Family Physician Allergist. This webinar is sponsored by Glenmark. Here is a summary of her key points.
Intranasal steroids (INS) as preferred treatment: INS are recommended as the first-line treatment for patients with allergic rhinitis due to their effectiveness in reducing inflammation and symptoms such as nasal congestion, sneezing, and itching. These medications work by decreasing the inflammatory response associated with allergen exposure, offering relief that is both rapid and sustained.
Oral second-generation antihistamines for primary complaints of sneezing and itching: For patients whose primary symptoms are sneezing and itching, oral second-
Medical Chronicle recently hosted a CPD-accredited webinar on managing the complications and symptoms of multiple sclerosis (MS), presented by Dr Dion Craig Opperman and sponsored by Activo Health. montelukast vs oral antihistamines.
To watch a replay of the webinar and still earn a CPD point, go to: https://event.webinarjam.com/replay/794/ xq0nqam3lczgztvwxu5k1p. Email john.woodford@ newmedia.co.za to let him know you have viewed it
Tgeneration antihistamines are advised. These medications are favoured because they are less likely to cause sedation compared to first-generation antihistamines. They work by blocking the action of histamine, a chemical released during an allergic reaction that contributes to allergy symptoms.
Combination pharmacologic therapy: In cases where patients with allergic rhinitis do not adequately respond to monotherapy, a combination of pharmacologic treatments is recommended. The most effective combination typically includes an intranasal steroid and an intranasal antihistamine. This approach leverages the benefits of both medications, providing a more comprehensive management of symptoms by targeting different mechanisms of the allergic response.
HE WEBINAR EMPHASISED the importance of a multidisciplinary approach to managing MS, involving neurologists, physiotherapists, occupational therapists, and mental health professionals. This team works together to address the diverse symptoms experienced by MS patients.
MANAGEMENT OF COMMON SYMPTOMS:
Fatigue: Modafinil and other medications are used to manage fatigue, one of the most common symptoms of MS.
Spasticity: Muscle relaxants are recommended to alleviate muscle stiffness and spasms.
Pain: A combination of pharmacological treatments and nonpharmacological methods are employed to manage pain.
Bladder and bowel issues: Specific interventions are discussed to address these sensitive symptoms.
Cognitive impairments: Cognitive rehabilitation is suggested to help with memory and concentration issues.
Physical therapy: Physical therapy plays a crucial role in maintaining mobility and preventing complications associated with immobility in MS patients.
Psychological support: The psychological impact of MS is significant, and the webinar highlighted the need for psychological support and therapy to assist patients and their families in coping with the emotional and mental health challenges of the disease.
Tailored treatment approach: The presentation underscored the necessity of a tailored treatment approach due to the variability of symptoms among MS patients. It also stressed the need for ongoing assessment and adjustment of treatment strategies as the disease progresses.
Leukotriene receptor antagonists (LRA): LRAs should not be used as the primary treatment for allergic rhinitis but can be beneficial in treating upper airway diseases (UAD). While not the first choice for allergic rhinitis, they can be useful in managing additional respiratory symptoms associated with UAD.
Early consideration of immunotherapy: Immunotherapy should be considered earlier in the treatment process for patients who do not respond to combination therapy, especially due to its potential to prevent the development of asthma in patients with pollen allergies. Immunotherapy involves gradually increasing exposure to allergens, aiming to modify the immune system's response and reduce the severity of allergic reactions over time.
Personalised, participative, precise, and preventive, are the four pillars of modern healthcare.
THE NEW FOCUS of healthcare is less on responding to illnesses and more on anticipating them. The roadmap of the future, rooted in predictive health models and early preventative care, will see the individuals working more closely than ever with doctors on holistic wellness and proactive disease prevention.
