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2019/06/06 11:28

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The doctor's newspaper

SEPTEMBER 2019

The erosion of ethics

By Nicky Belseck, medical journalist

The loss of ethics and serious de-professionalisation of the medical profession keeps Health Professions Council of South Africa (HPCSA) president, Dr Kgosi Letlape, awake at night.

DDRESSING DELEGATES AT the first-ever Health Professions Council of South Africa (HPCSA) National Conference last month, the Council’s president, Dr Kgosi Letlape, delivered an impassioned talk on what he considers to be the key problems in SA healthcare. “What keeps me awake at night?” Dr Letlape asked the audience. “The greatest problem I see is the erosion of ethics. We have lost our ethical framework. We have moved from seeing the people who come to see us as patients, as clients. When you’re a client, you get what you can pay for. And what you can’t pay for, you get shown the door. Sadly, that is what we’ve become. When we see patients, we tailor the treatment to what is in their

wallet,” Dr Letlape said. “The other problem is that we are trained to be disease orientated. So, when you see a patient you see a disease, not the person. Training should produce ethical, competent practitioners. LAW TRUMPS ETHICS “We’ve made the law to be above ethics. What we’re taught by the World Medical Association is that ethics are above the law, and when the law conflicts with ethics, then we change the law,” said Dr Letlape. “You don’t compromise ethics. We are in environments where confidentiality and putting patients first is what makes us professionals. If we stop doing that, we’re just retailers. And then there’s no need for regulations, because anyone can do retail,” said Dr Letlape. Making matters worse, Dr Letlape accused medical practitioners of being acquiescent. “What we’ve done, is that

when we see ethical erosion in our society, we just stand by.” PUBLIC HEALTH IN THE 80s Acknowledging the fact that SA has faced many challenges, Dr Letlape said, “You know, one of the challenges that we face in SA is that you had this rich well that had its own problems prior to 94. And some of you might be

surprised when I tell you that the white public healthcare system of pre-94 was the best healthcare system on the planet. It produced the first heart transplant. “And then you go back to that procedure, Professor Barnard and his team never had to negotiate fees with the patient. They just concentrated on the care. The recipient never had to worry about co-payment and shortfalls and got holistic care from a team that was backed with sound research. So, no payment at the point of service. But the recipient was in a privileged, sheltered, universal healthcare system. For the privileged, for certain clients. Speaking about starting his own family, Dr Letlape said, “I remember a white colleague wondering why my children were born in a private hospital. And was boasting to me that his kids were born at the Johannesburg Hospital. continued on page 3

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That was in the 80s, and none of the private hospitals could even compete with the public system. “When I started practicing, the private sector would send patients into the public sector for investigation. Ophthalmologists would send their patients into the public sector for EEGs and other investigations, because they didn’t have the capability to do it themselves. When the technology was introduced it was introduced into the public sector. And those [who were in private practice], would come into the public sector to re-tool themselves. When cataract surgery advanced it was in the public sector, and those in private practice came in to be reskilled. CURRENT PUBLIC HEALTH SYSTEM Dr Letlape explained that we’re now in a system which produces graduates who lack certain basic skills. “Because even the basic equipment is not available on the training platform. “I was fortunate to be raised when ethics were high. Where when you were on call your consultant would never forsake you. You never looked for your consultant. Our consultant would say to us, you look tired, go rest, I will stay on the post. Today, trainees cannot find consultants to come in for procedures they do not have the skills for,” said De Letlape. “Mortality is rising. Litigation is rising. The ethical framework has disappeared. And that is what keeps me awake at night.” DE-PROFESSIONALISATION The other element keeping Dr Letlape awake is the de-professionalisation of the medical profession. “I still practice and [recently] saw a gentleman that is due to have a procedure at a St John’s Eye Hospital,” said De Letlape. “He’s sufferers from glaucoma, has been treated, and now needs surgery. He came to see me for a second opinion. He’s been going to St John’s hospital for over a decade. He’s nearly blind in one eye, and there’s absolutely nothing wrong with what that they have done. “I sat and explained to him that he has glaucoma. He asked if he’ll be able to see again after surgery? I explained that unfortunately when you lose nerve cells they don’t come back, and

that the important thing with glaucoma is to prevent further damage. In ten years, he’s never had a good understanding of his disease. No one explained it to him. “So, we treat diseases, not patients. We’re too busy, and this happens in the private sector too, where we are not person focused, we’re not making sure people understand. We don’t have time to be professional professionals. There’s serious de-professionalisation of the profession. If we cease to be professionals, we will be replaced,” warned Dr Letlape. “By Dr Google and technology. What people don’t understand is that for compliance, for healthcare to be a partnership between a provider and a patient you’ve got to make the person understand. And we’re failing to do that. We are no longer professionals, we are traders".

