Medical Chronicle Dec Jan 2025

The doctor's newspaper

The ethics of antimicrobials in dying patients

N THE REALM of healthcare, few conversations are as critical yet nuanced as the decision-making process surrounding antimicrobial use in end-oflife care. These decisions are not solely clinical but are deeply entrenched in ethical considerations. As highlighted in the recent NICD ethics webinar, understanding how to best navigate this complex environment is essential for healthcare professionals dedicated to providing respectful and compassionate care.

“The use of antimicrobial in end of life presents a unique and complex ethical and clinical dilemma. While antimicrobials can provide symptom relief and improve quality of life in terminally ill patients, their use may also contribute to the rising global burden of antimicrobial resistance. This then raises pressing questions: How can we balance compassionate care with antimicrobial stewardship principles? Are antimicrobials at end of life a benefit or do they impose a

hidden cost on society by driving resistance?

And what studies can healthcare providers adopt to navigate this delicate balance?”

Caroline Maluleka (senior pathologist at NICD) said opening the NICD’s ethics webinar on the use of antimicrobial at end-of-life: impact on antimicrobial resistance.

To unpack these questions, Maluleka was joined by globally respected expert in clinical microbiology and infectious diseases, Professor Adriano Duse (previous chair and academic head of Clinical Microbiology and Infectious Diseases in the Wits Faculty of Health Sciences) and Dr Kuban Naidoo (senior paediatric intensivist at Chris Hani Baragwanath Academic Hospital).

ETHICAL DECISION-MAKING:

BALANCING PRINCIPLES OF CARE

When considering the use of antimicrobials in end-of-life scenarios, the panel stressed that physicians must address a critical balance between antimicrobial stewardship and the compassion embedded in end-of-life care.

Prof Duse and Dr Naidoo explained that the ethical principles of autonomy, beneficence,

non-maleficence, and justice present both a guide and a challenge.

Autonomy: Respecting patient autonomy entails honouring their wishes and those of their families, even when these wishes might diverge from the medical advice or the best practices surrounding antimicrobial stewardship. Engaging in meaningful conversations about treatment goals is crucial in ensuring patients’ desires are respected.

Beneficence and non-maleficence: These principles are about ensuring that any intervention, antimicrobial or otherwise, is likely to result in more good than harm. At the end of life, the harms of medication may not just be physiological but could prolong the dying process or reduce the quality of remaining life. Consequently, every decision requires a reflective assessment of the riskbenefit ratio.

Justice: The concept extends beyond individual patient care to consider societal implications, such as antimicrobial resistance. While primarily a public health concern, maintaining the balance between

appropriately treating an individual’s infection and contributing to a larger public health challenge forms a fundamental part of the decision-making process. The speakers emphasised nuanced, patient-centred care where these principles serve as a moral compass guiding clinical decisions.

CLINICAL APPLICATION: GUIDELINES AND RECOMMENDATIONS

In the clinical setting, Prof Duse and Dr Naidoo discussed how guidelines aim to streamline decision-making with a focus on patient comfort rather than cure. The guidelines underscore:

Establishing clear objectives: It is essential to differentiate between actions taken to alleviate symptoms versus those aimed at prolongation of life. When life expectancy is significantly limited, care goals often shift towards maximising comfort.

Involving interdisciplinary teams: Approaching patient care through a multidisciplinary lens ensures comprehensive evaluation and management.

The role of metformin in neuropathy

Adobestock, Credit: vetrana

By Nicky Belseck, medical journalist

Teams comprising doctors, nurses, pharmacists, and palliative care specialists can assess the appropriateness of antimicrobial choices considering various dimensions – medical, ethical, and logistic. Education and training: Continuous training and education in antimicrobial use at the end of life are vital. This equips healthcare providers with the necessary knowledge to make informed decisions that align with both patient's desires and best practice standards.

ILLUSTRATIVE

CLINICAL SCENARIOS: LEARNING FROM EXPERIENCE

Reflecting on clinical scenarios, Prof Duse and Dr Naidoo offered doctors valuable insights into effective care delivery at life’s end. Managing infections with sensitivity: For patients with terminal illnesses experiencing infection-related discomfort, antimicrobials can be crucial in symptom management. However, this use should never compromise the broader goal of ensuring comfort and preserving the dignity of the dying patient. Perspectives on pain management: Considering scenarios where patients suffer from pain due to infections, physicians must balance between antimicrobial administration for symptom relief and potential side effects, which may worsen the patient's condition. Family engagement and advanced directives: Scenarios where family members struggle to accept the imminent reality of death highlight the importance of direct and empathetic communication. Advanced directives serve as tools for reinforcing patient preferences, reducing familial distress, and guiding clinical interventions. Transitioning to hospice:

As patients approach the end of their lives, transitioning from aggressive interventions to hospice care often necessitates discussions emphasising quality over quantity of life. These transitions should be managed with sensitivity to patient and family emotions, aligning practices with established directives.

RECOMMENDATIONS FOR PRACTICE: ENHANCING PATIENTCENTRED CARE

Prof Duse and Dr Naidoo offered several action-oriented recommendations designed to reinforce effective, ethical practices: Reinforce advanced care planning: Encourage the use of advance care directives to pre-emptively establish the patient's wishes regarding antimicrobial use, ensuring care aligns with their values and desires. Facilitate open discussions: Engaging patients and their families in discussions about potential outcomes, the limitations of antimicrobial treatments, and the central goal of optimising quality of life at end stages should be routine practice. Apply antimicrobials judiciously: Focus on symptomatic relief rather than prolonging life unnecessarily. This judicious use requires critical consideration of antimicrobial resistance and its global implications. Embrace interdisciplinary protocols: Leverage the expertise within interdisciplinary teams to promote balanced and informed decisionmaking, allowing each team member to contribute uniquely to the care process.

Prioritise education and training: Ensure healthcare teams have access to up-to-date training programmes on antimicrobial use, particularly in palliative

care settings. Promote engagement with the latest research and best practices.

CHALLENGES TO OVERCOME:

RESOURCE AND DATA LIMITATIONS

The panel raised concerns that the lack of robust data on antimicrobial resistance in palliative care settings poses significant challenges. High antimicrobial usage rates without supportive microbiological evidence and inadequate de-escalation after broad-spectrum antibiotic use highlight ongoing issues in resource allocation and resistance management. Ethical discomfort concerning research in vulnerable populations and legislative gaps in advance care planning further complicate efforts to establish effective stewardship. In discussing these challenges, the webinar underscores the need for systemic improvements and resource investment to align antimicrobial practices with ethical and clinical standards.

A CALL TO ACTION

The NICD webinar underscores a vital call to action for healthcare professionals involved in end-of-life care. The complexity of making these decisions demands not only a sound understanding of ethical principles but also a commitment to patient-centred care that honours individual preferences while considering broader public health implications. By integrating these insights into everyday practice, healthcare providers can better navigate the intricate landscape of end-of-life care, ensuring that their noble mandate to relieve suffering and uphold dignity remains steadfast at the heart of their professional endeavours.

Navigating innovation and tradition in healthcare for 2025

AS WE STEP INTO 2025 and festively celebrate the end of 2024, the landscape of healthcare continues to evolve, bringing with it both challenges and opportunities for innovation. Our latest issue of Medical Chronicle is packed with insightful articles that look at critical topics impacting healthcare professionals and patients alike.

Our lead article examines end-of-life ethical decision-making in terms of using antimicrobials. We look at how healthcare providers can both care kindly for patients and wisely manage the use of antibiotics, especially towards the end of a patient's life. The article suggests having open talks with patients and their families, planning carefully for the future, and using antibiotics only when really needed to ensure a good quality of life. It highlights the importance of teamwork among different healthcare experts and ongoing education to guide professionals through the challenges of

end-of-life care and rising antibiotic resistance.

In our CPD-accredited articles, we present a comprehensive overview of allergic conjunctivitis, equipping you with the latest knowledge on its management. This comprehensive overview covers its causes, symptoms, and provides insights to improve patient care. In addition, we explore the role of metformin beyond diabetes management, highlighting its potential in addressing neuropathy.

The integration of indigenous knowledge into modern health practices is gaining momentum. Our article on ethnopharmacology highlights how traditional wisdom is being woven into drug discovery and healthcare delivery. In line with this, we explore the crucial role medical boards play in combatting misinformation, especially when it comes from within the profession. As we acknowledge World AIDS Day 2024, there is a special focus on this topic. We address the ongoing challenge of HIV/AIDS in South Africa, focusing on the stigma surrounding the disease and the critical role of adherence to antiretroviral therapy in improving patient health outcomes.

Thank you for your dedication to advancing healthcare. We look forward to continuing this journey with you. Have a safe and happy festive season.

Happy reading!

Misinformation about biosimilars threatens health policy in the US

The US biosimilar programme, exemplified by its successful track record with 53 biosimilars approved by the FDA, is now encountering new policy challenges that could alter its current trajectory.

By Nicky Belseck, medical journalist

THESE BIOSIMILARS ARE approved as safe and effective alternatives to higher-priced branded biological products, and in the US, all can be prescribed in place of their reference products. However, for automatic substitution at the pharmacy level, a biosimilar must receive an "interchangeable" designation, signifying additional safety data supporting its efficacy after multiple switches between products. Thirteen biosimilars currently hold this designation.

In October, the FDA approved the 50th biosimilar, reflecting the increased availability of biosimilar products, which treat a wide range of chronic and severe illnesses, and which have already had an important impact on patient access. Biosimilars are now approved for 15 different reference biologics, and treat illnesses like rheumatoid arthritis, inflammatory bowel disease, some cancers, psoriasis, diabetes, macular degeneration, and osteoporosis among others.

POLICY SHIFTS AND IMPACT ON STANDARDS

The debate intensifies as policymakers and legislators consider altering the data requirements that uphold the interchangeable designation. A recent metaanalysis frequently cited by policymakers suggests these standards could be lowered. The study's conclusions, however, are under scrutiny. Critics argue that the findings, largely based on single-switch studies, not adequately represent the safety and efficacy outcomes if multiple product switches occur, challenging the push for less stringent data requirements.

RISKS OF COMPROMISING STANDARDS

Lowering the standards for interchangeability could undermine patient care quality and trust. The unintended consequence risks destabilising patient treatment regimens, especially for those managing complex chronic conditions like arthritis and cancer that require heavily

personalised approaches. Physicians remain wary of non-medical switches, those initiated for reasons unrelated to achieving the best health outcomes.

PHYSICIAN CONCERNS AND LEGISLATIVE PROPOSALS

Surveys indicate that while a majority of US physicians trust the safety and efficacy of biosimilars, many oppose non-medical switches without their consent. Proposed legislative changes such as the "Biosimilar Red Tape Elimination Act" threaten to eliminate the distinction between biosimilars and interchangeable biosimilars, potentially allowing all biosimilars to be automatically substituted, irrespective of additional safety data.

FUTURE IMPLICATIONS

Policymakers argue that streamlining biosimilar approval processes will encourage market competition and reduce costs. However, critics caution against hasty policy changes, noting that trust in biosimilars is

built upon rigorous evidence standards. The FDA's discretion in setting these standards, including the potential need for switching studies, remains vital for maintaining physician confidence and ensuring patient safety.

The future of biosimilar regulation in the US hinges on balancing policy changes with protecting the integrity of patient care and upholding the delicate relationship between patients and healthcare providers. Legislative and regulatory bodies face a critical decision in how they manage these nuanced and consequential standards.

Closer to home, the South African Health Products Regulatory Authority (SAHPRA) is reviewing its guideline on substitution of biological medicines.

Sources: Reilly MS, McKibbin RD. Misinformation about interchangeable biosimilars undermines US health policy, physician confidence, and patient health. Generics and Biosimilars Initiative Journal (GaBI Journal). 2024;13(2):55-60. DOI: 10.5639/ gabij.2024.1302.009. South African Health Products Regulatory Authority.

Regulatory gaps necessitate medical scheme contribution increases, says HFA

The Health Funders Association (HFA) has highlighted a critical regulatory gap undermining the foundational principles of medical schemes, which are designed to maintain affordable healthcare coverage through risk pooling and cross-subsidisation.

THESE ISSUES HAVE contributed to the necessity for double-digit increases in medical aid contributions for 2025.

Barry Childs, a respected healthcare actuary from Insight Actuaries and Consultants, and Thoneshan Naidoo, CEO of the HFA, explained the factors behind these increases, which affect approximately nine million South Africans who self-fund their healthcare through medical schemes. Naidoo points out that medical schemes, being not-for-profit entities, are facing challenges due to outdated regulations initially meant to support the Medical Schemes Act of 1998. These regulatory gaps mean that many South Africans are finding it increasingly difficult to afford their medical scheme contributions. Moreover, Childs notes that the original

reforms intended to accompany the Medical Schemes Act were never implemented, shifting focus to the National Health Insurance (NHI) and overshadowing necessary reforms that could have curtailed costs and expanded access to private healthcare. Key principles, such as open enrolment and community rating, were designed to ensure equitable access to essential health benefits for all members without risk-based pricing. However, over 22 years, medical scheme contributions have risen by 8.2% annually, outpacing the Consumer Price Index (CPI) increase of 5.5%. Christoff Raath, also from Insight Actuaries, attributes recent contribution spikes to surplus shedding during the Covid-19 era when schemes reduced contributions or enhanced benefits to manage surpluses. Post-pandemic, many

members returned to healthcare facilities in worse health, increasing treatment costs.

Additionally, the regulatory framework has been insufficient in controlling healthcare utilisation within an ageing membership, further driving up costs and discouraging new entrants. Measures like late joiner penalties and underwriting have been applied but remain inadequate to address the issue of anti-selection, where individuals join schemes only when needing extensive care.

Childs notes that a proposed risk equalisation fund could have helped balance the financial burden by offsetting costs for higher-risk members, potentially preventing significant contribution increases.

The current trajectory, marked by regulatory neglect since 2000, reflects a need for comprehensive reforms. Despite

issues with regulatory frameworks and the lack of updates to Prescribed Minimum Benefits (PMBs), the value of private medical schemes remains vital, contributing significantly to reducing the strain on the public health sector.

Naidoo asserts that social security is integral to health funding, with medical scheme members indirectly supporting public health services. Implementing recommendations from the Health Market Inquiry to address cost inefficiencies could attract younger, healthier members, balancing costs and enhancing affordability.

The HFA continues to advocate for urgent reforms to bridge these regulatory gaps, enhance healthcare affordability, and reinforce the principles of social solidarity, aiming for a positive impact on healthcare for all South Africans.

Unlocking nature's secrets: global congress celebrates indigenous knowledge in medicine

UP congress pushes boundaries in ethnopharmacology and indigenous wisdom.

THE UNIVERSITY OF PRETORIA

(UP) recently hosted the ISE-APSS 2024 congress at the Cape Town International Convention Centre, focusing on natural product research and integrating indigenous knowledge systems into healthcare. The event drew about 300 delegates from 22 countries, underscoring the critical role of ethnopharmacology in drug discovery.

Congress chairperson and President of the International Society for Ethnopharmacology, Professor Namrita Lall, highlighted the historical role of traditional medicines, noting, “Medicinal plants have been crucial in healthcare for centuries, providing a rich source of therapeutic natural phytochemicals.” She emphasised SA's biodiversity, pointing out that the Cape Floristic Region houses over 9 000 plant species, offering significant potential for modern drug development.

Under the theme 'The Footprint of Ethnopharmacology in Drug Discovery’, discussions revolved around the current and prospective paths of traditional medicine research. Professor Sunil Maharaj, UP’s Vice-Principal for Research, Innovation, and Postgraduate Education, emphasised the need for natural medical alternatives, stating, “There is a pressing need for natural alternatives... exploration of this avenue opens opportunities to address the challenges posed by conventional

therapies.” He urged delegates to collaborate and innovate in this growing field. A major focus was the integration of indigenous knowledge into national healthcare frameworks. Unlike the traditional Chinese and Ayurvedic systems, which are embedded in their national health systems, African traditional medicines often lack systematic integration. The congress showcased the Department of Science and Innovation’s transdisciplinary model that includes recognising 'wisdom keepers' as equal research partners to promote inclusive innovation.

Key speakers included Professor Vinesh Maharaj, who discussed developing a natural product library targeting health issues like drug-resistant infections and cancer. Professor Dave Berger shared research on the Greyia species for cosmetic uses, illustrating the diverse applications of South African flora. The congress also featured exhibitions from companies engaged in natural product research, underlining the spirit of collaboration. It concluded with cultural performances, celebrating the synergy between traditional practices and scientific advancement.

The ISE-APSS 2024 congress underscored natural products' vital role in healthcare, encouraging partnerships among researchers and advocating for integrating indigenous knowledge into modern medical practices.

By Nicky Belseck,

medical journalist

Congress host and chairperson, Prof Namrita Lall addresses attendees during the gala dinner.

The ISE-APSS 2024 delegation.

Mental health crisis: majority of doctors feel pressured to work while unwell

Silent suffering as 72% of SA doctors work despite mental health struggles, survey reveals.

IN A REVEALING new survey released by the Medical Protection Society (MPS), alarming statistics shed light on a pressing issue among healthcare practitioners in SA. The survey of 802 doctors indicated that a staggering 72% have continued to work despite not feeling mentally well enough to do so. This phenomenon, often driven by increasing patient demand and a workplace culture that discourages taking time off for mental wellbeing, poses significant risks to both doctors and their patients.

In exploring the root causes, the survey revealed almost half (49%) of doctors continued working while mentally unwell because their patients relied on them. Another 45% felt pressured due to the burgeoning patient workload, while 40% reported that taking time off for mental wellbeing was simply unacceptable in their

work environment.

