Medical Chronicle May 2024

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Dapagliflozin 5 mg; 10 mg 10/1000 5/1000 Dapagliflozin 5 mg; 10 mg Metformin hydrochloride 1 000 mg (extended release) TARGETED CARDIO-RENAL-METABOLIC PROTECTION¹ AN APPLE A DAY... Sagalatin 10mg & Synglutra 10mg/ 1000mg Now on Discovery Health Scheme Chronic Illness Benefit formulary2 S4 Reg. No. 53/21.2/0720, 0721. Sagalatin 5 / 10 mg. Each film-coated tablet contains dapagliflozin propanediol equivalent to 5; 10 mg dapagliflozin. S4 Reg. No. 53/21.2/0651, 0652. Synglutra 5/1000, 10/1000. Each film-coated tablet contains the equivalent of 5; 10 mg dapagliflozin (as dapagliflozin propanediol) and 1 000 mg of metformin hydrochloride. References: 1. Salvatore, T. et al., Int. J. Mol. Sci.2022,23(7), 365. 2. Discovery Health Medical Scheme 2024 Chronic Illness Benefit List. For full prescribing information, refer to the Professional Information approved by the medicine’s regulatory authority. References available on request. CIPLA MEDPRO (PTY) LTD. Co. Reg. No. 1995/004182/07. Building 9, Parc du Cap, Mispel Street, Bellville, 7530, RSA. Website: www.cipla.co.za Customer Care: 080 222 6662. [1345313200b] MED The doctor's newspaper Chronicle Impact of substandard and falsified medications in SA MAY 2024 www.medicalchronicle.co.za gettyimages Credit : chpua

MED

Chronicle

The doctor's newspaper

S Impact of substandard and falsified medications in SA

Substandard and falsified medications pose a significant threat to public health and economic well-being in SA.

According to the World Health Organization, 1 in 10 medical products sold in Africa are substandard or falsified.

UBSTANDARD AND FALSIFIED (SF) medications are a growing threat to public health globally, with devastating consequences. Head of Regulatory Compliance at the South African Health Products Regulatory Authority (SAHPRA), Daphney Mokgadi Fafudi explained that SF medications are either authorised but fail to meet quality standards (substandard) or deliberately misrepresent their identity, composition, or source (falsified). Often indistinguishable from genuine medications, SF products can be ineffective at best and harmful at worst, jeopardising patient safety, eroding trust in healthcare systems, and hindering economic growth. Fafudi was speaking at a recent webinar hosted by SAHPRA on Awareness of Substandard and Falsified Medications to get a better understanding of the impact in a South African context.

THE DEVASTATING IMPACT OF SF MEDICATIONS

“According to the WHO, 1 in

10 medical products sold in Africa are SF. When looking at global prevalence of SF medical products, Africa is leading with 40% prevalence,” Fafudi said. The prevalence of SF medications in SA has severe consequences for individuals and the healthcare system as a whole including:

• Ineffective treatment and worsened health outcomes: When patients unknowingly consume SF medications, they don't receive the intended treatment for their illnesses. This can lead to delayed diagnoses, worsened existing conditions, and even treatment resistance. For example, falsified antimalarial drugs can render malaria parasites resistant to effective medications, making the disease difficult to treat.

• Adverse health effects and increased mortality: SF medications may contain incorrect ingredients, fillers, or contaminants that can cause a range of adverse health effects, including allergic reactions, organ damage, and even death. In the absence of effective treatment, some illnesses can progress to lifethreatening stages..

• Antimicrobial resistance (AMR)

threat: Misuse of antibiotics due to SF versions exacerbates the problem of AMR. Ineffective antibiotic use breeds bacterial resistance, complicating future treatment. This poses a significant threat to public health, as common infections could become untreatable.

• Economic burden on individuals and the healthcare system: The spread of SF medications burdens the economy, leading to extra healthcare expenses from ineffective treatments and prolonged illnesses. Healthcare systems bear higher costs from treating complications and managing preventable illnesses due to SF medications. Legitimate pharmaceutical companies suffer financial losses due to counterfeiters, impeding investment in lifesaving drug research and development..

• Loss of trust in healthcare systems: SF medications undermine trust in healthcare systems and regulators, causing patients to delay care and treatment, worsening health outcomes.

• Unequal Impact on vulnerable populations: Low-income communities, lacking quality healthcare and reliable medication sources, bear the brunt of SF

medications. This exacerbates healthcare disparities and perpetuates cycles of poverty and ill health.

THE SOUTH AFRICAN LANDSCAPE: CHALLENGES AND VULNERABILITIES

Several factors contribute to the proliferation of SF medications:

• Weak legal framework and enforcement: Outdated legislation and limited resources within regulatory bodies hinder effective enforcement and prosecution of offenders involved in the trade of SF medications.

• Limited public awareness: Many people, particularly in rural communities, lack awareness about the dangers of SF medications and how to identify them. This makes them vulnerable to unknowingly purchasing and consuming harmful products.

• Porous borders and weak regional collaboration: Porous borders and limited collaboration with neighbouring countries create opportunities for smuggling SF medications across borders. Regional cooperation and harmonised regulations are crucial to address this challenge.

• Large informal market and cybercrime:

Joining forces in treating ocular inflammatory conditions

Dapagliflozin 5 mg; 10 mg 10/1000 5/1000 Dapagliflozin 5 mg; 10 mg Metformin hydrochloride 1 000 mg (extended release) TARGETED CARDIO-RENAL-METABOLIC PROTECTION¹ AN APPLE A DAY... Sagalatin 10mg & Synglutra 10mg/ 1000mg Now on Discovery Health Scheme Chronic Illness Benefit formulary2 S4 Reg. No. 53/21.2/0720, 0721. Sagalatin 5 / 10 mg. Each film-coated tablet contains dapagliflozin propanediol equivalent to 5; 10 mg dapagliflozin. S4 Reg. No. 53/21.2/0651, 0652. Synglutra 5/1000, 10/1000. Each film-coated tablet contains the equivalent of 5; 10 mg dapagliflozin (as dapagliflozin propanediol) and 1 000 mg of metformin hydrochloride. References: 1. Salvatore, T. et al., Int. J. Mol. Sci.2022,23(7), 365. 2. Discovery Health Medical Scheme 2024 Chronic Illness Benefit List. For full prescribing information, refer to the Professional Information approved by the medicine’s regulatory authority. References available on request. CIPLA MEDPRO (PTY) LTD. Co. Reg. No. 1995/004182/07. Building 9, Parc du Cap, Mispel Street, Bellville, 7530, RSA. Website: www.cipla.co.za Customer Care: 080 222 6662. [1345313200b] continued on page 2
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MAY 2024 www.medicalchronicle.co.za gettyimages Credit : chpua

The vast informal market, including physical stalls and online platforms, fosters the sale of SF medications. Additionally, cybercrime has led to fraudulent websites selling counterfeit medications, complicating consumers' ability to differentiate between genuine and fake products.

COMBATING THE THREAT: A MULTIFACETED APPROACH

Addressing the challenge of SF medications requires a multipronged approach:

• Education and awareness campaigns: Public education campaigns are vital for raising awareness about SF medication dangers. These should target healthcare professionals, patients, and the public, disseminating information on identifying SF medications.

• Strengthening legal frameworks and enforcement: Robust laws with precise definitions of SF medications and harsher penalties for involved parties are necessary. Effective enforcement with ample resources for regulatory bodies like SAHPRA is crucial to deter criminal activity and disrupt the supply chain.

• Multi-stakeholder collaboration: Collaboration between various stakeholders is critical to combat SF medications. This includes:

- Regulatory bodies: SAHPRA and other relevant authorities must collaborate with international organisations like the World Health Organization (WHO) to share best practices and intelligence on SF medications.

- Law enforcement agencies: Collaboration between police, customs officials, and regulatory bodies is crucial to investigate and dismantle criminal networks involved in the production and distribution of SF medications.

- Healthcare professionals: Doctors, pharmacists, and other healthcare professionals play a vital role in identifying and reporting suspected cases of SF medications to authorities.

- The pharmaceutical industry: Pharmaceutical companies can contribute by implementing robust quality control measures throughout the supply chain and collaborating with regulatory bodies to track and trace medications.

- Consumer organisations: Consumer protection organisations can advocate for stricter regulations and educate consumers about their rights regarding access to safe medications.

• Securing supply chain integrity: Robust tracking and tracing systems throughout the pharmaceutical supply chain is essential to prevent the infiltration of SF medications. This can involve using technologies like serialisation and barcoding to track medications from manufacturing to the point of dispensing. Additionally, strengthening quality assurance measures at all

stages of the supply chain can help to identify and prevent the distribution of SF products.

• Harnessing technology: Technological advancements can play a crucial role in combating SF medications. Examples include:

- Track and trace systems: As mentioned earlier, using serialisation and barcoding technologies can track medications throughout the supply chain, allowing for the identification of potential infiltration points for SF products.

- Mobile authentication tools: Smartphone applications can be developed to allow consumers to verify the authenticity of medications using unique packaging features or QR codes. This empowers individuals to make informed choices.

- Data sharing and analysis: Utilising data analytics tools can help regulatory bodies identify trends and patterns associated with the trade of SF medications, enabling them to target their interventions more effectively.

INTERNATIONAL COOPERATION: A UNITED FRONT

The fight against SF medications cannot be confined to national borders. SA needs to collaborate with neighbouring countries and international organisations to address this global problem. This includes:

• Harmonisation of regulations: Regional and international collaboration can harmonise medication regulations for manufacturing, distribution, and sale. This consistency would streamline efforts against SF medications worldwide.

• Intelligence sharing: Sharing information about criminal networks involved in the trade of SF medications between countries can help to disrupt operations.

• Joint Operations: Collaborative efforts between law enforcement agencies from different countries can be crucial in dismantling international criminal operations involved in the production and distribution of SF medications.

“The prevalence of substandard and falsified medical products poses a significant threat to public health and requires concerted efforts to address,” said Adesanya Oluwaseun Adedotun, Nigeria’s National Agency for Food and Drug Administration and Control. “By fostering a culture of drug awareness and advocacy for quality assurance in healthcare and understanding the risks and implementing proactive measures, we can safeguard patient safety, preserve trust in healthcare systems, and mitigate the economic impact of counterfeit medications.

Through education, vigilance, and collaboration, we can work towards a future where access to safe and effective medical products is a universal reality.”

Iodine-based dressings in burns

EAR DEVOTED READERS (Drs),

May is Burns Awareness Month.

In acknowledging this potentially devastating injury, we look at a critical aspect of wound care: the use of iodine-based products, particularly in the context of burns. Dr Ethel Andrews, South African Burn Society Past President and wound specialist, provides valuable insights into the complexities surrounding the use of iodine in burns.

The scenario presented shows the challenges clinicians face when treating burns, especially in infants. While iodine-based dressings have long been relied upon for their efficacy

in combating infection, Dr Andrews explains on the nuanced considerations that must accompany their use.

Key concerns regarding cytotoxicity, half-life, and frequency of changes are meticulously examined through available evidence and clinical experience. With comprehensive analysis, Dr Andrews shows the importance of aligning treatment decisions with the latest evidence and patient-specific factors.

Prof Morgan Chetty shares a thought-provoking piece on climate change. You might have noticed the topic cropping up at many medical conferences too. He argues that it is the greatest threat to humanity and that the entire foundation of good health is in jeopardy with the ever-increasing number of climate events.

Don’t miss out on our webinar announcements and ophthalmology CPD article. Find webinar replays, CPD articles and feature articles on www.medicalchronicle.co.za

Happy reading

CONTENTS All content in Medical Chronicle is sourced independently and under no circumstances should articles be considered promotional unless specified. Please note that all advertising is intended for healthcare professionals only. NEWS continued from page 1 MEDICAL CHRONICL E | May 2024 4 D NEWS Impact of substandard and falsified medications in SA 1 Elevating palliative care standards in SA 3 Immune-enhancing therapies to target TB 6 Global quest: Scaling up HPV vaccination to combat cervical cancer 7 Cardio-oncology: The new clinical field you can’t ignore 8 Change might be hard but electronic health records are fast becoming a necessary 12 SARS-CoV-2 mutation mystery solved 14 Widening private health access quicker than NHI 15 CLINICAL WEBINAR ANNOUNCEMENTS Parafengen IV: Unlocking synergy- fusing the power of paracetamol & Ibuprofen the ultimate blend for pain relief 13 Exploring Inflammatory Bowel Disease in children: Enhancing understanding of the disease and diagnostic testing 23 Can Mobile Health Improve Diabetes Management? A Review of its Effectiveness 26 PRACTICE MANAGEMENT The features and benefits of electronic scripting in GoodX Software 16 ONLINE CPD Joining forces in treating ocular inflammatory conditions 18 WOUND CARE The use of iodine in burns 19 WINTER AILMENTS The role of bronchodilators in managing airway disorders 21 The diverse advantages of acetylcysteine in respiratory health 30 OPHTHALMOLOGY Clinical review: Bacterial conjunctivitis management 22 Best practices to prevent and manage allergic conjunctivitis 34 SMOKING CESSATION E-cigarette use associated with increased risk of heart failure: Recent findings and implications 24 DERMATOLOGY Mitigating musculoskeletal side effects of isotretinoin 27 ENDOCRINOLOGY How do I broach obesity with my patients? 28 NEUROLOGY Autoantibody signature predicts MS 32 WEBINAR REPORT Recent advances in micronised bioidentical progesterone: Implications for obstetrics and gynaecology practice 35 Navigating overactive bladder treatment: A Comparative analysis of mirabegron and anticholinergics 35 Optimising Vitamin D Deficiency Management: Understanding the Superiority of Vitamin D3 36 Introduction into understanding and when to suspect MS in general practice 36 Obesity treatment: What patients want vs what we can provide 37 OPINION Climate change in Sub-Saharan Africa 38 PLACEBO Surviving the night of the hyena 39
MAY 2024

Elevating palliative care standards in SA

Hospice Week takes place from 5 – 11 May 2024. Annually, this week focuses on

N SOUTH AFRICA, The Association of Palliative Care Centres (APCC) is a member organisation for 91 palliative care centres, many of which call themselves hospices. In 2023, these members cared for 38 228 people. From this, 16 327 (41%) were patients and 21 901 (59%) were patient household members. The predominant diagnosis of patients was HIV/AIDS (37%), followed by cancer (25%), chronic illness (23%), Covid (12%), and TB (3%). Some patients had more than one diagnosis. ‘Our members adhere to the Standards for Palliative Healthcare Services,” says Dr Ewa Skowronska, CEO of the APCC.

“The APCC is the only organisation in South Africa that has developed accredited Standards for Palliative Healthcare Services. Since the release of the National Policy Framework and Strategy for Palliative Care,

there has been a mushrooming of Service Providers that are not accredited as palliative care Service Providers and that do not have the knowledge, skills, and experience to provide palliative care. The APCC is currently actively engaging with the public and private sector about the importance of integrating quality palliative care into all healthcare provision. It is a specialised skill and should be treated as one by all healthcare providers.”

To support members in gaining their accreditation, the APCC established a Mentorship Programme. The mentors (who are also members), take other

MEDICAL CHRONICLE | May 2024 5 NEWS
I
role the palliative care sector plays in healthcare. S0 ® FROM THE EXPERTS IN IRON TECHNOLOGY1-4 FERROUS FORTE® SOMAL - IT’S WHAT’S ON THE INSIDE THAT MATTERS References: 1. Ferrous Forte® Somal professional information, August 2022. 2. Ferrous Forte Tablets professional information, September 2021. 3. Kim HJ, Bae SH, Kim HJ, et al. Cytotoxicity, Intestinal Transport, and Bioavailability of Dispersible Iron and Zinc Supplements. Front Microbiol 2017;8:749. doi:10.3389/fmicb.2017.00749. 4. Data on file, iNova Pharmaceuticals. 2022. 5. Sucrosomial iron patent document. Scheduling status: S0 Proprietary name (and dosage form): Ferrous Forte® Somal Capsules. Composition: Each capsule contains: 24 mg elemental iron (from SunActive™ ferric pyrophosphate. SunActive™ is a registered trademark of Taiyo Kagaku Co., Ltd), 350 mcg folic acid (from Magnafolate™ C, a registered trademark of Lianyungang Jinkang Hexin Pharmaceutical Co., Ltd), 15 mcg vitamin B12, 60 mg vitamin C. Complementary Medicines: Health Supplements. This unregistered medicine has not been evaluated by the SAHPRA for its quality, safety or intended use. For full prescribing information, refer to the professional information available at www.inovapharma.co.za. Further information is available on request from iNova Pharmaceuticals. Name and business address of applicant: iNova Pharmaceuticals (Pty) Ltd Co. Reg. No. 1952/001640/07, 15E Riley Road, Bedfordview. Tel. No. 011 087 0000. IN/2257/24. F P F P F P P WHO: World Health Organisation Contains the smallest endosomal iron particles with 99 % bioavailability & no expected digestive system side effects 1,4,5 AWARD WINNING TECHNOLOGY ENDORSED BY THE WHO 23479L Ferrous Forte medical chronical 1/4 page advert R2.indd 1 2024/01/26 16:45
the
Burger
Tersia The APCC Mentorship Programme, empowers members through guidance and expertise. Duduza Hospice

Immune-enhancing therapies to target TB

New therapies could revolutionise TB treatment just as checkpoint inhibitors have in cancer.

EXPERTS ARE DELVING into innovative immune-enhancing therapies known as host-directed therapies (HDT) to harness the body’s immune system against tuberculosis (TB), even targeting drug-resistant strains. TB remains a significant global health concern, with 7.5 million new cases and 1.3 million deaths reported in 2022, including 410 000

cases of multidrug-resistant TB (MDR-TB).

Associate Professor Susanna Brighenti from the Karolinska Institutet, Sweden, emphasised the adaptability of Mycobacterium tuberculosis (Mtb) in evading immune responses, necessitating novel treatment approaches. While antibiotic treatments persist, their efficacy against TB, especially MDR-TB,

EPCLUSA® is indicated for the treatment of chronic hepatitis C infection irrespective of genotype in treatment naïve or treatment experienced patients aged 12 years and older and weighing at least 30 kg:

- without cirrhosis or with compensated cirrhosis

- with decompensated cirrhosis in combination with ribavirin 1

is limited, underscoring the urgent need for adjunct therapies.

“Mycobacterium tuberculosis (Mtb) have evolved a remarkable ability to manipulate the human immune response and undermine antimicrobial effector functions in host immune cells,” explained Prof Brighenti. “While some new antimicrobial therapies are coming through, treatment with

Proven cure ratec: 98,9 % in real-world analysis2,3

1 tablet once daily, with or without food, for 12 weeks1

Footnotes: aDespite unknowns in baseline characteristics of some patients, such as: HCV genotype, fibrosis stage, former/current IV drug use, PPI use at baseline and treatment history.3 bA large-cohort international real-world study showed that patients with unknown genotype (n = 42), unknown fibrosis score (n = 82) and unknown treatment history (n = 33) were cured with EPCLUSA® for 12 weeks. Cure is defined as SVR i.e., undetectable HCV RNA after treatment completion.3,4 Cases of HBV reactivation, some of them fatal, have been reported during or after treatment with direct acting antiviral agents including EPCLUSA®. HBV screening should be performed in all patients before initiation of treatment. Treatment with EPCLUSA® should not be initiated in patients who screened positive for hepatitis B virus infection. HBV/HCV coinfected patients are at risk of HBV reactivation, and should therefore be monitored and managed according to current clinical guidelines. dPatients with decompensated cirrhosis use EPCLUSA® + ribavirin for 12 weeks.