CONTENTS SEPTEMBER 2019 All content in Medical Chronicle is sourced independently and under no circumstances should articles be considered promotional unless specified.

WOMEN'S HEALTH

NEWS The erosion of ethics ....................................1 Regulating health professionals in the 21st century.........................................6 Is SA PrEPared for the HIV crisis?.......8 Combat depression with ketamine....10 NHI: What we know......................................14 Medical technology industry welcomes tabling of NHI Bill...................14

A clinical case for value-based care in oncology...........................................32

CONGRESS ALERT

SA heart, PASCAR, and AfricaPCR coming up ........................................................15

PRACTICE MANAGEMENT

CLINICAL

ONCOLOGY

NUTRITION

Nutritional care for surgery patients..........................................34

DERMATOLOGY

Sustaining AK and sBCC clearance..38

GASTROENTEROLOGY

INFECTION CONTROL

Testing for functional diarrhoea and IBS-D........................................................ 40

RESPIRATORY

The role of silver in healing DFUs.......42

ALLERGY

Care for the burn patient after discharge........................................................ 44

Mundipharma explores Betadine to fight MDR-superbugs ...............................17 SA's influenza activity...............................18 Saluting saline rinses and sprays.......19

PSYCHIATRY

Treating schizophrenia symptoms....21

CPD

Screening for sepsis ................................22

GUILT THROUGH INACTION Once again raising concerns about healthcare professionals failing to take action, Dr Letlape said, “We’ve never fought for being professionals. If you look at the legal profession, they fight for being professionals. No one speaks in court except for the professionals. “We have allowed people who have never seen a door of a health faculty to dictate what happens inside. We have not protected professional autonomy. We have people located elsewhere that dictate to professionals what to do. And as regulators we’ve turned it into a spectator sport. We have people that say, ‘we’ve paid you, you can breach confidentiality’. And we watch.

CENTRES OF EXCELLENCE

Making nuclear medicine patient friendly..............................................................30

Till debt do us part.......................................16

We have allowed people who have never seen a door of a health faculty to dictate what happens inside. We have not protected professional autonomy

Obs and Gynae Society intervenes to improve quality of women’s health in SA.....................................................29

Efficacy and safety of CPD hyaluronic acid in knee POINTS osteoarthritis ...............................................26

We have people who change treatment plans for things they are not competent to do. We have created people called medical advisors that sit out there and violate all ethical rules possible. We’ve allowed people outside us to promote supersession, to decide who sees patients, to take patients from people who have cared for them for years, to dump them where access is not possible. To take a patient from a township who now has to find two taxis to get to a suburb to a person that is a designated service provider, that can’t even speak his/her language. And we’ve allowed that to happen. There is no ethical framework.”

WOUND CARE

ETHICS

Doctors in the spotlight: What you should and shouldn't do when approached by the media..........45

OPINION

Shaping the future of healthcare.......46

PLACEBO

Mixing business with health..................47

ACCOUNTABILITY Dr Letlape called on delegates to take responsibility. “Why do we sit in a system where as trainers we are not even prepared to have our own healthcare in the institutions that we run? We have an opportunity to fix these issues. I hope all of you understand that we’re fighting for our humanity,” he said. “That we have not been what we should have been as advocates for society and advocates for our patients. We have veered from being professionals because it’s been convenient, and it’s time we find our path back to being those who are trusted in society.”

ED'S NOTE

NHI a hot topic at HASA

RECENTLY ATTENDED the Hospital Association of South Africa's annual conference, which saw a packed lecture hall filled with an audience of engaged, passionate and concerned health professionals. The highlight for me was the health minister’s address on NHI, and the panel discussion that followed. A noteworthy point made by Minister of Health, Dr Zweli Mkhize is that private hospitals will not be nationalised. How it will be funded and the role of medical schemes are still grey areas. Department of Health deputy director general, Dr Anban Pillay fielded some heated questions during the panel discussion. While industry players such as Dr Jonathan Broomberg of Discovery and Stavros Nicolaou of Aspen were positive about the implementation of universal healthcare in South Africa, SAPPF CEO

Dr Chris Archer voiced his concerns about the plan. Find out more in my article: NHI: What we know. Another feature article to look out for in this issue is on the topic of burns management, by Dr Daan den Hollander. He explores the importance of care when treating burns, as well as proper care for the patient. As a doctor, you have many roles to play. Dr Graham Howarth of Medical Protection addresses what you should and shouldn’t do when approached by the media in our ethics feature article. Our CPD section features the topics of osteoarthritis and screening for sepsis. Earn 3 CPD points by answering the questionnaire on www.medicalacademic.co.za.