The implications of doctors not addressing their mental wellbeing are far-reaching. Most respondents (61%) admitted that working while mentally unwell had diminished their empathy towards patients. Additionally, 58% reported a loss of concentration, 46% became more fearful of making mistakes, and 38% engaged in defensive medicine. Alarmingly, 55% suspected that their compromised mental state might have resulted in a lower standard of patient care, and 26% feared it may have led to a missed or incorrect diagnosis. MPS, which represents over 300 000 healthcare professionals globally, including more than 30 000 in SA, is calling for urgent measures to mitigate the culture of presenteeism. Dr Volker Hitzeroth, Medicolegal Consultant at MPS, emphasised the critical nature of this issue:

“It is concerning that so many doctors say they continue to work even though they are not mentally well enough to do so. When mental wellbeing is poor, a practitioner should feel able and supported to take time off to recuperate or seek appropriate support." “Working despite not being mentally well enough to do so can also impact on patient care and our survey shows the variety of ways this can manifest – from lack of empathy with patients, right through to a missed or incorrect diagnosis,” Dr Hitzeroth said. The survey also highlighted the systemic factors contributing to this culture. Nearly half of the respondents pointed to the relentless workload and the desire not to let colleagues down as major pressures. In the private sector, financial constraints also play a role, with many physicians feeling unable to afford time off.

“One member who engaged with

By Nicky Belseck, medical journalist

our survey anonymously even said they attempted suicide, but had to go in to treat patients the next day as there were no other doctors,” said Dr Hitzeroth.

Comprehensive strategies are needed to combat presenteeism. “Much more needs to be done to enable and support all healthcare practitioners to take time off when they are too unwell to work. This includes considering a range of measures to increase capacity, to allow doctors to take time off when they need to. The majority, 89% of survey participants, believed that such measures would be helpful in reducing presenteeism.”

Dr Hitzeroth said.

The survey findings serve as a critical call to action for the healthcare sector to address the mental wellbeing of practitioners, ensuring that both the doctors and their patients receive the highest standard of care.

Medical boards fall short in disciplining physicians over misinformation

Recent studies reveal that medical boards across the United States are infrequently taking disciplinary action against physicians who disseminate medical misinformation, even as such conduct has become a significant concern during the Covid-19 pandemic. This finding raises important questions about the effectiveness and readiness of the current regulatory frameworks to address this issue.

RARE DISCIPLINARY ACTIONS

A comprehensive analysis of medical board proceedings in California, Florida, New York, Pennsylvania, and Texas highlighted a surprising trend: misinformation was rarely cited as a reason for disciplinary action. Out of 3 128 cases reviewed, only six involved sanctions for spreading misinformation to the wider community. This represents a mere 0.1% of all disciplinary cases. Similarly low figures were found for patient-targeted misinformation and inappropriate advertising.

NEGLIGENCE AND OTHERS TOP THE LIST

In stark contrast, nearly 29% of disciplinary actions were due to physician negligence, making it the most common cause. Other prevalent reasons included problematic record-keeping and inappropriate prescribing practices. The infrequency of discipline for misinformation conduct remains despite increased discussion about its risks and repeated warnings from medical boards.

CHALLENGES IN ENFORCEMENT

Several hurdles complicate the medical boards' ability to act against misinformation:

• Ambiguity in definitions: Without a clear regulatory definition, differentiating between accepted medical advice and misinformation becomes challenging.

• Constitutional rights: Physicians' free speech rights further complicate disciplinary boundaries, limiting actions

that boards can take against misinformation.

• Resource limitations: Many boards face chronic underfunding, influencing their ability to prioritise complex misinformation cases over more straightforward misconduct.

POLICY CONCERNS AND IMPLICATIONS

The study suggests a significant gap between regulatory intentions and outcomes, questioning whether existing professional licensure systems are adequately equipped to handle the widespread and damaging effects of medical misinformation, particularly in the digital age.

There’s a growing call for medical boards to re-evaluate their frameworks and consider more robust and effective strategies. This could involve revising definitions, increasing resources, and developing clearer guidelines for information dissemination. Overall, balancing free speech with public safety remains a delicate challenge. As the health sector continues to battle misinformation, particularly concerning public health crises like Covid-19, effective regulation and clear communication channels between the boards and practitioners will be crucial to safeguard public trust and healthcare integrity.

Fundal height serves as a valuable indicator of fetal growth and position during pregnancy.

A Fundal height: A clinical perspective

T APPROXIMATELY 28 weeks of gestation, the fundal height typically measures around 28cm.

The primary objective of fundal height measurement is to assess fetal growth and detect potential abnormalities.

This article provides a detailed overview of fundal height measurements and their significance in monitoring pregnancy. Fundal height measurement is a straightforward, cost-effective method for evaluating fetal growth and identifying growth irregularities.

Measurements generally begin after 24 weeks of gestation. This technique is especially valuable in settings with limited access to advanced diagnostic equipment. However, fundal height measurements are most informative when interpreted alongside findings from an ultrasound.

ALTRON’S HealthONE COMPREHENSIVE PREGNANCY TRACKING ENABLES:

Previous pregnancy:

• Ability to record previous pregnancies, including success/failure, birth type, gestation, birth details, and additional notes

• Supports multiple births (twins, triplets, etc.).

Current pregnancy:

• Ability to record current pregnancies, including expected number of babies, gender, estimated delivery date

comprehensive assessment.

LOW FUNDAL HEIGHT:

• May indicate a smaller-than-expected fetus, which could be normal for the individual or suggest intrauterine growth restriction (IUGR).

• Can also be associated with oligohydramnios (low amniotic fluid levels),

which may lead to complications if untreated.

HIGH FUNDAL HEIGHT:

• Can signify accelerated fetal growth or conditions such as polyhydramnios (excess amniotic fluid).

• Multiple gestations, such as twins, may also result in a higher-than-expected

fundal height.

LAGGING FUNDAL HEIGHT:

• May suggest naturally slower fetal growth or a pathological restriction. Further evaluation with ultrasound is often warranted.

References available on request.

The gender gap in brain health: men see decline 10 years earlier

Discover why men at high cardiovascular risk face brain health decline a decade earlier than women, highlighting the crucial need for early intervention in combating neurodegeneration.

MEN AT HIGH risk of cardiovascular disease experience a decline in brain health approximately ten years earlier than women, according to a long-term study published in the Journal of Neurology

Neurosurgery & Psychiatry. The study found that men with cardiovascular risk factors, such as obesity, show signs of cognitive decline starting in their mid-50s, while women are most affected from their

mid-60s. The research involved 34 425 participants from the UK Biobank, who underwent both abdominal and brain scans, with an average age of 63.

The study assessed cardiovascular

disease risk using the Framingham Risk Score, which considers factors like age, blood fats, blood pressure, smoking, and diabetes. Neuroimaging techniques, specifically Voxel-based morphometry (VBM), were employed to analyse changes in brain structure and volume, revealing that higher levels of abdominal fat and visceral adipose tissue correlate with reduced brain grey matter volume in both sexes. Notably, the impact of cardiovascular risk and obesity on brain health was more pronounced in men, with the most significant effects observed between ages 55 and 74, while women showed vulnerability from ages 65 to 74.

The research identified the temporal lobes as the most affected brain regions, which are crucial for auditory, visual, emotional processing, and memory –areas that deteriorate early in dementia development. The findings underscore the association between cardiovascular risk factors and an increased likelihood of dementia, emphasising the need for early intervention. The researchers advocate for targeting modifiable cardiovascular risk factors, such as obesity, particularly before age 55, to mitigate neurodegeneration and potentially prevent Alzheimer’s disease.

Thefindings

underscore the association between cardiovascular risk factors and an increased likelihood ofdementia, emphasisingtheneed forearlyintervention

While the study provides valuable insights, it is observational, and the researchers caution against drawing definitive conclusions about causality. Limitations include the lack of specific Alzheimer’s biomarkers in the UK Biobank and the challenge of distinguishing between normal aging and neurodegenerative conditions. Biological mechanisms behind the observed neuronal damage may involve inflammation, insulin resistance, and the breakdown of the blood-brain barrier.

The study highlights the critical importance of addressing cardiovascular risk and obesity earlier in men than in women to potentially prevent cognitive decline and neurodegenerative diseases. The researchers suggest that repurposing existing treatments for obesity and type 2 diabetes could be beneficial in combating Alzheimer’s disease.

Welch

Date: 11 February 2025

Time: 7.30pm

Topic: Rekindling local anaesthetics

Speaker: Dr Ernest Welch

CLICK TO REGISTER https://bit.ly/FreseniusKabiWebinar11Feb25

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,

ChronicleMED

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.

Dr Ernest

(MBBCh, DA, FCA)

Enhancing quality of life through wellness: GoodX wellness online short Courses

In an increasingly fast-paced world and the high demands of providing healthcare, achieving, and maintaining wellness is more vital than ever.

ELLNESS ISN’T MERELY the absence of illness but the active pursuit of physical, mental, and emotional health. It involves a balanced approach to exercise, diet, sleep, stress management, and nurturing positive relationships. True wellness promotes self-awareness, personal growth, and adaptability, enhancing the quality of life.

Recognising the growing need for practical, accessible resources to support individual and organisational well-being, we are excited to introduce the new GoodX Wellness Online Short Courses. These courses offer personalised strategies to enhance well-being, fostering independence in private and professional environments.

WHY WELLNESS MATTERS

A proactive approach to wellness benefits individuals and healthcare practices. Employees with a strong foundation in wellness are healthier, happier, and more engaged, directly affecting the practice’s success. On an individual level, wellness reduces stress, boosts energy, and supports better decision-making. For healthcare practices, the ripple effect is apparent: improved productivity, higher retention rates, reduced absenteeism, and, in the long run, better care of patients.

THE BENEFITS OF THE

WELLNESS COURSES

Our Wellness Online Short Courses are specifically designed to address the diverse needs of today’s individuals and workplaces. With content rooted in the latest research and delivered by industry experts, these courses provide tools and insights that drive meaningful change.

HERE’S HOW YOUR HEALTHCARE

PRACTICE CAN BENEFIT:

1. Boost employee morale

Happy employees are motivated employees. Our courses empower participants with tools to manage stress, build resilience, and practice mindfulness. By prioritising emotional and mental well-being, healthcare practices can foster a positive workplace culture where employees feel valued and supported.

2. Increase productivity

Healthier employees mean sharper focus, better problem-solving, and greater efficiency. From stress management techniques to strategies for optimising energy levels, our courses equip participants with skills that directly translate to improved performance in their roles.

3. Reduce absenteeism

Workplace wellness initiatives have been shown to lower the incidence of illness-

related absences. Promoting healthier lifestyles and teaching preventive care strategies, our courses help employees maintain their health and well-being, leading to fewer sick days.

WHO CAN BENEFIT FROM THESE COURSES?

Our Wellness Online Short Courses are designed to meet the needs of:

1. Individuals committed to self-care For those looking to take charge of their health and well-being, our courses provide a roadmap for personal growth. Participants will learn to create sustainable habits supporting physical, mental, and emotional health.

2. Workplace teams

Healthcare practices can integrate these courses into employee development programmes to foster a culture of wellness, helping employees thrive in demanding work environments.

AVAILABLE COURSES

The following courses are available:

1. Sensory wellness 2024.

2. Unlock your leadership potential through self-integrity 2024.

3. Building trust and credibility in organisations 2024.

4. Restore balance and recover from burnout and compassion fatigue 2024.

THE PATH TO A HEALTHIER FUTURE

Wellness is an investment that pays dividends in every aspect of life. By incorporating wellness education into daily routines, individuals can experience improved relationships, heightened productivity, and greater fulfilment. Healthcare practices prioritising wellness create environments where employees and businesses can thrive. Our Wellness Online Short Courses are not just about learning – they’re about transforming. They offer a sustainable approach to maintaining balance and achieving long-term well-being.

JOIN THE WELLNESS MOVEMENT

Whether you’re an individual seeking self-improvement, a business looking to invest in its workforce, or a caregiver striving to support others, these courses provide the tools you need to succeed. Empower yourself or your team to embrace wellness for a healthier, happier future. Start your journey to well-being today. Visit our website courses.goodx.co.za, and download the prospectuses to learn more about these courses and how they can make a difference in your life and healthcare practice.

The role of metformin in neuropathy

Diabetic peripheral neuropathy (DPN) is a critical and widespread complication of diabetes, affecting approximately 30% to 50% of diabetic individuals.

DPN OFTEN OCCURS silently and asymptomatically, posing significant challenges in early detection and intervention. This complication underscores the importance of proactive and comprehensive management strategies, especially in patients undergoing long-term diabetes treatment. A prevalent choice in managing type 2 diabetes, metformin, while effective in controlling blood glucose levels, has been associated with an increased risk of vitamin B12 deficiency. This deficiency can lead to significant and potentially irreversible nerve damage, thereby heightening the risk of developing DPN. As a result, the relationship between metformin dosage and reduced serum vitamin B12 levels is a critical area of concern, necessitating regular and vigilant monitoring of vitamin B12 status in patients on metformin therapy.

One of the primary management strategies for addressing metformininduced DPN is the timely and effective supplementation of cobalamin, or vitamin B12. This strategy has been shown

to significantly reduce the risk of neuropathy associated with long-term metformin use. Recent studies, including those from Yang et al. (2023), have demonstrated that prolonged metformin therapy not only increases the risk of hospitalizsation due to DPN but does so particularly at higher dosages, especially those that exceed 2g/day. Younger and healthier patient populations are notably more affected, highlighting a demographic trend that challenges the assumption that younger patients are generally at lower risk for complications. Metformin's mechanism of action in relation to vitamin B12 deficiency involves its interference with the calcium-dependent processes critical for vitamin B12 absorption in the gut. This interference results in heightened levels of detrimental metabolic compounds such as methylmalonyl-CoA and homocysteine. Both compounds are implicated in exacerbating vascular and neurological damage, offering a biochemical explanation for the increased risk of DPN.

Notably, the risk is pronounced in individuals maintaining well-controlled blood glucose levels from treatment onset, suggesting that baseline control does not necessarily mitigate neuropathy risk in those patients.

Research further indicates that patients who receive vitamin B12 supplementation do not experience an increased risk of DPN, which suggests a protective effect when vitamin B12 is adequately managed. Such findings advocate for individualised patient management plans that integrate vitamin B12 supplementation as a core component of diabetes care, particularly for individuals considered at low risk for DPN. The personalisation of treatment plans, emphasising early intervention with vitamin B12, could significantly enhance patient outcomes and reduce the incidence of neuropathy. In addressing the broader implications, it is evident that while metformin remains a cornerstone in diabetes management due to its efficacy in regulating blood glucose levels and improving insulin sensitivity, its potential long-term effects

on neurological health warrant careful consideration. There is a clear need for healthcare providers to engage in proactive vitamin B12 monitoring, ensuring that patients are not only maintaining optimal glucose levels but also safeguarding their neurological health against the insidious effects of nutrient deficiencies.

In conclusion, the intersection of metformin therapy and DPN risk presents a nuanced challenge for healthcare providers. The evidence supports a multifaceted approach to diabetes management that balances effective blood glucose control with vigilant monitoring of potential side effects such as vitamin B12 deficiency.

References available on request.

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Allergic conjunctivitis

Overview, types & management

Allergic conjunctivitis is an inflammation of the conjunctiva, a clear membrane covering the inner eyelids and the sclera, resulting from exposure to allergens.1

COMMON ENVIRONMENTAL TRIGGERS include pollen, mold spores, dust, and animal dander, particularly prevalent during hay fever season.1 Allergic conjunctivitis affects 20%-40% of the population, with its prevalence increasing due to urbanisation, industrialisation, and climate change.2 The economic burden of allergic conjunctivitis includes both direct costs, such as medications and medical consultations, and indirect costs, including missed workdays.3

TYPES OF ALLERGIC CONJUNCTIVITIS

The condition is categorised into acute (seasonal or perennial) and chronic forms.2 Acute cases are triggered by specific allergens like pollen and tend to resolve quickly,2 while chronic forms such as vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC) may lead to severe complications.2

1. Acute allergic conjunctivitis: Occurs seasonally, typically during allergy season. Symptoms include sudden eyelid swelling, intense itching, burning, and a watery nose.1

2. Chronic allergic conjunctivitis: A more persistent condition that can occur yearround. It is typically caused by ongoing exposure to allergens such as dust or animal dander. Symptoms include itching, burning, and sensitivity to light, with varying intensity.1

PATHOPHYSIOLOGY AND RISK FACTORS

The immune system perceives allergens as threats, triggering the release of histamine and other inflammatory mediators. Those with a history of allergies are at a higher risk for developing allergic conjunctivitis. Seasonal allergies, especially, increase susceptibility.1

CLINICAL PRESENTATION

Key symptoms include:1

• Red, itchy, and watery eyes

• Burning sensation

• Grittiness

• Sensitivity to light

• Swollen or puffy eyelids, especially noticeable in the morning.

DIAGNOSIS1

Diagnosis primarily relies on clinical history and examination. Key diagnostic signs include redness of the sclera and small papillae on the conjunctiva. Diagnostic tests include:

• Allergy skin tests to identify specific triggers

• Blood tests to detect antibodies

• Conjunctival scrapings to evaluate eosinophil levels, common in

allergic reactions.

PREVENTION1

Prevention strategies focus on reducing exposure to allergens. Key steps include:

• Using scent-free soaps and detergents

• Installing air purifiers

• Regular vacuuming and dusting

• Reducing household dust by minimising carpets and soft toys.

THE ALLERGIC CASCADE

The allergic cascade in the eye is a series of events that occur when an allergen, such as pollen, animal dander, or dust, comes into contact with the eye. Here’s a step-by-step explanation of the process:

1. Allergen entry: An allergen enters the eye and binds to specific receptors on mast cells, which are immune cells located in the conjunctiva (the membrane covering the white part of the eye and the inside of the eyelids).4

2. Mast cell activation: The binding of the allergen to the H1 and H2 receptors on mast cells triggers these cells to become activated.4

3. Release of mediators: Activated mast cells release several chemical mediators, including histamine.4 Histamine is a key player in the allergic response and is responsible for many of the symptoms associated with allergic conjunctivitis.