References: 1. Epclusa Professional Information approved by the medicine’s regulatory authority. 10 March 2022. 2. Lawitz E, Bourliere M, Han L, McNally J, Stamm LM, Brainard DM, et al. Treatment with SOF/VEL or SOF/VEL/VOX is well tolerated and results in high SVR12 in genotype 1-6 HCV-infected patients with minimal fibrosis: a retrospective analysis of the ASTRAL and POLARIS clinical studies. Poster THU-273 presented at the International Liver Congress 2017, April 19–21, Amsterdam, The Netherlands. Available at: https://www.natap.org/2017/EASL/EASL_07.htm

treatment: Analysis of 5552 patients from 12 cohorts. Liver Int 2020;40:1841–1852. 4. National Guidelines for the Management of

antibiotics remains an intensive and long process even for drug-susceptible forms of the disease. Importantly, mutations conferring antibiotic resistance are intrinsic properties of mycobacteria that effectively develop resistance to old as well as new groups of antibiotics, accentuating the need for adjunct treatments. Thus, new treatments are going to be vital in the battle against TB.” Host-directed therapies (HDTs) aim to bolster the immune response against TB, targeting infected cells to enhance antimicrobial functions rather than directly inhibiting bacterial growth.

Research led by Prof Brighenti has explored the use of histone deacetylase (HDAC) inhibitors to boost immune defences. These compounds enhance the expression of antibacterial proteins, reducing Mtb growth within immune cells by up to 75% even without antibiotics. Combining these immunomodulatory compounds with antibiotics could potentially improve treatment outcomes and reduce dosage and duration.

“These drugs can regulate transcription of genes in cells such as those in the immune system, and thus enhance the expression of proteins associated with the antibacterial host defence. We have identified several HDAC inhibitors that reduce Mtb growth inside immune cells by some 50%-75%, even in the absence of antibiotics,” she explained. “That may not sound so impressive, but these immunomodulatory compounds could work well as a complement to standard therapy and exert additive or synergistic effects together with the antibiotics. This would provide the possibility to reduce the dose and treatment length required with antibiotics to improve patient outcomes.”

Implementing immunotherapy alongside standard TB treatment could revolutionise patient care, analogous to its success in cancer and autoimmune diseases.

Prof Brighenti said, “Implementation of immunotherapy as a complement to standard therapy has revolutionised the treatment of cancer, autoimmunity, and asthma/allergy. Similarly, our research on immune enhancement as a complement to antibiotics may become a game-changing treatment option for patients with TB that has the potential to impact clinical management and prevent spread of TB infections and drug resistance in this pivotal moment in our history when antimicrobial resistance constitutes a serious threat to human health.” TB treatment should be personalised based on sub-group classifications, rather than adopting a uniform approach. Tailored treatments optimised for each patient will shape the future of TB management. By exploring immune-enhancing therapies alongside conventional treatments there is hope for improved outcomes and reduced drug resistance in the fight against TB.

NEWS 8 May 2024 | MEDICAL CHRONICLE
[Accessed 24 March 2022]. 3. Mangia A, Milligan S, Khalili M, Fagiuoli S, Shafran SD, Carrat F, et al. Global real-world evidence of sofosbuvir/velpatasvir as simple, effective HCV
Health Republic of South Africa
https://sahivsoc.org/Files/SA%20 NDOH_Viral%20Hepatitis%20guideilnes%20final_.pdf [Accessed 10 March 2022]. For full prescribing information refer to the professional information approved by the Medicines Regulatory Authority. S4 EPCLUSA® 400 mg/100 mg film-coated tablets. Reg. No.: 51/20.2.8/0872. Each film-coated tablet contains 400 mg sofosbuvir and 100 mg velpatasvir. Gilead Sciences South Africa (Pty) Ltd., Reg No.: 2014/063761/07, Ground Floor Mac Mac Building, Maxwell Office Park, Magwa Crescent, Waterfall. (Tel: +27 10 346 1920). For any adverse events, please contact: Safety_FC@ gilead.com or drugsafetysouthafrica@gilead.com | EPCLUSA® the EPCLUSA® Logo, GILEAD and the GILEAD Logo are trademarks of Gilead Sciences, Inc. or its related companies. All other trademarks referenced herein are the property of their respective owners. ©2023 Gilead Sciences, Inc. All rights reserved. Date of preparation: 02/2023 Job code: ZA-EPC-0022 HAVE CONFIDENCE IN CUREb WITH EPCLUSA®1,2,3 PRESCRIBING WITH CONFIDENCEa,b,c 1,2,3
3
liver disease
Viral Hepatitis. Department of
Available at:
Pan-genotypic and pan-fibroticb,d
Suitable for patients with various levels of
severityb,d 2,3
Abbreviations: HCV = Hepatitis C Virus; RNA = Ribonucleic acid; IV = Intravenous; PPI = Proton pump inhibitor; SVR = Sustained virological response; HBV = Hepatitis B virus. 1232 03/23 1232 Epclusa Advert_A4_2023_MedChron.indd 1 12/04/2023 16:12

Global quest:

Scaling

up HPV vaccination to combat cervical cancer

Even though evidence is clear and continues to build that HPV vaccination is reducing cervical cancer incidence and mortality and HPV-related disease, there are high variations in coverage globally.

WITH THE ADVENT of safe and effective vaccines against human papillomavirus (HPV) in the early 21st century, the World Health Organization (WHO) set an ambitious goal to reduce cervical cancer incidence and mortality by 30% by 2030. This initiative entails vaccinating 90% of girls by age 15, ensuring 70% of women undergo high precision screening tests by ages 35 and 45, and ensuring 90% of women needing treatment receive it. Despite these targets, no country has yet been verified as reaching them, with the ultimate aim of achieving a cervical cancer incidence of less than four cases per 100 000 women annually, thereby eliminating it as a public health threat.

Prof Suzanne Garland, president of the International Papillomavirus Society and a leading expert from the University of Melbourne, Australia, highlighted at the recent ESCMID Global Congress that HPV vaccination significantly reduces cervical

cancer incidence, mortality, and related diseases like genital warts and precancers. However, there are high variations in coverage globally including between high-income countries that can easily afford the vaccines, while many lowand middle-income countries are yet to include this vital tool in their national vaccination programmes.

While emphasising the importance of high HPV vaccine coverage, especially among girls and boys before exposure, Prof Garland stressed the necessity of complementary prevention measures like condom use, sex education, male circumcision, and tobacco control. She cited WHO Dashboard data indicating that 71% of reporting countries have HPV in their national vaccination programmes, with varying degrees of coverage. Globally, 21% of girls have received at least one dose of the HPV vaccine by age 15, steadily increasing from

4% in 2010, albeit with a brief drop during the Covid-19 pandemic.

Notably, Australia has achieved outstanding vaccination coverage, with reductions in HPV prevalence and aims to eliminate cervical cancer as a public health threat. However, global disparities persist, with countries like Japan facing challenges due to negative media coverage and governmental hesitancy.

In high-income countries, vaccination coverage ranges widely, with countries like Canada, Ireland, Sweden, Spain, and Portugal surpassing 70%, while others like the USA and Germany lag. France, with historically low vaccine acceptance, is steadily improving, while Denmark experienced a temporary decline in coverage due to negative media influence.

Evidence from multiple studies supports the efficacy of HPV vaccination in reducing HPV infections and related diseases. Vaccination before sexual debut

is crucial, as it prevents infection but does not treat established infections. Moreover, vaccinating girls confers herd immunity, protecting even unvaccinated individuals, particularly men.

Efforts to boost HPV coverage globally include the adoption of single-dose regimens in 51 countries, particularly effective in younger age groups. However, challenges such as vaccine competition, pricing, political will, and logistical issues persist, exacerbated by global events like wars and pandemics.

Prof Garland concluded that HPV vaccination is vital for eliminating cervical cancer and reducing HPV-related diseases globally. Scaling up vaccine access and coverage is crucial to addressing disparities within and between countries, with success stories like Malaysia demonstrating that even low- and middle-income countries can overcome obstacles to achieve high coverage rates.

MEDICAL CHRONICLE | May 2024 9 400 mg paracetamol 8 mg codeine phosphate 200 mg meprobamate • Effective multimodal combination2 eaks the pain/anxiety cycle1,3,4 Delivers effective opioid-sparing analgesia1 C M Y CM MY CY CMY K NEWS
gettyimages Credit : Teka77

Cardio-oncology

The new clinical field you can’t ignore

I recently interviewed the top experts in the world on cardiology and oncology: Dr Alexander Lyon, chair of the ESC Cardio-Oncology Council; Prof Susan Dent, president of IC-OS and Dr Trishun Singh, SA’s first cardio-oncologist and president of the Cardio-Oncology Society of Southern Africa (COSOSA).

HERE IS WHY these two important specialties are fundamentally linked in a new clinical field.

There is a tsunami of new cancer drugs, which are curing people. However,

many of these lifesaving cancer therapies are associated with an increased risk of cardiovascular toxicity. The goal is to provide the optimal cancer therapy without compromising cardiovascular health.

“Cancer is so common. If you are a cardiologist in SA, you will see cancer patients, whether you choose to or not,” said Dr Singh. The FDA approved 207 cancer drugs between 2016 and 2021 in

oncology and malignant hematology. While the speed of drug development is great, and we are making important advances in the treatment of many cancers, many of these drugs are associated with cardiovascular toxicity.

“Cancer drugs and radiotherapy are fantastic at curing cancer, like never before. At the diagnosis of cancer, these patients think it is a death sentence. They don’t know or ignore all the other comorbidities,” Dr Singh said. “We have a massive problem in SA that these patients are developing cardiac issues, and their symptoms are subtle. One must be aware and listen to the patient very carefully, as to what they are presenting with. They might say: ‘I’m tired, I have palpitations, I don’t know why my ankles are swelling’. This is often mistakenly attributed to their cancer.”

“A lot of oncology uses a personalised approach and precision medicine. In a way, this is the same approach, to the toxicities. This doesn’t mean that everyone will experience cardiac issues, but it is about identifying who is at high risk and personalising and tailoring to the high-risk group, but also reassuring the low-risk group that they are low risk,” Dr Lyon added.

“My experience in SA is that the oncologists, cardiologists and haematologists may not be aware of the ESC cardio-oncology guidelines and that the very drugs that they are using to cure someone can lead to various cardiovascular problems,” Dr Singh said.

Dr Lyon added that cardiac problems can lead to the cancer treatment being stopped, and the cancer progressing. “We want people to have the most effective cancer treatment, safely,” he said. Another factor is that cancer treatments are extremely expensive. If treatment must be stopped because of cardiovascular (CV) issues and then started again, this contributes to the cancer cost. Heart treatments are also costly. “If you cure someone of cancer and then they go on to get heart disease from the cancer treatment that is also costly to society and the health system. Investing early in the prevention approach will save a lot of money across the board,” Dr Lyon stated. “Patients of today have done their research and know about the cardiac risks, but one has to help support their concerns and anxieties about the risks, by doing an assessment,” he explained.

CARDIO-ONCOLOGY’S BACKGROUND

The International Cardio-Oncology Society (IC-OS) started as a small organisation and is now 15 years old. Over the last 10 years, many countries around the world have established a national cardio-oncology programme and become associated with

NEWS 10 May 2024 | MEDICAL CHRONICLE
Claire Rush McMillan, editor

IC-OS. COSOSA was formed in 2019 by Dr Trishun Singh, whose interest in cardio-oncology started almost a decade ago. “If we look at the two diseases that drive morbidity and mortality in Southern Africa, it is ischaemic heart disease and cancer,” he said. He explained that the two diseases can be described as running parallel to each other, both being associated with advanced age.

“Every now and again I would get a referral from an oncologist to do a cardiac assessment on a patient if they were going to use anthracyclines or trastuzumab. This was because the package insert said there were cardiovascular effects. So, you had to ‘tick the box’ in checking the patient. Those were the early days of not understanding what this field was about. I wondered if anyone in SA was involved in the field, only to discover, surprisingly, that no one was involved in cardio-oncology.

“In 2019, I established COSOSA with the aim of upskilling and educating our oncologists, haemotologists, cardiologists, and primary care doctors as to what cardio-oncology is all about. This is not an easy task. People are set in their ways. This is compounded by a large number of the population (51 million people) with no medical insurance. However, people were dying, and we had to start somewhere. This was my aim in starting COSOSA.”

COSOSA is affiliated to IC-OS, which has over 30 country chapters, and SA is one

of them. Dr Singh encourages every doctor involved in cancer care to become members of COSOSA. It is free and is also affiliated to IC-OS.

“In doing this, they will be exposed to the literature, programmes, and meetings. You can’t practice cancer care without being a member of IC-OS. It is important that at primary care level, GPs, haematologists, cardiologists, and oncologists must be members of IC-OS. They will receive all the material and education that they need.

“As cardiologists, we did not deal with cardio-oncology in our training. It is a new field that is gaining interest,” Dr Singh said.

In 2025, SA will be hosting the Global Cardio-Oncology Summit, to be held in Cape Town.

THE ROLE OF THE GP

Dr Lyon explained that when a patient is diagnosed with cancer, this becomes the focus for the oncologist and patient. However, we need to think about other factors, such as cardiac health, throughout the patient’s cancer journey.

The oncologist is focused on managing the cancer. However, the GP or primary care doctor has a big role to play in monitoring these patients all the way through their cancer. A lot of the cardiac symptoms can be subtle, such as fatigue and breathlessness.

According to Prof Dent, the primary care physician can help with optimisation of the

underlying CV risk factors, even at the start of cancer treatment, such as blood pressure, cholesterol, and diabetes. “Oncologists don’t have the time, and often the expertise, to manage these conditions. They are focused on treating the cancer, so we can’t expect them to manage a patients comorbidities,” she commented.

be in large academic, tertiary care centres. “One of the challenges we face is how can we provide cardio-oncology care in the community, where the majority of cancer care is delivered. The expanding field of cardio-oncology will need to focus on bringing care to the patient and not the patient to the care,” she said.

“Ascardiologists,wedidnot dealwithcardio-oncologyinour training.Itisanewfieldthatis gaininginterest,”DrSingh

Dr Singh explained that patients go to their primary doctor first. The primary care doctor needs to be educated as to what issues may occur in cancer treatment. “They have a huge role in assessing patients before they even start their treatment, during treatment and after treatment,” he emphasised.

A MINDSET SHIFT

According to Prof Dent, there needs to be a shift among oncologists. They have traditionally been reactive, waiting until a patient with cancer develops heart failure or severe hypertension, and then consult a cardiologist. This mindset needs to shift to: we are exposing a patient with underlying risk cardiovascular risk factors (eg hypertension) to a cardiotoxic cancer therapy – we should be thinking about assessing an individual’s risk of developing cardiovascular toxicity prior to starting cancer treatment .

“Medicine tends to have a siloed approach to care. We need to move from a disease-centric approach to a person-centric approach. This involves communication, collaboration and working together as teams (oncologist, cardiologist, primary care provider, nurses) to improve the health of an individual. This is good in theory, but implementation can be challenging when systems are set up to be in silos,” she said.

Prof Dent explained that there are now many cardio-oncology clinics in different parts of the world, however they tend to

A WARNING

“If people are diagnosed with cancer, they will google. What will come up is cardiooncology, and cardiac assessment. I am finding this in my practice already. I would hazard a guess that very soon, when patients do develop serious CV issues and they succumb to it, the families are going to ask why they were not referred for a CV assessment.

CONCLUSION

“We have a dilemma. If you are going to be using drugs that cause CV problems, you need to be aware of it. You also need to make your patients aware of it and give them the right kind of advice. You need to manage the patient from the outset before you start treatment. This is what is lacking. I am seeing patients with advanced CV problems which can be irreversible, if not picked up early. So, the patient survives the cancer but succumbs to CV problems. This can be mitigated with appropriate therapy if the issue is picked up early and action is taken,” Dr Singh said.

Most cardiac, oncology and haematology societies throughout the world have supported and recognised this new field, and so should we.

RESOURCES:

2022 ESC Guidelines on Cardio-Oncology: https:// doi.org/10.1093/eurheartj/ehac244

IC-OC website: https://ic-os.org/new/ COSOSA website: https://cososa.org.za

NEWS MEDICAL CHRONICLE | May 2024 11
gettyimages Credit : mi-viri
Prof Susan Dent, president of IC-OS, Dr Trishun Singh, SA’s first cardio oncologist and president of the Cardio-Oncology Society of Southern Africa (COSOSA), and Dr Alexander Lyon, chair of the ESC Cardio-Oncology

Clinician Guide to the ABCs of Primary and Secondary Prevention of Atherosclerotic Cardiovascular Disease1

Atherosclerotic cardiovascular disease (ASCVD), composed primarily of coronary artery disease (CAD), cerebrovascular disease (CeVD) and peripheral artery disease (PAD) is a major component of cardiovascular disease (CVD).2 CVD is a major cause of disability and premature death throughout the world.3 Indeed, more people die each year from cardiovascular diseases (CVDs) than from any other cause.4 Furthermore, over three quarters of heart disease and stroke-related deaths occur in low and middle-income countries.4

THE DEVELOPMENT OF CVD is influenced by several modifiable risk factors including: 4

Continued exposure to these risk factors leads to progression of atherosclerosis, resulting in clinical manifestations of ASCVD such as angina pectoris, myocardial infarction, heart failure, stroke, and peripheral artery disease. However, risk factor modification can reduce clinical events and premature death both in people with established ASCVD as well as in those who are at high risk of ASCVD due to one or more risk factors.3 Therefore, attempts to prevent or reduce modifiable risk factors can reduce the burden of ASCVD, making it an attractive target for preventative measures. 2 Prevention has, in fact, played a pivotal role in the reduction in ASCVD morbidity and mortality seen over the last three decades. 2 Current approaches to prevention of ASCVD involve two categories of prevention for two categories of patients3:

• Primary Prevention

• People with risk factors who have not yet developed clinically manifest CVD

• Secondary Prevention

• People with established ASCVD viz.: CAD, CeVD or PAD.

Additionally, a critical step in the current approach to prevention of ASCVD is risk assessment which involves estimating a patient’s 10-year risk of an ASCVD event. 2 Knowledge of the 10-year risk for ASCVD events enables clinicians to target those who will benefit most from risk-reducing therapy. 2 This risk assessment is carried out using ASCVD Risk Estimator tools of which there are multiple available including: Framingham Risk Score, which predicts 10-year risk of MI or CAD-related death. 2

• 2013 ACC / AHA prevention guidelines (pooled cohort) ASCVD Risk Estimator which predicts the 10-year risk and lifetime risk of an ASCVD event (coronary death, MI, stroke). This pooled cohort risk assessment tool incorporates the same traditional elements of the Framingham Risk Score but includes a mechanism for predicting lifetime risk, which, when elevated, warrants early aggressive lifestyle and risk factor modification, even when the 10-year risk may not. 2

RISK ASSESSMENT

The first step in prevention is to assess a patient’s 10-year risk of having an ASCVD event using a validated ASCVD Risk Estimator Tool. This will facilitate the identification of those who will benefit most from risk-reducing therapy. Risk Assessment for Primary Prevention Risk assessment in primary prevention involves those patients with risk factors who have not yet developed clinically manifest CVD. The American College of Cardiology / American Heart Association (ACC / AHA) risk assessment guidelines recommend that5:

• Adults aged 20 to 79 years old should have risk factors assessed at least every 4 to 6 years for primary prevention.

• Adults aged 40 to 79 years should have a 10-year risk estimation done using the pooled cohort risk assessment tool.

• Younger adults aged 20 to 59 years at low 10-year risk should be considered for 30-year or lifetime ASCVD risk assessment.