Happy reading!

MEDICAL CHRONICLE | SEPTEMBER 2019

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NEWS

Delegates gathered for the first HPCSA National Conference

Exhibition Hall

Regulating health professionals in the 21st century

Delegates across all health sectors, health regulators, policy makers, academics, and service providers gathered at the Health Professions Council of South Africa (HPCSA) first-ever HPCSA National Conference. By Nicky Belseck, medical journalist

/03/25

FFICIALLY OPENED BY the Minister of Health, Dr Zweli Mkhize, the theme for the HPCSA’s inaugural conference held at Emperor’s Palace in

Gauteng last month, was ‘Regulating the Health Professionals in the 21st century’. The diverse programme involving both local and international speakers included

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interactive sessions that focused on the emerging gaps in the current regulatory framework in relation to universal health coverage and the impact of the current ethical rules in the delivery of universal health coverage (UHC) to ensure a sustainable healthcare system. Keynote speaker, director general of the National Health Department, Precious Matsoso, focused on the role of the regulator in UHC. Speaking to the current state of healthcare in SA Matsoso said, “Even though access has grown, quality of care has often been weak, and varies greatly, with excellent and inadequate care coexisting in the same country. The stark reality is that far too many people do not get what they deserve.” Stressing concern over the increase of medico-legal claims in SA that have put some practitioners out of practice, Matsoso said, “They are also threatening to collapse services in the public sector. While some call our hospitals high reliability

organisations, others have argued they should rather be termed high risk facilities. “Quality should in fact be the DNA of our health system. We have to embrace a changing environment that is responsive, and we call for a high-quality healthcare system that must be embedded in UHC. This is the moment for a health system quality revolution. But it can only be guaranteed if we have effective regulatory systems.” Matsoso called on healthcare professionals to take the lead with the implementation of National Health Insurance (NHI): “Professionalism is an essential part of being the driver of this reform. “In our lifetime I hope we’ll achieve UHC. We stand at a moment of exceptional possibilities. A moment where global health and sustainable development goals that long seemed unattainable are moving within our reach. A moment where dangers of unprecedented magnitude and disasters threaten the future of mankind. A moment

NEWS

HPCSA National Conference 2019

Sinegugu Malunga and Cynthia Sibanda

Nancy Ncapai and Boikanyo Mphaka

Vuyani Maphasa and Ruth Bielfeld

“With NHI we are reconfirming our shared commitment to improving primary healthcare but also to sort out the fragmentation within the public sector, and between the public and private sector. “The question is not whether we can afford NHI, the question is can we continue with this fatalistic exclusion of our people in having them access quality care? We know what the answer should be. “Together let’s build health equity and economic transformation and ensure that in this moment in the history of our country we can join hands to do it.” Matsoso challenged the HPCSA as the regulator of SA’s health profession to seize the moment. “Let us be the generation that delivers UHC. We must be the generation that breaks down the walls of poverty prisons and in their place build health dignity and prosperity for our people.”

Delegates enjoying the exhibits at the HPCSA conference

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that calls us to shed resignation and routine and rekindle the ambition that has marked the defining chapters of global public health. “HPCSA must be part of the generation that takes leadership ensuring we regulate properly. We cannot regulate just for the sake of regulation. We must regulate appropriately and guard against under-regulating because we expose people to harm, we must guard against over-regulation because it kills innovation. We must guard against self-regulation because that’s dereliction of duty, and guard against core regulation because it leads to regulatory capture. We should rather ensure it’s not only effective but appropriate. “Today we can and must connect the values expressed in our constitution as we implement NHI to afford every South African quality health services that lead to better health outcomes,” said Matsoso.

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NEWS

Is SA PrEPared for the HIV crisis?

We may have made great strides in tackling our HIV epidemic in recent years, but SA still has the biggest HIV epidemic in the world.