4. Histamine effects:

- Nerve stimulation: Histamine stimulates nerve endings in the eye, leading to itching.4

- Vasodilation: Histamine causes the blood vessels in the eye to dilate (widen), resulting in redness.4

Vascular permeability: Histamine increases the permeability of blood vessels, allowing fluid to leak into surrounding tissues, which leads to swelling.4

5. Symptoms: The combined effects of nerve stimulation, vasodilation, and increased vascular permeability result in the common symptoms of allergic conjunctivitis, which include itching, redness, swelling, tearing, mucous discharge, eyelid swelling, and a sensation of a foreign body in the eye.4

MANAGEMENT

Management includes both nonpharmacological and pharmacological approaches:

• Home care: Patients are advised to avoid rubbing their eyes, use artificial tears, apply cool compresses, and practice good hand hygiene. For those triggered by pollen, wearing hats and sunglasses outdoors, and showering after outdoor activities can help.1

• Pharmacological treatment:

- OTC antihistamine eye drops help reduce histamine H1, H2 and mast stabiliser release.

- Prescription drops containing ophthalmic H1 and H2 antagonists, as well as mast cell stabilisers offer effective relief.1

- Anti-inflammatory eye drops reduce inflammation, while vasoconstrictor eye drops help constrict congested vessels.1

- For severe cases, steroid eye drops are prescribed under medical supervision.1

- Epinastine hydrochloride prevents histamine binding to both the H1- and H2-receptors, and stabilises mast cells, providing fast relief from itching, lasting up to 12 hours.4

EPINASTINE HYDROCHLORIDE

Epinastine is a second-generation antihistamine and mast cell stabiliser, with additional anti-leukotriene, anti-PAF, and anti-bradykinin effects, enhancing its antiallergic properties. Antihistamines and mast cell stabilisers have long been used to treat allergic conditions.5 FDA-approved uses for epinastine include allergic conjunctivitis, which encompasses:

• Perennial allergic conjunctivitis (PAC)

• Seasonal allergic conjunctivitis (SAC)

• Vernal keratoconjunctivitis (VKC)

• Atopic keratoconjunctivitis (AKC).5

Epinastine is also used globally for chronic urticaria, psoriasis vulgaris, allergic rhinitis, and atopic dermatitis.5 Its chemical structure is based on benzazepine (6,11-dihydro-5H-dibenzo[b,e]azepine) and has a melting point of 205-208°C.5

MECHANISM OF ACTION5

Epinastine reduces inflammation through:

1. Mast cell stabilisation – preventing IgE-mediated allergic reactions by stopping mast cell degranulation.

2. Antihistamine action – blocking histamine H1 and H2 receptors, inhibiting the vascular and cellular inflammatory cascade.

3. Inhibition of pro-inflammatory mediators – halting further inflammatory responses.

ADMINISTRATION5

Epinastine is available in eye drops, oral tablets, and syrup:

• Eye drops: Used for allergic conjunctivitis with onset within three minutes and effects lasting eight plus hours. Patients use one drop per eye, twice daily.

• Oral tablets: Prescribed for allergic conditions, typically 10-20mg once daily.

• Syrup: Available for pediatric use, with dosing adjusted for age and weight.

ADVERSE EFFECTS5

Topical epinastine is well-tolerated but may cause mild eye irritation (eg burning, redness, increased tear production).

It doesn’t cross the blood-brain barrier, avoiding CNS side effects and cardiotoxicity. It has shown no teratogenic effects in animal studies, though human data is limited, so caution is advised during pregnancy.

CONTRAINDICATIONS AND SPECIAL CASES5

• Contraindicated: In patients allergic to epinastine

• Pregnancy: Classified as Category C; should be used with caution

• Breastfeeding: Minimal transfer into breast milk; consult required

• Pediatrics: Not established in children under two years

• Geriatrics: No dose adjustment needed, but liver and kidney function should be monitored.

PHARMACOKINETICS

Epinastine has a steady-state plasma concentration of 5.96-6.04ng/mL and does not cross the blood-brain barrier due to its polarity and charge, avoiding sedation and CNS effects. When applied as eye drops, it begins working in about 180 seconds, lasting around eight hours.5

MONITORING AND SAFETY

Regular monitoring of patients, particularly for symptom relief and adverse effects, is essential. Patient compliance and appropriate dose adjustments should be ensured. Overdose cases are not reported, but emergency response should ensure airway and circulatory stability.5

HEALTHCARE TEAM COORDINATION

Epinastine, due to its dual action as a mast cell stabiliser and antihistamine, is an important option for treating allergic conditions without CNS toxicity. Its safe administration requires coordination between clinicians, nurses, pharmacists, and other healthcare professionals to enhance patient outcomes.5

CONCLUSION

Allergic conjunctivitis is a widespread condition, impacting a significant portion of the global population. While the condition is manageable through avoidance strategies and pharmacological treatments, more severe cases may require specialist intervention. Emerging therapies promise to further improve patient outcomes, offering relief from the debilitating effects of this allergic condition.2

References available on request.

Protecting children from AR

Allergic rhinitis (AR) affects 20%-30% of the South African population and comorbid asthma impacts 20% of these individuals, increasing the risk of complications.

DR SIMANGELE NKOSI, a GP and trustee of the CompCare Medical Scheme, highlights that children are disproportionately affected by seasonal allergies, making this a critical issue for healthcare professionals advising families.

“Allergic rhinitis symptoms such as nasal congestion, sneezing, an itchy nose, and watery eyes can significantly disrupt daily activities, sleep, and school performance,” explains Dr Nkosi. “Untreated, it can lead to complications such as sinusitis, bronchitis, and otitis media. Children with comorbid conditions like eczema, asthma, or food allergies are particularly vulnerable to allergic rhinitis, which may worsen during warmer months due to pollen exposure.”

Emerging research suggests climate change is contributing to prolonged and intensified pollen seasons globally, including in SA, which boasts high biodiversity. This needs proactive management strategies to mitigate pollen exposure.

PRACTICAL RECOMMENDATIONS FOR POLLEN ALLERGY MANAGEMENT

While medications remain a cornerstone of allergic rhinitis management, Dr Nkosi emphasises the importance of lifestyle adjustments to reduce exposure to seasonal allergens:

• Maintain good hygiene Encourage frequent handwashing to prevent touching the face and exacerbating symptoms. For children, distractions like puzzles and fidget toys can help reduce eye-rubbing.

• Limit pollen exposure indoors

- Keep windows and doors closed in homes and vehicles

- Replace vacuum and air conditioner filters regularly and consider using air purifiers.

• Outdoor precautions

- Recommend that families wear hats and sunglasses outdoors to minimise pollen contact'

- Suggest having designated 'outdoor play clothes' to be changed upon returning indoors, especially during high pollen counts.

• Reduce triggers

- Recommend dust-mite-proof covers for bedding'

- Encourage keeping pets off furniture and out of bedrooms.

• Promote nasal irrigation

- For older children and adults, saline nasal irrigation is a safe and effective way to alleviate nasal congestion.

NUTRITIONAL SUPPORT FOR ALLERGY MANAGEMENT

A nutrient-rich diet can complement medical and practical interventions:

• Vitamin C: Found in citrus fruits, bell

peppers, and broccoli, it supports immunity and may have antihistamine effects

• Bromelain: Present in pineapple, it is being studied for its potential benefits in thinning mucus

• Turmeric: Known for anti-inflammatory properties, it may assist in reducing

symptoms

• Omega-3 fatty acids: Found in fatty fish, such as salmon, these may help regulate inflammation.

PROFESSIONAL MONITORING AND INTERVENTION

Dr Nkosi underscores the importance

of closely monitoring children with AR. Persistent or worsening symptoms should prompt referral for medical treatment to prevent progression to more severe illnesses. Healthcare professionals play a vital role in guiding families to adopt these preventive strategies and ensure early intervention when necessary.

Sex differences in pain reduction offer new insights

Meditation for pain relief may engage different biological systems in males and females, according to recent research, emphasising the need for sex-specific approaches to pain management.

HILE MEDITATION CAN alleviate pain for both sexes, this study reveals that the mechanisms underlying its effects differ. Females are more prone

to chronic pain than males and often experience less benefit from opioid-based painkillers. The body’s perception of pain and response to treatments involve various

systems, notably the endogenous opioid system, which naturally produces painrelieving chemicals. Opioid medications leverage this system to manage pain.

• Effective multimodal combination2

• Breaks the pain/anxiety cycle1,3,4

• Delivers effective opioid-sparing analgesia1

To explore whether differences in the endogenous opioid response contribute to sex-specific variations in pain relief, researchers led by Dr Fadel Zeidan from the University of California, San Diego, analysed data from two NIH-funded clinical trials. These trials assessed whether the body’s endogenous opioid system was essential for pain relief during meditation.

One trial included individuals with chronic back pain, while the other involved participants without chronic pain. A total of 98 individuals (51 females and 47 males) were randomly assigned to practice mindfulness meditation or a nonmindfulness-based technique. Participants meditated while being exposed to a painful but harmless heat source on their leg over two sessions.

Following the initial exposure, participants received either naloxone, a drug that blocks the endogenous opioid system, or a saline placebo, without knowing which they were given. They then repeated the pain exposure while meditating, and their pain levels were recorded before and after the infusions.

KEY FINDINGS

• Both meditation types reduced pain significantly during the saline infusion for males and females.

• For males, pain relief disappeared after naloxone was administered, indicating that meditation relies on the endogenous opioid system for pain reduction.

• For females, naloxone had little impact on pain relief during meditation, suggesting that another mechanism drives their pain reduction.

• “This is the first clear evidence of a biological difference in how the sexes utilise their endogenous pain-relief systems,” says Dr Zeidan. “It highlights the need to consider sex-based differences when developing and prescribing pain treatments.”

• The findings underscore the importance of further studies to explore sex-specific mechanisms in pain reduction strategies.

REFERENCE

Dean JG, Reyes M, Oliva V, et al. Selfregulated analgesia in males but not females is mediated by endogenous opioids. PNAS Nexus. 2024 Oct 14;3(10): page 453. Doi: 10.1093/pnasnexus/pgae453. eCollection 2024 Oct. PMID: 39430222.

A Tackling HIV stigma on World AIDS Day

Held annually on 1 December, ‘World AIDS Day’ is a global day dedicated to raising awareness of the AIDS pandemic caused by the spread of the HIV infection and remembering those who have died from this disease.

CCORDING TO UNAIDS, at the end of 2023, there were 7 700 000 adults and children living with HIV in South Africa. This is one of the highest prevalences in the world. Whilst antiretroviral therapy (ART) is saving many lives, HIV-related levels of morbidity and mortality remain high, especially in those not taking ARTs or in the first year after the start of ART.

From data recorded by 42 members, between 18 000 and 22 000 people with HIV/AIDS and their loved ones were assisted by Association of Palliative Care (APCC) members in 2023 and 2024. They range in age from newborn to past 80 years of age, across all racial and cultural demographics.

According to member data, KwaZuluNatal saw the highest number of patients per province in both 2023 and 2024.

While KwaZulu-Natal records the highest patient numbers due to high population density and socioeconomic challenges, all provinces encounter stigma, a key barrier to HIV prevention and care.

Co-infection with TB has become common as well as an increase in the levels of cervical and vulva cancer in HIV-positivewomen

In a 2024 PubMed Central study, the authors state: “HIV-related stigma remains a significant barrier to controlling the HIV epidemic. Stigmatising attitudes discourage individuals from getting tested for HIV, seeking medical care, and adhering to treatment. Fear of stigma can prevent people from disclosing their HIV status to family, friends, or sexual partners, leading to increased feelings of isolation and secrecy. Stigma also affects mental health and overall well-being for PLWH, and present challenges for those in need of health care services including older adults.”

“Co-infection with TB has become common as well as an increase in the levels of cervical and vulva cancer in HIV-positive women,” says APCC provincial vice-chair of KwaZulu-Natal, Diane van Dyk. “We put this down to people avoiding getting tested and therefore lacking the necessary medical support. Once someone is on the treatment programme, our priority is to assist them to adhere to the chronic medicine schedule. Compliance with ARTs saves lives.”

In van Dyk’s experience, the age groups that they most see are between 25-49. These are young age groups when the amount of information around avoiding infection with the disease is so available.

“Fifty-four per cent of the population are outside of urban areas,” says van Dyk. “Our patients come to us via referrals from clinics and regional hospitals as well as voluntarily through our HIV testing and

initiation. We are passionate about HIV education, as many don’t understand that when this disease is treated, the viral load can become undetectable, resulting in the virus being untransmissible through sexual

contact. We would like to see the numbers of HIV infected patients go down through safer sexual practices becoming the norm, and through screening, disclosure, and adherence to ARTs if infected!”

Dexlansoprazole ticks

all the GORD boxes

Gastro-oesophageal reflux disease (GORD), affecting up to 33% of the global population, is a chronic and relapsing condition marked by gastric contents flowing back into the oesophagus. Symptoms include heartburn, regurgitation, and chest pain, potentially leading to more severe oesophageal issues and linked to other diseases such as mental disorders and cardiovascular diseases.1,2

ORD IS CLASSIFIED into distinct phenotypes based on endoscopic and histopathologic features, each with unique predisposing factors.

Common risk factors for GORD include motor abnormalities like oesophageal dysmotility, anatomical factors such as hiatal hernia, and lifestyle factors like

obesity, tobacco, and excessive alcohol use3

The 2023 American Gastroenterology Association (AGA) report states that a singular diagnostic tool for GORD

does not exist. Diagnosis is based on a comprehensive evaluation of symptoms, response to therapy, and testing results. Initial testing should include endoscopy and reflux monitoring tailored to the patient's presentation5. Testing outside the GI disciplines should also be considered5

Proton Pump Inhibitors (PPIs) are the main pharmacological treatment for GORD, with therapies like dexlansoprazole MR (modified release) offering advanced options. Dexlansoprazole, available in South Africa since 2022, is used for treating erosive reflux oesophagitis and providing heartburn relief. Its dualrelease mechanism ensures prolonged drug retention and a powerful inhibitory effect on proton pumps6,7

This dual-action involves two phases at different pH values, releasing the active ingredient for extended serum concentrations, enabling effective acid secretion inhibition6. It also allows flexibility in administration, irrespective of meals, improving treatment adherence6

Studies demonstrate dexlansoprazole’s efficacy, showing significant heartburn reduction and symptom elimination within weeks. For instance, dexlansoprazole 60mg achieves similar results as esomeprazole in healing erosions and improving symptoms in non-erosive reflux disease (NERD) patients8,9. It has proven effective in reducing nocturnal heartburn and sleep disturbances, with studies showing better outcomes than placebos10,11

DEXILANT DDR:

• the MOST POWERFUL inhibitory effect on the proton pump of ALL available PPIs.4

• TRUE once-daily dosing.5

In terms of maintaining healing posttreatment, dexlansoprazole significantly outperforms placebo over long periods, particularly in severe cases of erosive oesophagitis (EE). It ensures sustained symptom control even after transitioning from twice-daily PPI treatments to once-daily administration15

Alternative treatments for GORD management include lifestyle modifications, such as avoiding trigger foods, postural changes, and weight loss. Surgical options are considered in cases with clear GORD evidence, with the AGA advising careful decision-making due to the potential lack of response in patients unresponsive to PPI therapy5

Overall, the introduction of dexlansoprazole MR offers a promising solution for managing GORD symptoms effectively, with its superior pharmacokinetic properties and flexibility in usage significantly supporting patient adherence and symptom control.

For adult patients with type 2 diabetes1,2

PROVEN GLYCAEMIC CONTROL*2-4

PROVEN CV RISK REDUCTION † 3-5

PROVEN WEIGHT LOSS ǂ3,4

3. Lingvay I, Catarig AM, Frías JP, et al. Efficacy and safety of once-weekly semaglutide versus daily canagliflozin as add-on to metformin in patients with type 2 diabetes (SUSTAIN 8): a double-blind, phase 3b, randomised controlled trial. Lancet Diabetes Endocrinol 2019;7(11):834-844. 4. Capehorn MS, Catarig AM, Furberg JK, et al. Efficacy and safety of once-weekly semaglutide 1.0 mg vs once-daily liraglutide 1.2 mg as add-on to 1-3 oral antidiabetic drugs in subjects with type 2 diabetes (SUSTAIN 10). Diabetes Metab 2020;46(2):100-109. 5. Marso SP, Bain SC, Consoli A, et al. SUSTAIN-6 Investigators. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med 2016;375(19):1834-1844. 6. Davies MJ, Aroda VR, Collins BS, et al. Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2022;45(11):2753-2786.