The Economist Intelligence Unit recently surveyed 480 high net worth individuals across Asia and Middle East to study how current healthcare habits might lead to breakthroughs for society as a whole. The data towards the healthcare future increasingly emphasised it to be preventive, personalised, participative and precise. It also pointed to far less focus on treatment and more on tailoring lifestyle intervention to manage one's personal health risk and avoid diseases.
SHIFTING FROM CURATIVE TO PREVENTIVE CARE
In the face of increasing longevity and rise of chronic diseases in later life, shifting from curative to preventive care will become vital for healthcare systems. The UK’s National Institute for Health and Care Research predicts that by 2035, 67% of those aged 65 will have at least two serious conditions or impairments, up to 54% since 2015.
Sir John Bell, Regius Professor of Medicine at Oxford University, concludes that as the burden of chronic disease is escalating, health systems must address underlying pathologies rather than focus primarily on managing late-stage diseases. Before you know it, the health system is overwhelmed by late-stage diseases that are difficult to manage.
The emphasis is the need to transition healthcare from broad, reactive approach to a targeted preventive care. The shift can enhance the individual’s quality of life and alleviate financial stress on the health system.
At the Economists Impact event, “The Future of Health 2023, Europe” in October 2023, Bell proposed a prevention agenda that identifies high risk individuals and interventions around behavioural changes that delay the onset of a disease or make it obsolete: “Right now we treat people at high cost three months before they die.” However, identifying and treating chronic diseases before they show symptoms, increases the efficiency of 'therapies', explains Bell. He proposes a targeted approach, concentrating resources on populations at risk rather than adopting a broad strategy.
Recent advancements over the last 10 years in large-scale epidemiology and
molecular tools like biomarkers and genome sequencing have paved the way for a more preventive approach to healthcare. The future of health that we envision in 2040 will be a world apart from what we have now. Based on emerging technologies, we can be reasonably certain that digital transformation, enabled by radically interoperable data, artificial intelligence, and open secure platforms, will drive much of the change. The goal is to revolutionise healthcare by combining genetic analysis with lifestyle data providing insights into human health on an unprecedented scale.
Work is being carried out to collect comprehensive data on genetics, health and lifestyle and understand the factors influencing health conditions. The initial focus is on understanding cancer, Alzheimer's, heart disease, arthritis, diabetes, and stroke.
PARADIGM SHIFT: PUTTING PREVENTIVE HEALTHCARE INTO ACTION
Preventive healthcare focuses on identifying and addressing health risks before they develop into serious illnesses. It involves adopting healthy habits, regular screenings, and an active lifestyle, empowering individuals to take control of their well-being and make informed decisions.
Engagement in preventive healthcare allows individuals to actively participate in their well-being. It empowers them with knowledge and tools to make informed health decisions, transforming them from passive recipients of care to proactive healthcare advocates.
Preventive care also plays a crucial role in promoting health equity by addressing disparities in accessing care and work towards a more inclusive healthcare system. The benefit of preventive healthcare is that it is a powerful tool that enables us to take charge of our well-being and invest in our future, reduce the burden of disease, and enhance quality of life. Embracing preventive healthcare requires a proactive mindset and commitment. Remember, your health is your most valuable asset, and prevention is the key to unlocking its full potential.
PRECISION HEALTHCARE
Today's innovations are driving change. Technologies like mobile apps, genetic testing, and advanced screening produce biometric data on an unprecedented scale. Big data analytics and AI leverage this information to provide powerful insights,
helping physicians and patients target health goals and measure progress. Precision medicine, immunology, and 3D printing enable personalised interventions for diseases. Wearables become essential for self-monitoring, making it a norm. The goal of big data is to enhance disease prevention through better personal health risk management. To fully harness big data's potential, we need to build ecosystems that integrate technologies like AI and data analytics, though gaps still exist.
New treatments are using today’s technologies to drive solutions that are more personal and precise. Barriers to mainstreaming these technologies include ethical concerns, cost, access, and resources. The outdated 'one size fits all' approach is fading in healthcare. Advanced patient engagement platforms like patient portals enable tailored health plans. The future of healthcare is personalised, offering seamless experiences with wearables powered by big data, AI, and predictive analytics.