NAIDS REPORTED THAT 7.7 million people were living with HIV in 2018. This compared to 7.2 million in 2017. “There has been progress in the number of AIDS-related deaths since 2010, with a 50% decrease, from 140 000 deaths to 71 000 deaths,” UNAIDS reported. “The number of new HIV infections fell from 390 000 to 240 000 in the same period.” Although the numbers are encouraging, SA still has the biggest HIV epidemic in the world. This begs the question – is enough being done to treat and prevent HIV/Aids in SA? In April the Center for Strategic & International Studies (CSIS) expressed concern that the HIV epidemic in SA is not being treated like a crisis. "In February, we travelled to SA, to understand what is happening in these areas with ‘hyperendemic’ HIV epidemics, where prevalence rates exceed 15% among adults,” said Sara

Allinder (CSIS – executive director and senior fellow, Global Health Policy Center). “We were alarmed by the complacency toward the rate of new infections at all levels and the absence of an emergency response, especially for young people." PRE- (PREP) AND POST-EXPOSURE PROPHYLAXIS (PEP) In December 2015, SA became the first country in sub-Saharan Africa to fully approve pre-exposure prophylaxis (PrEP), the use of antiretroviral drugs to protect HIV-negative people from infection. However, the CSIS said PrEP rollout in SA has been slow and inadequate since it was approved in national guidelines in 2016. “PrEP offers a tool to help break the transmission cycle,” said Allinder. “In areas where there is so much HIV circulating, every sexual encounter is high risk, and widespread PrEP could be a

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prevention lynchpin.” Southern African HIV Clinicians Society (SAHCS) CEO, Lauren Jankelowitz, agreed. “PrEP works 100% if used correctly.” According to AVAC (Global Advocacy for HIV Prevention) as of July 2019 there were 23-24 thousand current PrEP enrolees. “These numbers are concerning,” she said. “We are still far from the era of no new HIV transmissions, and as such, need to ensure all people who are sexually active have access to PrEP to prevent HIV. Anyone engaging in risky (or risk unknown) sex should have access to PrEP to prevent contracting HIV, said Jankelowitz. “We believe, for everyone else, post-exposure prophylaxis (PEP) should be available for preventing HIV (after the potential exposure).”

A study done late last year delivered a black eye to ketamine, and as a result of the coverage, there was a wholesale acceptance by both potential patients and physicians that ketamine is an opioid The SAHCS stressed concerns that the National Department of Health (NDoH) is not doing enough to educate healthcare professionals and the public on the existence, benefits, and availability of PrEP and PEP. “The majority of people in the public sector do not know about PrEP especially as it is only available in demo projects to sex workers and MSM (men who have sex with men). This creates stigma about PEP and PrEP and many patients/ prospective PrEP/PEP users perceive they will be judged,” said Jankelowitz.

“The NDoH rolled out a hugely successful campaign for breastfeeding and HIV (including for example national billboards) and we believe the same should be done for PrEP and PEP, especially as we move towards it becoming available in pharmacies. PrEP and PEP should be as accessible as asking a pharmacist for emergency contraception. THE FUTURE OF HIV IN SA “Healthcare workers attitudes are slowly shifting,” said Jankelowitz. “Many NDoH employees (nurses, doctors) aware of PEP use it for their own needle stick injuries. Healthcare professionals should be educating themselves about the new drug options and delivery methods available. They should be educating their patients about knowing their status, and their HIV negative patients about the benefits of PrEP” According to Avert (charity focussing on HIV and sexual health worldwide), “SA has made great strides in tackling its HIV epidemic in recent years and now has the biggest HIV treatment programme in the world. Moreover, these efforts are now largely funded from SA's own resources. However, while the short-term financing of SA's HIV epidemic is secure, in the longer term, the government needs to explore other strategies in order to sustain and expand its progress.” “This is no time for business as usual from South Africa or its partners,” warned Allinder. “The epidemic is exacerbated by its concentration in 15-49-year-olds, those of reproductive and working age who are the backbone of SA. Without aggressive action to reduce the rate of new infections in young people, HIV will continue to take a tremendous toll on the country for years and generations to come. Collective action is needed to push beyond the complacency and internal barriers to implement policies and interventions that directly target HIV prevention and treatment for young people.

Children : 1 year and over ( under 45 kg) ZITHROMAX is indicated for

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NEWS

Combat depression with ketamine Experts insist ketamine isn’t an opioid and can treat depression that hasn’t responded to other treatments.

By Nicky Belseck, medical journalist

ETAMINE HAS RECEIVED a bad rap as an opioid, according to John Hopkins experts, and that when there’s plenty of evidence suggesting it isn’t one.

They believe this reputation may hamper patients from getting necessary treatment for the kinds of depression that don’t respond to typical antidepressants. In hopes

of restoring the therapy’s standing among healthcare professionals and the public, the researchers clarify the mechanism behind ketamine’s mechanism in a new paper.