RISK ASSESSMENT

These guidelines make further recommendations regarding situations where quantitative risk decisions remain uncertain even after risk estimation. In such situations, it is recommended that additional factors be considered, which includes coronary artery calcium (CAC) scoring. CAC scoring as measured by noncontrast cardiac computed tomography is the most predictive test of CVD risk in those for whom the decision to start a statin is still uncertain. 2

Risk Assessment for Secondary Prevention

Risk assessment in secondary prevention involves those with established ASCVD or very high levels of individual risk factors but is much more straight-forward. In this

group of patients, risk assessment is not necessary for making treatment decisions because they are considered to already be at a high risk of ASCVD. They are all recommended for aggressive lifestyle interventions, and furthermore the benefits of pharmacotherapy (i.e.: aspirin, statin) are well established in this group of patients.1,2

Clinician Guide to the ABCs of Primary and Secondary Prevention of Atherosclerotic Cardiovascular Disease1

The ABCDEs of cardiovascular disease prevention was first proposed in 2001 as a simple template to address the key components of risk factor modification. The “Clinician Guide to the ABCs of Primary and Secondary Prevention of Atherosclerotic Cardiovascular Disease” is an update of these prior papers.1, 6, 7 It is a template for clinicians to address the key components of risk factor modification in the primary and secondary prevention of CVD. It is a structured approach intended to identify patients at a high risk for CVD and to provide appropriate lifestyle and pharmacological interventions in a time constrained busy clinical practice. The recommendations are based on updated guidelines. The initial step in prevention is the assessment and estimation of an individual’s 10-year risk of having an ASCVD event in order to identify high risk patients. This is followed by appropriately addressing the key components of risk factor modification in the ABCDEF flow format as summarised next.

ASSESS RISK:

Primary Prevention

• Assess all adults for risk factors at least every 4 – 5 years, starting from the age of 20 years.

• For asymptomatic adults aged 40 – 79, not already on a statin:

- Apply a CVD Risk Estimator (pooled cohort equation or similar alternative such as Framingham Risk Score), to estimate the 10-year risk of having an ASCVD event.

• Some patient groups are often at a higher risk than predicted, including:

- Those with HIV or chronic inflammatory disorders.

- Women with a history of preeclampsia, pregnancyinduced hypertension, polycystic ovarian syndrome and / or gestational diabetes.

• When risk-treatment decisions are still uncertain after risk assessment, consider the use of coronary artery calcium (CAC).

• For Adults aged 20 – 59 years with a low 10-year risk, estimate the 30 year or lifetime risk for ASCVD.

Secondary Prevention

• Aggressive comprehensive risk factor modification if known or established ASCVD:

- Coronary artery disease

- Cerebrovascular disease

- Peripheral artery disease.

ANTIPLATELET THERAPY

• Consider aspirin 81 mg / day if:

- 10-year ASCVD risk estimate is ≥10 %, and

- Potential benefit outweighs bleeding risk after clinicianpatient risk discussion.

Secondary Prevention

• Aspirin 81 – 162 mg/day indefinitely.

• If PCI was performed after ACS event Aspirin plus clopidogrel, prasugrel or ticagrelor (ie P2Y12 Inhibitor) as follows:

- If bare metal stent, P2Y12 inhibitors should be taken for ≥1 month

- If drug-eluting stent, P2Y12 inhibitors should be taken for ≥1 year

- If on dual antiplatelet therapy (DAPT), use aspirin 81 mg/day

• If no PCI was performed after an ACS event, use either clopidogrel or ticagrelor

• Do not use prasugrel if history of stroke or TIA. Caution in those over 70 years of age

• Aspirin 81 mg to 325 mg/day or clopidogrel for all patients following a non-cardioembolic ischaemic stroke.

ATRIAL FIBRILLATION

Primary Prevention

• Control and prevention of risk factors for:

- Hypertension

- Obesity

- Diabetes mellitus

Secondary Prevention

• Warfarin or direct oral anticoagulant (DOAC) for CHA2DS2-VASC ≥ 2*8

• Aspirin if CHA2DS2-VASc ≤

• Consider rhythm control

BLOOD PRESSURE

Primary Prevention

• Lifestyle interventions:

- Exercise, diet, weight management, smoking cessation

- Limit alcohol consumption:

- Male ≤ 2 drinks per day

- Female ≤ 1 drink per day

Secondary Prevention

• BP goal < 130/80 mmHg

• Pharmacotherapy according to guidelines:

- May start with lifestyle changes depending on:

- Stage of hypertension, and

- ASCVD risk estimate:

- If ASCVD risk estimate < 10 %, can start with lifestyle changes alone.

CHOLESTEROL

• Lifestyle interventions:

- Exercise, diet, weight management, smoking cessation

- Limit alcohol consumption:

- Male ≤ 2 drinks per day

- Female ≤ 1 drink per day

• Patients aged 40 – 75 years with diabetes mellitus and LDL-C: 70 - 189 mg/dL (1.8 - 4.8 mmol/L), but without clinical ASCVD:

- If 10-year ASCVD risk ≥ 7,5 %: high intensity statin therapy

- If 10-year ASCVD risk < 7,5 %: moderate intensity statin therapy.

Primary Prevention

• Patients with primary elevations of LDL-C: ≥ 190 mg/ dL (4.9 mmol/L):

- High or moderate intensity statin therapy

• Consider moderate to high intensity statin therapy after risk discussion with patient if:

- ASCVD risk estimate is ≥ 7,5 %

- If still uncertain after risk assessment and discussion, consider use of CAC scan if risk estimate is between 5 – 20 %

- Factors supporting statin use if risk decision is uncertain:

- LDL-C ≥ 160 mg/dL (4.1 mmol/L)

- Family history of premature ASCVD

- High lifetime ASCVD risk

- Presence of CAC – especially if > 75th percentile for age / gender or absolute score ≥ 100.

Secondary Prevention

• Lifestyle interventions

• Moderate to high intensity statin therapy for patients with:

- Clinical ASCVD (acute coronary syndromes, MI, stable or unstable angina, coronary or any other arterial revascularization, stroke, TIA, or PAD).

- Unless NYHA Class II – IV heart failure or receiving haemodialysis.

• If after trial of highest tolerated dose of high-intensity statin:

- LDL-C ≥ 70 mg/dL (1.8 mmol/L), non-HDL-C ≥100 mg/dL (2.5 mmol/L) and high risk for another ASCVD event, then

- Consider Ezetimibe and / or PCSK9 Inhibitors.

• If triglycerides > 500 mg/dL then consider fibrates and / or high dose omega 3.

CIGARETTE / TOBACCO CESSATION

Primary and Secondary Prevention

- Education

- Assessment of triggers and counselling

- Pharmacotherapy (nicotine patches, varenicline,

CLICK to link to the full article

bupropion)

DIET / WEIGHT MANAGEMENT

Primary and Secondary Prevention

- If overweight, aim for loss of 3 – 10 % of body weight by caloric restriction and increased physical activity as part of a comprehensive lifestyle programme.

- Goal BMI: 18,5 – 24,9 kg/m2

- Goal waist circumference:

- Male : < 94 cm

- Female : < 80 cm.

DIABETES: PREVENTION AND TREATMENT

• Lifestyle Interventions:

- Exercise, diet, weight management, smoking cessation

- Limit alcohol consumption

- Male ≤ 2 drinks per day

- Female ≤ 1 drink per day

• Treat elevated cholesterol as outlined above

Secondary Prevention

• Lifestyle interventions

• Nutritionist

• Anti-hyperglycaemics as per guidelines

• Treat hypertension if present

• Treat elevated cholesterol.

EXERCISE

Primary and Secondary Prevention

• Controlled cardiac rehabilitation for patients who have had an ASCVD event or heart failure with reduced ejection fraction (LVEF ≤ 35%)

• Moderate to vigorous aerobic exercise for a total of at least 150 minutes per week:

- eg: 30 minutes, five sessions per week, or

- Another reasonable target based on baseline activity.

HEART FAILURE

Primary Prevention

- Treat heart failure risk factors

- Lifestyle Interventions:

- Exercise, diet, weight management, smoking cessation

- Limit alcohol consumption:

- Male ≤ 2 drinks per day

- Female ≤ 1 drink per day

- Hypertension, diabetes mellitus, dyslipidaemia.

Secondary Prevention

- Lifestyle interventions:

- Control blood pressure, blood sugar, blood cholesterol

- Reinforce adherence to medications

- Cardiac rehabilitatione.

CONCLUSION

Guidelines summarise and evaluate available evidence with the aim of assisting healthcare professionals in appraising and selecting the best management strategies for their patients. These recommendations should facilitate decision making in daily practice. However, the final decisions concerning patients must be made by the responsible healthcare professional in consultation with the patient.

Healthy lifestyle choices and the treatment and control of concomitant CVD risk factors (eg: blood pressure, lipids, blood sugar) remain essential components of both primary and secondary prevention of CVD.

Furthermore, risk factor modification can reduce clinical events and premature death in people who are at high cardiovascular risk due to one or more risk factors (primary prevention) as well as in people with established CVD (secondary prevention). In view of this, the ABCDEF prevention strategy has been proposed for use by healthcare professionals in the management of their patients in an attempt to decrease the overall CVD burden. In addition, this format can be used for easy communication of recommendations to other members of the healthcare team that might be involved in patient care and the patients themselves.

References available on request

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ASCVD = atherosclerotic cardiovascular disease References: 1. Impact Rx data. October 2022. 2. Jackowski L, Worthley D, Phillips P. Cardioprotective aspirin in type 2 diabetes. Med Tod 2012;13(1):44-47. 3. Visseren FJL, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2021;42:3227-3337. 4. Steinhubl SR, Bhatt DL, Brennan DM, Montalescot G, Hankey GJ, Eikelboom JW, et al. Aspirin to Prevent Cardiovascular Disease: The Association of Aspirin Dose and Clopidogrel With Thrombosis and Bleeding. Ann Intern Med 2009;150:379-386. 5. Karha J, Rajagopal V, Kottke-Marchant K, Bhatt DL. Lack of effect of enteric coating on aspirin - induced inhibition of platelet aggregation in healthy volunteers. Am Heart J 2006;151:976.e72976.e11 6. South African Medicine Price Registry. Database of Medicine prices 23 December 2022. http://www.mpr.gov.za/. S2 Ecotrin 81mg. Each tablet contains Aspirin 81mg. Reg. no.: 29/2.7/0767. For full prescribing information, please refer to the professional information approved by the medicines regulatory authority (02/2023). Further information available on request from the holder of certificate of registration. HCR: Acino Pharma (Pty) Ltd. Reg. no.: 1994/008717/07. 106 16th Rd, Midrand. Tel.: 087 742-1860. www.acino.co.za. LP 4526 04/2023. Exp. 03/2025. Cost Effective Recommended dose • Strong evidence supports the use of low-dose aspirin in the secondary prevention of CVD
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Change might be hard

but electronic health records

are fast

becoming a necessary global way of work

Sceptical about storing health records online? You needn’t be. EHR is the future of safe, streamlined, and efficient medical care that prioritises the patient.

AS TOUGH AS it is for anyone to wrap their heads around digital advances, especially in the field of medicine, it’s becoming increasingly important for medical professionals to embrace cloud-based technology. Electronic health records (EHR) are fast becoming synonymous with streamlined efficiency

in a practice, as well as optimised patientcentric care. But, to professionals in an industry that has traditionally relied on the 'trusty yellow filing system’ managing your practice online and storing classified health records electronically might seem risky, or suspicious at best.

However, the time has come to switch

from the analogue approach to running your practice. Here are three reasons why:

1. A CLOUD-BASED CLINICAL SYSTEM IS MORE SECURE

With news of data leaks making headlines daily, it makes sense that cloud-based data storage feels like a risky business decision. But with the right products, the right

partner, and the right level of encryption, this couldn’t be further from the truth.

Storing patient records in the cloud ensures that only approved users have access to classified information. It also means that data can be shared quickly and safely between clinicians, and that there’s no risk of records being lost or destroyed.

2. RUNNING A DIGITAL PRACTICE

SAVES YOU TIME AND MONEY

There’s no better experience – for doctor or patient – than when a practice runs smoothly and efficiently. Intelligent, interoperable EHR software will give you optimised visibility over your diary and will even prompt you if you’re running behind.

With that said, an efficient practice is about so much more than your schedule running on time. It extends to seamless day-to-day administration and patient care, from scheduling appointments to processing payments and inputting new client data. A medical practice saves hours of analogue time when a patient (even a new one) arrives, and their data is already loaded onto your system. Easy in, easy out.

The right EHR software, coupled with a user-friendly interface, will also ensure that you can access a patient’s full medical history in one place, without delay. It also allows you to input new information. or draw up a prescription quickly and easily without detracting from hands-on patient care.

Moreover, EHR leaves less margin for human error, which can be flagged with developing AI. It also enables medical professionals to access their patient database remotely, helping doctors work safely and securely from anywhere in the world. It’s a win-win for both the medical fraternity and their patients.

3.

EHR OPTIMISES PATIENT-CENTRIC CARE

Doctors and medical service providers are the gatekeepers of ethical, patient-centred healthcare. Medical professionals are there to bring human influence, and to provide the support needed to uphold the public’s right to quality healthcare.

It’s therefore more crucial for doctors to leverage the tools available to them to ensure that digital technology is used ethically and responsibly, especially with recent advances in AI. In the medical space, this extends to pathology, diagnosis, recordkeeping and a collaborative approach to patient-centric care.

Use EHR for the good of your patient by working together with a team of clinicians to tackle diagnoses and treatment plans. Engage with your peer network to initiate treatment swiftly and efficiently, to upload data seamlessly and to eliminate timeconsuming bottlenecks that could cost a patient time, money, or even their life.

14 May 2024 | MEDICAL CHRONICLE NEWS
This webinar is sponsored by Acino

Date: 12 June 2024

Time: 7:00pm

Topic: Parafengen IV: Unlocking synergy- fusing the power of paracetamol &Ibuprofen the ultimate blend for pain relief

Speakers: Dr Erni Welch, Dr Hartley Atkinson

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Dr Erni Welch obtained his MBBCh at the University of the Witwatersrand. He then specialised in Anaesthesiology on the WITS Anaesthesia circuit whereafter he took up a consultant post at Baragwanath Hospital. In 2003 he joined the Dunkeld Practice. Erni has been a feature of academic anaesthesia in South Africa and Johannesburg for many years. He has been a convenor examiner for the Fellowship Part 1 exams, and has been intimately involved in Part 1 teaching on the WITS Circuit and at various Refresher Courses. He is the chair of the Anaesthetic Foundation which runs academic meetings in Johannesburg yearly. He co-authored Applied Pharmacology in Anaesthesiology and Critical Care with Prof Analee Milner, which has become a staple text of Pharmacology. He is passionate about pharmacology and Intravenous anaesthesia techniques and has lectured widely on these topics.

An effective fixed combination, non-opioid analgesic2,3

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Safety profile of the fixed dose comparable to either active drug alone2

Dr Hartley Atkinson is a Pharmacologist and registered pharmacist who has a Masters of Pharmaceutical Chemistry with distinction and Doctorate in Pharmacology from Otago University, New Zealand. He has published over 30 research papers [including the world leading New England Journal of Medicine] and 2 book chapters. Hartley was previously Medical Director for Roche New Zealand and left to found, with his wife Marree, AFT Pharmaceuticals 25 years ago which is now listed on the Australian and New Zealand stock exchanges. AFT Pharma undertakes extensive drug development work to repurpose existing drugs for the treatment of various medical conditions such as Maxigesic which avoids the need for opioids. Other examples of R&D projects include treatments for Burning Mouth Syndrome, Port Wine Stains, Strawberry Birthmarks, Keloid Scars, Vulva Lichen Sclerosis and Antibiotic Resistant Eye Infections. Its R&D based products are presently sold in over 70 countries around the globe with regulatory approvals across EU and USA.

Synergy: The combined effect of medicine, muscles, etc., that exceeds the sum of their individual effects.1

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Researchers developed a new method to precisely track mutations in SARS-CoV-2, the virus causing Covid-19. This improved technique addresses limitations of existing methods and provides fresh insights into the virus's evolution.

A SARS-CoV-2 mutation mystery solved

HE EMERGENCE OF new variants

has been a hallmark of the Covid-19 pandemic, caused by the SARSCoV-2 virus. Unlike some viruses with stable genomes, SARS-CoV-2 readily generates variants, posing a challenge to our immune response and hindering vaccine development. Researchers at Baylor College of Medicine and collaborating institutions

have developed a new technology called Targeted Accurate RNA Consensus sequencing (tARC-seq). This method addresses limitations of existing techniques that struggle to detect rare mutations, especially in samples with low viral loads like those from patients.

“Because samples from patients have very few SARS-CoV-2 RNA copies, it is

difficult to distinguish between the errors made by SARS-CoV-2 RNA-dependent RNA polymerase (RdRp), the enzyme that makes copies of this virus’ RNA, and the errors from the other enzymes used in the sequence analysis,” said corresponding author Dr Christophe Herman, professor of molecular and human genetics and of molecular virology and microbiology at

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March 2021. 3. Levine SB. Erectile Dysfunction: Why drug therapy isn’t always enough. Cleve Clin J Med 2003;70(3):241- 246. 4. Accord data on file. 5. Wrishko R, Sorsaburu S, Wong D, Strawbridge A, McGill J. Safety, efficacy, and pharmacokinetic overview of low-dose daily administration of tadalafil. J Sex Med 2009;6:2039-48. DOI: 10.1111/j.1743-6109.2009.01301.x. 6. Tolrà JR, Campaña JMC, Ciutat LF, Miranda EF. Prospective, randomized, open-label, fixed-dose, crossover study to establish preference of patients with erectile dysfunction after taking three PDE-5 inhibitors. J Sex Med 2006;3:901- 909. DOI: 10.1111/j.1743-6109.2006.00297.x. 7. Accord Data on File.

S4 CYFIL 5 (film-coated tablet). Each 5 mg film-coated tablet contains 5 mg tadalafil and 91,572 mg lactose (as monohydrate). Reg No.: 50/7.1.5/0772.

S4 CYFIL 20 (film-coated tablet). Each 20 mg film-coated tablet contains 20 mg tadalafil and 367,584 mg lactose (as monohydrate). Reg No.: 50/7.1.5/0773. For full prescribing information please refer to the professional information approved by the Regulatory Authority (SAHPRA). Accord Healthcare (Pty) Ltd. Reg. No.: 2004/011257/07. Tel: +27 11 234 5701/2/3. Building 31, Woodlands Office Park, 20 Woodlands Drive, Woodmead, 2191, Gauteng, SOUTH AFRICA. Postnet Suite 182, Private Bag X51, Rivonia, 2128. Email: medinfo@accordhealth.co.za. CYF/002/MAR24/AD.

Baylor. “TARC-seq allows us to measure true errors when copying specific RNA present in very low amounts.”

WHY STUDYING MUTATION RATES IS IMPORTANT

SARS-CoV-2 replicates its genetic information using RNA, which is more prone to errors compared to DNA. The virus also possesses an internal proofreading mechanism to correct these errors. However, the frequent emergence of variants during the pandemic suggested this repair system might not be as efficient as initially thought.

TARC-SEQ REVEALS HIGHER MUTATION RATE AND HOTSPOTS

TARC-seq's ability to detect rare mutations allowed researchers to measure SARSCoV-2's mutation rate more accurately. The results showed a higher mutation rate than previously expected, explaining the frequent appearance of variants. Additionally, tARCseq identified hotspots within the virus's RNA – areas with a higher frequency of mutations. Notably, one such hotspot resided in the spike protein region, a crucial target for vaccines.

TEMPLATE

SWITCHING

TARC-seq uncovered a surprising mechanism for variant formation: template switching. During RNA replication, the enzyme copying the viral RNA can jump between different viral templates, creating a hybrid RNA molecule containing mutations from both sources. “This template switching will result in sequence insertions or deletions that bring about viral variability,” said Dr Herman.

COMPLEX MUTATIONS & MONITORING CAPABILITIES

TARC-seq also observed complex mutations involving multiple changes within a single viral sequence. “SARS-CoV-2 takes advantage of these two powerful biological mechanisms, template switching and complex mutations, that allow it to evolve quickly, generating variants to adapt to and persevere in human populations,” said Dr Herman. Notably, the technology successfully captured mutations in lab cultures that mirrored those observed in real-world data from the pandemic. This ability to track mutations in patient samples holds promise for monitoring viral evolution in human populations.