Abbreviated Professional Information

Scheduling status: S4 Name of the medicine: Ozempic® Qualitative and quantitative composition: Semaglutide 1,34 mg/ml. Therapeutic indication: Ozempic® is indicated: a) for the treatment of adults with insufficiently controlled type 2 diabetes mellitus as an adjunct to diet and exercise • as monotherapy when metformin is considered inappropriate due to intolerance or contraindications. • as combination therapy with oral anti-diabetic medicines (metformin, thiazolidinediones, sulphonylurea), basal insulin with or without metformin and pre-mix insulin. b) to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction or non-fatal stroke) in adults with type 2 diabetes mellitus and established cardiovascular disease. Posology and method of administration: Ozempic® starting dose is 0,25 mg once weekly. After 4 weeks, the dose should be increased to 0,5 mg once weekly. After at least 4 weeks with a dose of 0,5 mg once weekly, the dose can be increased to 1 mg once weekly to further improve glycaemic control. Ozempic® is to be administered once weekly at any time of the day, with or without meals. Ozempic® is to be injected subcutaneously in the abdomen, in the thigh or in the upper arm. The injection site can be changed without dose adjustment. Ozempic® should not be administered intravenously or intramuscularly. The day of weekly administration can be changed if necessary as long as the time between two doses is at least 2 days (>48 hours). When Ozempic® is added to existing sodium-glucose cotransporter 2 (SGLT2) inhibitor therapy, the current dose of SGLT2 inhibitor can be continued unchanged. Contraindications: Hypersensitivity to semaglutide or to any of the excipients, a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2), pregnancy and lactation. Special warnings and precautions for use: Ozempic® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. Ozempic® is not a substitute for insulin. Acute pancreatitis has been observed with the use of Ozempic®. Patients should be informed of the characteristic symptoms of acute pancreatitis. If pancreatitis is suspected, Ozempic® should be discontinued; if confirmed, Ozempic® should not be restarted. Patients treated with Ozempic® in combination with a sulfonylurea or insulin may have an increased risk of hypoglycaemia. The risk of hypoglycaemia can be lowered by reducing the dose of sulfonylurea or insulin when initiating treatment with Ozempic®. Risk of Thyroid C-cell Tumours: Cases of MTC in patients treated with liraglutide, another GLP-1 receptor agonist have been reported in the post marketing period; the data in these reports are insufficient to establish or exclude a causal relationship between MTC and GLP-1 receptor agonist use in humans. Interaction with other medicines and other forms of interaction: In vitro studies have shown very low potential for Ozempic® to inhibit or induce CYP enzymes and to inhibit drug transporters. The delay of gastric emptying with Ozempic® may influence the absorption of concomitantly administered oral medicines. The potential effect of Ozempic® on the absorption of co-administered oral medicines was studied in trials at Ozempic® 1 mg steady state exposure. Fertility, pregnancy and lactation: Ozempic® is contraindicated during pregnancy and lactation. Undesirable effects: The most frequently reported adverse reactions with Ozempic® in clinical trials were gastrointestinal disorders, including nausea, diarrhoea and vomiting. Adverse reactions by system organ class and absolute frequencies identified in all phase 3a trials listed here as Very common (≥1/10): Hypoglycaemia when used with insulin or sulfonylurea, nausea, diarrhoea; Common (≥1/100 to <1/10): Hypoglycaemia when used with other OADs, decreased appetite, dizziness, diabetic retinopathy complications, vomiting, abdominal pain, abdominal distension, constipation, dyspepsia, gastritis, gastrooesophageal reflux disease, eructation, flatulence, cholelithiasis, fatigue, increased lipase, increased amylase, weight decreased; Uncommon (≥1/1,000 to <1/100): hypersensitivity, dysgeusia, increased heart rate, injection site reactions, hypersensitivity, acute pancreatitis; Rare (≥1/10,000 to <1/1,000): anaphylactic reaction.Frequency unknown: angioedema. Overdose: There is no specific antidote for overdose with Ozempic®. In the event of overdose, appropriate supportive treatment should be initiated according to the patient’s clinical signs and symptoms. A prolonged period of observation and treatment for these symptoms may be necessary, taking into account the long half-life of Ozempic® of approximately 1 week. Reg. No.: 53/21.13/0497. For full prescribing information, refer to the Professional Information approved by the Medicines Regulatory Authority.

Addressing AMR is critical for SA

As antimicrobial resistance (AMR) intensifies, South Africa faces a significant threat to public health, with increasing instances of infections that are resistant to treatment.

THE EFFECTIVENESS OF antimicrobials is critical not only for treating simple infections but also for ensuring the safety of surgeries and treatments like chemotherapy and transplants. This situation is alarming, with projections indicating that 39 million people may succumb to drug-resistant infections over the next 25 years.

Key actions to combat AMR:

• Limit the prescription and use of unnecessary antibiotics

• Adhere strictly to prescribed dosages

• Maintain rigorous hand hygiene practices

• Minimise exposure to infectious individuals

• Ensure up-to-date vaccinations, including the influenza vaccine.

In the context of AMR, prescribing an antibiotic and expecting recovery is becoming increasingly unreliable. AMR renders drugs less effective, necessitating trials of multiple antibiotics, and in some cases, resulting in untreatable infections.

The reality is stark and worsening. In 25 years, drug-resistant infections could cause approximately 39 million deaths, a toll exceeding Covid-19 fatalities and those anticipated from cancer.

The World Health Organization identifies AMR among the top ten global health

threats, responsible for 4.7 million deaths annually, with significant impact in subSaharan Africa.

UNDERSTANDING ANTIMICROBIALS

Antibiotics are a subset of antimicrobials, which are agents that eliminate or inhibit microorganisms. They are categorised by the type of organism they target, such as antibiotics for bacteria, antifungals for fungi, and antivirals for viruses. AMR arises when these organisms develop resistance, reducing the efficacy of treatments. This resistance is bolstered by misuse, declining drug effectiveness, and a shortage of new pharmaceuticals. In response, Mediclinic Southern Africa is implementing targeted strategies to curtail antibiotic overprescribing and misuse while fostering judicious use of all antimicrobials.

FACTORS CONTRIBUTING TO AMR IN SA

Inappropriate prescription practices and the use of antibiotics without a valid prescription significantly contribute to AMR development in South Africa.

AMR's effects are universal but exacerbated by socio-economic factors like poverty and inequality, which hinder access to proper healthcare, water, sanitation, and hygiene, facilitating infection spread.

"The unavailability of safe, quality, and

affordable healthcare limits individuals' ability to make informed decisions about infection prevention and management, especially regarding antibiotic use," explains Dr van Jaarsveld, clinical pharmacy specialist. AMR prevalence is similar across public and private sectors due to microbial resistance patterns, affecting not just the patient but the broader community, notes Dr van Jaarsveld.

IMPACT ON HEALTHCARE

South Africa generally has access to antibiotics for common infections, but not always for multidrug-resistant ones, which are costly and scarce. No new antibiotics have been developed in 30 years that differ mechanistically from existing ones, underscoring the critical need to conserve current options. "We have treatments for most multidrug-resistant infections, but further resistance will leave us without effective options," says Dr Coetzee. Procedures that raise infection risk, such as surgeries, chemotherapy, and transplants, will become exceedingly perilous without viable antimicrobials."

“Certain infections, like complicated urinary tract infections, are becoming increasingly resistant, challenging treatment," Dr van Jaarsveld warns.

MEDICLINIC'S EFFORTS TO

COUNTER AMR

Aligning with the South African Antimicrobial Resistance National Strategy Framework, Mediclinic targets reducing AMR-related deaths by 10% by 2030, in line with global initiatives.

Mediclinic's comprehensive approach includes strict antimicrobial prescribing guidelines and educational campaigns during World Antimicrobial Resistance Awareness Week, emphasising infection prevention and public education on hygiene, vaccination, and social distancing.

Dr van Jaarsveld advises:

1. Eliminate antibiotic overprescribing and misuse; insist on necessity.

2. Follow prescribed antibiotic regimens conscientiously.

3. Maintain health and prevent infections by:

a. Washing hands with soap and water for at least 20 seconds or using hand sanitiser with at least 60% alcohol.

b. Covering mouth and nose when coughing or sneezing.

c. Staying home when ill.

d. Avoiding touching face with unwashed hands.

e. Steering clear of close contact with sick individuals.

f. Receiving recommended vaccinations, including the flu vaccine.

Adobe Stock, Credit : Ilja

Experience the freedom* with a 2-in-1 insulin co-formulation providing basal and mealtime control1-5

Targets both FPG and PPG for HbA1c control1,3,6,7

Ryzodeg® offers lower rates of nocturnal hypoglycaemia3,6,7

Once- or twice-daily dosing with

2013; 15:826-832. 7. Philis Tsimikas A, et al. Similar glycaemic control with

- In type 1 diabetes mellitus, Ryzodeg® should be

hypoglycaemia. Patients whose blood-glucose control is greatly improved may experience a change in their usual warning symptoms of hypoglycaemia and must be advised accordingly. Usual warning symptoms of hypoglycaemia may be altered in patients with long-standing diabetes. The patient’s ability to concentrate and react may be impaired as a result of hypoglycaemia. Patients must be advised to take precautions to avoid hypoglycaemia while driving or operating machinery. Hyperglycaemia: Ryzodeg® should not be used to treat severe hyperglycaemia. Inadequate dosing and/or discontinuation of treatment in patients requiring insulin may lead to hyperglycaemia and potentially to diabetic ketoacidosis, which is potentially lethal. Concomitant illness, especially infections, may lead to hyperglycaemia and thereby cause an increased insulin requirement. Transferring to a new type, brand, or manufacturer of insulin must be done under strict medical supervision. Interactions: When using Ryzodeg® in combination with thiazolidinediones, patients should be observed for signs and symptoms of congestive heart failure, weight gain and oedema. Thiazolidinediones should be discontinued if any deterioration in cardiac function occurs. The following substances may reduce the insulin requirement: Oral antidiabetic medicines, glucagon-like peptide-1 (GLP-1) receptor agonists, monoamine oxidase inhibitors (MAOI), beta-blockers, angiotensin converting enzyme (ACE) inhibitors, salicylates, anabolic steroids and sulphonamides. The following substances may increase the insulin requirement: oral contraceptive, thiazides, glucocorticoids, thyroid hormones, sympathomimetics, growth hormones and danazol. Beta-blocking medicines may mask the symptoms of hypoglycaemia and may reduce the body’s response to hypoglycaemia. Octreotide and lanreotide may either increase or decrease the insulin requirement. Alcohol may intensify or reduce the hypoglycaemic effect of insulin. Insulin antibodies: Ryzodeg® administration may cause insulin antibodies to form. In rare cases, the presence of such insulin antibodies may necessitate adjustment of the insulin dose to correct a tendency to hyper- or hypoglycaemia. Immediate-type allergic reactions to either insulin itself or the excipients may potentially be life threatening. Skin and subcutaneous tissue disorders: Injection site reactions may occur. Patients must be instructed to perform continuous rotation of the injection site to reduce the risk of developing lipodystrophy (including lipohypertrophy, lipoatrophy) and cutaneous amyloidosis. There is a potential risk of delayed insulin absorption and worsened glycaemic control following insulin injections at sites with these reactions. A sudden change in the injection site to an unaffected area has been reported to result in hypoglycaemia. Blood glucose monitoring is recommended after the change in the injection site from an affected to an unaffected area, and dose adjustment of antidiabetic medications may be considered. In children, extra care should be taken to match insulin doses with food intake and physical activities to minimise the risk of hypoglycaemia. Paediatric population: Ryzodeg® may be associated with higher occurrence of severe hypoglycaemia compared to a basal-bolus regimen in the paediatric population, particularly in children 2 to 5 years old. For this age group, Ryzodeg® should be considered on an individual basis. Insulin initiation and glucose control intensification: Intensification or rapid improvement in glucose control has been associated with transitory, reversible ophthalmologic refraction disorder, worsening of diabetic retinopathy, and acute painful peripheral neuropathy. However, long-term glycaemic control decreases the risk of diabetic retinopathy and neuropathy. Fertility, pregnancy and lactation: Safety has not been established in pregnancy and lactation and Ryzodeg® should not be recommended for use during pregnancy. Posology and administration: Ryzodeg® can be administered once- or twice-daily with the main meal(s). When needed, the patient can change the time of administration, if Ryzodeg® is dosed with a main meal. The potency of insulin analogues, including Ryzodeg®, is expressed in units (U). 1 unit (U) Ryzodeg® corresponds to 1 international unit (IU) of human insulin and one unit of all other insulin analogues. In patients with type 2 diabetes mellitus, Ryzodeg® can be combined with oral anti-diabetic products approved for use with insulin, with or without bolus insulin. When using Ryzodeg® once-daily, it is recommended to consider changing to twice-daily when reaching 60 units. Split the dose based on individual patient’s needs and administer with main meals. In type 1 diabetes mellitus, Ryzodeg® is combined with short-/rapid-acting insulin at the remaining meals. Ryzodeg® is to be dosed in accordance with individual patients’ needs. Dose-adjustments are recommended to be primarily based on pre-breakfast glucose measurements. An adjustment of dose may be necessary if patients undertake increased physical activity, change their usual diet or during concomitant illness. Initiation: For patients with type 2 diabetes mellitus, the recommended total daily starting dose of Ryzodeg® is 10 units once daily with meal(s) followed by individual dosage adjustments. For patients with type 1 diabetes mellitus, Ryzodeg® is to be used once-daily at a mealtime and a short-/rapid-acting insulin should be used at the remaining meals with individual dosage adjustments. The recommended starting dose of Ryzodeg® is 60 - 70 % of the total daily insulin requirements. Transfer from other insulin medicines: Close glucose monitoring is recommended during transfer and in the following weeks. Patients with type 2 diabetes: Patients switching from once-daily basal or premix insulin therapy can be converted unit-to-unit to once- or twice-daily Ryzodeg® at the same total insulin dose as the patient’s previous total daily insulin dose. Patients switching from more than once-daily basal or premix insulin therapy can be converted unit-to-unit to once- or twice-daily Ryzodeg® at the same total insulin dose as the patient’s previous total daily insulin dose. Patients switching from basal/bolus insulin therapy to Ryzodeg® will need to convert their dose based on individual needs. In general, patients are initiated on the same number of basal units. Doses and timing of concomitant antidiabetic treatment may need to be adjusted. Patients with type 1 diabetes: For patients with type 1 diabetes mellitus, the recommended starting dose of Ryzodeg® is 60 - 70 % of the total daily insulin requirements in combination with short-/rapid-acting insulin at the remaining meals followed by individual dosage adjustments. Doses and timing of concurrent short-/rapid-acting insulin products may need to be adjusted. Flexibility: Ryzodeg® allows for flexibility in the timing of insulin

A new therapeutic approach for glaucoma

Glaucoma remains a challenging ophthalmic condition, primarily due to its multifaceted nature that affects not only retinal ganglion cells (RGCs) but the entire visual processing system.

WHILE INTRAOCULAR PRESSURE

(IOP) management is a cornerstone of treatment, recent research highlights the importance of addressing neurodegenerative processes inherent in glaucoma. In this context, a study by Rossi et al. has explored the efficacy of an oral fixed-dose combination of citicoline and homotaurine, offering promising insights into a novel therapeutic strategy.

SIGNIFICANT IMPROVEMENTS IN RETINAL FUNCTION

This study has underscored the beneficial role of the citicoline and homotaurine combination in enhancing retinal function. Measured through pattern electroretinogram recordings, the treatment significantly improved neural conduction, suggesting enhanced functionality of ganglion cells which are crucial for maintaining optimal

visual signal processing.

ENHANCED VISUAL FIELD AND QUALITY OF LIFE

Secondary outcomes of the study revealed significant improvements in visual field metrics and patient-reported quality of life measures. Of note was the enhancement seen in the 'vision specific dependency' scale of the NEI-VFQ 25 questionnaire.

This suggests that patients experienced a notable reduction in their reliance on others due to visual impairments, signalling a potential shift in how quality of life and treatment outcomes are evaluated in glaucoma management.

UNDERSTANDING THE COMPLEXITY OF GLAUCOMA

Traditionally, elevated IOP has been recognised as a principal risk factor for glaucoma progression. However, this research highlights the disease’s complexity, pointing toward neurodegenerative processes as significant contributors to RGC apoptosis.

This understanding necessitates therapeutic interventions that extend beyond mere IOP management to include neuroprotection. Citicoline is renowned for its neuroprotective effects, facilitating membrane integrity and deterring oxidative stress—a crucial aspect of protecting neuronal health. Homotaurine, on the other hand, is postulated to mitigate amyloid aggregation, a process linked to RGC apoptosis. Together, these compounds offer a potentially synergistic effect that enhances ocular health and function. The study suggests that the combination of citicoline and homotaurine may allow for effective treatment at lower doses compared to previous studies using citicoline alone.

This finding opens a new avenue for glaucoma treatment, wherein a synergistic approach could yield greater neuroprotective benefits, potentially improving patient outcomes with lower medication doses.

ELECTROPHYSIOLOGICAL ADVANCES

The use of advanced electrophysiological techniques in this study has been pivotal in uncovering improvements in peripheral RGC function during treatment. These findings reinforce the positive impact on the visual system, thereby broadening the scope of glaucoma management beyond traditional approaches.

CONCLUSION

The study not only underscores the clinical improvements in retinal function but also emphasises the significance of vision-related quality of life in therapeutic evaluations. By enhancing patients’ independence and reducing their reliance on external assistance, the treatment aligns with broader health care goals of holistic patient care.

Source: Rossi GCM, Rolle T, De Silvestri A, et al. Multicenter, Prospective, Randomized, Single Blind, Cross-Over Study on the Effect of a Fixed Combination of Citicoline 500 mg Plus Homotaurine 50 mg on Pattern Electroretinogram (PERG) in Patients With Open Angle Glaucoma on Well Controlled Intraocular Pressure. Front Med (Lausanne). 2022;29;9:882335. doi: 10.3389/fmed.2022.882335. PMID: 35572982; PMCID: PMC9106378.

Dr Eugene Allers Specialist psychiatrist

Date: 22 January 2025

Time: 7pm

Topic: Alcohol use disorder: Treatment of withdrawal symptoms and further management

Speaker: Dr Eugene Allers

CLICK TO REGISTER https://bit.ly/AdcockWebinar22Jan25

Dr Allers, a specialist Psychiatrist in private practice since 1993, for a one hour CPD accredited webinar as Dr Allers explores schizophrenia. Dr Allers completed his MBChB at the University of Cape Town in 1984. He completed his MMed (Psych) in 1992 and qualified for his FC (Psych) in 2005 (by peer review). He initially started his practice in Springs and is now working in Benoni at the Glynnview Hospital, which has a 80 bed private psychiatric unit and is licensed to admit involuntary and assisted patients. He is the clinical director at the hospital and manages the outcomes based model at the hospital. Dr Allers has served on many committees and has also been active in management of psychiatry since 1998. He served as president of the South African Society of Psychiatrists (SASOP) from 2002-

Introducing

2004 and was chairperson of the Psychiatry Management Group (PMG) from July 2009 to May 2011 (he was a director from 2007). He was a member of the executive committee of SAMA (2006-2008). He is a founder member of the PsychMG and P3 and serves on the board of the PsychMG. He is one of the founding members of the SAPPF and served as the deputy CEO (2009-2011). He was a previous convenor of the South African Psychiatric Treatment Guidelines Project and head of the PMG clinical peer review committee (2006-2009) and was a member of the Confidentiality Task Team, ICD-10 Code implementation for the Council for Medical Schemes (March 2006-2008).