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In March the US Food and Drug Administration approved esketamine, a version of the ketamine molecule, as a nasal spray to treat depression that hasn’t responded to other treatments. “A study done late last year delivered a black eye to ketamine, and as a result of the coverage, there was a wholesale acceptance by both potential patients and physicians that ketamine is an opioid,” said Dr Adam Kaplin, assistant professor of Psychiatry and Behavioural Sciences at the Johns Hopkins University School of Medicine. “This is most worrisome if people continue to think this way, particularly in the wake of the opioid epidemic; clinicians won’t refer patients for treatment, despite that it has been shown to be incredibly effective for many patients with treatment-resistant depression.”

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Naltrexone (the drug used to reverse accidental opioid overdoses) binds to opioid receptors on the surface of brain cells and prevents opioids like morphine or heroin from sticking to them and acting on the brain, preventing the high. In late 2018, researchers at Stanford University and Palo Alto University showed that naltrexone also blocks the antidepressant effects of ketamine, which led them to propose that ketamine must also bind to the same opioid receptors and thus concluded that ketamine must be an opioid. Dr Kaplin said there’s plenty of contrary evidence demonstrating that ketamine sticks to an entirely different receptor on brain cells: the NMDA receptors – involved in learning and memory – instead of the opioid receptors. According to Dr Kaplin it works as follows: Normally, NMDA receptors get turned on when the chemical messenger glutamate binds to them. Turning on the NMDA receptors turns off a master control switch in the cell called mTOR, which ultimately results in learning a behaviour or forming a new memory. Ketamine can also continued on page 12

NEWS continued from page 10

The FDA specified that ketamine is to be administered under the watch of physicians in small doses and in a healthcare setting

bind to the NMDA receptors, but it has the opposite effect of glutamate, in that it turns these receptors off. Turning off the NMDA receptors turns on the master control switch mTOR, which is required for ketamine’s antidepressant properties. Separately opioid receptors are normally turned on at low-levels all the time, even without opioids to turn them on all the way, said Dr Kaplin. This low activity of the opioid receptors normally suppresses the level of another chemical messenger called cyclic AMP (cAMP). When the overdose drug naltrexone is administered, it sticks to the opioid receptors, turning them completely off, which releases the brakes on cAMP. This increase in cAMP is what then interferes with the master switch mTOR, shutting it down. When ketamine is taken, it turns on the master switch mTOR to enable antidepressant effects, but if naltrexone is given on top of that, naltrexone obstructs and shuts off the mTOR again. It is through cAMP that naltrexone overrides and extinguishes the antidepressant effects of ketamine.

With most medications, like Valium, the antianxiety effect you get only lasts when it is in your system These NMDA receptors are found together with the opioid receptors on brain cells, and Dr Kaplin said it’s no surprise their components can meddle with one another, like interference picked up on a phone call or on the radio. “This interference and cross-talk does not mean ketamine is an opioid, and to wrongly label it as such could eventually keep patients from essential antidepressant medications that could make a huge difference in their quality of life,” said Dr Kaplin. The FDA specified that ketamine is to be administered under the watch of physicians in small doses and in a healthcare setting to minimise any chance of abuse. The drug works much faster than other traditional antidepressants on the market, sometimes even after one or two uses. Chief psychiatrist at Yale Medicine and one of the pioneers of ketamine research in the US, Dr John Krystal has called esketamine ‘a game changer’. “With most medications, like Valium, the anti-anxiety effect you get only lasts when it is in your system. When the Valium goes away, you can get rebound anxiety. When you take ketamine, it triggers reactions in your cortex that enable brain connections to regrow. It’s the reaction to ketamine, not the presence of ketamine in the body that constitutes its effects,” he explained. “And this is exactly what makes ketamine unique as an antidepressant, Dr Krystal said. Dr Kaplin and his team are in the process of setting up their own ketamine clinic at Johns Hopkins, which they anticipate will be opening within the next year. 12 SEPTEMBER 2019 | MEDICAL CHRONICLE

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NEWS

NHI: What we know

This year’s Hospital Association of South Africa's annual conference saw a packed lecture hall filled with an audience of engaged, passionate and concerned health professionals.