IMPLICATIONS FOR THE FUTURE

By providing a clearer picture of SARS-CoV-2's mutation mechanisms, tARC-seq offers valuable insights for researchers. This technology can be used to track the emergence of new variants, understand how they evade our immune response, and potentially guide the development of more effective vaccines and antiviral therapies.

16 May 2024 | MEDICAL CHRONICLE NEWS
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Widening private health access quicker than NHI

State of public health signals SA is not ready

AS THE PRESIDENT PREPARES

to sign the National Health Insurance (NHI) Bill into law, millions of South Africans are anxious that the promises of improved healthcare will materialise.

“Relegating the necessary private healthcare reform as secondary to a NHI that will take decades to implement, will mean that the situation is likely to create significant uncertainty before it gets better,” cautions Craig Comrie, chairperson of the Health Funders Association (HFA).

“This uncertainty will create greater problems regarding resource constraints in both the public and private sectors as highly skilled healthcare specialists seek certainty in attractive global destinations eager to boost their own countries health assets.”

“There is a very long way to go towards building confidence in the public health system and the State’s capacity to effectively manage a single pool of funds as envisaged in the NHI Bill,” he says.

“Currently, state clinics and hospitals are overwhelmed, struggling to deliver the most basic care, often inadvertently risking lives. If private healthcare can no longer alleviate at least some pressure on the public system, the NHI’s promised reforms will not be realised.”

“The emotive political rhetoric around NHI recently does not consider the transformative power of shifting more people to private healthcare, thereby improving access to quality healthcare and

resource allocation, which weigh heavily on public facilities and those reliant on them,” Comrie says. “In collaboration with private health funding infrastructure already in place, South Africa could be so much closer to raising the standard of healthcare for millions more people while easing the burden on public hospitals and clinics during the preparation for providing NHI services.

“The ongoing delay in finalising Low Cost Benefit Options [LCBO] is denying at least 2.5 million people currently wholly reliant on public healthcare the opportunity to access more accessible private health services, and their rights in healthcare should be protected under the Medical Schemes Act.”

As a major stakeholder in South African health resource distribution, the Health Funders Association (HFA) is a professional body representing medical schemes and almost half the national medical aid membership. According to Comrie, if the NHI Bill were enacted by the President with Section 33, which precludes private health funding involvement, it would have devastating consequences.

“Such a move would erode the current world-class private healthcare system and further threaten the country's already stretched healthcare provider base,” he says. “Medical practitioners themselves have indicated they would no longer feel comfortable remaining in a country where they are effectively employed by the

state without the option of servicing patients privately. The practicalities of catering to so many people in a single healthcare system that will inevitably be under-resourced for a country with our extensive needs suggest that NHI protocols to access health may include nurses as a first point of call before being able to access doctors, who in turn will be overwhelmed and have little time for patients individually. Under such pressure, healthcare en masse will likely resemble a factory assembly line with little time for quality healthcare measurements,” asserts Comrie. The HFA points out that depending on the number of dependents, medical scheme members contribute more each year to South Africa’s public health purse than the value of healthcare benefits the State budgets for each person, while medical scheme members do not draw on any significant public health resources, which they are entitled to.

“At present, medical scheme members are already subsidising someone else in need to benefit from the resources they may have used in public health facilities. The debate around removing the tax rebate should be considered next to the fact that private healthcare contributes significant VAT to the Fiscus, and this could also be lost should medical schemes be relegated to a smaller share of the market.

“Removing the medical scheme tax rebate would punish these individuals and

their families, equivalent to squeezing the life out of the goose that lays the golden egg to feed a public health system already stretched to breaking point.

“Progress towards Universal Health Coverage does not need to wait until NHI is eventually operational. Medical schemes are mutual associations operating on a notfor-profit basis, and private health funders can help raise the standard of healthcare for a significant proportion of South Africans much sooner than NHI can become a practical reality.”

The HFA asserts that with relatively minor changes compared to the mammoth NHI project, including regular Prescribed Minimum Benefit reviews and finalisation of the LCBO framework, progress towards the goals of UHC could be made.

“More than half of medical scheme members have a combined monthly household income below R30 000, and we see the opportunity to increase the affordability of private health cover and greater freedom of choice in healthcare so that every employed person has this security,” Comrie says.

“Should it become necessary, the HFA will challenge the constitutionality of the NHI Bill and fight for the freedom of all South Africans to access healthcare privately. Our members’ collective expertise and experience continue to demonstrate the need for a rational approach to elevating the standard of healthcare for all.”

MEDICAL CHRONICLE | May 2024 17
NEWS
gettyimages Credit : everythingpossible
Craig Comrie, chairperson of the Health Funders Association (HFA)

I The features and benefits of electronic scripting in GoodX Software

Though e-scripting is not a new technology, GoodX Software's many features are rapidly evolving into a tool that significantly benefits healthcare practitioners, patients, and pharmacists.

T IS NOTEWORTHY that

e-scripting has two main applications:

1. The means to electronically capture information into a practice management application (PMA)

2. The means to electronically exchange information between practitioners and pharmacies.

This article discusses the core features of e-scripting, which captures and exchange information, and its benefits for practitioners, patients, and pharmacies.

1. CORE FEATURES OF E-SCRIPTS TO CAPTURE AND EXCHANGE INFORMATION

a. GP to Pharmacy to GP Practitioners can push scripts to selected pharmacies and mark the medications as non-substitutable, ensuring that only the originally prescribed product is dispensed. Data is pushed back to the practitioner for recordkeeping and adherence information as soon as the medication is dispensed. In other words, you, as a doctor, can see what and how much medicine was dispensed to your patient.

b. Electronic Medical Records (EMR)

As soon as the practitioner captures clinical information into the software solution, it becomes part of the patient's electronic clinical history. The patient’s clinical history will then automatically inform and guide all future treatment plans. When, for example, chronic scripts must be refilled, the software will provide a list of issued scripts from which the practitioner can choose, eliminating the unnecessary time spent researching the history of chronic medication. In addition, an inline scripting history adds the list of chronic medication lines with one button to the current script. Thus, a 20-line script can be refilled in less than 15 seconds, saving the practitioner an immense amount of time.

c. EM Guidance

EM Guidance is a free and trusted online medicines and guideline resource for medical professionals that provides up-to-date information. This product has been integrated into GoodX Software, making crucial medicine information immediately accessible to the practitioner. This feature allows the practitioner to prescribe better for better outcomes due to this expanded knowledge base at the practitioner’s fingertips.

d. Chronic script reports

A chronic script reporting tool allows the doctor to see which patients are due for renewal and which patients are taking their medicines (provided they fill their prescriptions at participating pharmacies). The doctor can search for the active ingredient, patient, or script age.

e. Allergy Warning System and Drug Interaction Checker

Allergies captured and linked to drug classes and active ingredients will trigger the warning system in the software. The drug interaction checker built into GoodX will automatically assess the information on the newly created script and warn the practitioner of any interactions between the medications captured in the script. This feature allows the practitioner to ensure that no interactions will adversely affect the patient and warn the practitioner in advance so that appropriate alternatives can be prescribed. This single-platform approach allows for a holistic view of the patient and all their chronic conditions and allergies.

f. Unified platform for dispensing GPs

Dispensing GPs can rest assured that only one software system must be used and maintained for all clinical work and dispensing. Additionally, being able to bill, switch, dispense, print labels, and capture electronic remittance advices (ERAs) in one system allows the practitioner to manage his practice and finances effectively.

2. THE BENEFITS E-SCRIPTS

OFFER HEALTHCARE PROVIDERS AND PATIENTS

a. Medical practitioners benefit from e-scripts in the following ways:

1. The software provides complete insight into the previous prescriptions given to the patient at the click of a button.

2. The practitioner will be able to see which medication the pharmacy dispensed.

3. Allergy alerts and potential drug interactions allow the practitioner to choose medication wisely, avoiding clinical and legal risks.

4. The practitioner builds a standard list of medications.

5. The practitioner can easily choose generic medicines from the list that Medical Funders cover and, in that way, be sensitive to the patient’s financial constraints.

6. Fast repeats of previous scripts save time and effort.

7. The practitioner can create templates and macros for scripts, enhancing their workflow.

8. The paperless workflow saves costs and filing space.

9. Medication adherence can be measured and is, therefore, reportable for future healthcare decisions.

b. Pharmacists benefit from e-scripts in the following ways:

1. e-Scripts received from a trusted software provider using a secured transmission source eliminate the risk of scripting fraud and double dispensing.

2. The pharmacist saves time and frustration by avoiding phone calls to practitioners due to illegible handwriting.

3. Imported patient and script information saves capturing time and the possibility of human error.

c. Patients benefit from e-scripts in the following ways:

1. Firstly, the patient can easily choose the pharmacy’s location and won’t have to stand in long queues if the pharmacy pre-packed and prepped the medication. It is far better for the prescription to wait for the patient than for the patient to wait for it.

2. When e-scripts are sent directly to the preferred pharmacy, patients won’t lose their scripts. This adds security to the process and lightens the patient's burden and the practice's workload since extra printing is avoided.

3. Chronic medication adherence will increase since patients will experience a more convenient way of acquiring their medication.

4. Patients can have a more meaningful conversation with their pharmacist if they do not have to pick and pack the medication. Instead, patients won’t feel the pressure of waiting in a long queue if they want to discuss their medicines with their pharmacist.

5. When the practitioner sends the medication to the pharmacy, the patient information accompanies the e-script, saving capture time and reducing human error. In addition, by the time the patient arrives at the pharmacy, their information is already in the pharmacy system, making the engagement at the pharmacy highly convenient.

CONCLUSION

The e-scripting in GoodX Software makes it very valuable to practitioners, patients, and pharmacists.

So, if you are still using other means of scripting, it is time to reconsider the benefits of e-scripting.

18 May 2024 | MEDICAL CHRONICLE
PRACTICE MANAGEMENT

Facial recognition

SAGTEWARE | SOFTWARE What makes us different? Do you want a PAPERLESS practice? Let GoodX help you transform your practice! GoodX Software is one of the market leaders in medical practice management software with over 35 years of experience in the South African medical market. +27 (0)83 391 1074 012 804 6831 sales@goodx.co.za www.goodx.healthcare All-in-one solution
software with a built-in switch (with real-time claiming) Full clinical module Patient portal (www.myGC.co.za) Accessible from any device with Internet and Google Chrome 1 2
Billing
Features Voice to typing/Dictation
Stylus compatible for those who think when writing Turn your phone into a clinical camera (Capture App)

Joining forces in treating ocular inflammatory conditions

The treatment of ocular inflammatory conditions

COMBINING CORTICOSTEROIDS

WITH antibiotics has become a standard approach in ocular inflammatory conditions. Loteprednol etabonate 0.5% and tobramycin 0.3% (LE/T) represent one such combination,

exhibiting efficacy in conditions like blepharokeratoconjunctivitis (BKC).

Ocular inflammation encompasses a range of conditions such as giant papillary conjunctivitis, allergic conjunctivitis, uveitis, and dry eye syndrome, often leading to

symptoms like redness, pain, and swelling. Left untreated, these conditions can result in vision impairment or loss. Corticosteroids like loteprednol etabonate (LE) play a crucial role in managing inflammation by blocking inflammatory mediators, providing relief

from symptoms without significant adverse effects like elevated intraocular pressure and cataract formation commonly associated with traditional corticosteroids.

LE/T combines the anti-inflammatory properties of loteprednol with the broad antibacterial activity of tobramycin. This combination addresses both inflammation and bacterial infection risk, offering a safer alternative to corticosteroid therapy alone. FDA-approved for steroid-responsive inflammatory ocular conditions with bacterial infection, LE/T has shown promising results in real-world applications, as indicated by a retrospective study evaluating its use, dosing regimens, safety outcomes, and clinical efficacy.

In treating BKC, a chronic inflammatory disorder often associated with bacterial infection, LE/T has demonstrated comparable anti-inflammatory effects to other standard treatments like dexamethasone/tobramycin combinations but with a lower risk of elevated intraocular pressure. Studies support its safety and tolerability in both adults and children, indicating a lower risk of clinically significant increases in intraocular pressure compared to alternative treatments.

The efficacy of LE/T extends beyond BKC to postoperative uses, particularly in cataract surgery. Studies comparing loteprednol etabonate with prednisolone acetate for controlling postoperative inflammation have shown equivalency between the two treatments, with less fluctuation in intraocular pressure observed with loteprednol etabonate. Additionally, LE gel formulation has proven effective and safe in treating postoperative inflammation and pain following cataract surgery.

Loteprednol etabonate also holds promise in ocular and corneal transplant surgery postoperative pain management. Peer-reviewed articles support its efficacy in controlling inflammation and pain following various ocular surgeries, including cataract surgery and keratoplasty.

combination: a review of their impact on current treatment regimens. Expert Opin Pharmacother. 2010 ;11(5):843-52. 6. Lane SS, Holland EJ. Loteprednol etabonate 0.5% versus prednisolone acetate 1.0%

CONCLUSION

In conclusion, the combination of loteprednol etabonate and tobramycin offers a safer and more efficient option for managing ocular inflammation, with potential applications in various ocular surface inflammatory conditions and postoperative settings. Its broad-spectrum antimicrobial properties make it suitable for conditions with a risk of bacterial infection, emphasising its importance in clinical practice. Further research and clinical trials may provide additional insights into its efficacy and safety profile in diverse ocular conditions.

References available on request.

20 May 2024 | MEDICAL CHRONICLE ONLINE CPD
presents unique challenges due to the necessity of managing inflammation while mitigating the risk of bacterial infection. References: 1. Lotemax® Co package insert, April 2022. 2. Pavesio CE, et al. Treatment of ocular inflammatory conditions with loteprednol etabonate. Br J Ophthalmol 2008;92:455– 459. 3. Dell SJ, et al. A randomized, double-masked, placebo-controlled parallel study of 0.2% loteprednol etabonate in patients with seasonal allergic conjunctivitis. J Allergy Clin Immunol 1998;102:251-5. 4. Gong L, et al. Loteprednol Etabonate Suspension 0.2% Administered QID Compared With Olopatadine Solution 0.1% Administered BID in the Treatment of Seasonal Allergic Conjunctivitis: A Multicenter, Randomized, Investigator Masked, Parallel Group Study in Chinese Patients. Clin Ther. 2012;34:1259–1272.  5. Comstock TL, Holland EJ. Loteprednol and tobramycin in
for the treatment of inflammation after cataract surgery. J Cataract Refract Surg. 2013:39(2):168-73. S4 Proprietary name and dosage form: Lotemax® Co Ophthalmic Suspension. Composition: Each 1 ml contains: Loteprednol etabonate 5,00 mg (0,5 % m/v), Tobramycin 3,00 mg (0,3 % m/v) and Benzalkonium chloride (preservative) 0,01 % m/v. Pharmacological classification: A 15.3 Ophthalmic preparations - combination antibiotics. Registration number 51/15.3/9038.  For full prescribing information, refer to the professional information as approved by the South African Health Products Regulatory Authority (SAHPRA). © 2024 Bausch & Lomb Incorporated or its a liates. ®/TM denote trademarks of Bausch & Lomb Incorporated or its a liates. Soflens (Pty) Ltd. Reg. No.: 1968/011787/07. 254 Hall Street, Centurion, 0157. Tel: +27 10 025 2100. www.bausch.co.za. BL623/23 An anti-infective and corticosteroid combination to treat a wide range of ocular infl ammation with infection or a risk of infection 1
% Loteprednol Etabonate with site-specific, high anti-inflammatory e cacy 2-4 0,3 % Tobramycin with broad spectrum activity 5 Reduced propensity for elevation in intraocular pressure 6 NEW When inflammation and infection hits, strike back with our double-agent 1 Ocular relief to therescue 321186 Lotemax Co Ad MC.indd 1 2024/01/19 11:06:01 This is a summary of a CPD-accredited article available on www.medicalchronicle.co.za
0,5

The use of iodine in burns

SCENARIO

A five month-old child was brought into consulting rooms after obtaining a scald burn a week ago to both arms and chest. Wounds are wet, weepy, and infected. Historically iodine ointments have been known to be effective on infected wounds and are prescribed daily on the child as no other ointments are kept in stock.

WHILE THE USE of iodine in wound care is widely accepted, there has been concerns raised about cytotoxicity, half-life, and frequency of changes. The reasons cited for using Iodine based dressings is cost effectiveness, availability, lack of alternatives in clinical settings and clinician preference.

Iodophors are solutions that contain iodine and a solubilising agent.1 Iodophors were developed in the 1950s to overcome the side effects associated with elemental iodine, being safer, but just as effective as elemental iodine. The mechanism of action for iodophors is it penetrates the cell walls and membranes of microorganisms and interfere with DNA synthesis, and it bind to proteins, causing their inactivation.1 As a rule, iodophors enhance the bactericidal activity of iodine.3 The most commonly used iodophors in modern wound dressings are povidone iodine (PVP-I): a chemical complex of polyvinylpyrrolidone (also known as povidone and PVP) and elemental iodine. Examples include dressings, solutions, and cadexomer iodine, an iodine and polysaccharide complex.2

Iodophore-based formulations’ broad-spectrum activity, ability to penetrate biofilms, lack of associated resistance, anti-inflammatory properties, low cytotoxicity and good tolerability and no negative effect on wound healing in clinical practice have been cited as important factors as dressing of choice.4 However, some studies have cited the opposite effect in certain situations, particularly:

1) When the integrity of the skin is compromised

2) In infants, who have greater skin permeability

3) After mucosal application (eg, vaginal instillation)

4) After excessive topical application.3

The authors further highlight that goitre and hypothyroidism, dermatitis, liver function abnormalities, and neutropenia have also been described after prolonged exposure to povidone-iodine and other iodophors. Serum iodide concentrations can increase 100-fold in those who have iodophors applied to open wounds, burns, or pressure injuries, and iodide-related fatalities are reported.3

Iodine based dressings have been indicated to prevent wound infection or recurrence of infection in patients at increased risk of infection, to treat localised infection and to treat spreading infection when healing is delayed.2 The types of wounds treated with iodine-based dressings include pressure ulcers (injuries), venous

Rapid

considerations

(short

Pregnant/breast feeding/newborns up to the age of six months

considerations

Prolong kidney failure Slow release formulas Use of Iodine in burns

leg ulcers, diabetic foot ulcers, minor burns, and superficial skin-loss injuries according to Sibbald, et al (2011), surgical site infections.4 On the contrary, these dressings have been contraindicated in patients with thyroid diseases, known or suspected iodine sensitivity, in pregnant or breastfeeding women or in newborn babies and children up to the age of six months, persons with significant renal impairment.2

The same authors also warned that iodine products should be used with caution in children, in persons with large burns, and where prolonged treatment of large open wounds is required. Iodine absorption has been found to be dependent on the size of the wound and the duration of treatment.

Some reviews have analysed the conflicting evidence and have reported that in certain instances cytotoxicity have been found. Cytotoxicity is dose (concentration) and /or time (duration of exposure) dependent.5, 6 Even though cytotoxicity has been mainly reported in animal studies systemic absorption from large surface area wounds may be a concern.

There have been reports of patients developing systemic iodine toxicity from wounds dressed with gauze soaked in PVP-I or when PVP-I solution was used as a continuous wound irrigant.4

Low-concentration, slow-release iodine formulations are effective without the cytotoxicity concerns. It has been recommended that the single maximum application dose of Iodophor dressings is 50g and a weekly maximum dose of 150g.7 Due to its cost effectiveness, availability,

Large burn TBSA > 10% Thyrotoxicosis

Significant renal disease

and lack of alternatives in clinical settings and clinician preference iodine-based products continues to be used in burns of all sizes.

Based on the evidence, one must review if current practice is evidence based?