Precision targeting of tumours and metastases

The introduction of the Varian TrueBeam™ 4.0 linear accelerator (linac) at Netcare Alberton Hospital has revolutionised cancer care for Johannesburg’s southern suburbs and beyond.

THIS ADVANCED RADIOTHERAPY

technology has expanded treatment options for a diverse range of malignancies, offering renewed hope to oncology patients and their families.

ENHANCED TREATMENT CAPABILITIES

Clinical oncologists Dr Sylvia Rodrigues and Dr Karen Motilall have been using the TrueBeam system for the past year, leveraging its cutting-edge capabilities to deliver precision radiotherapy for cancers across the body.

“This technology has transformed how we approach radiation therapy, enabling us to target tumours with sub-millimetre precision,” says Dr Rodrigues. “Its versatility allows for the treatment of complex cases, including tumours in challenging locations or near critical structures, with minimal collateral damage to surrounding healthy tissue.” The system’s ability to administer high-precision stereotactic body radiation therapy (SBRT) is particularly notable. Dr Rodrigues explains, “SBRT provides a non-invasive option for patients who cannot undergo surgery, offering effective

treatment for tumours while sparing nearby vital organs and tissues.”

APPLICATIONS ACROSS A BROAD SPECTRUM OF CANCERS

Dr Motilall highlights the wide-ranging applications of the TrueBeam™ system:

“We routinely treat breast, colorectal, gynaecological, head and neck cancers, among others. For patients with metastatic disease, we can accurately target metastases wherever they occur, improving treatment outcomes and preserving quality of life.” The system’s real-time imaging capabilities play a crucial role in ensuring accuracy. “We can visualise tumours and adjust for even the slightest movement, such as breathing, during treatment,” says Dr Rodrigues.

INNOVATIVE FEATURES FOR PRECISION AND SAFETY

According to Demare Wahl, regional medical physics manager for Netcare Cancer Care in Gauteng, the TrueBeam’s respiratory gating technology is a game-changer. “This feature synchronises radiation delivery with the patient’s breathing cycle, ensuring

precise targeting of tumours that move with respiration, such as those in the lungs or breast. It also significantly reduces radiation exposure to critical structures like the heart, enhancing patient safety and outcomes.”

The system incorporates multi-leaf collimators (MLCs) for tailored radiation delivery, shaping the beam to conform precisely to the tumour’s dimensions while minimising exposure to healthy tissue. Additionally, the treatment table’s multidirectional adjustability ensures optimal patient positioning for accurate radiation delivery.

TRANSFORMING PATIENT CARE

Since its installation in February 2024, the TrueBeam system has enabled over 300 patients to receive state-of-the-art radiotherapy at Netcare Alberton Hospital. Radiation therapy unit manager, Busi Mzelem, notes that the system’s efficiency has enhanced patient comfort by reducing treatment times.

“Our team is committed to delivering holistic, patient-centred care,” Mzelem emphasises. “The TrueBeam system has extended our ability to provide

comprehensive cancer treatment, supporting improved outcomes and better quality of life for our patients.”

HOPE FOR THE FUTURE

Dr Motilall reflects on the system’s impact on clinical practice: “This technology provides unparalleled precision in visualising and treating tumours, whether in the pelvic region or elsewhere. For cancers such as cervical, liver, lung, and pancreatic, we can confidently deliver focused radiation, protecting surrounding organs and nerves.”

Wahl underscores the value of the system’s real-time imaging and motiontracking capabilities: “These features allow us to personalise treatment plans with exceptional clarity and accuracy, empowering clinicians to address each patient’s unique needs effectively.”

As advancements in radiotherapy continue to redefine oncology care, the team at Netcare Alberton Hospital remains dedicated to harnessing these innovations to improve patient outcomes. “We have more tools than ever to combat cancer,” says Dr Rodrigues. “And with that, more reason to hope.”

Dr Karen Motilall and UM Busi Mzelem: Clinical oncologist Dr Karen Motilall and Netcare Alberton Hospital radiation therapy unit manager Busi Mzelem are pictured with the sophisticated new radiation therapy system which enables targeted external radiotherapy treatment for a wide spectrum of cancers.

NAH Radiation Therapy Team: Netcare Alberton Hospital radiation therapy unit manager Busi Mzelem and the caring, experienced radiation therapy team are pictured with the Varian TrueBeam™. More than 300 people have been treated with the precision system since it was installed in February 2024.

Date: 13 February 2025

Time: 7pm

Topic: Multiple myeloma and the role of lenalidomide

Speaker: Dr David Brittain

CLICK TO REGISTER https://bit.ly/AdcockWebinar13Feb25

Dr David Brittain graduated his MB ChB in 1988 from the University of the Witwatersrand. He specialised in Haematopathology (1996) and super specialised in Clinical Haematology (1998) from the same university. After running his own private practice in Johannesburg from 2000 - 2008 he joined the Alberts, Bouwer & Jordaan practice where he has worked as a director in the Haematology and Cellular Therapy field. He has a special interest in treating Leukaemia, Lymphoma, Myeloma, Stem Cell Transplantation and CAR-T Therapy. He is a

The most common of which is a disease affecting white blood cells called Multiple Myeloma. This webinar is sponsored by Adcock

Member of the South African Society of Clinical Haematology (SACHaS), the American Society of Haematology (ASH), chairman of BloodSA, chairman of the BloodSA Multiple Myeloma Working Group, member of BloodSA Cell and Gene Therapy Working Party and serves on the Executive Committee of the South African Stem Cell Transplant Society (SASCeTS). He also is an honorary senior lecturer in the division of Clinical Haematology at the University of Cape Town. In his spare time, he cycles, runs and rows.

Adcock Ingram strengthens its oncology lineup with a

Dr David Brittain

More cardiac capacity at St Anne’s

Netcare St Anne’s Hospital is proud to announce the opening of a dedicated cardiac ward featuring advanced technology, further strengthening private cardiac care in the KwaZulu-Natal Midlands.

THE PREVALENCE OF cardiovascular conditions is a significant concern in our communities. However, ongoing advancements in cardiac medicine and cutting-edge treatment technologies are bringing renewed hope,” says resident cardiologist Dr Yuvashnee Govender.

The newly established cardiac ward provides a centralised and serene environment tailored for patients undergoing heart procedures, recovering from cardiac events, or requiring acute hospitalisation for a range of heart conditions.

“Our multidisciplinary approach ensures that patients benefit from the expertise of leading specialists working collaboratively,” Dr Govender adds.

ELEVATING CARDIAC CARE

Resident cardiothoracic surgeon Dr Jehron Pillay, who played a pivotal role in creating the specialised cardiac care unit, notes the team’s capability to perform complex and routine cardiac interventions. “This facility represents the next step in delivering world-class cardiac care, addressing a critical healthcare need,” says Dr Pillay. Patients requiring advanced heart failure management, catheterisation, and other essential cardiac procedures now have access to:

• A resident cardiac team

• Skilled nursing care

• A state-of-the-art, digitally integrated ward focused on heart health.

The hospital’s catheterisation laboratory supports this care with sophisticated imaging technology for precise diagnosis and minimally invasive treatments.

ENHANCED FACILITIES

Netcare St Anne’s Hospital general manager Sharon Singh highlights the thoughtful design of the 12-bed cardiac ward.

“The ward offers single, double, and fourbedded rooms, all with adjoining bathrooms. Shared rooms feature partitioned cubicles to ensure privacy, and we have included an isolation cubicle with flexible air pressure controls and a luxurious VIP suite,” she explains.

Additionally, the newly refurbished 23-bed medical unit offers advanced technology for patient safety and comfort. “This unit includes six private rooms, two isolation suites, and access to garden areas in many rooms, promoting recovery in a calming environment,” Singh notes.

PROMOTING

HEART HEALTH AWARENESS

Addressing healthcare professionals, Dr Pillay stresses the importance of preventative care. “Cardiovascular disease remains the leading global cause of mortality, as highlighted by the WHO. Regular health screenings for risk factors such as

hypertension, elevated glucose, cholesterol, and obesity are essential,” he says. Dr Govender adds, “Early identification and management of these risk factors through lifestyle adjustments and medical intervention can significantly reduce the risk of heart attack, stroke, and other lifethreatening conditions.”

Both specialists emphasise the critical role of public education in fostering heart health awareness while underscoring the hospital’s commitment to delivering excellence in cardiac care for Pietermaritzburg and the greater KwaZulu-Natal region.

TAKE CHARGE OF HEART HEALTH

Cardiovascular disease is a leading cause of death globally and in South Africa. According to the Heart and Stroke Foundation of South Africa, daily statistics are stark: 215 South Africans lose their lives to heart disease or strokes, with five heart attacks and ten strokes occurring every hour. Ten of these cases result in death.

Sameera Kumandan, a pharmacist at Medipost Holdings, highlights the insidious nature of cardiac conditions: “Many cardiovascular diseases progress silently, underscoring the importance of proactive management and patient education.”

RECOGNISING SYMPTOMS EARLY

Subtle signs like persistent headaches, shortness of breath, or swollen ankles may indicate cardiac issues. Kumandan advises healthcare providers to emphasize the importance of routine blood pressure checks for early detection and timely intervention.

“Regular monitoring, combined with patient awareness, can prevent severe complications such as heart attacks and strokes. Encouraging patients to report anything that feels unusual is critical for early diagnosis,” she notes.

PHARMACISTS AS EDUCATORS AND SUPPORTERS

Pharmacists are uniquely positioned to:

• Promote cardiovascular screenings: Educate patients on the importance of regular health checks, including monitoring blood pressure, cholesterol, and glucose levels.

• Encourage adherence to treatment plans: Explain the long-term benefits of consistent medication use in managing conditions like hypertension and high cholesterol.

• Provide accessible guidance: Support patients, particularly those with limited access to traditional healthcare services, by offering telephonic consultations and regular check-ins. Kumandan highlights that pharmacists can assist patients in understanding the implications of their treatment choices, offering practical advice on integrating heart-healthy lifestyle changes.

MEDICATIONS FOR CARDIOVASCULAR CONDITIONS

Healthcare professionals can guide patients in understanding common treatments for managing high blood pressure, high

cholesterol, and clot prevention:

High blood pressure treatments:

• Diuretics (eg. hydrochlorothiazide): Reduce blood volume

• Beta-blockers (eg. atenolol): Slow heart rate

• Calcium channel blockers (eg. amlodipine): Reduce the force of heart contractions.

• ACE inhibitors/ARBs (eg. enalapril, losartan): Promote vasodilation.

High cholesterol treatments:

• Statins (eg, simvastatin): Lower cholesterol production.

Blood thinners:

• Aspirin: Prevent clot formation.

ADDRESSING SIDE EFFECTS AND ADDITIONAL MEDICATIONS

Side effects from treatments, such as muscle pain or coughing, can affect adherence. Kumandan advises open communication between patients and providers to explore alternatives or supportive therapies, such as magnesium for statin-induced discomfort.

Patients should also be cautioned about over the counter and herbal products that may interfere with heart health. For example, decongestants can raise blood pressure, necessitating pharmacist consultation before use.

LIFESTYLE INTERVENTIONS

Promoting heart health extends beyond medication. Encourage patients to:

• Follow a low-sodium, nutrient-rich diet

• Engage in daily physical activity, such as 30-minute walks

• Quit smoking and reduce alcohol consumption

• Manage stress through techniques like meditation and breathing exercises.

A COLLABORATIVE APPROACH

By fostering education, accessibility, and adherence, healthcare professionals can empower patients to take control of their heart health. Pharmacists, as part of the healthcare team, are essential allies in preventing and managing cardiovascular diseases, ensuring better patient outcomes and quality of life.

St Annes Cardiac Ward Opening: Cardiothoracic surgeon Dr James Chen, medical ward unit manager Zamani Cele, enrolled nurse Gugu Mahlaba, PA Vanessa Davids, Netcare St Anne’s Hospital general manager Sharon Singh and Clinical Application Support Specialist Jamie Lee Hein are pictured at an event to mark the opening of the dedicated medical and cardiac wards. (Photo credit Jason Lisher Photography)

Cardiac ward Netcare St Annes: (Front row from left to right) Enrolled nurse

Cindy Moodley, resident cardiologist Dr Yuvashnee Govender, registered nurse Nadira Ittal, cardiac ward unit manager Donna Marillier, and (back) resident cardiothoracic surgeon Dr Jehron Pillay.

I Respiratory Syncytial Virus A significant threat to young children

Respiratory Syncytial Virus (RSV) is a relatively contagious but highly circulating seasonal virus that poses a significant threat to young children.1

T IS A PRIMARY cause of lower respiratory tract infections (LRTIs), such as bronchiolitis and pneumonia, often necessitating hospitalisation.1 The vast majority of children experience an RSV infection by their second birthday, with infants, especially those born prematurely, facing the greatest risk of severe complications. 1,2

RSV is spread from human contacts and community contact, including childcare settings, and is the largest contributor to infection risk.1 The virus can survive on surfaces for several hours, particularly with low temperatures and high humidity and can remain viable for up to half an hour on hands.1 Bronchiolitis, the most common LRTI caused by RSV, is associated with necrosis and sloughing of the epithelium of the small airways, with oedema and increased secretion of mucus.1 In young children, this leads to obstruction of air flow and the typical picture of hyperinflation, atelectasis, wheezing and hypoxaemia.1,3

HIGH BURDEN OF RSV ASSOCIATED ILLNESS IN CHILDREN < 5 YEARS IN SOUTH AFRICA4

Approximately 90% of children will contract RSV within their first two years of life, with the majority of these children being otherwise healthy.1,2 Data from South Africa (2011-2016) reveals that RSV accounted for an estimated 4.7 % of all acute respiratory illnesses (ARIs) and 1.7 % of severe ARIs in children under five.4 The highest incidence of RSV infection occurred in two-month-old infants, while the highest incidence of severe illness was observed in infants less than one month old.4 Tragically, the incidence of RSV-associated deaths also peaked in the first two months of life.4

RSV IS A LEADING CAUSE OF HOSPITALISATIONS IN INFANTS2

Although prematurity is the most significant predictor of RSV hospitalisation, the majority of RSV hospitalisations (up to 75%) occur in otherwise healthy term infants.1,2 In South Africa, RSV accounts for a substantial proportion of paediatric hospitalisations, with one in four hospitalisations for severe acute respiratory illness in children under five being attributed to RSV.5 Furthermore, the vast majority (75%) of RSV hospitalisations occur in children less than one year old, with 74% of these cases occurring in infants younger than six months.3 Early-life RSV bronchiolitis can have lasting respiratory consequences, increasing the risk of both recurrent wheezing and the development of asthma in later childhood.1 Children who experience their first lower respiratory tract infection (LRTI) due to RSV are also three times more likely to develop recurrent LRTIs compared with those with non-RSV LRTIs, particularly if they were hospitalised (p < 0,0001).6

RSV INFECTION DOES NOT ELICIT LONG-LASTING IMMUNITY1

A key challenge in managing RSV is the lack of long-lasting immunity following infection.1 This characteristic leads to frequent reinfections throughout life, with the highest incidence in institutionalised elders.1 This persistent circulation of the virus within the population, while potentially contributing to maintained immune competence in adults, also ensures ongoing exposure and risk for vulnerable infants.1 Currently, universally available preventative options for all infants remain limited.1 A monoclonal antibody (mAb) treatment exists that offers short-term

protection; however, its application is restricted to high-risk infants, such as those born prematurely, representing a small percentage of the overall infant population.1 Several promising preventative strategies are currently under development,1 offering hope for more comprehensive protection against RSV in the future. These include:

• Maternal vaccines administered during the third trimester of pregnancy to provide passive immunity to newborns1

• Extended half-life monoclonal antibodies (mAbs) designed to offer longer-lasting protection for infants1

• Paediatric vaccines intended for older infants and children who have developed a more mature immune system.1

These advancements hold significant potential to mitigate the impact of this pervasive and consequential virus.

However, conspiracy theories pose a major challenge to vaccine uptake, especially among pregnant women worried about safety for themselves and their foetus.7 Proactive education campaigns emphasising RSV vaccine benefits and addressing side effect concerns are crucial for increasing acceptance.7 Parents should also be educated about ways to decrease exposure and transmission of the virus through proper handwashing, disinfecting surfaces and avoiding close contact with infected individuals.8

REFERENCES:

1. Baraldi E, Lisi GC, Costantino C, Heinrichs JH, Manzoni P, Riccò M, et al. RSV disease in infants and young children: Can we see a brighter future? Hum Vacc Immunother. 2022;18(4):e2079322.

2. Alonso JAN, Bond LJ, Bozzola E, Herting E, Lega F, Mader S, et al. RSV: perspectives to strengthen the need for protection in all infants. Emerg Themes Epidemiol. 2021;18:15.

3. White DA, Madhi SA, Zar HJ, Mesekela R, Risenge S. Acute viral bronchiolitis in South Africa: Viral aetiology and clinical epidemiology. S Afr Med J. 2016;106(5):443-445.

4. Moyes J, Tempia S, Walaza S, McMorrow ML, Treurnicht F, Wolter N, et al. The burden of RSVassociated illness in children aged < 5 years, South Africa, 2011 to 2016. BMC Med. 2023;21:139.

5. Valley-Omar Z, Tempia S, Hellferscee O, Walaza S, Variava E, Dawood H, et al. Human respiratory syncytial virus diversity and epidemiology among patients hospitalized with severe respiratory illness in South Africa, 2012-2015. Influenza Other Resp Viruses 2022;16:222-235.

6. Zar HJ, Nduru P, Stadler JAM, Gray D, Barnett W, Lesosky M, et al. Early-life respiratory syncytial virus lower respiratory tract infection in a South African birth cohort: epidemiology and effect on lung health. Lancet Glob Health. 2020;8:e1316-e1325.