INISTER OF HEALTH, Dr Zweli Mkhize stated that government has undertaken to achieve a turnaround with NHI. Refurbishing and building infrastructure for the public sector will be done within seven years, working with private sector. “Universal healthcare doesn’t need to wait for a better economic situation to be instituted,” he stated, but remained mum on the funding of it, for now. “NHI will not bankrupt the country and will be run by qualified individuals. It will get the funds from fiscals – not like the Eskoms and SAAs,” he stated. He emphasised that strict accountability and anticorruption will be enforced. The NHI bill envisages a fund based on single payer model. “The aim is not to nationalise private hospitals. These will still be privately run. The Office of Health Standards Compliance will standardise all hospitals, which is a bigger issue for the public than the private sector,” he stated. He acknowledged that

"The aim is not to nationalise private hospitals. These will still be privately run. The Office of Health Standards Compliance will standardise all hospitals, which is a bigger issue for the public than the private sector,” he stated there are challenges in the system, but there is something that is more important – equal access to health services. “If we perpetuate this inequality, we jeopardise our future,” he stated.

Department of Health deputy director general, Dr Anban Pillay, explained that an individual will identify the services they want to access and register at that GP or pharmacy. He told the conference there would be a strong focus on primary care as the first point of reference. "The GP will become the gatekeeper,” he said. The NHI Benefits Committee would decide what will be funded, and access to healthcare services based on a human rights approach. “South Africans have a right to purchase services not covered by the fund, through medical aid schemes.” Although he was pushed for an answer, he didn’t clarify the complementary role of medical schemes. Dr Chris Archer, CEO of the SA Private Practitioners Forum said as part of the panel discussion: “I do not have much faith in NHI as the solution to our health care problems in this country. The current NHI model is not the correct

one – it based on a political decision and not research.”

Dr Zweli Mkhize

Medical technology industry

welcomes tabling of NHI Bill

The SA Medical Technology Industry Association (SAMED) welcomes today’s release of the National Health Insurance (NHI) Bill and expresses commitment to continued engagement in the process of NHI policy development and implementation, and collaboration with the Department of Health and other relevant parties.

AMED REPRESENTS 223 medical technology companies*, who’s products and devices play a vital role across the continuum of patient care – prevention, screening, diagnosis, treatment and rehabilitation. “SAMED recognises the inequities of the current fragmented healthcare system. We view the proposed NHI as a crucial

element that can assist South Africa in advancing universality and social solidarity as the pillars of a people-centred health system that does not discriminate along economic lines,” says Dr Terence Moodley, the chairperson of SAMED’s NHI Committee. The tabling of the Bill for parliamentary debate and public commentary follows last

14 SEPTEMBER 2019 | MEDICAL CHRONICLE

week’s SAMED annual conference, which featured a special session on NHI, where Dr Anban Pillay, the deputy director General of Health, invited the medical technology industry to remain an active participant in the NHI processes. SAMED has followed the progress of NHI policy-making since the outset: • It has reviewed and made submissions on both the Green and White Papers and the draft NHI Bill in 2018. It recommended changes relating to the aspects that directly affect procurement, reimbursement and use of medical technologies, as well as other critical elements where the Association felt it could provide relevant inputs. These include governance, accreditation, work of NHI committees and determination of the benefits package that will be covered by the NHI

• SAMED regularly holds member sessions on NHI so that the sector understands and manages the developments as it pursues its vision to build a sustainable medical technology industry that enhances patient access to innovative solutions • This year, SAMED joined Business Unity South Africa, through which it contributes to the Presidential Health Compact, notably in the area of strengthening supply-chain management. “SAMED is an eager partner in the mission to improve the nation’s healthcare and health outcomes, and will continue to mobilise support within our sector as well as the broader society for universal health coverage and the NHI,” concludes Dr Moodley. * Including companies that are members of the SA Laboratory and Diagnostics Association (SALDA)

CONGRESS ALERT

SA Heart, PASCAR, and AfricaPCR coming up Message from PASCAR

EAR FRIENDS AND COLLEAGUES, On behalf of the governing council of the PanAfrican Society of Cardiology it gives me great pleasure to invite you to attend the PASCAR Congress which will be held in partnership with the South African Heart Association. Building on successful previous partnerships, we are delighted to welcome you to beautiful Sandton in South Africa. The four-day programme will be designed to bring together distinguished international and regional faculty to deliver high calibre scientific content, covering almost all aspects of clinical cardiology and dealing in particular with specific endemic cardiac problems in Africa. The joint meeting will be held in association with Africa PCR, Cardiac Imaging and African Heart Network as the 2019 partners is expected to be one of the largest conferences in the region with your support.

international colleagues. An outstanding platform of leaders and teachers will provide four days of scintillating cardiovascular science and medicine. We both look

forward to welcoming you all to Sandton, Johannesburg on the 31st October 2019. David Jankelow President, SA Heart

Rob Dyer Chairman, Scientific Programme Committee, SA Heart 2019.