The literature is clear on the benefits of iodine-based dressings, but there are certain indications where using iodinebased dressings might be inappropriate as the preferred dressing such as large burns for instance. When medications are prescribed for patient's health workers are fully conversant on the indications, contraindications, half-life, frequency, and maximum dosages, yet wound dressings are not enjoying the same considerations.

When considering iodine-based dressings one needs to take patient and product considerations into account. Product considerations are the concentration of the product, the release formulation and the frequency of dressing changes required. Patient considerations on the other hand are the size of the burn (wound), thyroid disease and iodine sensitivity, pregnancy, age of the infant or child and significant renal disease.

Based on the evidence, a decision tree based on the evidence has been compiled (Figure 1). Evidence-informed decision making is based on best available evidence, clinical experience and patient/ family preferences and values.10 In the scenario presented, the product consideration required frequent dressing changes of a rapid release iodine-based ointment. The patient considerations were the

Do not use

Do not use

Safe to use

child’s age and the size of the burn injury. In line with evidence-based practice and decision making, slow-release iodine-based products with a low concentration have been proven to be safer and as effective in the management of the correct type of wounds.

REFERENCES

1. Chauret. C.P. 2014. Sanitization. Encyclopedia of Food Microbiology (Second Edition), Academic Press. https://doi.org/10.1016/B978-0-12384730-0.00407-9.

2. Sibbald, R.G, Leaper, D.J, Queen, D. 2011. Iodine Made Easy. Wounds International. 2(2): Available from http://www.woundsinternational.com

3. Perez,A & MacKay , C. 2017. Halogens (Bromine, Iodine, and Chlorine Compounds). Chapter 96 in: Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose (Fourth Edition), W.B. Saunders. https://doi.org/10.1016/B978-0-72160693-4.50101-8

4. Bigliardi PL, Alsagoff SAL, El-Kafrawi HY, Pyon JK, Wa CTC, Villa MA. Povidone iodine in wound healing: A review of current concepts and practices. Int J Surg. 2017 Aug;44:260-268. doi: 10.1016/j.ijsu.2017.06.073. Epub 2017 Jun 23. PMID: 28648795.

5. Slavario, L. Avruscio, G, Vindigni, V & ToccoTussardi. 2018. Antiseptics for burns: a review of the evidence. Ann Burn Disasters, 31 (3): 198-203

6. International Wound Infection Institute (IWII) Wound Infection in Clinical Practice. Wounds International 2022

7. Morgan, D.A. 2000. Formulary of wound management products. 8th Edition. Haslemere. Euromed Communications. Ltd.

8. Pudner, R. 2001. Iodine impregnated dressings. Journal of Clinical Nursing. Vol 15. Issue 07. 9. Jones V, Milton T. When and how to use iodine dressings. Nurs Times 2000; 96(45): 2

10. Sackett, D. L., Rosenberg, W.M, Muir Gray, M., et al. 1996. Evidence based medicine: what it is and what it isn’t. BMJ. https://doi.org/10.1136/ bmj.312.7023.71

MEDICAL CHRONICLE | May 2024 21 CLINICAL | WOUND CARE
Dr Ethel Andrews (RN PhD), South African Burn Society Past President. Wound specialist: Netcare Milpark hospital/ Netcare Mulbarton hospital/ Life Brenthurst hospital
Smallburn
Less
< 10% TBSA
cytotoxic
Figure 1: A decision tree based on the evidence
>1%
Cytotoxic effect on osteoblast, myoblastfibroblastand Do not use
Less cytotoxic
Safe to use Safe to use
release formulas 2-3 daily
half-life) Do not use <1%
Less cytotoxic
Do not use
Thyroid disease/ iodine sensitivity Hyperthyroidism
Do not use Hyperthyroidism
Product
Patient

RELIEF OF A TIGHT CHESTY COUGH

• Highly β-2 selective bronchodilator1

• Rapid relief of a tight chest2

• Effective mucolytic3.4

• Reduces mucus viscosity to aid its clearance2

• Comparable mucolytic effect vs carbocysteine and acetylcysteine5

Suitable from 2 years old4 | Sugar free4 | Diabetic friendly4

Suitable for elderly4 | 5 ml syringe included

S2 Duro-Tuss® Linctus. Each 5 ml liquid contains: Salbutamol sulphate 2,41 mg, Bromhexine hydrochloride 4 mg. Reg.No.:A39/10.1/0390. For full references and legals visit www.inovapharma.co.za. IN4739/24.

The role of bronchodilators in managing airway disorders

Cough is a prevalent and troublesome symptom associated with lung diseases, frequently encountered in both general and hospital settings.1

IT

IS A reflexive action triggered when sensitive receptors in the larynx and upper airways are stimulated, although the precise central organisation of the cough reflex loop remains poorly understood. These receptors, located under and between airway epithelial cells, include rapidly adapting receptors (RAR) connected to myelinated fibers of the vagus nerve, as well as non-myelinated C fibers. Upon activation, these receptors release neuropeptides, leading to neurogenic inflammation and further stimulation of RARs. The threshold and expression of the cough reflex depend on the intricate interplay between RARs and C fiber receptors, involving both peripheral and central components.1

Cough presents a significant clinical challenge, with causes categorised into eosinophilic and non-eosinophilic disorders. Eosinophilic disorders encompass conditions like asthma, cough variant asthma, atopic cough, and non-asthmatic eosinophilic bronchitis (NAEB).1

Productive coughs expel phlegm or mucus from the respiratory tract, aiding in the removal of foreign material or responding to airway irritation. Conversely, non-productive coughs are dry and do not produce sputum, often occurring after exposure to irritants like dust or smoke.1

Dry coughs can result from various factors such as allergies, inhibitors used for hypertension, occupational exposure to dust or chemicals, or underlying conditions like asthma. In asthma management, inhaled medications are preferred to minimise systemic effects, with fast-acting agents used for symptom relief and long-acting agents for maintenance therapy.1

Wet coughs, characterised by the production of mucus, may stem from viral illnesses like the common cold, chronic

lung diseases such as chronic obstructive pulmonary disease (COPD), respiratory infections, or smoking-related lung damage. Other potential causes include gastro-oesophageal reflux disease and bronchospasm.1

BRONCHODILATORS

Bronchodilators play a central role in managing airway disorders, serving as the cornerstone in COPD treatment and providing symptomatic relief in asthma. Salbutamol, a widely used bronchodilator, acts by relaxing airway smooth muscles and inhibiting the release of bronchoconstrictor mediators. It offers rapid relief from acute bronchospasm symptoms with minimal cardiovascular effects.1

Combinations of bronchodilators with mucolytics like bromhexine can effectively alleviate symptoms of chesty coughs. Bromhexine acts as an oral mucolytic agent, reducing the viscosity of mucus and helping its expectoration. It may also enhance the effectiveness of antibiotic therapy in respiratory infections.1

Bromhexine is a widely prescribed mucoactive drug used to treat respiratory conditions associated with mucus secretion disturbances. It is used as a secretolytic expectorant for the effective treatment of cough with phlegm. Bromhexine is used to treat respiratory disorders linked with viscid or excessive mucus. It is secretolytic, which means that it increases the production of serous mucus in the respiratory tract and makes the phlegm less sticky and thinner. This leads to secretomotoric effect and helps the cilia transport the phlegm out of the lungs. Cilia represent the tiny hairs that line the respiratory tract. For this reason, bromhexine is added to some antitussive syrups.1

It acts on the mucus at the formative stages in the glands, within the mucussecreting cells. Bromhexine disrupts the structure of acid mucopolysaccharide fibres in mucoid sputum and produces a less viscous mucus, which is easier to expectorate. The mechanism of action is based on phlegm degradation, thereby easing coughs. It helps in enhancing the production of serous mucus in the respiratory tract and aids in the production of thinner and less viscous phlegm. This produces a secretomotoric effect by assisting the cilia in expectorating the phlegm out of the lungs. For this reason, it is often regarded as an important component of cough syrup. Bromhexine may also affect antibiotic penetrance and enhance the effects of antibiotic therapy –data showed that bromhexine increased the concentration of oxytetracycline within the secreted mucus and enhanced the concentration of erythromycin in bronchial fluid.1 Studies in children have demonstrated favourable outcomes with bromhexine therapy, showing reductions in nasal secretions, improvement in respiratory symptoms, and enhanced ease of expectoration. However, caution is advised in patients with gastric ulceration history or severe hepatic or renal impairment due to potential mucolytic-induced disruption of the gastric mucosal barrier.1

SALBUTAMOL

The short-acting β-agonist (SABA) salbutamol has a history of over 60 years in effectively relieving acute bronchospasm. Its rapid onset of action makes it a popular choice for managing respiratory distress. Acting directly on the smooth muscles of the airways, salbutamol induces bronchodilation while also mitigating

bronchial oedema.2

Comparative studies have consistently shown salbutamol to be superior to terbutaline in terms of both efficacy and tolerability. When evaluated for overall clinical activity based on pharmacokinetic and pharmacodynamic properties, salbutamol outperformed terbutaline, resulting in fewer incidences of central nervous system or musculoskeletal side effects.2

In a study involving moderate to severe asthmatics, the acute cardiopulmonary effects of oral albuterol (4mg), metaproterenol sulfate (20mg), and terbutaline sulfate (5mg) were examined over an eight-hour period. Both albuterol and terbutaline exhibited comparable magnitudes and time courses of bronchodilation, with a duration of action lasting at least eight hours. However, they significantly outperformed metaproterenol in bronchodilation from six to eight hours post-dosing. Notably, albuterol demonstrated a lower incidence of central nervous system or musculoskeletal side effects compared to terbutaline, highlighting its favourable safety profile. These findings suggest potential therapeutic advantages of oral albuterol and terbutaline in terms of dosing frequency, while the rapid onset of action of oral metaproterenol may be advantageous for as-needed use.2

REFERENCES

1. Bronchodilators Central in the treatment of airway disorders. Medical Chronicle. 2023:5. https://www.medicalacademic. co.za/courses/bronchodilators-central-in-thetreatment-of-airway-disorders/ 2. Wolfe JD, Yamate M, Biedermann AA, Chu TJ. Comparison of the Acute Cardiopulmonary Effects of Oral Albuterol, Metaproterenol, and Terbutaline in Asthmatics. JAMA. 1985;253(14):2068–2072. doi:10.1001/jama.1985.03350380084026

CLINICAL | WINTER AILMENTS MEDICAL CHRONICLE | May 2024 23
gettyimages Credit : Jacob Wackerhausen

Clinical review: Bacterial conjunctivitis management

Conjunctivitis, commonly known as 'pink eye’, is a prevalent ophthalmologic issue in primary care settings, characterised by eye redness, discomfort, and discharge.

ACTERIAL CONJUNCTIVITIS

POSES significant challenges due to its morbidity. This review aims to elucidate the evaluation and treatment of bacterial conjunctivitis, emphasising the role of healthcare teams.

AETIOLOGY

Bacterial conjunctivitis often stems from

Haemophilus influenzae, Streptococcus pneumoniae, or Moraxella catarrhalis in children, while Staphylococcus aureus predominates in adults.

Methicillin-resistant Staphylococcus aureus (MRSA) is increasingly prevalent, especially in hospitalised patients. Neonates can contract it from vertical transmission of Neisseria gonorrhoeae

or Chlamydia trachomatis.

EPIDEMIOLOGY

Bacterial conjunctivitis accounts for a significant portion of conjunctivitis cases, particularly in children.

Empiric antibiotic usage exceeds the actual bacterial involvement, leading to

UnleashPower Against Pathogens ofConcern

Against common and prevalent ocular pathogens in bacterial conjunctivitis1-3

PATHOPHYSIOLOGY

Direct transmission of pathogens to the conjunctiva or compromised ocular defence mechanisms leads to bacterial conjunctivitis, often favoured by immunocompromised states.

HISTORY

Patients typically present with redness, tearing, and discharge, with clinical history aiding in diagnosis. However, distinguishing bacterial conjunctivitis from other causes can be challenging.

EVALUATION

Laboratory and radiographic testing play a limited role, with conjunctival cultures reserved for specific scenarios, such as neonatal conjunctivitis or treatment failure.

TREATMENT AND MANAGEMENT

Management revolves around clinical assessment, considering antibiotic benefits, disease course, and antibiotic resistance. Topical antibiotics are commonly prescribed, with newer fluoroquinolones showing promising results. Systemic antibiotics are necessary for severe cases or concurrent otitis media.

DIFFERENTIAL DIAGNOSIS

It's essential to differentiate bacterial conjunctivitis from viral and allergic causes, trauma, keratitis, or iridocyclitis.

PROGNOSIS AND COMPLICATIONS

Uncomplicated cases have a good prognosis, with rare adverse events. Severe infections can lead to keratitis, corneal ulcers, and blindness.

CONSULTATIONS AND PATIENT EDUCATION

Referral to ophthalmologists is called for for severe cases or treatment failure. Patient education on symptoms, hygiene, and safe sex practices is crucial.

ENHANCING HEALTHCARE TEAM OUTCOMES

An interprofessional approach involving clinicians, pharmacists, nurses, and specialists ensures optimal patient care, antimicrobial stewardship, and better outcomes through collaboration, education, and evidence-based practices.

CONCLUSION

In summary, bacterial conjunctivitis presents diagnostic and management challenges, emphasising the importance of a comprehensive, interprofessional healthcare approach.

REFERENCE

Pippin MM, Le JK. Bacterial Conjunctivitis. [Updated 2023 Aug 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546683/

B
CLINICAL | OPHTHALMOLOGY 24 May 2024 | MEDICAL CHRONICLE
COVERAGE
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1-3 References: 1. Haas W, et al. Besifloxacin, a novel fluoroquinolone, has broad-spectrum in vitro activity against aerobic and anaerobic bacteria. Antimicrob Agents Chemother. 2009;53(8):3552–60. 2. Torkildsen G, et al. Concentrations of besifloxacin, gatifloxacin, and moxifloxacin in human conjunctiva after topical ocular administration. Clin Ophthalmol. 2010;4:331–41. 3. Malhotra R, et al. The safety of besifloxacin ophthalmic suspension 0.6 % used three times daily for 7 days in the treatment of bacterial conjunctivitis. Drugs R D. 2013;13(4):243–52. S4 Besivance eye drops, suspension, Besifloxacin 6,00 mg/ml, 47/15.1/1186. For full prescribing information, refer to the professional information as approved by the South African Health Products Regulatory Authority (SAHPRA) © 2024 Bausch & Lomb Incorporated or its affiliates. ®/™ denote trademarks of Bausch & Lomb Incorporated or its affiliates. Soflens (Pty) Ltd. Reg. no.: 1968/011787/07. 254 Hall Street, Centurion, 0157. Tel: +27 10 025 2100. www.bausch.co.za. BL525/21 Ch ro-Fluoroquinol e 13 First&OnlyDual Halo nat ed 320561 Besivance Advert MC.indd 1 2024/01/19 10:23:05

Dr Lesego Ndhlovu, Paediatrician & Paediatric Gastroenterologist

This webinar is sponsored by Thermo Fisher Scientific

Date: 26 June 2024

Time: 7:00pm - 8:00pm (SAST)

Topic: Exploring Inflammatory Bowel Disease in children: Enhancing understanding of the disease and diagnostic testing

Speaker: Dr Lesego Ndhlovu

CLICK TO REGISTER https://bit.ly/ThermoFisherWebinar26Jun24

Dr Lesego Ndhlovu is a Specialist Paediatrician and a Paediatric Gastroenterologist. Originally from Johannesburg, she obtained her medical degree from the University of the Witwatersrand (Wits) in 2012. After completing her internship and community service years in Mahikeng and Tzaneen respectively, she went on to train in the field of paediatrics through Wits in 2016, and qualified as a paediatrician in 2019. She obtained a masters in medicine paediatrics degree from Wits in 2020. She went on to sub-specialise in Paediatric Gastroenterology, Hepatology, and Nutrition at Red Cross

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War Memorial Children’s Hospital through the University of Cape Town (UCT) in 2020, and qualified as a paediatric gastroenterologist in 2022. Dr Lesego Ndhlovu is a senior lecturer at Stellenbosch University, and a part-time consultant in the department of Paediatric Gastroenterology, Hepatology, and Nutrition at Tygerberg Hospital. She has a passion for child nutrition and the fight against childhood malnutrition, and she is the co-founder of Marotholi Outreach which is an organisation aimed at preventing childhood malnutrition in vulnerable communities.

1
WEBINAR
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efficiency Increase COMPLETELY AUTOMATED © 2012 Thermo Fisher Scientific Inc Al r ghts reserved All trademarks are the property of Thermo F sher Scientific Inc. and its subsidiaries Lega Manufacturer: Phadia AB, Uppsala, Sweden EliATM Calprotectin • For further information please visit: https://www.thermofisher.com/phadia/wo/en/ our-solutions/elia-autoimmunity-solutions/inflammatory-bowel-diseases.html 3 Susan Street, Strijdom Park, 2194 Tel.: 011 793 1064 • • Join Medical Chronicle for a free, one-hour, CPD-accredited webinar on Exploring Inflammatory Bowel Disease in children: Enhancing understanding of the disease and diagnostic testing Adobe Stock Credit : eddows

E-cigarette use associated with increased risk of heart failure: Recent findings and implications

The rising popularity of e-cigarettes has sparked concerns regarding their potential health effects.

ECENT STUDIES HAVE suggested a link between e-cigarette use and adverse cardiovascular outcomes, including respiratory disease, heart attacks, and stroke. A new study presented at the annual scientific meeting of the American College of Cardiology sheds further light on this issue. Analysing data from the US National Institutes of Health's All of Us Research Program, researchers found that individuals who had ever used e-cigarettes faced a 19% higher risk of heart failure compared to non-users. This prospective study, the largest of its kind, underscores the need for continued research into the cardiovascular consequences of e-cigarette use. Since the outbreak of vaping-related lung injuries in 2019, concerns about the health risks associated with e-cigarette use have escalated. While earlier studies have highlighted respiratory complications, emerging evidence suggests a potential link between e-cigarettes and cardiovascular disease. This article reviews recent findings from a study investigating the association

between e-cigarette use and heart failure, emphasising the need for comprehensive research to inform public health policies and interventions.

Amongthestudy participants, individuals who reportedeverusing e-cigarettesexhibited a 19% increased risk of heart failure

Methods:

Researchers analysed health records from 175 667 adults participating in the US National Institutes of Health's All of Us Research Program. Participants were categorised based on e-cigarette use, and incidents of heart failure were documented over a median follow-up period of nearly four years. Statistical adjustments were made for confounding variables such as

age, sex, and comorbidities associated with heart failure.

Results:

Among the study participants, individuals who reported ever using e-cigarettes exhibited a 19% increased risk of heart failure compared to non-users. This association persisted after accounting for known risk factors, highlighting a potentially independent effect of e-cigarette use on cardiovascular health. Notably, the risk was particularly elevated among individuals who also smoked traditional cigarettes, suggesting a synergistic effect of dual tobacco product use.

Discussion:

The findings from this study contribute to a growing body of evidence implicating e-cigarette use in adverse cardiovascular outcomes. While the precise mechanisms underlying this association remain unclear, several hypotheses have been proposed, including the direct impact of e-cigarette aerosols on cardiac function and the

Since the outbreak ofvaping-related lunginjuriesin2019, concerns about the health risks associated with e-cigaretteusehave escalated

systemic effects of nicotine exposure. Additionally, the presence of harmful substances in e-cigarette formulations, such as nicotine and flavourings, may contribute to cardiovascular toxicity.

Conclusion:

The results of this study underscore the importance of continued surveillance and research into the health effects of e-cigarette use. Public health initiatives aimed at reducing e-cigarette uptake, particularly among youth, may help mitigate the long-term burden of cardiovascular disease associated with these products. Further investigation is warranted to elucidate the underlying mechanisms and inform evidence-based interventions aimed at reducing the adverse cardiovascular effects of e-cigarettes.