7. Nazir Z, Habib A, Ali T, Singh A, Zulfizar E, Haque MA. Milestone in infant health: unveiling the RSV vaccine’s shielding effect for newborns. Int J Surg. 2024;1101836-1838.

8. Krause CI. The ABCs of RSV. Nurse Pract. 2018;43(9):20-26.

Photo credit: 123rf 193660815

Understanding HIV transmission in children: A comprehensive overview

HIV, A VIRUS THAT has shaped medical practices and public health policies worldwide, presents distinct challenges when it affects children. Motherto-child transmission (MTCT) remains the predominant route of HIV infection in children. "The primary ways children get HIV is usually through their mother during pregnancy, delivery, and breastfeeding," Dr Turner said. Understanding these pathways is crucial for healthcare professionals who are at the forefront of preventing new pediatric infections.

PREVENTING MOTHER-TO-CHILD TRANSMISSION

Preventing MTCT is a primary focus of antenatal and paediatric HIV care. The success of prevention strategies hinges on early identification and management of HIV in pregnant women. The implementation of universal antenatal screening for HIV represents a critical entry point for prevention. Once identified, HIV-positive mothers can be enrolled in programmes offering antiretroviral therapy (ART) to significantly reduce viral load.

ART has revolutionised the landscape of HIV prevention and treatment. For pregnant women, maintaining a suppressed viral load through consistent ART use is paramount in preventing HIV transmission to their baby. This preventive measure extends beyond childbirth into the breastfeeding period, which presents its own risks of transmission. Healthcare providers must weigh these risks against the benefits of breastfeeding, especially in resource-limited settings where formula feeding might not be feasible or safe.

COMPLEXITIES IN INFANT DIAGNOSIS

Diagnosing HIV in infants is more complex than in adults. Traditional antibody tests are ineffective due to the presence of maternal antibodies, which can lead to false positives. Instead, infant diagnosis relies on virological testing, such as the HIV polymerase chain reaction (PCR) tests. This provides a more accurate picture of the infant’s HIV status.

Early detection through these methods is crucial. It allows for the commencement of ART at the earliest possible stage, which is critical for reducing morbidity and mortality and for promoting optimal growth and development in HIV-infected children. This early start is associated with better long-term health outcomes and presents the best chance for normal physical and cognitive development.

ADVANCEMENTS IN ANTIRETROVIRAL THERAPY

The evolution of ART has been a gamechanger in the fight against HIV. Current regimens are more effective, have fewer side effects, and are easier to administer. These advances have transformed HIV into a manageable chronic condition, even for children born with the virus. For many children, adherence to ART is facilitated by newer formulations, including fixed-dose combinations that reduce the pill burden.

"Theprimaryways childrengetHIV isusuallythrough theirmotherduring pregnancy,delivery, andbreastfeeding", Dr Turner said

"ARVs work phenomenally well. People these days can live a completely normal life with normal life expectancy, if they just take the tablet," Dr Turner emphasised.

Paediatric formulations, often in liquid or dispersible tablet form, cater specifically to young patients, making it easier for them to adhere to treatment regimens. Such innovations are particularly important in resource-limited settings where adherence can be compromised by logistical challenges.

Emerging therapies, such as long-acting injectable antiretrovirals, hold promise for

further simplifying treatment regimens. These injectables, administered once every few months, could replace daily pills and significantly reduce the adherence burden. This is particularly beneficial for adolescents, who often face unique adherence challenges as they transition towards adult care.

PSYCHOSOCIAL IMPACTS AND STIGMATISATION

Living with HIV, even as a child, means navigating various psychosocial challenges, primarily due to stigma and discrimination. Children with HIV frequently encounter marginalisation, which can affect their self-esteem and mental health. Addressing these challenges requires a comprehensive approach that includes community education and support systems.

Family plays a pivotal role in this regard. Encouraging open dialogue about HIV within the family can demystify the disease, reduce internalised stigma, and empower children with knowledge about their condition. Age-appropriate disclosure of HIV status is recommended. This helps children understand their condition.

Healthcare professionals can facilitate this process by providing resources and counselling to families on how to approach these conversations. Moreover, implementing programmes in schools that promote understanding and acceptance of HIV can further diminish stigma and ensure that children with HIV receive the support they need.

ROLE OF EDUCATION AND COMMUNITY SUPPORT

Education is a powerful tool in the fight against paediatric HIV. It is crucial for healthcare professionals to stay up to date with the latest advancements in HIV management and to convey this information clearly and compassionately to families. Community education programmes can help dispel myths about HIV transmission and encourage practices that protect all children. “We should take the same precautions for everyone. There shouldn’t be a need for a

parent to have to tell a teacher that the child has HIV," Dr Turner commented.

In schools, educators can foster environments that embrace diversity and promote empathy and understanding. By integrating HIV education into school curricula, children learn from an early age that HIV is a manageable health condition, not a moral failing.

FUTURE DIRECTIONS IN HIV TREATMENT FOR CHILDREN

The future of HIV treatment holds exciting possibilities. Newer fixed dose combinations regimens that are easy to administer, efficacious and safe, as well as long acting therapies, suggests a shift towards treatments that simplify management and improve research into the development quality of life. Additionally, ongoing development of vaccines and potential curative therapies represents the frontier of HIV research into the development, offering hope for a future without HIV.

The continued commitment to research, education, and comprehensive care is essential in the pursuit of ending pediatric HIV. By embracing advancements in treatment and striving for social acceptance, we pave the way towards a healthier future for children affected by this virus, ensuring they lead lives full of potential and without prejudice.

The following article is based on a podcast interview with Dr Julia Turner, senior technical advisor HIV Care and Treatment, Right to Care.

Adobe Stock, Credit : Liza

Dr Julia Turner To listen to the full podcast, go to https://www.youtube.com/watch?v=TfCWhIS_DvY

The leading cause of untreated mental health

Three-quarters of the South Africans who suffer common mental health disorders such as depression, anxiety and post-traumatic stress (PTSD) go untreated1 – not only due to healthcare system constraints, but also the barriers of stigma, misinformation, and fears of discrimination, job loss or social rejection.

POOR MENTAL HEALTH is a major contributor to absenteeism, poor work performance and productivity losses, with depression rated as the leading global cause of disability and ill-health2 and costing the South African economy over 5% of Gross Domestic Production (GDP) annually.3

Prof Renata Schoeman, head of the MBA in Healthcare Leadership programme at Stellenbosch Business School, said stigma, a major contributor to untreated mental health, involved negative labelling and stereotyping of people with mental health conditions, leading to discrimination, loss of individual identity and community status, and exclusion from social networks and work opportunities.

She said organisations and the media play a key role in breaking down the stigma surrounding mental health which prevents people in distress from seeking the help they need to participate fully in the economy and society.

“Mental health is too often surrounded by silence, stigma, and misconceptions. The way it is portrayed in the media and addressed in the workplace can profoundly impact the lives of those affected by mental health conditions.

“The impact is not only on the quality of life and ability to be productive members of society for those living with mental health conditions; the impact for organisations and the economy is also substantial,” she said.

“Stigma becomes a barrier to asking for help and seeking out mental healthcare, due to a lack of information and understanding of the causes of mental health disorders. People are told to ‘just get over it’; they fear they will be seen as weak or be overlooked

for work opportunities or promotion.”

“Stigma becomes internalised, resulting in poor self-esteem, a lack of self-belief – people don’t believe they can be helped or can succeed at work or in life. All of this adds up to a barrier to people restoring their lives, participating fully in work, education and social and family life, thriving and having quality of life,” Prof Schoeman said.

ROLE OF LEADERS

Leaders need to 'normalise the conversation' about mental health, stress and emotions, she said, and show employees that taking care of their mental health is as important as looking after their physical health.

“Responsible leadership is about being vulnerable and authentic. As a leader, if you have struggled with your own stress and mental health, if you have undergone treatment or counselling – talk about it. It is a positive story to share and makes it easier for others to talk about their own struggles.”

“Convey the message, through talking and action, that seeking help is a sign of strength, not weakness,” she said.

She said that while employers were legally obliged to make reasonable accommodations in the workplace, for mental health conditions as much as for physical health conditions, the conversation should also turn to resilience.

“All work has stress factors and employees also need to be encouraged to take responsibility for their own health, selfcare and the stress caused by issues outside of the workplace.”

“Responsible leaders need to enable people to function optimally at work by removing the factors that cause people not to cope. They can support access to

treatment, ensure that workplace health and wellness programmes provide mental health support, but they must also consider what is reasonable and not reasonable.”

HOW CAN THE MEDIA CONTRIBUTE TO BREAKING DOWN STIGMA?

The portrayal of people with mental health conditions in the media can play either a positive or a negative role in perpetuating stigma and stereotypes, she said. “The media can avoid perpetuating stigma by considering the use of language about mental illness and people with mental illness, for example using neutral and technically accurate terms rather than slang or stereotypes of mental health conditions.

“A key aspect for avoiding sensationalism and combatting misinformation and misconceptions, is for the media to build relationships with mental healthcare professionals who can provide factual information and comment on mental health conditions, treatments and scientific research.

“When reporting on issues surrounding mental health, a qualified, experienced mental health professional can contribute to a more balanced view based on the experiences of the many people they have treated,” Prof Schoeman said.

She also highlighted the misuse of technical, diagnostic terms in society and in the media as contributing to the stigmatisation of people living with mental health conditions.

“People very easily say that they or someone else are depressed, have ADHD, are ‘on the spectrum’, or are bipolar, but this is disrespectful and hurtful to people who have actually been diagnosed, are living with the

condition and receiving treatment.

“Ticking the boxes of symptoms does not add up to a diagnosis. The core element of diagnosis is whether the symptoms negatively affect the person’s ability to function emotionally, interpersonally, at work and socially.

“In that case a diagnosis and prescription of appropriate treatment – for example, counselling, medication and/or lifestyle changes – is made specifically to restore the person’s ability to function optimally in daily life,” she said.

Prof Schoeman said leaders and business in the media could contribute to reducing stigma around mental health by creating platforms for people with mental health conditions to tell their stories about their experiences and difficulties as well as their path to recovery and positive functioning. “Conveying positive and accurate portrayals of what it is like to live with a mental illness, drawing from lived experiences, enables greater understanding, empathy and compassion, based on factual information,” she said.

REFERENCES

Sorsdahl K, et al. A reflection of the current status of the mental healthcare system in South Africa. SSM - Mental Health, Volume 4, 2023. https://doi. org/10.1016/j.ssmmh.2023.100247 World Health Organisation (WHO). 2017. "Depression: let’s talk" says WHO, as depression tops list of causes of ill health. https://www.who.int/news/ item/30-03-2017--depression-let-s-talk-says-whoas-depression-tops-list-of-causes-of-ill-health Evans-Lacko, S., Knapp, M. Global patterns of workplace productivity for people with depression: absenteeism and presenteeism costs across eight diverse countries. Soc Psychiatry Psychiatr Epidemiol 51, 1525–1537 (2016). https://doi.org/10.1007/ s00127-016-1278-4

Adobe Stock, Credit : ita_tinta_

Date: 24 February 2025

Time: 7.00pm

Topic: Food Allergies: Understanding the Basics

Speaker: Eva Södergren

CLICK TO REGISTER https://bit.ly/ThermoFisherWebinar24Feb25

Experience: Nutritionist with a PhD Clinical Nutrition and a broad scientific foundation combined with marketing experience gained from the University, BioTech and Pharma industry.

Goals: Use my experiences from both science and marketing to bridge information needs of different target groups and create value.

Specialties: Scientific/Clinical: Opinion leader relations, congress symposia

management, literature searches/reviews, medical writing, clinical studies, GCP Marketing: Clinical information & marketing, communication to health care providers (Dr's, nurses, dietitians, nutritionists), marketing strategies, marketing plans

Medical areas: Clinical nutrition, allergy, food allergy, lipids, antioxidants Laboratory: biotechnology, biochemistry, lipid chemistry, protein chemistry, GLP

Healthcare trends for 2025

The healthcare landscape is rapidly evolving, and 2025 is poised to bring significant changes driven by technological advancements and shifting patient needs.

AS THE SECTOR faces ongoing challenges such as rising costs, limited access, and increasing demand for mental health services, innovative solutions will be key to addressing these issues. From the rise of virtual healthcare and wearable technologies to the growing influence of artificial intelligence, these trends are reshaping how care is delivered and experienced. "The healthcare sector must embrace innovation to address challenges like affordability and accessibility while leveraging technologies such as AI, virtual healthcare, and wearables to reshape how we deliver care," said Dr Jessica Voerman, chief clinical officer at SH Inc. Healthcare.

KEY TRENDS POISED TO DEFINE HEALTHCARE IN 2025

1. Rising healthcare costs and access challenges

As we approach 2025, the escalation of healthcare costs is expected to persist, with medical aid contributions outpacing inflation and the general expense of healthcare services becoming increasingly burdensome. This growing financial pressure is placing significant strain not only on patients, but also on healthcare providers and the broader healthcare system. In response, identifying and implementing innovative solutions to alleviate this looming financial crisis remains a critical priority for healthcare businesses nationwide. For many South Africans, the rising cost of healthcare is exacerbating issues of accessibility and affordability, with an increasing number of individuals unable to access necessary medical care. Considering this, we anticipate a strong focus on policy reform aimed at addressing these inequalities. As such, addressing healthcare disparities will continue to be a central theme in the ongoing development of healthcare policies and initiatives in the coming years.

2. Increasing demand for mental healthcare services

One of the most prominent shifts anticipated in the healthcare landscape by 2025 is the significant rise in demand for mental healthcare services. The recognition that mental health is integral to overall well-being has led to a growing push to integrate mental health services into primary healthcare systems. Such integration is proving to be both preventative and curative, as early intervention can improve long-term outcomes. Furthermore, mental healthcare is particularly well-suited for the adoption of digital health tools, such as virtual consultations, which can enhance access to care, particularly in underserved or rural areas. The increased focus on mental health will likely continue to drive growth in this sector, as more individuals seek professional support to manage mental health challenges.

3. Expansion of virtual healthcare

The trend towards virtual healthcare is expected to continue its upward trajectory in 2025, as more patients turn to telemedicine as either a primary or supplementary means of accessing healthcare services. According to a McKinsey report, telemedicine is projected to account for more than 20% of outpatient consultations by 2025. This shift is expected to be particularly pronounced in areas

such as primary healthcare, chronic disease management, dermatology, and mental healthcare. Virtual consultations offer patients the convenience of receiving care remotely, which can help to reduce barriers related to distance, time, and accessibility. For healthcare providers, virtual healthcare offers opportunities to streamline services, increase operational efficiency, and reach a broader patient population.

4. The role of wearables and health data collection Wearable health technologies, including biosensors capable of monitoring, transmitting, and analysing vital signs, represent another exciting frontier in digital health. These devices have the potential to revolutionise the management of both acute and chronic conditions by providing continuous, real-time data that can inform clinical decision-making. With their ability to track everything from heart rate and blood glucose levels to oxygen saturation and sleep patterns, wearables offer unprecedented insights into an individual’s health status. This wealth of data has the potential to improve patient outcomes, empower individuals to take a more proactive role in managing their health, and help healthcare providers tailor interventions more precisely. As these technologies evolve, they will become an increasingly important tool in both disease prevention and management.

5. The growing impact of artificial intelligence (ai) Artificial intelligence (AI) continues to make significant strides in healthcare, particularly in areas such as clinical decision-making, diagnostics, and operational efficiency. AI algorithms have demonstrated their ability to improve the speed, accuracy, and reliability of diagnoses, enabling healthcare professionals to make more informed decisions. Furthermore, AI-driven tools are improving clinical workflows, optimizing resource allocation, and enhancing the overall patient experience.

In the realm of surgery, robotic-assisted technologies are increasingly being used to improve the precision of procedures, reduce the risk of human error, and shorten recovery times for patients. Additionally, the use of virtual and augmented reality technologies in medical training and physical rehabilitation is gaining traction, offering immersive, interactive experiences that improve learning outcomes and accelerate recovery for patients.

CONCLUSION

Looking ahead to 2025, healthcare is set to evolve rapidly, driven by technological advancements and growing demand for accessible, affordable care. Key trends such as rising costs, expanded mental health access, virtual healthcare, wearable technologies, and artificial intelligence are reshaping the sector.

For businesses and policymakers, staying ahead of these changes is crucial to ensuring sustainable, equitable, and effective care. By embracing digital tools, AI, and data-driven solutions, the healthcare system can improve both patient outcomes and overall efficiency. Collaboration and innovation across all sectors will be essential to meeting the evolving needs of patients and society.

Patient blood management, anaemia and the ethics of blood transfusion

Medical Chronicle recently hosted the Acino Anaemia Symposium, focusing on patient blood management, anaemia, and the ethics of blood transfusion. This symposium was sponsored by Acino.

To watch a replay of this webinar and still earn a CPD point, go to: https://wipapp.wipster.io/review/ CUSKUgBYlkdbXNFg7C0enRhrVjCFwuS2PozV0k76pQKYYedYzA . Email john.woodford@newmedia.co.za to let him know to allocate your point/ request an attendance certificate for those who don’t fall under the HPCSA.

I

THE SAFETY OF INTRAVENOUS IRON

The presentation by Prof Philip A. Kalra focused on the safety and efficacy of intravenous (IV) iron therapy, particularly for iron deficiency anemia (IDA) and chronic kidney disease (CKD). It highlighted that anemia affects 24% of the global population, with significant cases linked to dietary iron deficiency and chronic diseases, especially in high-income countries.

Prof Kalra discussed the physiological role of iron in erythropoiesis and compares oral iron with IV iron treatments. While oral iron is suitable for non-inflammatory conditions and when a gradual increase in hemoglobin (Hb) is acceptable, IV iron is essential for rapid iron replenishment in inflammatory states, advanced CKD, and pre-operative scenarios. Evidence indicates that IV iron can produce greater Hb increases than oral iron, especially at higher doses.