Analysis of cost-effectiveness of preventive care can guide policymakers to allocate scarce resources.
However, often the focus is only on costeffectiveness of childhood immunisation and with adults on the use of low-dose aspirin. This does not allow a lens across the various health prevention programmes to allow for a collective overview. Prevention can reduce the incidence of disease, but savings may be partially offset by healthcare costs associated with increased longevity.
Whether these additional competing risk costs outweigh the savings from avoiding targeted disease depends on how healthy people are during the added life years.
Few preventive services save money or reduce healthcare spending if the focus is solely on costs. It's important to differentiate between cost savings and the high value of preventive care, which also considers increased longevity and quality of life.
To improve quality of life of the elderly and reduce the cost of long-term care, needs new methods of preventive medicine, use of new technology, creation of new programmes and pathways and use of newer and sometimes expensive molecules. These costs cannot be kept at bay by preventive medicine alone. The Social Security System itself must be continually reformed.
The progress of medicine is remarkable. Drugs to prevent Alzheimer’s and photoimmunotherapy in cancer are pointers that hint at a future where almost all incurable diseases will disappear, with forecasts placing this around 2050.
Conquering disease is a wish shared across the world, but we cannot celebrate yet. Technological advancements fuel new preventive medical services.
The challenge of ensuring sustainability of public finances while accommodating lengthening life spans will need reform of social security systems.
A successful preventive care programme depends on consumer engagement and understanding of the rationale behind specific recommendations, as well as continued commitment to following them.
Extending the time of wellness visit lengths to 60–90 minutes annually. This removes the barriers cited by physicians as hampering their ability to counsel on lifetime modification. This contrasts with the medical visit lengths of 15.7 minutes in typical primary care physician (PCP) office.
Spending more time with patients and providing counselling on behaviours have been linked to higher patient trust. This trust improves patient-physician communication, satisfaction with healthcare, compliance with medical protocols, and continuity of care. Strengthening patient-physician relationship may be an important strategy to enhance patient engagement and motivation to adopt healthy lifestyle behaviours. Managing lifestyle health risks remains especially important to patients in midlife as they delay the onset of disease and disability and to facilitate the management of existing chronic conditions.
Medical service utilisation shows reduced ER use in early years and less urgent care in later years, reflecting better access to PCPs and reduced need for external care. Inpatient admissions and readmissions remain relatively low.
Healthcare expenditure trends indicated initially increased costs due to increased prescription drugs and screening, but over the years the expenditures level out, an indication of higher quality of care for dollar SPEND.
The results of many of the research programmes show that a model of personalised preventive care focused on wellness, prevention and augmenting the physician-patient relationship, can improve health management and reduce healthcare use and expenditure and promote higher quality care.
ARARE FORM OF healing has taken root in the radiotherapy unit at Johannesburg’s Netcare Olivedale Hospital, where therapy dogs are doing more than hospital rounds by transforming the essence of patient care and bringing joy to patients living with cancer.
Commenting on the programme, Netcare’s Cancer Care quality manager, Dr Julie Herold, says, “These unconventional therapists, with their wagging tails and gentle spirits, bring an unparalleled sense of comfort, joy and warmth to patients in ways that no conventional treatment can.”
Orlando, a beautiful Golden Retriever, and his charming colleague Honey, a Labrador, are therapy dogs on a mission to bring comfort. Prioritising patients' health and safety, the dogs are fully vaccinated, impeccably clean and groomed, and dressed in their ‘TOP Dogs’ uniforms. They visit the radiotherapy unit at Netcare Olivedale Hospital on the first Monday of every month between 11h00 and 12h00, offering tender loving care and a morale boost to patients undergoing radiation treatment for their cancer.