Sources: Science Alert; Bene-alhasan, y, Mensah, S, Almaadawy, O. et al. Electronic nicotine product use is associated with incident heart failure – the all of us research program. J Am Coll Cardiol. 2024 Apr, 83 (13_Supplement) 695.https://doi.org/10.1016/S07351097(24)02685-8

R
CLINICAL | SMOKING CESSATION 26 May 2024 | MEDICAL CHRONICLE
gettyimages Credit : AND-ONE

Date: 19 June 2024 | Time: 7:00pm

Topic: Can Mobile Health Improve Diabetes Management? A Review of Its Effectiveness

Presenters: Prof Fasanmade Olufemi Adetola, Dr Joyce Wangechi Mbogo, Dr Ankia Coetzee

Prof Fasanmade Olufemi Adetola MBBS, FWACP, FACE, MPA, MD, FAMedS, Consultant Physician/ Endocrinologist

Prof Fasanmade Olufemi Adetola is a distinguished medical professional with expertise in surgery and endocrinology. With an outstanding academic journey, he passed all preliminary science and medical exams at first sitting. His residency in surgery led to him becoming a Fellow of the West African College of Surgeons. He passed primary exams at the West African Postgraduate Medical College and Nigerian Postgraduate Medical College. His commitment culminated in him being recognised as a Fellow of the American College of Endocrinologists in 2008.

Dr Joyce Wangechi Mbogo Paediatrician Endocrinologist

Dr Joyce is Kenya and American Board of Pediatrics certified pediatrician with a sub-specialty in pediatric endocrinology currently working at Kenyatta University as a lecturer at the Department of Pediatrics and Child Health. She has solid clinical and research experience garnered in Kenya and the USA. She has also led efforts in training both medical and non-medical personnel on aspects on endocrine disorders and diabetes. Dr. Joyce is a training director for the Allied Healthcare Diabetes Educator course for Africa (ADECA).

Dr Ankia Coetzee Endocrinologist

Dr Ankia Coetzee is a prominent consultant chysician and subspecialist endocrinologist affiliated with Stellenbosch University and Tygerberg Hospital, alongside a private practice in Cape Town. Specialising in diabetes in pregnancy and complex endocrine disorders, she boasts over a decade of experience. Dr Coetzee holds degrees from the University of Pretoria and Stellenbosch University, including an M.Phil in Endocrinology. Her Ph.D. submission focused on hyperglycemia in pregnancy. An adept educator, she mentors students at Stellenbosch University and actively contributes to international conferences and publications, earning recognition for her contributions to South African medicine.

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Mitigating musculoskeletal side effects of isotretinoin

Acne vulgaris, a chronic inflammatory condition, often requires treatment with isotretinoin.

ISOTRETINOIN HAS REVOLUTIONISED the lives of many patients using it, as it is arguably our best defence against acne vulgaris. It has various side effects, including musculoskeletal issues such as arthralgia, myalgia, and sacroiliitis, have been reported in patients taking isotretinoin. However, controlled studies on these side effects are lacking. Karaosmano ğlu et al evaluated musculoskeletal symptoms in acne vulgaris patients treated with isotretinoin compared to healthy controls.

This study focused on musculoskeletal side effects in acne patients treated with isotretinoin, finding that a significant percentage experienced musculoskeletal pain. Notably, back pain was common, and its occurrence was dose dependent. Sacroiliitis, while rare, was observed, often presenting as inflammatory back pain. Clinicians should be vigilant, especially during the initial months of treatment. Notably, all rheumatologic symptoms of the patients disappeared after the discontinuation of the drug and the complaints were drug related.

Previous studies have reported similar findings, with musculoskeletal symptoms emerging within the first few months of isotretinoin therapy. This study corroborated these findings, emphasising the importance of early monitoring. The incidence of sacroiliitis was comparable to previous reports, although back pain was more prevalent in the isotretinoin group. Interestingly, sacroiliitis did not correlate with total cumulative drug dose, suggesting other factors may contribute. All the patients with sacroiliitis were completely symptom free at the sixth month of the discontinuation of the drug.

Research on isotretinoin-induced tendinopathy and enthesitis is limited but suggests a potential association. Clinical examination revealed tendinopathy in some patients, highlighting the need for further investigation. The exact mechanism of isotretinoin-induced musculoskeletal issues remains unclear but may involve alterations in cellular structures and stimulation of certain enzymes. MRI findings of sacroiliitis should be interpreted cautiously, as they may not always indicate pathology.

CONCLUSION

Low back pain is a very common side effect of isotretinoin and it is dose related. While sacroiliitis is rare, inflammatory back pain can occur. Clinicians should inquire about drug usage in patients presenting with musculoskeletal symptoms, as this may be overlooked. The statistically significant high prevalence of musculoskeletal

findings in drug users in the same age group was considered as an important indicator that their symptoms were significantly drug dependent. Further research is needed to fully understand

the musculoskeletal effects of isotretinoin. Considering that musculoskeletal complaints are mostly temporary, they can be often overlooked by clinicians.

REFERENCE

Karaosmanoğ lu, N, Mülkoğ lu, C. Analysis of musculoskeletal side effects of oral Isotretinoin treatment: a cross-sectional study. BMC Musculoskelet Disord. 2020:21,63. https://doi.org/10.1186/s12891020-03656-w

MEDICAL CHRONICLE | May 2024 29 CLINICAL | DERMATOLOGY
gettyimages Credit : utkamandarinka

CLINICAL | ENDOCRINOLOGY

How do I broach obesity with my patients?

Engaging in conversations about weight with adult patients is an integral aspect of primary care practice. While these discussions can pose challenges, especially with patients who are overweight or obese, using sensitive and effective communication strategies is key.1

ESEARCH INDICATES THAT many individuals who are overweight or obese appreciate guidance from healthcare providers regarding weight management to mitigate associated health risks. However, initiating such discussions may be difficult for some patients.1

Patients who are overweight or obese may benefit from dialogues concerning weight-loss objectives, lifestyle modifications, available weightmanagement strategies, and potential treatments such as medications or surgical interventions. Collaborating respectfully with patients can facilitate the attainment and maintenance of a healthier weight.1

IDENTIFYING PATIENTS FOR WEIGHT-LOSS DISCUSSIONS

Patients who have, or are at risk of developing, health issues related to being

overweight or obese are suitable candidates for weight-related discussions. This risk is elevated in adults who:

• Are overweight (BMI 25-29.9) or obese (BMI ≥30)

• Exhibit a waist size exceeding 88cm for women or 102cm for men

• Experience metabolic syndrome, high blood pressure, unhealthy lipid levels, or elevated blood glucose levels.1

However, relying solely on BMI and waist size may not give the full picture of health risks associated with excess body fat. Therefore, considering additional factors such as age, race, ethnicity, sex, health status, medical history, and cardiometabolic disease risk is imperative in determining the appropriateness of weight-loss interventions.1

ADDRESSING WEIGHT STIGMA

Individuals who are overweight or obese frequently encounter negative attitudes, prejudice, and discrimination, including from healthcare professionals. Acknowledging that weight can be influenced by various factors beyond lifestyle choices is crucial during weight-related discussions.1

Negative weight-related stigma can adversely impact individuals by diminishing self-esteem, exacerbating mental health issues, promoting unhealthy behaviours, and deterring healthcare-seeking behaviour.1

CREATING A SUPPORTIVE ENVIRONMENT

Establishing a welcoming environment in waiting areas and consultation rooms, equipped with furniture and tools suitable for patients of all sizes, is essential. This includes providing stable, accessible scales, sturdy examination tables and furniture, and appropriately sized gowns and blood pressure cuffs.1

CHOOSING APPROPRIATE LANGUAGE

To address these challenges, efforts to destigmatize obesity are essential. The Joint International Consensus Statement for Ending Stigma of Obesity emphasises condemning discriminatory language and policies and supporting initiatives to prevent weight-based discrimination.2

Using nonjudgmental language when discussing weight is essential to avoid inadvertently causing offence. Instead of using terms like "heavy," "fat," "overweight," or "obese," opt for more neutral phrases such as "weight" or "having too much weight for health."1

Person-first language emphasises individuals' identities beyond their weight,

creating a more respectful and inclusive dialogue.1 Using motivational interviewing and person-first language empowers patients to set realistic goals and engage in their healthcare journey.2

INITIATING WEIGHT-RELATED CONVERSATIONS

Approaching weight-related discussions with sensitivity and respect is vital. Begin by addressing the patient's primary health concerns before broaching the topic of weight. Seeking permission to discuss weight and respecting the patient's decision sets a tone of collaboration and trust.1

ASSISTING PATIENTS WITH LIFESTYLE CHANGES

Many patients, regardless of their desire to lose weight, can benefit from discussions about healthy eating and physical activity habits. Conducting thorough assessments of eating habits, physical activity levels, weight history, and potential eating disorders is essential.1

Encouraging patients to set specific, measurable, achievable, realistic, and timebased (SMART) goals for lifestyle changes encourages active participation in their care. Providing ongoing support, monitoring progress, and acknowledging achievements, irrespective of changes in weight, are vital for effective care.1

ADDRESSING CHALLENGES AND SETBACKS

Recognising that setbacks are normal and refraining from judgment are important when patients encounter obstacles in their weight-management journey. Collaborating with patients to identify barriers, explore alternative strategies, and adjust goals as needed will assist with resilience and progress.1

DESTIGMATISING OBESITY AND ENCOURAGING PATIENT ENGAGEMEN

t

Obesity is burdened with social stigma that can impact individuals from childhood, affecting various aspects of their lives. This stigma, often perpetuated by misconceptions about laziness and lack of self-control, can significantly influence patient care. Recognising and addressing this stigma within the healthcare community is crucial for enhancing the quality of care provided to patients with obesity.2

Early experiences of discrimination due to weight can shape lifelong perceptions and behaviours. Despite healthcare professionals being key influencers in patients' lives,

studies have shown that many harbour biases against individuals with obesity. These biases can hinder communication, creating a barrier in the delivery of appropriate care.2

Research from different countries, including France, Australia, Britain, and Israel, highlights negative attitudes among healthcare providers towards patients with obesity. These attitudes often manifest as frustrations regarding patient motivation and compliance, attributing obesity solely to lifestyle choices, or even perceiving overweight individuals as lazy.2

The consequences of weight stigma on patient health are well-documented, leading to increased risk of binge eating, reduced physical activity, and heightened stress responses. Stigma also contributes to patients’ reluctance to seek medical care, increasing health risks.2 Tools like the Antifat Attitudes Test (AFAT) can help assess healthcare providers' attitudes towards obesity, fostering awareness and discussion to drive positive change.2 Reframing obesity as a chronic disease caused by multifactorial influences can help shift the focus from personal responsibility to a collaborative treatment.2

CONCLUSION

Creating a weight-friendly clinical environment with appropriate equipment and respectful language is crucial for ensuring patient comfort and dignity.2

Implementing zero-tolerance policies against stereotypical language in the practice and promoting perspective-taking exercises can enhance provider empathy and understanding. Educational interventions, such as obesity simulation suits and lectures, can challenge biases and foster a more empathetic approach to patient care.2

By implementing these strategies and adopting individualised, multidisciplinary treatment plans, healthcare teams can work towards destigmatising obesity and providing equitable care to all patients.2

REFERENCES

1. NIH: National Institute of Diabetes and Digestive and Kidney Diseases. Talking with Your Patients about Weight. https://www.niddk.nih.gov/health-information/ professionals/clinical-tools-patient-management/ weight-management/talking-with-your-patientsabout-weight#:~:text=Ask%20for%20your%20 patient's%20permission%20to%20start%20a%20 conversation%20about%20weight.&text=For%20 example%2C%20you%20may%20want,they%20 feel%20about%20their%20weight.

2. Ginsburg BM, Sheer AJ. Destigmatizing Obesity and Overcoming Inherent Barriers to Obtain Improved Patient Engagement. [Updated 2023 Jan 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www. ncbi.nlm.nih.gov/books/NBK578197/

30 May 2024 | MEDICAL CHRONICLE R
*Studies were conducted on the HCl formulation. Duromine is available as sustained action ion exchange resinate granules in capsules containing phentermine 15 mg or 30 mg. Duromine should be used in conjunction with an exercise, diet and behaviour modification program. Patients require medical review after a defined course of treatment, which ideally should not exceed 3 months. References: 1. Duromine® approved professional information, October 2020. 2. Moldovan CP, Weldon AJ, Daher NS, Schneider LE, Bellinger DL, Berk LS, et al. Effects of a Meal Replacement System Alone or in Combination with Phentermine on Weight Loss and Food Cravings. Obesity 2016; 24:2344-2350. 3. Munro JF, Maccuish A. C, Wilson EM, Duncan LJP. Comparison of Continuous and Intermittent Anorectic Therapy in Obesity. Br Med J 1968;1:352-354. 4. Based on internal analysis by iNova Pharmaceuticals (Pty) Ltd using data from the following source: IQVIA Rx_OTC Jul 2023, ATC3- A8A, Brands measured in Dispensed Units, reflecting estimates of real-world activity. Copyright IQVIA. All rights reserved. Scheduling status: S5 Proprietary name (and dosage form): Duromine 15 mg and 30 mg Capsules. Composition: Sustained action ion-exchange resinate granules, available as capsules containing phentermine 15 mg and 30 mg Pharmacological classification: A 11.3 Anorexigenics. Indications: Duromine is an anorectic agent used in the management of obesity. Reference number: 15 mg: B657; 30 mg: B658 [Act 101/1965]. Name and business address of applicant: iNova Pharmaceuticals (Pty) Limited. Co. Reg. No. 1952/001640/07, 15e Riley Road, Bedfordview. Tel. No. 011 087 0000. www.inovapharma.co.za. For full prescribing information, refer to the professional information as approved by the SAHPRA (South African Health Products Regulatory Authority). Further information is available on request from iNova Pharmaceuticals. 23436L. IN4631/24. Become an iLiveLite Doctor Scan the code and make a submission SCAN ME CURB APPETITE AND CRAVINGS *1,2 Help them take back control 9.16 kgs 3 months 3 36 % reduction in cravings in 12 weeks*2 Committed to weight loss iLive Lite SOUTH AFRICA’S NUMBER 1 APPETITE SUPPRESSANT TO SUPPORT YOUR PATIENTS ON THEIR WEIGHT LOSS JOURNEY4

CLINICAL | WINTER AILMENTS

The diverse advantages of acetylcysteine in respiratory health

Acetylcysteine (NAC), the N-acetyl derivative of L-cysteine, has been a staple in medical practice since the 1960s, initially as a mucolytic agent and later, in the 1970s, for acetaminophen poisoning. Over time, its applications have expanded to encompass various respiratory conditions, particularly chronic obstructive lung disease (COPD), indicating its growing clinical significance.1

ACCORDING TO MARKS et al, overthe-counter (OTC) medications like nonsteroidal anti-inflammatory drugs, antitussives, decongestants, mucolytics, and expectorants are currently available options for treating upper respiratory tract infections (URTIs). However, while these medications may provide some relief from URTI symptoms, there is a strong desire for more effective treatments.2

NAC, a thiol compound, serves as a precursor to L-cysteine and reduced glutathione (GSH), a vital component of the cellular redox system. GSH plays a pivotal role in neutralising reactive oxygen species (ROS), oxidative molecules, and certain toxins. By replenishing intracellular GSH levels, NAC acts as an antioxidant, crucial in conditions marked by heightened oxidative stress and inflammation. Studies have demonstrated a significant increase in GSH concentrations in bronchoalveolar lavage fluid following oral NAC administration, highlighting its therapeutic potential across diseases associated with oxidative stress.2

NAC is a naturally occurring amino acid solution, it acts as a mucolytic agent, aiding in the clearance of mucus that may obstruct breathing or other functions. Additionally, its potent antioxidant properties may protect the lungs from free radicals generated by inflammation due to viral infections like

influenza.1 Chalumeau et al's meta-analysis on acetylcysteine's efficacy in treating acute upper and lower respiratory tract infections revealed a 63% reduction in cough risk after six-seven days of treatment. The studies reviewed suggest that acetylcysteine could potentially reduce the frequency, intensity, and duration of symptoms in both upper and lower RTIs.2 In the context of recurrent acute rhinosinusitis, Macchi et al demonstrated that adding NAC to standard treatment with flunisolide via nasal douche effectively breaks the pathogenetic loop sustaining the condition, resulting in improved patient outcomes lasting up to six months post-treatment.2 Yadav et al found NAC, when combined with antibiotics, beneficial in treating chronic sinusitis by enhancing nasal mucociliary clearance and augmenting antibiotic efficacy.2 Supporting the efficacy of alternative medical treatments for sinusitis and colds, MedHelp recommends a dosage of 600mg two-three times daily, citing NAC’s anti-inflammatory properties, which can potentially shorten illness duration by two-three days.2

MECHANISMS OF ACTION

The mechanisms underlying NAC's efficacy are multifaceted:

• Mucolytic Activity: NAC disrupts disulfide bridges in high-molecular-weight

glycoproteins of mucus, reducing its viscosity

• Antioxidant Activity: NAC directly scavenges free radicals and indirectly boosts intracellular cysteine levels, augmenting GSH production

• Anti-inflammatory Activity: NAC inhibits NF- B, a key regulator of inflammatory responses, and suppresses the release of inflammatory cytokines

• Antibacterial Activity: Emerging evidence suggests NAC's potential antibacterial properties, including its ability to penetrate biofilms and eradicate embedded bacteria2

CLINICAL INDICATIONS

• Cystic fibrosis: NAC’s mucolytic properties aid in reducing sputum viscosity, facilitating its clearance and potentially mitigating mucus hypersecretion

• Chronic bronchitis and COPD: Numerous trials attest to NAC's efficacy in reducing exacerbations, improving lung function, and enhancing quality of life in COPD patients

• Bronchiectasis: Studies indicate a reduction in exacerbations and

improvement in quality of life with NAC treatment

• Idiopathic pulmonary fibrosis: Highdose NAC supplementation has shown promise in preserving lung function in IPF patients.2

BEYOND RESPIRATORY CONDITIONS

NAC's anti-inflammatory properties extend its potential therapeutic utility to psychiatric disorders, neurodegenerative diseases, and even tuberculosis. Recent investigations explore its potential in mitigating lung disease severity in SARS-CoV-2 patients.1

In conclusion, decades of clinical use have established NAC as a safe and effective therapeutic agent. Ongoing research continues to uncover its diverse benefits across a spectrum of systemic conditions, underscoring its potential as an adjunctive treatment alongside conventional therapies.1

REFERENCES

1. Multifaceted benefits of acetylcysteine in respiratory conditions. Medical Chronicle. June 2023. https:// www.medicalacademic.co.za/courses/multifacetedbenefits-of-acetylcysteine-in-respiratory-conditions/ 2. Acetylcysteine and upper respiratory infections. Pharmacy Magazine. March 2023. https:// www.medicalacademic.co.za/winter-ailments/ acetylcysteine-and-upper-respiratory-infections/.

32 May 2024 | MEDICAL CHRONICLE
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References available on request. For full prescribing information, refer to the individual professional information available at www.inovapharma.co.za. Further information is available on request from iNova Pharmaceuticals. Name and business address of applicant: iNova Pharmaceuticals (Pty) Limited. Co. Reg. No. 1952/001640/07, 15e Riley Road, Bedfordview. Tel. No. 011 087 0000. www.inovapharma.co.za. 23837L. IN4740/24.

Autoantibody signature predicts MS

Blood samples can reveal signs of multiple sclerosis (MS) years before diagnosis.

BLOOD SAMPLES REVEALED a distinct autoantibody signature in a subgroup of individuals with MS well before the onset of clinical symptoms, according to findings reported by Dr Michael Wilson and colleagues from the University of California San Francisco (UCSF).