Safety considerations for IV iron include immediate infusion-related reactions, which can be either allergic or non-allergic, as well as medium to long-term risks such as hypophosphatemia and potential infections or cardiovascular events. His presentation stressed the importance of understanding these risks and preparing healthcare providers and patients for possible adverse reactions.

Different formulations of IV iron, such as ferric derisomaltose (FDI), are examined for their safety profiles, particularly concerning non-transferrin-bound iron (NTBI) and its effects on iron bioavailability and oxidative stress. A meta-analysis concludes that IV iron does not significantly increase the risk of serious adverse events compared to other treatments, supporting its safety when administered properly.

KEY FINDINGS INCLUDE:

1. Adverse events: The risk of serious hypersensitivity reactions was low across studies, with FDI showing non-inferiority to iron sucrose (IS) in safety profiles.

2. Adverse drug reactions (ADRs): Patients on FDI experienced fewer ADRs compared to those on IS, indicating a lower

incidence of side effects with FDI.

3. Management of infusion reactions: An algorithm for managing infusion reactions is proposed, emphasising accurate diagnosis and the use of second-generation antihistamines for isolated symptoms.

4. Long-term safety: The PIVOTAL trial found that a high-dose IV iron protocol did not increase infection risk in hemodialysis patients and reduced serious cardiac events compared to standard care.

5. Cardiovascular outcomes: The proactive high-dose IV iron group had fewer myocardial infarctions and hospitalisations for heart failure, suggesting cardiovascular benefits.

6. Hypophosphatemia: The incidence of hypophosphatemia varies among IV iron therapies, with FDI showing a significantly lower incidence compared to ferric carboxymaltose (FCM).

He also discussed the clinical implications of hypophosphatemia, noting its potential to cause bone complications and symptoms like fatigue. Studies indicate that higher doses of FDI lead to better hemoglobin responses, reinforcing the efficacy of higher IV iron doses.

The findings suggest that FDI is a safe and effective alternative to IS, with a favourable profile regarding adverse events and potential cardiovascular benefits in specific patient populations. The presentation advocates for careful administration of IV iron, adherence to local guidelines, and monitoring for adverse reactions, particularly hypophosphatemia.

THE ETHICS OF BLOOD TRANSFUSION IN A PATIENT BLOOD MANAGEMENT SETTING

Dr Petro-Lizé Wessels examined the ethical and legal aspects of transfusion medicine in South Africa, with a particular focus on patient blood management (PBM) and the role of the South African National Blood Service (SANBS) in fostering trust between healthcare providers and patients. It highlights key ethical principles such as autonomy, beneficence, non-maleficence, and justice.

Autonomy: Emphasises the importance of informed consent, allowing patients to make knowledgeable decisions about

their treatment.

Beneficence: Requires healthcare providers to act in the best interests of patients, ensuring transfusions are necessary and risks are communicated.

Non-maleficence: Stresses the need to avoid causing harm.

Justice: Pertains to fair treatment and equitable resource distribution.

Shwe also outlined legal requirements under the National Health Act, which mandates informed consent and specifies the responsibilities of healthcare providers in administering blood products. She detailed circumstances under which treatment can occur without consent and underscores the necessity of patient involvement in decision-making and accurate recordkeeping. Additionally, she discussed the importance of haemovigilance, which requires organisations involved in transfusions to monitor adverse events and ensure traceability. Legal implications, including delictual and criminal liability, are addressed, particularly concerning negligence and the administration of transfusions without consent. Practitioners are urged to be aware of their legal responsibilities, especially regarding blood compatibility. She emphasised the need for healthcare practitioners to remain informed about their ethical and legal obligations, prioritising patient safety and ethical standards in blood transfusion practices while empowering patients through information and involvement in their care decisions.

THE RELEVANCE OF ANAEMIA IN CONGESTIVE HEART FAILURE

Prof Nqoba Tsabedze gave a comprehensive overview of iron deficiency in heart failure.

Iron deficiency (ID) is a common condition among patients with heart failure, significantly impacting their symptoms and overall prognosis. He highlighted the importance of understanding iron metabolism, the pathophysiology of iron deficiency, and its diagnosis and management in heart failure patients.

IRON METABOLISM AND PATHOPHYSIOLOGY

Iron deficiency can lead to mitochondrial dysfunction, which exacerbates the

symptoms and progression of heart failure. This condition is particularly concerning for patients who have recently been hospitalised for heart failure, as they experience high event rates and a diminished quality of life.

DIAGNOSIS AND MANAGEMENT

The presentation underscores the importance of accurate diagnosis and effective management of iron deficiency in heart failure patients. Intravenous (IV) iron therapy, especially with ferric carboxymaltose, has been shown to improve quality of life, exercise capacity, and potentially reduce hospital readmissions. Clinical trials, such as the FAIR-HF trial, have demonstrated that IV iron supplementation can enhance New York Heart Association (NYHA) class and patient global assessment (PGA) scores in heart failure patients, regardless of their anaemia status.

TAILORED MANAGEMENT STRATEGIES

The need for tailored management strategies for iron deficiency in heart failure is emphasised, considering specific patient populations, treatment timing, and dosing regimens to optimise outcomes. Addressing iron deficiency is crucial in the comprehensive management of heart failure, ensuring better patient outcomes and quality of life.

PATIENT BLOOD MANAGEMENT

Prof Vernon Louw is chair and head of the Division of Clinical Haematology in the Department of Medicine at the University of Cape Town. He gave two comprehensive presentations on Patient blood management, examining where we are globally and in South Africa in 2024. His second presentation addressed maternal anaemia and the neurocognitive effect on the foetus and child.

CONCLUSION

In conclusion, iron deficiency is a significant concern in heart failure management. Understanding its impact and implementing effective treatment strategies, such as IV iron therapy, can lead to substantial improvements in patient health and well-being.

T WAS PRESENTED BY Prof Vernon Louw, Prof Nqoba Tsabedze, Prof Philip Kalra and Dr Petro-Lizé Wessels.

90% of individuals who commit suicide haveapsychiatric disorder

began by discussing the epidemiology of suicide, emphasising the need for increased awareness and understanding. “Creating awareness is crucial,” he asserted, as he outlined three primary areas of focus: prevention, intervention, and postvention.

Dr Korb highlighted the sobering statistics surrounding suicide, noting that over 700 000 individuals died from suicide each year globally. “Suicide is a global emergency and the second leading cause of death among young people,” he stated, emphasising that this crisis was particularly acute in low- and middle-income countries. In South Africa, alarming statistics have revealed high suicide rates and a concerning prevalence of suicidality among the youth.

He discussed the findings of a Washington Post article that examined the preparedness of medical students to handle suicidal patients, concluding that many were ill-equipped for this responsibility

societal attitudes on the topic.

The World Health Organization (WHO) reported that 77% of global suicides occurred in low- and middle-income countries, with common methods including pesticide ingestion, hanging, and firearms. Korb highlighted a particularly troubling statistic regarding pesticide accessibility: “In South Africa, rat poison can be purchased on the street for as little as R10, making it a dangerously accessible means for young people.”

SUICIDE PREVENTION STRATEGY

Dr Korb pointed out that, unlike the United States, which had developed a national strategy for suicide prevention, South Africa lacked an official government suicide prevention plan. However, organisations like the Southern African Development Community (SADC) were taking steps to address the issue at grassroots levels,

health landscape, Dr Korb cited a 2022

WHO report revealing that South Africa had one of the highest suicide rates globally.

“Lesotho had the highest, but South Africa was not far behind,” he noted, stressing that men were five times more likely to die by suicide than women. He advocated for tailored approaches to mental health for men, stating, “We need to focus on male mental health.”There has been a significant increase in calls to suicide helplines, particularly in the aftermath of the Covid-19 pandemic. From an average of 600 calls per day, the number surged to over 3 000, with one in five related to suicide.

He cited a troubling study conducted across 17 South African universities, revealing that 24.4% of students had contemplated suicide within the last month.

“These figures are staggering,” he stated, emphasising the urgent need for preventive measures in educational institutions.

of risk factors contributing to suicidal behaviour, including psychiatric disorders, substance abuse, and psychosocial stressors. He highlighted the importance of understanding that “90% of individuals who commit suicide have a psychiatric disorder,” emphasising the need for early intervention and effective screening processes. Korb concluded with a call to action, emphasising that conversations about suicide must be normalised to reduce stigma and promote awareness.

He encouraged health professionals to ask patients about suicidal thoughts, stating, “Asking about suicide does not plant the seed of suicide; rather, it provides relief and opens up essential conversations.” By fostering open dialogue and creating supportive environments, society can take significant strides towards preventing suicide and addressing the underlying issues that contributed to it.

Lacosamide – A practical update on the new anti-seizure medication

In a recent enlightening webinar with prominent speakers Drs James Butler and Sally Ackerman, the focus was on lacosamide, a significant player in anti-seizure medication. This webinar was sponsored by Macleods.

To watch a replay of this webinar and still earn a CPD point, go to: https://event.webinarjam.com/go/ replay/892/pl64luxy3swoptvzquq Email john.woodford@newmedia.co.za to let him know to allocate your point/ request an attendance certificate for those who don’t fall under the HPCSA.

LACOSAMIDE, APPROVED BY the FDA since 2008, is utilised for treating focal onset seizures in children from one month old and primary generalised tonic-clonic seizures in patients aged four and above. The medication’s mechanism includes enhancing the slow inactivation of voltage-dependent sodium channels and possibly interacting with the CRMP2 protein, potentially affecting epileptogenesis. Dr Ackerman emphasised Lacosamide’s efficacy, where clinical trials revealed a considerable reduction in seizure frequency compared to placebos, proving particularly effective

in cases of refractory epilepsy. Its appeal is augmented by a favourable side effect profile, where common issues such as dizziness and headache are primarily mild, and serious adverse effects remain rare. With excellent oral absorption, Lacosamide can be administered with or without food, maintaining an approximate half-life of 13 hours, supporting a convenient twice-daily dosing schedule. Of particular interest, Dr Butler discussed Lacosamide's expanding role within epilepsy treatment, especially as the use of sodium valproate wanes due to associated concerns in women of childbearing potential. He underscored

Lacosamide's integration alongside other preferred medications like Lamotrigine and Levetiracetam, particularly benefiting patients with both focal and generalised seizures.The webinar further explored Lacosamide’s practical application within paediatric populations, including neonatal use and hospitalised children, advocating for personalised treatment plans tailored to specific seizure types and individual patient needs. Notably, the challenge of distinguishing focal from generalised seizures and monitoring side effects, especially during medication combination, was addressed. Moreover, the discussion

highlighted the significant impact of sleep on seizure management, examined ongoing research into Lacosamide’s safety during pregnancy, and navigated the complexities of treating epilepsy in younger demographics. The panelists stressed the need for individualised therapies, considering factors beyond seizure control, such as mood, cognitive function, and drug interaction potential. Conclusively, the webinar painted Lacosamide as a promising anti-seizure drug, valuing its efficiency and safety while enhancing patients' quality of life, encouraging a personalised approach to epilepsy treatment.

Revolutionising diabetes care: The power of mobile health solutions

This webinar brought together experts Prof Fasanmade Olufemi Adetola and Dr Ankia Coetzee to discuss innovative approaches in diabetes care, aligning with the themes of World Diabetes Day.

To watch a replay of this webinar and still earn a CPD point, go to: https://event.webinarjam.com/go/ replay/868/6k0wkh5p9h3y1t9n9h6. Email john.woodford@newmedia.co.za to let him know to allocate your point/ request an attendance certificate for those who don’t fall under the HPCSA.

THE FOCUS WAS on using technological advancements to enhance diabetes management, particularly for underserved communities. This webinar was sponsored by Roche.

CASE STUDY: SARAH'S DIABETES MANAGEMENT

Dr Ankia Coetzee presented the case of Sarah, a 22-year-old student with type 1 diabetes, who struggles with maintaining her blood sugar levels. Despite her efforts, Sarah's HbA1c level was at 10%, indicating poor glycemic control. She experienced symptoms such as fatigue and weight gain, which pointed to defensive eating habits aimed at avoiding hypoglycemia. The discussion underscored the necessity for tailored insulin therapy, with particular attention to meal timing and carbohydrate consumption. The webinar suggested employing rapid-acting insulin to fit Sarah's

hectic lifestyle.

INSULIN'S ROLE IN DIABETES CONTROL

The presentation explained the functions of basal and prandial insulin. Basal insulin is crucial in maintaining stable glucose levels, while prandial insulin is used to manage blood sugar spikes after meals. Accurate carbohydrate counting and insulin administration timing are essential to prevent sugar level fluctuations. The MySugar app was showcased as a tool aiding in glucose tracking and insulin management, effectively demonstrated through Sarah's case study.

DIETARY MANAGEMENT AND INSULIN STRATEGY

Key strategies included understanding carbohydrate exchanges to permit diverse food selections without modifying insulin

doses, emphasising protein intake to handle hunger without substantially impacting glucose levels.

The panelists introduced the concept of correction doses to manage high glucose levels, advocating for personalised correction factors tailored to individual needs.

TECHNOLOGICAL ADVANCEMENTS IN DIABETES CARE

Prof Adetola delved into the advancement of diabetes care via mobile health solutions and telemedicine. The discussion highlighted a move from a generic approach to personalised medicine, leveraging artificial intelligence and continuous glucose monitoring (CGM) devices for real-time glucose tracking.

The importance of patient engagement in treatment planning and mobile app usage for progress monitoring was highlighted.

COMMUNITY AND LEGAL CONSIDERATIONS

The presentation acknowledged the significance of community support through social media for balanced dietary management while cautioning against overly restrictive diets. Legal concerns regarding data privacy and financial reimbursement for glucose monitoring technologies were addressed, reinforcing the imperative for healthcare systems to adapt to these innovations.

In conclusion, the webinar emphasised the transformative impact of technology on contemporary diabetes care. It highlighted the significance of individualised treatment plans and encouraged both patients and healthcare providers to adopt new methodologies to enhance health outcomes and the quality of life for diabetes patients.

Adobe Stock, Credit : Thares2020

The diagnosis of seasonal allergies

The following is an article summarising the key points from a webinar presentation led by Dr Carla van Heerden, a chemical pathologist who specialises in allergies. The session focuses on the diagnosis and management of seasonal allergies, particularly those induced by pollen. This webinar was sponsored by Thermo Fisher Scientific.

To watch a replay of this webinar and still earn a CPD point, go to: https://event.webinarjam.com/go/ replay/864/382q8clpoi2z9czvwt5 Email john.woodford@newmedia.co.za to let him know to allocate your point/ request an attendance certificate for those who don’t fall under the HPCSA.

THE WEBINAR BEGINS with a historical overview of allergies, covering major milestones and explaining the immune system's role in allergic reactions. It also distinguishes between allergies, immune deficiencies, and autoimmune conditions. Dr van Heerden elaborates on the classification of hypersensitivity reactions, referring to the modern nomenclature from the European Academy of Allergy and Clinical Immunology, which aids in patient management. She focuses on IgE-mediated allergies, particularly type 1 reactions, and discusses how environmental factors, such as climate change, influence pollen seasons.

This is especially pertinent in South Africa, where these factors are causing changes in the prevalence of allergies. A key resource mentioned is the South African Pollen Network, which monitors pollen levels and helps in understanding local allergenic plants. The presentation details the seasonal patterns of grass and weed pollen, noting that grass pollen peaks in October, and that humidity and rainfall play significant roles in pollen release. Recognising local flora, including common allergenic plants, is emphasised as crucial for effective allergy management. Diagnosis of seasonal allergies is a central theme of the presentation. It involves

a thorough clinical history and physical examination to identify allergens. Various testing methods, including skin prick tests and specific IgE tests, are discussed, each with its pros and cons. The importance of timely treatment and allergy testing to guide management strategies is highlighted. The webinar makes a distinction between true allergic disease and sensitisation, explaining that not all patients with positive IgE tests display clinical symptoms. It suggests specific IgE testing over total IgE testing, providing more relevant information about sensitisation and potential reactions. The concept of cross-reactivity in allergy testing is addressed, and the introduction

of allergy component testing is posited to improve personalised management. A case example illustrates how these concepts can be used to diagnose seasonal rhinitis. The presentation concludes with recommendations for diagnosing suspected seasonal allergies, stressing the need for tailored testing based on clinical history and regional pollen data. It discusses the role of multiplex testing for complex cases and the importance of interpreting test results in conjunction with clinical findings. Overall, the necessity of comprehensive allergy testing and thorough patient history is underscored for the effective diagnosis and management of seasonal allergies.

Secondary dry eye & diabetes

Dr Marsha Oberholzer an optometry expert, looked at the intricate connection between diabetes and secondary dry eye disease. This webinar was sponsored by Pharmaco.

To watch a replay of this webinar and still earn a CPD point, go to: https://event.webinarjam.com/login/ xq0nqamg5iz48bv8oc9s9. Email john.woodford@newmedia.co.za to let him know to allocate your point/ request an attendance certificate for those who don’t fall under the HPCSA.

ASTAGGERING 10% OF adults between the ages of 20 to 79 worldwide are affected by diabetes, a condition that significantly contributes to the rising incidence of dry eye disorders.

THE SCIENCE BEHIND THE SYMPTOMS

Dr Oberholzer explained that diabetes fosters chronic hyperglycemia and triggers diabetic neuropathy, impairing lacrimal gland function and disrupting tear dynamics, leading to the unpleasant symptoms of dry eye. Dry eye, as highlighted in the presentation, is a multifactorial disorder involving a tear film imbalance and ocular surface inflammation, which can manifest as either aqueous deficient or evaporative dry eye. Notably, diabetes often reduces corneal sensitivity and causes meibomian gland dysfunction.

Statistical data shared during the webinar underscored a strong correlation

between uncontrolled diabetes and increased dry eye symptoms, with evidence suggesting that up to 80% of patients with inadequately managed diabetes show signs of ocular dryness.