We look forward to welcoming you all to this Cardiology premier event. Best wishes Saad Subahi FRCP FESC PASCAR President MESSAGE FROM SA HEART Dear Colleagues, We are extremely proud to announce the 20th Annual Congress of the South African Heart Association (SA Heart 2019), in conjunction with the Pan African Society of Cardiology (PASCAR), AfricaPCR, the Cardiovascular Magnetic Resonance Congress of South Africa (SA-CMR) and the African Heart Network (AHN). The coming together of five major groups will be an important milestone for cardiology in Africa. Our theme â€˜Meeting the Needs for Africaâ€™ is highly relevant in an ever changing landscape and epidemic of cardiovascular disease (CVD) on this continent. It is now timeous and most appropriate to hold SA Heart 2019 in association with AfricaPCR, a practical case-based interventional cardiology programme. PCR encompasses interventional cardiology in Africa and blends extremely well with the overall theme. SA-CMR will bring a unique imaging dimension to the meeting. Advocacy and policy will be the focus of AHN to identify and address our unmet needs if we are reduce the burden of CVD in Africa, a stated aim of the WHO. SA Heart 2019, PASCAR, AfricaPCR, SA-CMR and AHN will stimulate a creative exchange of ideas and will offer many opportunities to network with both local and MEDICAL CHRONICLE | SEPTEMBER 2019

PRACTICE MANAGEMENT

Till debt do us part

Medical Chronicle invited us to write an article focussing on debt collection in the healthcare industry. Our company has a great deal of experience in the aforesaid sector, as it forms a large part of our clientele. We hope to share some practical advice to improve your recovery rate on outstanding debts.

HERE HAS BEEN an exponential increase in non-paying clients in all business segments of South Africa. The current economic climate, combined with the high unemployment rate, is most likely to blame. Unfortunately, we have no control over these external factors and can only deal with the aftermath (in the form of nonpaying clients) to the best of our abilities. So, what can you, as a medical practitioner, do to improve your debt collection results? BE PROACTIVE As Stephen King said: "There’s no harm in hoping for the best as long as you’re prepared for the worst.” Being prepared starts long before prospective patients/ clients enter your establishment. In most instances you will provide your patient/client with a form of some sort, gathering all their personal, financial and medical information. This form should also state the terms and conditions of your institution. The patient/ client signs the document, agreeing to these terms. Adding specific clauses to this agreement may ease the collection process dramatically. The new buzzword in all industries is “POPI” or “POPIA”. What is POPI/A? POPIA refers to the

Protection of Personal Information Act. In short, this legislation aims to protect consumers’ personal information. Although the legislation has only been partly implemented, it is estimated that it will be in full effect by mid-2021. It is therefore important to know what POPIA expects of you as the “responsible party”. To be future proof, a clause granting permission for the collection and processing of the patient’s/client’s personal information (for a specific purpose like debt collection etc), would be a wise addition to any form. To compliment the aforesaid clause, it is advisable to add a clause consenting to the tracing of the specified individual if it is ever needed. It is imperative to explicitly state that should the patient/client be handed over for collection, they will be personally liable for all costs and fees (including legal fees) relating to the recovery of the outstanding debt. This acts as an extra precautionary measure should the matter ever end up in court. The importance of internal credit controls cannot be overstated. These controls are set in place to prevent accounts from being dormant more than 90 days. Ensuring that you have confirmed

contact numbers and addresses are key for successful debt collection for both you and your future debt collection partner. A credit control strategy is always advisable. It can be as simple or as complicated as you deem necessary. For example, communications (telephone calls, emails, text messages etc) sent to debtors around payday, reminding them of their outstanding accounts, can prompt them to make payment. ACT SWIFTLY The prescription clock starts ticking the moment the debt becomes due (the date payment should have taken place). What is prescription? This is not your usual medical prescription you issue to patients/clients for their medical needs, but rather the time period allowed to act against a debtor. Prescription can be interrupted (restarted or stopped) in various ways, for example receiving payment, an acknowledgement of debt or issuing summons. If prescription is not interrupted, the debt will usually prescribe within three years of it becoming due. It is also noteworthy to mention that collection success rates are always better on more recent accounts. If you intend listing a specific debtor at a credit bureau,

Hugo Homann, Legal Advisor: VeriCred Collections

you should take note of Guideline 002/2014 issued by the National Credit Regulator regarding the requirements for listing medical accounts. PARTNER WISELY If your efforts to collect your outstanding debts have failed, it is time to contact a third party for assistance. Choosing the right partner to serve your specific needs is critical in determining the effectiveness of your debt recovery. Do thorough research on the party, contact their existing patient/ clients for references and do not shy away from asking questions. Once you have decided on the third party, you will usually be presented with a service level agreement to formalise the arrangement. Take special note of the duration of the contract, how fees and costs are calculated, cancellation clauses, if it is a sole mandate, and how often payments will be received from this party. Outstanding debts are unavoidable. Be proactive, act swiftly and partner wisely to minimise the financial impact thereof on your business. *Disclaimer: The information in this article does not constitute professional advice and is general in nature. Contact your relevant professional for assistance.