This specific set of autoantibodies

emerged in approximately 10% of MS patients up to five years before the appearance of symptoms. These autoantibodies showed affinity towards both human cells and common pathogens and were associated with elevated levels of serum neurofilament light (NfL).

The persistence of this autoantibody

profile over time indicates an immunologically active preclinical phase occurring years before the onset of clinical symptoms, as detailed by Wilson and the research team in Nature Medicine.

This autoantibody signature could serve as a valuable starting point for further characterisation of this patient subset

and may hold clinical utility as an antigenspecific biomarker for identifying highrisk individuals with clinically isolated or radiologically isolated syndromes, the authors stated.

Dr Colin Zamecnik, co-author from UCSF, emphasised the importance of B cells, which produce antibodies, in MS disease progression. He explained that profiling antibodies in individuals with or at risk of developing MS offers valuable insights into the disease and could potentially unveil a biomarker.

The study suggests that a subset of individuals prone to developing MS may possess antibodies targeting a common protein domain found in humans and viruses. Dr Zamecnik noted that these patients exhibit these antibodies many years before symptom onset and continue to have them in both blood and cerebrospinal fluid at the time of their first disease flare.

The research, using data from the Department of Defence Serum Repository, employed phage display immunoprecipitation sequencing (PhIP-Seq) to screen blood samples for autoantibodies. This repository, known for its previous contribution to establishing a link between Epstein-Barr virus and MS, provided samples from over 10 million US armed service members.

In both the Department of Defence and UCSF ORIGINS cohorts, individuals diagnosed with MS exhibited higher serum NfL levels years before their first clinical flare compared to matched controls. Furthermore, approximately 10% of MS patients in both cohorts displayed a distinctive autoantibody pattern predictive of an MS diagnosis.

Although the role of autoantibodies in MS could lead to earlier diagnosis and treatment, potentially moving towards a cure for some MS patients.

Source: Zamecnik, C.R., Sowa, G.M., Abdelhak, A. et al. An autoantibody signature predictive for multiple sclerosis. Nat Med (2024). https://doi.org/10.1038/ s41591-024-02938-3.

CLINICAL | NEUROLOGY 34 May 2024 | MEDICAL CHRONICLE
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SA’s Dr Kgosi Letlape advocates for harm reduction as a transformative approach to improving public health

Dr Kgosi Letlape, co-founder of the Africa Harm Reduction Alliance, recently called on governments to prioritise evidence-based harm reduction strategies in improving public healthcare.

SPEAKING AT THE 4th Africa Healthcare Awards and Summit (AHAS) in Accra, Dr Letlape said prohibitory approaches do not work in mitigating the risk of substances and behaviours that are detrimental to health including smoking, drug, and alcohol abuse as well as sexually transmitted diseases.

“Bans don’t solve any behavioural problems, and this truth should not be overlooked by policymakers. Harm reduction offers a practical and transformative approach. It empowers individuals to make informed choices, promoting health and self-direction,” says Dr Letlape.

Giving tobacco harm reduction as an example he said there was evidence showing that countries that embraced non-combustible nicotine products as an alternative to cigarettes were bringing their smoking rates down, adding that these products reduced the risks of tobacco related illnesses.

“In Sweden the uptake of snus has been demonstrated to have reduced the incidence of tobacco related disease for example lung cancer and cardiovascular disease,” Dr Letlape said, highlighting the critical role of risk reduced products.

“The problem with cigarettes lies in combustion, not nicotine itself. Non-combustible nicotine delivery methods significantly reduce harm. By choosing

non-combustible options, individuals can mitigate risks associated with tobacco use.”

That is the reason Nicotine Replacement Therapy has been offered for the last three decades.

Under the theme 'Advances in Population Health – Tackling Inequalities and Access: A One Health Approach', AHAS 2024 was attended by healthcare professionals, policymakers, innovators, and stakeholders from across Africa to discuss pressing issues in healthcare and foster collaboration for sustainable solutions.

DrLetlapesaidprohibitoryapproachesdonotworkinmitigatingtherisk ofsubstancesandbehavioursthataredetrimentaltohealthincluding smoking,drug,andalcoholabuseaswellassexuallytransmitteddiseases

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MEDICAL CHRONICLE | May 2024 35
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Best practices to prevent and manage allergic conjunctivitis

No need for alarm regarding KwaZulu-Natal outbreak.

NETCARE MEDICROSS

REASSURES residents amidst the recent warning from the KwaZulu-Natal Department of Health regarding a pink eye outbreak in certain areas of the province.

While there's no cause for alarm, understanding this eye condition is crucial

to prevent its spread and complications.

General practitioner Dr Nishen Gounder from Netcare Medicross Malvern provides essential insights.

UNDERSTANDING PINK EYE

“Pink eye, or conjunctivitis, entails

inflammation of the conjunctiva, a thin membrane covering the whites of the eye and the inner part of the eyelid. It can stem from viral or bacterial infections, allergic reactions, or environmental irritants,” explains Dr Gounder.

Goes beyond itchy eyes.1, 2

Symptoms include:

• Redness

• Itching

• Pain

• Swelling

• Fluid discharge

• A gritty sensation, akin to having sand in the eye.

Both viral and bacterial causes are highly contagious and easily transmitted through close contact and contaminated hands.

VIRAL CONJUNCTIVITIS

Often linked with viruses causing common cold symptoms, viral pink eye is highly contagious. Symptoms typically resolve within a week or two without intervention. However, individuals using contact lenses should promptly consult a GP to rule out potential corneal infections.

BACTERIAL CONJUNCTIVITIS

While less contagious than its viral counterpart, bacterial conjunctivitis presents with distinct symptoms, including yellow, white, or green discharge and crust formation overnight. Treatment usually involves antibiotic drops or ointment prescribed by a GP.

RED FLAGS

Warning signs for immediate attention include:

• Eye pain or tenderness

• Vision changes

• Light sensitivity or difficulty keeping eyes open

• Additional symptoms such as severe headaches with nausea.

TOP TIPS FOR PREVENTION AND MANAGEMENT

• Patients should be booked off work/ school while waiting for a resolution, which is typically within 24 hours of antibacterial treatment

• Emphasise general hygiene, including frequent handwashing with soap or alcohol-based sanitisers

• Minimise contact with individuals diagnosed with pink eye

• Wash hands regularly and change bed linen daily if exposed to pink eye

• Discontinue contact lens use if pink eye is suspected

• Look out for severe symptoms or signs of infectionPay careful attention to immunocompromised individuals, and infants or young children displaying symptoms

• Patients should take precautions to prevent spreading pink eye at home.

CLINICAL | OPHTHALMOLOGY
References: 1. Ketagex™ package insert, August 2022. 2. Kidd M, et al. Ee cacy and safety of ketotifen eye drops in the treatment of seasonal allergic conjunctivitis. Scientific report, Br J Ophthalmol., 2003; 87:1206-1211. 3. Ganz M, Koll E, Gausche J, Detjen P, Orfan N. Ketotifen fumarate and olopatadine hydrochloride in the treatment of allergic conjunctivitis: a real-world comparison of e cacy and ocular comfort. Adv Ther. 2003 Mar-Apr;20(2):79-91. 4. Abelson MB, Chapin MJ, Kapik BM, Shams NB. E cacy of ketotifen fumarate 0.025% ophthalmic solution compared with placebo in the conjunctival allergen challenge model. Arch Ophthalmol. 2003 May;121(5):626-630. S2 KETAGEX™ 0,035 % eye drops, solution, Ketotifen fumarate (0,035 % m/v). Preservative: Benzalkonium chloride 0,1 mg/ml (0,01 % m/v). Reg. No.: 47/15.4/1166. For full prescribing information, refer to the professional information as approved by the South African Health Products Regulatory Authority (SAHPRA). © 2024 Bausch & Lomb Incorporated or its a liates. ®/TM denote trademarks of Bausch & Lomb Incorporated or its a liates. Soflens (Pty) Ltd. Reg. no.: 1968/011787/07. 254 Hall Street, Centurion, 0157. Tel: +27 10 025 2100. www.bausch.co.za. BL627/23
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Recent advances in micronised bioidentical progesterone: Implications for obstetrics and gynaecology practice

Dr Sanli Erkan, specialist in obstetrics and gynaecology based in London, shares insights into the use of micronised bioidentical progesterone in various clinical scenariosprevalence ranging from 12% to 18% of the population.

HIS PRESENTATION LOOKED at recent updates on the role of progesterone in fertility treatments, miscarriage management, and preterm birth prevention.

PROGESTERONE’S ROLE IN REPRODUCTIVE PHYSIOLOGY

Progesterone plays a pivotal role during both the luteal phase and pregnancy, exerting multifaceted effects on the endometrium and uterine environment. Dr Erkan elucidated how progesterone facilitates endometrial receptivity, promotes embryo implantation, and maintains uterine quiescence throughout pregnancy. This hormone also modulates maternal immune responses and improves utero-placental circulation, crucial for foetal development and pregnancy success.

ROUTES OF PROGESTERONE ADMINISTRATION: CHOOSING THE OPTIMAL APPROACH

Dr Erkan discussed various routes of progesterone administration, highlighting

the advantages and limitations of each. While intramuscular injections and oral formulations are common, vaginal progesterone emerges as a preferred option due to its targeted delivery to the endometrium, stable plasma concentrations, and minimal systemic side effects. Micronised bioidentical progesterone, administered vaginally, offers superior efficacy and safety compared to synthetic alternatives.

LUTEAL PHASE SUPPORT IN FERTILITY TREATMENTS

For patients undergoing fertility treatments, adequate luteal phase support is essential for successful embryo implantation and pregnancy maintenance. Dr Erkan outlines strategies for managing cases with low serum progesterone levels, emphasising dose optimisation and individualised approaches. By tailoring progesterone therapy to each patient's needs, clinicians can enhance treatment outcomes and improve pregnancy rates.

MANAGEMENT OF MISCARRIAGE WITH MICRONISED PROGESTERONE

Miscarriage remains a challenging aspect of reproductive medicine, often posing diagnostic and therapeutic dilemmas for clinicians. Dr Erkan discusses the role of micronised vaginal progesterone in preventing recurrent miscarriages, citing compelling evidence from clinical trials and meta-analyses. Recommendations from NICE guidelines advocate for the use of micronised progesterone in women with a history of miscarriage and early pregnancy bleeding, offering hope for improved pregnancy outcomes.

PREVENTION OF PRETERM BIRTH

Preterm birth represents a significant global health burden, necessitating effective preventive strategies. Dr Erkan underscores the role of micronised bioidentical progesterone in reducing the risk of preterm birth, particularly in high-risk populations. Drawing from NICE guidelines, he provides clear recommendations for initiating vaginal progesterone therapy in women

with a history of preterm birth or cervical insufficiency, emphasising the importance of early intervention and continued treatment until at least 34 weeks of gestation.

KEY MESSAGES

• Luteal phase support with progesterone is obligatory in IVF fresh and artificial cycles, and the vaginal route is the most preferred option among clinicians globally. UK guidelines recommend micronised vaginal progesterone 400mg twice daily to women with a history of one or more miscarriages and early pregnancy bleeding to treat miscarriage

• Treatment should be started immediately at the time of presentation and if foetal heartbeat is confirmed, progesterone should be continued until pregnancy week 16. The benefit of micronised bioidentical progesterone increases as the number of miscarriages increase

• Preterm birth is a global problem affecting millions of babies and it is the single biggest cause of mortality in children under the age of five

• A prior history of preterm birth and a short cervical length (<25mm) are the strongest predictors of recurrence of preterm birth

• This benefit of natural micronised bioidentical progesterone pessaries cannot be extrapolated to other progesterone preparations, doses, or routes

• Micronised bioidentical progesterone will not do harm to the mother or to the baby.

Overactive bladder (OAB) presents a significant challenge for patients and healthcare providers alike, with its prevalence ranging from 12% to 18% of the population.

U Navigating overactive bladder treatment: A comparative analysis of mirabegron and anticholinergics

NDERSTANDING THE NUANCES of treatment options is crucial for effective management. Dr David Smart looked at the complexities of OAB treatment, and discussed the comparative efficacy, safety, and tolerability of mirabegron and anticholinergic drugs. The webinar highlighted key insights into OAB management based on Dr Smart's expertise in the field. One of the fundamental points emphasised was the definition of OAB as a symptom complex characterised by urgency, often accompanied by frequency and nocturia, with or without incontinence. Notably, detrusor overactivity is a prevalent underlying condition, observed in 64% of OAB patients and in 83% of those with

detrusor overactivity.

Anticholinergic drugs have long been a mainstay in OAB treatment. However, Dr Smart outlined several challenges associated with their use. Of particular concern is the increasing evidence linking anticholinergic use to enhanced dementia risk and acute cognitive dysfunction. To aid healthcare providers in navigating these risks, tools such as the Anticholinergic Burden Calculator have been developed to quantify the cumulative burden of anticholinergic medications, available at www.acbcalc.com

Considering these challenges, Dr Smart highlighted mirabegron as a promising alternative to anticholinergics. As a beta-3 agonist, mirabegron offers

comparable efficacy and tolerability while boasting a favourable safety profile when compared to both placebo and anticholinergic medications.

Despite the availability of alternatives, discontinuation rates for OAB treatments remain high, driven by factors such as side effects, cost, and reimbursement issues, as well as patient and physician expectations. Dr Smart emphasised the importance of managing these factors to optimise treatment adherence and patient outcomes.

CONCLUSION

In summary, while there have been no major changes in the sequence of OAB management, a better understanding of the risks associated with drug therapy

has emerged. Newer agents, such as mirabegron, offer improved tolerability and lower cardiovascular side effects compared to traditional medications. However, it is essential to recognise that no drug is perfectly safe, underscoring the need for individualised treatment approaches tailored to each patient's unique circumstances.

Dr Smart's webinar provides valuable insights into the nuanced landscape of OAB treatment, equipping healthcare providers with the knowledge needed to navigate treatment decisions effectively. For those who missed the live presentation, the replay is available for viewing, offering an opportunity to gain CPD-accredited education on this critical topic.

WEBINAR REPORT MEDICAL CHRONICLE | May 2024 37
This was presented by Dr
by Cipla.
watch the recording and still earn a CPD point, go to: https://vimeo.com/event/4185174.
Medical Chronicle recently hosted a CPD-accredited webinar on Recent Updates on the use of Micronised Bioidentical Progesterone. Sanli Erkan and was sponsored
To
Dr David Smart
If you missed this CPD-accredited webinar on Navigating overactive bladder treatment: A Comparative analysis of mirabegron and anticholinergics, go to https://vimeo.com/event/4185364 to view the replay. The webinar is sponsored by Cipla.
Dr Sanli Erkan

Optimising Vitamin D deficiency management: Understanding the superiority of Vitamin D3

Dr Gary Hudson presented on the importance of Vitamin D3, shedding light on its implications for cardiovascular health, immune function, and beyond.

If you missed this compelling webinar focused on optimising the treatment of Vitamin D deficiency by understanding the role of Vitamin D3, go to: https://vimeo.com/event/4140219 to view the replay video.

VITAMIN D, LONG recognised for its role in bone health, has emerged as a critical player in various physiological processes, captivating medical professionals worldwide. This thoughtprovoking, CPD-accredited webinar was sponsored by Austell Pharmaceuticals.

THE CARDIOVASCULAR CONNECTION

Low circulating levels of serum 25-hydroxyvitamin D (25(OH)D) have surfaced as a notable health risk marker for cardiovascular disease (CVD) in otherwise healthy young adults. Dr Hudson underscores the significance of this unconventional risk factor, previously overlooked but entirely treatable. Traditionally, cardiovascular risk assessment relied on measures like the CAC score, but the ACTIBATE trial unveils a new perspective.

INSIGHTS FROM THE ACTIBATE TRIAL

The ACTIBATE trial, focusing on activating brown adipose tissue through exercise,

establishes a compelling association between 25(OH)D levels and CVD risk.

The trial, encompassing sedentary individuals aged 18-25 with no apparent risk factors, delineates clear thresholds for Vitamin D status, ranging from deficiency to toxicity. Elevated parathyroid levels often accompany deficiency, highlighting secondary hyperparathyroidism as a pertinent concern.

DECIPHERING VITAMIN D DEFICIENCY

Vitamin D deficiency stems from various factors, including inadequate sunlight exposure, malabsorption issues, accelerated catabolism, certain medications, and insufficient intake in breastfed infants. Contrary to its classification as a vitamin, Vitamin D behaves as a prohormone, synthesised in the skin's basal layers upon exposure to UVB radiation.

IDENTIFYING DEFICIENCY SYMPTOMS

While manifestations of Vitamin D

deficiency can be subtle, they hold significant implications. Children may present with skeletal deformities like bowing legs and kyphosis (rickets), while adults may experience chronic muscle aches and periosteal bone pain, detectable upon firm pressure on the sternum or tibia.

SCREENING RECOMMENDATIONS

Given its far-reaching impact, screening for Vitamin D deficiency is paramount across various clinical contexts, including osteoporosis, autoimmune disorders, cardiovascular disease, malignancies, malabsorption syndromes, and more. Dr Hudson emphasises the global prevalence of deficiency, affecting over a billion individuals worldwide.

BEYOND BONE HEALTH

Vitamin D's role extends beyond bone health, influencing diverse physiological processes such as cell proliferation, immune modulation, neurotrophic factor regulation, and nitric oxide synthesis. Optimal serum

levels are crucial for maintaining immune homeostasis and mitigating risks of infections, autoimmune diseases, and metabolic disorders.

NAVIGATING SUPPLEMENTATION

Supplementation strategies for Vitamin D remain a subject of debate, with conflicting evidence on its efficacy in mitigating risks of various conditions. While Vitamin D3 supplementation demonstrates benefits in certain populations, randomised trials reveal nuanced outcomes, underscoring the need for individualised approaches and continuous research.

In conclusion, Dr Hudson's comprehensive overview underscores the pivotal role of Vitamin D3 in human health, transcending its conventional association with bone metabolism.

As medical professionals, understanding the intricacies of Vitamin D physiology equips us to optimise patient care and navigate the evolving landscape of preventive medicine.

Introduction into understanding and when to suspect multiple sclerosis in general practice

Multiple sclerosis (MS) presents a complex diagnostic challenge in general practice due to its varied and sometimes subtle symptoms.

DR DION OPPERMAN, a distinguished authority in the field, sheds light on the intricacies of MS diagnosis and management in a recent CPDaccredited webinar sponsored by Activo Health. MS is a chronic autoimmune disease affecting the central nervous system (CNS), characterised by damage to myelin, axons, and oligodendrocytes. The CNS comprises the brain, brainstem, cerebellum, spinal cord, and optic nerves. Damage to myelin leads to scar tissue formation (sclerosis), disrupting nerve impulse transmission and causing symptoms.

AETIOLOGY AND EPIDEMIOLOGY

While the exact cause remains elusive, factors such as viral infections (eg, EpsteinBarr virus), smoking, and low vitamin D levels are implicated. In South Africa, MS

is more prevalent in women, typically onset between ages 16 and 45, and more common in individuals of Northern European descent, though there's a rising incidence among ethnic South Africans.

DIAGNOSTIC CRITERIA AND GP'S ROLE

Diagnosing MS requires a thorough evaluation based on dissemination in time and space, presence of oligoclonal bands, and exclusion of other conditions. General practitioners play a crucial role in early detection by taking detailed histories of present and earlier neurological symptoms, inquiring about fatigue and urinary urgency, and assessing symptom exacerbation in hot conditions.

CLINICAL PRESENTATION

If you missed this CPD-accredited webinar, go to https://vimeo.com/event/4150833 to view the replay. The webinar is sponsored by Activo Health.

AND EXAMINATION

MS presents with diverse sensory symptoms, often with subacute onset. Understanding upper and lower motor neuron signs is essential for accurate diagnosis. Examinations may reveal optic neuritis, spinal cord attacks (eg, MS hug, bladder dysfunction), brainstem involvement (eg, trigeminal neuralgia), cerebellar dysfunction (eg, ataxia, tremor), or cerebral manifestations (eg, cognitive impairment).