A CALL FOR COMPREHENSIVE CARE

The webinar emphasised the necessity for healthcare professionals to proactively assess and manage diabetic patients because they may suffer significant ocular surface damage despite minimal or absent symptoms. Clinicians are urged to conduct thorough evaluations and engage in conversations about potential risk factors for dry eye, adopting a holistic approach that considers both ocular and overall health.

Patient education was also identified as vital in managing dry eye, especially in those with diabetes. Dr Oberholzer advocated for educating patients on recognising symptoms such as redness, irritation, and environmental sensitivity,

recommending a preventive strategy that includes regular use of lubricating eye drops.

STEPS TOWARDS EFFECTIVE MANAGEMENT

A structured, four-step management process was proposed, starting from simple home-based treatments like artificial tears and lid hygiene to more advanced measures coordinated with ophthalmologists if needed. The discussion further shed light on the impact of increased screen time, which exacerbates dry eye symptoms by reducing blink rates.

CONCLUSION

The webinar served as a valuable platform for healthcare professionals to gain a deeper understanding of the complexities of dry eye in diabetic patients. By promoting a compassionate and comprehensive approach to care, it aimed to improve the

quality of life for these patients, offering them better health outcomes and greater comfort.

Managing treatment resistance in major depressive disorder

The recent webinar, featuring neuropsychiatrist Dr Anersha Pillay provided an insightful discussion on the management of treatmentresistant depression (TRD) within the larger scope of major depressive disorder (MDD).

To watch a replay of this webinar and still earn a CPD point, go to: https://event.webinarjam.com/go/ replay/870/8r8prbnqgfkvkuwn6so Email john.woodford@newmedia.co.za to let him know to allocate your point/ request an attendance certificate for those who don’t fall under the HPCSA.

THE SESSION WAS particularly aimed at GPs, to better equip them to handle TRD effectively before patients are referred to specialist care, and was sponsored by Accord.

Dr Pillay began by defining treatment resistance, explaining that 10%-30% of patients with MDD may experience it, and she stressed the global impact of MDD, which affects approximately 185 million people. The webinar highlighted results from the STAR-D study, illustrating the increased risk of suicide among TRD patients and how each unsuccessful treatment leads to diminished chances of response in subsequent trials. Emphasis was placed on the importance of early intervention, especially within the critical initial weeks of treatment. The concept of "difficult-to-treat depression" (DTD) was also introduced,

focusing on those who continue to suffer significant symptoms despite intervention.

Dr. Pillay advocated for a compassionate approach to management that prioritises improved patient functionality over mere symptom remission. Addressing various risk factors such as older age, comorbidities, family history of disorders, and early life trauma, she highlighted the necessity of thorough patient histories to tailor treatment strategies effectively.

Additional focus was given to the treatment of older patients and those with additional health conditions, covering specific symptoms they might display.

Dr Pillay talked about the influences on treatment resistance, including the chronicity of depression, recurrence, and the impact of anxiety and other chronic illnesses. She also touched on

crucial elements like the initial choice of antidepressants, the adequacy of dosing, and treatment duration, noting the risk of resistance from premature treatment cessation. She underscored the importance of building strong therapeutic relationships to foster medication adherence, addressing widespread issues like patients discontinuing their treatment regimens.

The psychosocial repercussions of untreated TRD, including isolation and family dysfunction, were discussed alongside the necessity for a structured approach to TRD management. This includes conducting diagnostic and treatment reviews and recognising the need for personalised care, evaluating medication effectivity, and being prepared to adjust treatment as needed.

Various treatment modalities were

explored, including medication adjustments, combination therapies, and supplemental treatments, with electroconvulsive therapy (ECT) highlighted as vital for managing TRD. Newer neuromodulatory treatments like transcranial magnetic stimulation (TMS) and deep brain stimulation were also discussed. Emerging treatments such as ketamine and psychedelics were considered, with a focus on the importance of educating patients and equipping them with selfmanagement tools.

In summary, the webinar offered a thorough look at the complexities and strategies for managing TRD, advocating for a patient-centred, collaborative approach. It emphasised the need for regular monitoring, teamwork across disciplines, and adhering to evidence-based practices to improve treatment outcomes.

Life after stroke: The journey towards recovery

The webinar presentation titled: Life After Stroke: The Journey Towards Recovery, was led by Dr Mohammed Khan, a neurologist specialising in stroke management. This webinar was sponsored by Pharmaco.

To watch a replay of this webinar and still earn a CPD point, go to: https://event.webinarjam.com/go/ replay/894/7worwh760s4w4tzw1fw. Email john.woodford@newmedia.co.za to let him know to allocate your point/ request an attendance certificate for those who don’t

THE SESSION OPENED with a definition of a stroke as a sudden disruption in the brain's blood supply, underscoring its impact as a leading cause of death and permanent disability globally. Dr Khan elaborated on the causes of stroke, noting that atherothrombosis is the predominant cause, and clarified the distinction between ischaemic and haemorrhagic strokes, with ischemic strokes being more prevalent. He underscored the value of organised stroke unit care, which significantly improves patient outcomes, and the criticality of rapid intervention

captured in the phrase 'time is brain'.

Regarding prognosis, the presentation highlighted the persistent disabilities that many stroke survivors face, affecting quality of life. It also noted the heightened risk of recurrence shortly after the initial event and the complications like post-stroke dementia. The variability in recovery was discussed, emphasising that while some patients regain functions, recovery can be unpredictable due to numerous influencing factors.

The presentation explored novel neurorehabilitation strategies aimed at leveraging brain plasticity to enhance

recovery. It mentioned ongoing research into non-invasive brain stimulation and experimental therapies, including Chinese herbal extracts MLC601 and MLC901, which hold promise for promoting neuroplasticity and neuroprotection. Management approaches discussed included the necessity of immediate intervention measures such as thrombolysis and thrombectomy and the importance of starting physiotherapy early poststroke. The session also covered the risks associated with these treatments, especially the potential transition from

ischemic to hemorrhagic strokes, and highlighted the need to manage vascular risk factors effectively.

Key takeaways included the critical role of MRI in stroke diagnosis, particularly in young females, and the greater incidence of strokes among those with renal vascular disease. The webinar concluded with a call to increase public awareness of stroke symptoms and the critical need for timely treatment to maximize recovery potential, while acknowledging the need for ongoing exploration of treatment options in clinical settings.

Adobe Stock, Credit : Thipphaphone

An overview of capitation reimbursement

We

HAT IS CAPITATION IN HEALTH?

Capitation in healthcare is a payment model where providers receive a fixed amount per patient over a set period, such as monthly or yearly. Providers deliver all necessary services to their assigned population, focusing on preventive care, chronic disease management, and costeffective treatments to improve outcomes and control costs.

Aligned with Value-Based Care (VBC), capitation emphasises quality and efficiency over service volume. However, economic incentives can influence physician behaviour, often increasing the use of ancillary services they own. Capitation can reduce hospitalisations and specialist visits but may risk underuse of quality monitoring for chronic illnesses. In this model payments are made prior to care delivery and are determined by the range of services provided, as well as average use of these services and the local cost of care.

[Independent Primary Care Practices Blog –April 10, 2024, Leona Rajaee]

STRATEGIES TO MANAGE CAPITATION REIMBURSEMENT

This reimbursement model covers only primary care services. Under a capitation agreement, a Primary Care Provider (PCP) agrees to deliver a set range of services, which may vary by plan.

Typical services include:

• Routine vision and hearing screenings

• Preventive, diagnostic, and treatment services

• In-office health education and counselling

• Injections, immunisations, and medications administered on-site

• Outpatient lab tests conducted in-office.

The specific services depend on the negotiated capitation rate. PCPs should avoid accepting services that impose excessive financial or clinical risk. Capitation contracts can mitigate risks with 'carveouts', excluding specific procedures or services from the basic contract and reimbursing providers for these separately. Clearly defining ICD-10 and CPT-4 codes in the basic contract is crucial to avoid

programs that unfairly shift financial risk to care providers.

SECONDARY CARE CAPITATION

Secondary care capitation creates a relationship between PCPs and secondary providers, who receive capitated payments based on the PCP’s enrolled membership. Secondary care services include radiology, diagnostic imaging, physical therapy, and other services not provided by PCPs.

GLOBAL CAPITATION

Global capitation reimbursement covers all services for a patient population. This fixed payment model allows providers to deliver patient-centred care in areas that lack primary care access.

CAPITATION AND SHIFTING THE LOCUS OF RISK

As physicians we need to manage several concurrent risks. Foremost is to manage the individual health risks of our patients. These risks could be associated with lifestyle, predisposition to illness or diagnosed conditions. We must prudently manage society’s healthcare resources and our own financial risks from personal and external decisions. Hence every physician reimbursement model poses different distribution of these risks: patient health risk, society’s financial risk and physician financial risk.

RISK

Capitation can increase patient health risks by incentivising reduced services and deferring care beyond the pre-payment period. However, it also encourages investment in preventive care and early treatment to lower long-term costs. Transferring financial risk to physicians creates a disincentive for managing complex or chronically ill patients.

RISK ADJUSTMENT: REDUCING

PHYSICIAN – FINANCIAL RISK

Risk adjustment poses a significant challenge in capitation models. Since capitation payments are based on average care costs, providers serving sicker patients may incur losses due to 'adverse selection,'

which can unintentionally incentivise withholding care. Risk adjustment is used to address predictable differences in the cost of care: age, gender, diagnosis (inpatient or outpatient) or health status information. Risk adjustment systems are intended to limit overpayment or underpayment for plan enrolees, resulting from health status differences. These risk adjusters still require protecting physicians from unpredictable high-cost illnesses.

STRATEGIES ADOPTED TO LIMIT RISK

1. Reinsurance: Typically covers the cost of care for a patient or group of patients whose cost exceed a specified amount.

2. 'Stop loss'

Stop loss clauses can be incorporated into capitation contracts to achieve the same goal by covering individual expenses beyond established thresholds.

3. Risk corridors:

Set limits on the dollar amount of risk or gain that may be experienced for individual patients eg 10% or 20% or below capitation payments. Unfortunately, many physicians who have these capitation contracts lack this basic protection.

DISEASE CARVE OUTS

Disease carve outs can be used to limit risk by narrowing the range of services covered under a capitated care contract.

With carve outs specific services (eg mental health, substance abuse) or care of specific disease conditions (eg AIDS, cancer, heart failure) are provided by designated providers under contract with the health plan or physician group.

CHALLENGES WITH CARVE OUTS

While sometimes beneficial, carve-outs can fragment care, weaken physicianpatient relationships, and discourage generalists from providing comprehensive care.

In the worst cases, carve outs become a tool to limit access by making the referral process awkward or inconvenient. [Goodson et al, The future of Capitation]

PANEL SIZE

Establishing the ideal panel size to accept risk is problematic.

Capitated payments to small groups or individual doctors, for most part violate the law of large numbers, whereby the low-risk individuals balance those of high risk.

To establish a 'safe' level of risk we need to weigh a number of factors:

• The type of practice [Primary Care or Specialty Care].

• The severity of illness and need for healthcare [The case mix].

• The scope of capitation [Risk for own services, hospitalisation expenses, specialty care].

• Level of stop loss coverage or reinsurance.

• The proportion of practice revenue covered by the contract.

• The historical variability in patient expenditure for the practice.

There are many elements affecting the structure of capitated compensation arrangements, each with different financial incentives, each exposing patients, society, and physicians to different risk.

Hence capitation quantum, risk adjustment, risk protection and quality and appropriate care delivered is a scientific process supported by relevant data.

Capitation offers opportunities to improve patient care despite concerns about its inherent conflicts and potential risks to patients and professionals. To optimise its implementation, the following proposals are recommended for physician groups:

1. Subspecialist reimbursement should reflect both patient encounters and administrative care management.

2. Reimbursement should account for access to subspecialist expertise alongside patient care.

3. Physician groups should accept financial risk only if equipped with adequate tools and resources.

4. Physicians sharing financial risk should meet regularly to address clinical care and resource management.

5. Physicians must disclose financial relationships with health plans and actively involve patients and communities in resource allocation discussions.

Prof Morgan Chetty, Visiting Prof: Health Sciences, DUT chairman, IPAF, CEO: KZNDHC

PLACEBO

Baby Thomas beats the odds

Remarkable premature birth outcome for resolute single mother.

I

T TOOK EIGHT rounds of in vitro fertilisation (IVF), four miscarriages, 75 days in hospital and a heartbreaking journey to premature birth for a brave and tenacious new mother to bring her baby home. A few months on, this committed parent can say with certainty – it was worth every moment. Tired of waiting for ‘the right guy’, Robyn Ireton decided to take her future into her own hands three years ago at the age of 37, opting to join the ranks of single mothers by choice, through sperm donation and IVF. “I could never have imagined just how long and hard the road would be, the pain my body and heart would endure or what my children would go through,” she says, reflecting on the tragic loss of baby girl Libby at 24 weeks and the premature birth of twin brother Thomas at 29 weeks.

Dr Nelis Pretorius, a gynaecologist and obstetrician practising at Netcare Blaauwberg Hospital, notes that pregnancies of multiple babies include a high risk for premature birth and while the hope was for Robyn to carry two healthy babies as close to term as possible, the focus shifted to keeping Thomas safe in the womb when Libby’s chance of survival diminished.

“Each of the babies had their own sac and placenta, which is not always the case with twins, as sometimes the sac and placenta are shared. When Robyn’s waters broke at just 18 weeks into the pregnancy, we quickly ascertained that it was only Libby’s sac that had burst. It would not be possible for Libby to survive outside the womb at this stage, and the chances of her sac repairing were negligible.

“At the same time, we were very concerned about Thomas and were trying to avoid his sac rupturing early too. Furthermore, with the first sac having broken, there was a risk of infection, which might have made it necessary to terminate the pregnancy completely and perform a hysterectomy as a last resort in the case of severe infection or sepsis to ensure Robyn’s safety. It was a challenging set of circumstances, and we had to take it step by step, but our aim was to try to see both babies through without jeopardising Robyn’s health,” says Dr Pretorius.

A HARD ROAD AHEAD

Knowing the risks, Robyn forged ahead. However, a few weeks later, she went into labour with Libby, who tragically passed away. “It was heartbreaking,” says Robyn. “Everyone had fought so hard for her, and losing her was devastating, but I am very fatalistic, and in a way, it’s like she sacrificed herself at that moment so that her brother could live because she left us without impacting Thomas’ chance at life.” Dr Pretorius explains that after Libby’s delivery, Robyn’s cervix closed again – a natural response enabling Thomas to remain safely undisturbed in the womb. He notes that a delayed interval between the delivery of twins is fairly uncommon and comes with its own set of challenges. In this case, Libby’s placenta had remained in the uterus, and Thomas was still at risk for premature birth, so Robyn remained in the hospital until the birth of her son so that they could be closely monitored.

When Robyn experienced some bleeding – a sign of possible early labour – she went on antenatal steroids, which have been proven to help with foetal lung maturity, prevent brain bleeds, and boost vital functioning and decrease infection in the gut of the newborn. According to Dr Ricky Dippenaar, a neonatologist practising at Netcare Blaauwberg Hospital, these steroids should ideally be administered between 24 hours and seven days prior to delivery. “The longer the antenatal steroids have to work, the better an unborn baby is prepared to transition to life outside the womb,” notes Dr Dippenaar.

SAFE DELIVERY

Robyn does not recall feeling any contractions on the day of Thomas’ birth, but she had experienced some bleeding, and during a check-up with Dr Pretorius, it transpired that she was already 7cm dilated. Her baby boy would soon arrive. At just 29 weeks old, Thomas was born and taken straight to the neonatal intensive care unit (NICU), where he was placed under the expert care of Dr Dippenaar and his multi-disciplinary team.

Despite a relatively quick labour, Robyn

experienced sudden blood loss shortly after the birth and was rushed to surgery by Dr Pretorius, who stresses that postpartum haemorrhaging is one of the top five causes of maternal death and requires immediate intervention. Fortunately, Robyn was able to receive life-saving surgery and blood transfusions in time.

“Dr Pretorius really fought for what I was trying to do and found solutions to the many challenges of my pregnancy and the birth. I felt incredibly supported by him and his colleagues at the hospital, obstetrician and gynaecologist Dr Sumaya Shah and Dr Dippenaar. Dr Lou Pistorius, a foetal specialist, also played a significant part in our journey. All the while, the nurses in Netcare Blaauwberg Hospital‘s maternity ward were my hospital family and helped keep me sane during my lengthy stay,” laughs Robyn. “They were amazing.”

Thomas spent two months in the NICU, where he grew from strength to strength until finally being discharged as a healthy, happy baby to go home with his mother at last, only returning to the hospital for routine check-ups with paediatrician Dr Sheilie Eloff. While Robyn’s journey to parenthood may be out of the ordinary, premature birth is common, and Dr Dippenaar advises expecting parents to be informed about what this can entail.

“Preserving life and boosting development are also significantly influenced by maternal breastmilk, which provides nutrients, growth hormones, and stem cells. New mothers can expect to express milk throughout the day to ensure continued access to this ideal source of nutrition for their babies. “While no outcome can ever be certain with premature birth, and the experience can be tough on parents, we are reminded every day of how strong the will to survive is, even in cases of extreme prematurity.

The role of the NICU is to provide medical intervention in a supportive capacity until such time as a baby is ready to go home, and we consider parents very much as part of the treatment team in getting to that happy stage,” concludes Dr Dippenaar.

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Thomas Ireton was born at just 29 weeks at Netcare Blaauwberg Hospital, with a delayed interval of five weeks after his twin sister Libby did not make it.

Robyn Ireton delivered baby Thomas at Netcare Blaauwberg Hospital where treating teams were able to provide the level of care needed by both mother and infant.

Robyn Ireton and baby Thomas are living proof of silver linings for those facing seemingly insurmountable challenges on the journey to becoming a parent. The two are now settled into a new rhythm of life together at their home in Cape Town.

Season's greetings

to our devoted readers (DRs) and your loved ones.

May you have a safe and happy festive season, as we welcome 2025 and all its possibilities