Dr Herold notes that the presence of therapy dogs in radiotherapy units, like the one at Netcare Olivedale Hospital, aligns with a growing trend in the healthcare industry. “Dr Cindy Aitton, the head of Netcare’s Cancer Care division, is a strong advocate of this initiative and has played a crucial role in its implementation across Netcare facilities. Our ultimate goal is to extend the benefits of animal therapy to all our radiotherapy units, enhancing patient care and wellbeing.
“Research indicates that on a physical level, therapy dogs can help lower blood pressure, increase beneficial hormones, and decrease stressful hormones. But the real benefit is on a psychological level, as therapy dogs can help with stress relief and ease feelings of loneliness and depression. The interaction with the dogs gives patients some sense of normality
and loads of selfless love and affection when coming for their radiotherapy treatment. Interacting with the dogs is also meaningful and impactful for our staff, who thoroughly enjoy their presence. The therapy dogs bring joy and touch the lives of our patients and our staff, brightening up their day at work. It is lovely to see everyone welcoming the dogs as they walk around the hospital greeting familiar faces,” says Dr Herold.
The comforting effects of animals have been noticed throughout the years, with Florence Nightingale recommending 'a small pet animal' as a good companion for the sick. A growing number of studies, including “The ‘pet effect’ in cancer patients: Risks and benefits of humanpet interaction” (Mei Mei Chan, Gonzalo Tapia Rico 2019) for The Royal Adelaide Hospital, support this anecdote with evidence that animals really can aid in the healing process, particularly for patients who are facing the challenges of a long therapeutic journey.
Radiation therapy unit manager at Netcare Olivedale, Nancy Tshishimbi, has seen the difference in patients since the TOP Dogs programme was introduced earlier this year: “Bringing therapy dogs into our radiation unit has transformed the experience, opening a whole new world for patients. You can see their eyes light up with joy when they see the four-legged therapists.”
“The dogs are extremely well behaved and gentle, and the difference in patient morale is clear; these dogs bring a sense of calm and happiness that traditional treatments alone cannot provide,” adds Nancy. Wendy Carter, TOP Dogs area coordinator for Johannesburg, says the therapy dogs all have exceptional temperaments and are assessed continuously. “These dogs must be calm, gentle, and responsive to the needs of individuals experiencing physical and emotional stress.
“TOP Dogs recruits their members
from the public who are willing to volunteer with their pets, together as a humandog team. Critical in the selection of the dogs is that they have an already existing confidence and calmness around other dogs, people and unusual surroundings. At TOP Dogs, we often say therapy dogs are 'born', not 'bred'. Our ethos is outlined in the Therapy Dog Bill of Rights to ensure that the wellness of our pets when performing the role of therapy dogs is always upmost in the handler’s mind. A gentle demeanour suitable for interacting with patients of all ages is most important. Handlers, too, undergo training to ensure they can effectively manage their dogs and support the patients they serve.
“Patients can choose whether to interact with the dogs at all. Depending on their needs, the dogs may place their paws on the patient’s arm or hand or rest a head on the patient’s lap. Some of the dogs will ‘speak’ on command,” says Wendy.
She explains that extremely rigorous hygiene protocols are observed to ensure that the health and wellbeing of patients are in no way compromised.
“Dogs are bathed and groomed 24 to 48 hours before hospital visits. They have their teeth cleaned, mouth fresheners applied, and even their nails filed. They are also sprayed with an anti-bacterial spray. As they enter the reception area of the radiotherapy unit via a separate entrance, their paws are sanitised to remove the dust they may have picked up on their paws when crossing the car park. After touching the dogs, the hands of the patients are also sprayed with an anti-bacterial cleanser as a further precaution.
“We have positively impacted the lives of hundreds of people in need, and our dearest wish is to continue improving the lives of young and old in all stages of health,” concludes Wendy.
To read more about TOP Dogs and the vital work they do go to https://www. therapytopdogs.co.za/
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