IMPORTANCE

OF EARLY DIAGNOSIS

Early diagnosis is paramount as MS evolves from an inflammatory to a degenerative phase. Timely intervention during the inflammatory stage is crucial as treatments are more effective, while options for the degenerative phase are limited. Clinical trials now focus on achieving NEDA (No

Evidence of Disease Activity) and preventing progressive brain atrophy.

RESOURCES AND SUPPORT

The Multiple Sclerosis South Africa (MSSA) organisation offers invaluable support and education to both patients and healthcare professionals. Their services extend to various disciplines, including doctors, physiotherapists, occupational therapists, biokineticists, and psychologists. In conclusion, enhancing awareness and understanding of MS among general practitioners is vital for early detection and optimal management, ultimately improving outcomes for patients affected by this complex neurological condition.

For further information and support, visit www.multiplesclerosis.co.za or contact info@multiplesclerosis.co.za.

38 May 2024 | MEDICAL CHRONICLE
WEBINAR REPORT
Dr Gary Hudson Dr Dion Opperman

Obesity treatment: What patients

want vs what we can provide

How does one manage patient expectations during a weight loss journey? How many of these expectations are even realistic? Medical Academic and iNova Pharmaceuticals proudly hosted specialist physician and endocrinologist Dr Jocelyn Hellig on 13 March for a presentation on patient expectations in obesity therapy.

N OBESITY THERAPY, what patients want is often not congruent with what we can offer them,” Dr Hellig pointed out. “Often patients will expect to be thin at the end of therapy, but the concept of thinness is itself rather outdated.” Patients will often fixate on achieving a number on a scale, and this number often relates to specific life events during which patients felt at ease and which they would like to return to.

“This is often a throwback to their weight at marriage, or just before the birth of their first child,” Dr Hellig said. From a clinical perspective, the weight they seek is therefore often an arbitrary number, and not necessarily the one most suited to them from a cardiometabolic perspective. Dr Hellig indicated that many patients also wish to lose to attain a sensation of 'feeling normal’.

“This is quite reasonable and really relates to improving quality of life in tangible ways – tying one’s own shoelaces, fitting into an aero plane seat, not shopping at a plus-size clothing store or playing with your kids.” But what does the current landscape of clinical practice offer these patients?

WHAT THE THERAPIES OFFER

Current medications can, in the medium term, induce weight loss of between 6% and 16% of total body weight, Dr Hellig said. This pales in comparison to the efficacy of bariatric surgery (gastric bypass in particular), which can typically cause an average weight loss between 25% and 35%. While both pharmaceutical and bariatric interventions result in radical weight loss, they typically don’t conform to patient expectations about being 'thin' at the end of a treatment regime.

“Sadly, the drugs we currently have are

expensive and are generally unavailable to the general public, due to the extent of global demand,” Dr Hellig said. She pointed out that, while BMI and metabolic were correlated, it is impossible to get a clear picture of a person’s metabolic risk strictly by focusing on their BMI. A far more sensitive marker of metabolic health is waist circumference.

“The International Diabetes Federation defines obesity as a waist circumference of more than 80cm in women and more than 90cm in men,” Dr Hellig pointed out. In male patients of South Asian descent, the wait circumference cutoff is slightly lower.

WEIGHT BIAS AND STIGMA

Dr Hellig was quick to point out that a doctor’s perception of obese patients can adversely affect their ability to treat them. “Two of the most common societal perceptions around obesity are weight bias

and stigma,” she said. Weight bias refers to the idea that obese people lack willpower or won’t be cooperative with lifestyle management approaches, while stigma is when one acts on weight-biased beliefs.

“Both weight bias and stigma are prevalent in the healthcare industry,” Dr Hellig said. These judgmental beliefs are not helpful for developing a true understanding of obesity, which at its core is a disease resulting from a deficit between energy intake and energy expenditure.

What factors contribute to energy intake? Does being thinner help you live longer? How many minutes of exercise per week is required to keep the kilos off? To find out, watch a recording of this webinar here: https://vimeo. com/922838800/5d3184d96a, accredited for 1 CPD point.

WEBINAR REPORT MEDICAL CHRONICLE | May 2024 39
I
CURB APPETITE AND CRAVINGS*1,2 Help them take back control Become an iLiveLite Doctor Scan the code and make a submission 9.16 kgs 3 months3 36 % reduction in cravings in 12 weeks*2 Name and business address of applicant: iNova Pharmaceuticals (Pty) Limited. Co. Reg. No. 1952/001640/07, 15e Riley Road, Bedfordview. Tel. No. 011 087 0000. www.inovapharma.co.za. For full prescribing information, refer to the professional information as approved by the SAHPRA (South African Health Products Regulatory Authority) available at www.inovapharma.co.za. Further information is available on request from iNova Pharmaceuticals. 23891L. IN4718/24. *Studies were conducted on the HCl formulation. Phentermine is available as sustained action ion exchange resinate granules in capsules as 15 mg or 30 mg. Phentermine should be used in conjunction with an exercise, diet and behaviour modification program. Patients require medical review after a defined course of treatment, which ideally should not exceed 3 months. References: 1. Phentermine approved professional information, October 2020. 2. Moldovan CP, Weldon AJ, Daher NS, Schneider LE, Bellinger DL, Berk LS, et al. Effects of a New Meal Replacement System Alone or in Combination with Phentermine on Weight Loss and Food Cravings. Obesity 2016; 24:2344-2350. 3. Munro JF, Maccuish A. C, Wilson EM, Duncan LJP. Comparison of Continuous and Intermittent Anorectic Therapy in Obesity. SCAN ME PHENTERMINE

Climate change in Sub-Saharan Africa

Climate change is one of the greatest threats to humanity. The entire foundation of good health is in jeopardy with the ever-increasing number of climate events.

N AFRICA, FREQUENT floods, water and vector-borne diseases are deepening the crisis. Although the continent contributes the least to global warming, it bears the full consequences, said Dr Matshidiso Moeti, the WHO regional director for Africa.

AFRICA SUFFERS

DISPROPORTIONATELY FROM CLIMATE CHANGE

- Temperature increase is accelerating - Extreme weather worsens food insecurity, displacement and conflict - Agricultural productivity is falling - Adaptation financing is insufficient - Losses and damages are rising - Early warning must reach everyone.

The impact of climate change is harming food security, ecosystems, and economies, fuelling displacement and migration and worsening the threat of conflict over dwindling resources, according to the new report from the World Meteorological Organization (WMO). More than 110 million people on the continent were directly affected by weather, climate and waterrelated hazards in 2022, causing more than US$ 8.5bn in economic damages. There were 5 000 fatalities reported, of which 48% were associated with drought and 43% were associated with flooding according to the Emergency Event Database [There may be under-reporting].

However, Africa is a continent which is least able to cope with the negative impact of climate change.

ANALYSIS BY THE WHO

The analysis by WHO found that 2 121 Public Health events were recorded in the African region, between 2001 and 2021. Of these, 56% were climate related. The region is witnessing an increase in climate linked emergencies, with 25% more climate related events recorded in 2011 and 2021 compared to the previous decade.

Africa is also grappling with other health impacts linked to climate shocks including malnutrition, hunger and food security due to adverse weather on agricultural production. Long-term health and development challenges on children, as well as other infectious diseases such as malaria.

WHO is supporting countries to reinforce their health systems to adapt, to be more resilient and to better cope with climate linked emergencies. Climate change's profound impact on health necessitates reframing it primarily as a health concern, demanding a response from the healthcare sector. Africa is expected to bear some of the most damaging effects of climate change, including irregular rainfall patterns.

Air pollution is another cause of

morbidity and mortality in Africa. Outdoor air pollution contributes to an estimated 40 000 deaths in Africa each year, exacerbated by rapid urbanisation and the poor infrastructure that often accompanies it. Nearly a quarter of all deaths in Africa are reportedly due to environmental causes including the impact of climate change. There is a need to promote and for coordination between health and environmental linkages for achieving the sustainable development goals. Hence, climate change is described as one of the important ecological drivers of changes. This includes air quality, food production, infectious disease exposure, access to fresh water and exposure to natural hazards, such as extreme weather events. Greenhouse gas emissions have significantly increased global temperatures and have led to climate change. Changes in climate have significant implications for human health and wellbeing as well as for health services generally.

The effects of climate change can be of a rapid onset (such as cyclones) or slow onset (such as droughts), leading to a range of health effects which are mostly negative. These can include injury and trauma, malnutrition, infectious diseases, healthrelated conditions, non-communicable diseases and poor mental health.

There are also associated social impacts such as loss of livelihoods, migration, displacement of populations, food insecurity and conflict. Hence climate change is one of the biggest threats to global health and primary healthcare. In Africa, building climate resilient primary healthcare is a challenge as there is little evidence to inform health systems and policy makers.

The negative impact of climate change is experienced more by the vulnerable populations and in locations where their ability to adapt is lowest. Hence, the low- and middle-income countries (LMIC) in Africa are amongst those predicted to experience the worst impact of climate change. Recent WHO survey showed that lack of funding is one of the main barriers countries face in implementing effective protection measures for their populations, with only 0.3% of global funding currently assisting health systems.

Health systems are beginning to address the effect of climate change from three different areas.

1. Effect of climate change on morbidity and mortality and the way health systems respond to the changing burden of disease.

2. The health systems must reduce its own carbon footprint. One and sixty countries signed the Paris Agreement to have committed to reduce emissions variably over different time scales.

3. Facilities and health services need to adapt to become more resilient to reduce the health risks of populations and maintain service delivery despite climate related disruptions.

CLIMATE CHANGE AND PRIMARY HEALTHCARE

Primary healthcare is the foundation of every health system and if implemented efficiently can reduce and contain the vulnerabilities of communities.

At the Astana Declaration, governments of the world re-committed to primary healthcare with a focus on:

a. Multi-sectoral policy and action

b. Empowered people and communities

c. Integrated health services with an emphasis on PHC and essential public health functions.

In the African continent, PHC is often poorly developed, in terms of both access and quality. The WHO published a new framework to help with the measurement and improvement of PHC. The emphasis was based on the concept of resilient PHC facilities and services and recognises that resilient health systems are based on primary healthcare as a foundation for universal healthcare.

The WHO considered climate resilience across the traditional building blocks of the health systems. With the impact of climate change in Africa, PHC services will face increasing challenges such as malnutrition, infectious diseases, heat-related conditions, injuries, non-communicable diseases, mental health problems and migration.

These challenges will be due to:

a. The absence of real surveillance or monitoring data on the actual effects on primary care associated morbidity and mortality.

b. The need to strengthen PHC service delivery as a way of building community resilience is noted.

c. A need for new indicators to monitor climate sensitive diseases and the need to get early warning of extreme events.

d. The importance of multi-sectoral policy and action and the need for a communityoriented approach was also emphasised.

e. The need to educate and train healthcare workers on climate change.

“The WHO’s Operational framework for building climate resilient Health Systems provides a useful lens to identify the gaps in our knowledge.” [CL Lokotolo et al – climate change and primary healthcare in Africa – a scoping review]

Climate change health hazards in Africa and health systems preparedness At present there is ineffective preparedness of the public health systems in African

countries to cope with the climate change hazards. Climate change effects have extensively been experiences in Africa –with floods and extreme temperatures experiences in West Africa (mostly Ghana and Nigeria). Drought and extreme temperatures have been experiences in East African countries especially in Ethiopia and Kenya. Whilst South Africa and Namibia have experienced drought and extreme temperatures. Extreme weather events have caused increased disease prevalence, such as malaria and vector-borne diseases in Ethiopia and Nigeria. Other impacts of climate change have been malnutrition, food insecurity and food-borne diseases, notably occurring in Ethiopia and Nigeria. Climate change also has an impact on mental health as well as on public health. There is a diversity of the impact of resilience strategies across the continent and on each country’s preparedness based on its available resources to deal with the effects of climate change on the health systems. South Africa is making significant progress in policy frameworks, implementation of surveillance systems and training curricula for health workers. Each nation’s emergency preparedness, responses and recovery activities should include human resource resilience building. Health workers need training to deal with climate change impacts as health workers appear at the frontline when it comes to hazards that impact human health.

CONCLUSION

Africa is expected to bear some of the most damaging effects of climate change, including irregular rainfall patterns. Africa needs management of the linkages between natural resources management, environmental stewardship and human health. It may mean some specific environmental interventions (early warning systems for extreme weather; mapping ground water etc). Nearly a quarter of all deaths in Africa are reportedly due to environmental causes, including the impact of climate change. There is a need to promote synergies and coordination between health and environmental linkages for achieving the Sustainable Development Goals. If left unattended, the coming decades and years would be characterised by climate induced pressure on the continent’s economies, livelihood and nature. Given Africa’s high exposure, fragility and low adaptive capacity, the effects of climate change are expected to be felt more severely. The loss and damage costs in Africa due to climate change are projected to range between US$290bn and US$440bn, depending on the degree of warming according to UNECA’s African Climate Policy Center.

OPINION
Prof Morgan Chetty, Visiting Prof: Health Sciences, DUT chairman, IPAF, CEO: KZNDHC
40 May 2024 | MEDICAL CHRONICLE I

Surviving the night of the hyena Trauma system in action after wildlife attack

An unsuspecting Frans Ndlovu was lying on the cool floor with his door open to catch the evening breeze after a 40°C day spent guarding wildlife against poachers on a Musina game farm during a heatwave in November.

Copyright Medical Chronicle 2024

EDITORIAL

EDITOR: Claire Rush McMillan

Claire.Rush@newmedia.co.za

NEWS WRITER: Nicky Belseck

Nicky.Belseck@newmedia.co.za

SUB-EDITOR: Gill Abrahams

EDITORIAL CONTRIBUTORS

Craig Comrie, Dr Ethel Andrews, Prof Morgan Chetty.

"IT WAS VERY, very scary, but I am alive,” Ndlovu, a father of two, says of the night he narrowly survived an encounter in the dark with a brazen hyena.

“I was sleeping soundly, and it was a huge shock being attacked in the dark. The animal had my head in its jaws; it was so powerful, and I could feel its teeth in my eye as it dragged me from my room.” Remarkably, through the pain and shock of the experience, Ndlovu managed to catch hold of a nearby pole as he was being dragged towards the bushes, and he held on with all his strength while screaming for help.

“The people staying in the neighbouring rooms came out to help me, and they fought the hyena off.”

According to Ndlovu’s employer, Izak Nel, the animal reportedly would not let go until one of the men broke a chair over it, and even then, it did not retreat. Bleeding profusely from his head and shoulder, Ndlovu was rushed to a local hospital, where doctors initially stabilised him before he was transferred by helicopter to the emergency department at Netcare Pholoso Hospital in Polokwane.

Dr Vusi Khosa, who has worked in emergency medicine since 2013, says time was critical for Mr Ndlovu’s massive injuries. “It was a life-threatening situation, and the treatment required was complex. On his face, part of the facial muscles were torn away, and the bone was splintered from the crushing fracture due to the force of the hyena’s bite,” says Dr Khosa.

The spotted hyena has one of the strongest bites of all carnivorous mammals, measuring approximately 1 100-pound force per square inch (that is, 77.3kg per square centimetre), according to BBC Science Focus.

“A CT scan revealed the full extent of his injuries, and it was fortunate that the doctors who initially treated him in Musina recognised the need for multidisciplinary expertise and referred Mr Ndlovu to the level II trauma centre here at Netcare Pholoso Hospital.” Trauma Society of South Africa (TSSA) accreditation of the facility certifies that it has the necessary medical expertise and systems aligned with international best practice in trauma medicine to provide 24-hour emergency care, even in potentially life-threatening and complex cases such as Ndlovu’s. Shortly before 6am on 26 November 2023, Mr Ndlovu arrived at the hospital via medical helicopter transfer and the trauma team was activated

“In line with established trauma protocols, emergency surgery addressed the most time-critical aspects, and the

wounds were cleaned and flushed, and we started antibiotics because animal bites can go septic easily and progress to septic shock, which can be fatal,” Dr Khosa says.

That evening just before 7pm, maxillofacial surgeon Dr James Masipa, ophthalmologist Dr Isaac Lesenya and plastic and reconstructive surgeon Dr Puritan Madzhia then began the painstaking task of reconstructing the left side of Mr Ndlovu’s face in a lengthy nine-hour emergency procedure that was completed shortly before dawn at 03:45am the following day.

The team had to remove the last residue from the splintering, crushing force of the hyena’s bite in preparation for Dr Masipa to reconstruct the areas of the eye socket and complex facial structure. “Time was not on our side, and without a moment to spare for preparation, we had to move in with precision to assist Mr Ndlovu,” Dr Masipa says.

“After the traumatic injury he had sustained, Mr Ndlovu needed quite extensive facial reconstruction, including a forehead flap to rebuild his upper and lower eyelid, although later the damage to his eye, unfortunately, proved too extensive for it to be saved,” Dr Madzhia says.

“As with any bite, animal or human, the bacteria from the mouth causes a severe risk of infection, and we had to be deeply mindful of this during the surgery – this was a case where antibiotics were crucial for his survival and healing,” she says.

Mr Ndlovu spent 22 days recovering at Netcare Pholoso Hospital. “My employer brought my wife and children to visit me at the hospital, and that helped me to cover more quickly. I knew I had to get well for them,” he says. "It's incredibly heartening to witness Ndlovu's survival and the remarkable healing he's undergone despite the severity of his injuries,” Dr Khosa emphasises. "To witness a father restored to his children is profoundly rewarding for us as medical professionals."

Reflecting on his harrowing ordeal, Ndlovu believes he has much to be grateful for: “First of all, I want to thank the hospital and the doctors for taking good care of me, as well as for the people who fought off the hyena to save me. I’m thankful to my employer and manager for acting fast, or I wouldn’t be alive today, and to my wife and family for supporting me through this.

“This experience has not changed my belief that wildlife should be protected. These animals are part of nature and provide the livelihood to support my children,” concludes a thankful Ndlovu

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Mr Ndlovu has returned to work and is able to drive again with a special dispensation
S3 TELMISARTAN SIGNIFICANTLY REDUCED BP* VS VALSARTAN THERAPY 2 For full prescribing information please refer to the professional information approved by the Medicines Regulatory Authority. S3 TESAMOLOT™40/5. Reg. No.: 53/7.1.3/0250. Each tablet contains 40 mg telmisartan and 5 mg amlodipine base (as besilate salt). Contains sugar (mannitol). S3 TESAMOLOT 40/10. Reg. No.: 53/7.1.3/0251. Each tablet contains 40 mg telmisartan and 10 mg amlodipine base (as besilate salt). Contains sugar (mannitol). S3 TESAMOLOT™ 80/5. Reg. No.: 53/7.1.3/0252. Each tablet contains 80 mg telmisartan and 5 mg amlodipine base (as besilate salt). Contains sugar (mannitol). S3 TESAMOLOT™ 80/10. Reg. No.: 53/7.1.3/0253. Each tablet contains 80 mg telmisartan and 10 mg amlodipine base (as besilate salt). Contains sugar (mannitol). Reference: 1. TESAMOLOT 40/5;40/10;80/5; 80/10 [Professional information]. Sandton. South Africa: Dr. Reddy’s Laboratories (Pty) Ltd; 2023. 2. Takagi H, et al. HypertensRes. 2013:36;627–633. Dr. Reddy’s Laboratories (Pty) Ltd., 204 Rivonia Road, Block B, Morningside, Sandton, 2057. Reg.No.: 2002/014163/07. Tel: +27 11 324 2100. www.drreddys.co.za R1201851-ZA-CO-04102023-0138-31 Oct 2026 THIS INFORMATION IS INTENDED FOR HEALTHCARE PROFESSIONALS ONLY *BP, blood pressure
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