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018 294 1000 www.vericred.co.za 16 SEPTEMBER 2019 | MEDICAL CHRONICLE

CLINICAL | INFECTION CONTROL

Mundipharma explores Betadine to fight MDR-superbugs Studies demonstrate Povidone-iodine being able to eradicate stubborn Candida auris fungus. *Sponsored content

LOBAL PHARMACEUTICALS AND consumer healthcare organisation, Mundipharma, is exploring the potential of its Betadine® antiseptic product range as a way to prevent the transmission of the multi-drug resistant superbug, Candida auris, in hospitals or clinical spaces based on research that demonstrates its ability to kill the stubborn fungus. A recent New York Times feature story called attention to the threat to global public health by the fungus, which has been described by United States’ Center for Disease Control and Prevention (CDC) as a ‘global emerging threat’.1 A major issue is the risk associated with environmental transmissions in hospitals and clinical environments, where the difficultly in effectively disinfecting surfaces and equipment puts vulnerable patients at risk and can lead to the quarantining of patients and facilities. While various disinfectant techniques have been used, studies note that these are often

compromised by Candida auris’ tenacity and its ability to persist on dry surfaces and equipment for periods of up to 28-days.2 However, four recently published in vitro studies point to a potential solution, demonstrating the effectiveness of Povidone-iodine (PVP-I) solutions in eradicating Candida auris as a skin disinfectant. One of these studies notes the efficacy of 10% Povidone-iodine solution against pure Candida auris samples within 2-to-5 minutes exposure while a further study suggests that PVP-I can kill the superbug and deemed it one of the most effective skin disinfectants available.2-5 Research and testing are now underway by Mundipharma to determine if the same speed and effectiveness can be translated into clinical practice to prevent the transmission of Candida auris in hospitals and eliminate patient risk. “We are greatly encouraged by the potential of Betadine products, which

contain the active ingredient PVP-I to solve this emerging global public health problem, based on its proven effectiveness as a way to quickly and efficiently eradicate Candida auris as shown through in vitro studies,” said Mundipharma CEO, Raman Singh. “Our aim now is to provide a solution to prevent transmission at an environmental level, and to provide hospitals and clinics with a level of confidence that they can safely and thoroughly disinfect facilities to prevent further contagion of this tenacious superbug,” he added. Betadine has been used by hospitals around the world for over 55 years to prevent and treat infections and kill a broad range of bacteria, viruses and fungi including antibiotic-resistant strains that cause infections. In-vitro testing of Betadine products which contain PVP-I has demonstrated virucidal efficacy against infectious pathogens such as MERS, SARS, Ebola and influenza that

have been reported to cause serious consequences on public health.6,7 References available on request.

MEDICAL CHRONICLE | SEPTEMBER 2019

CLINICAL | RESPIRATORY

SA’s influenza activity Influenza is a viral respiratory disease of global importance. Many experts believe that an influenza pandemic is the greatest threat to global public health.

N 2018, THE world observed the centenary of the start of the 1918–19 influenza pandemic. Its estimated toll of up to 50 million deaths exceeded that of the World War 1, resulting in a dramatic decline in life expectancy in many countries at the time of the pandemic. Its impact led to fundamental changes in public health and health care systems, including centralised and consolidated health care, greater recognition of the role of socioeconomics in health, and the coordination of public health at national and global levels. Since the 1918–19 pandemic, there has been significant progress in medical science, including the development of influenza vaccines, antiviral drugs and better diagnostics. Subsequent pandemics occurred in 1957–58, 1968–69 and 2009–10, resulting in 1-4 million, 1-4 million and 100 000-400 000 deaths, respectively. Pandemic (H1N1) 2009 caused significant deaths, particularly in those aged under 65 years; it also tested national health response systems (in particular, the pandemic vaccine response capacity) and exposed weaknesses in those systems. It reiterated that influenza viruses of both avian and swine origin can cause a pandemic, and it underscored the importance of intersectoral collaboration for pandemic preparedness. Although it is impossible to predict when the next pandemic might occur, its

occurrence is considered inevitable, and it could well occur during the time frame of this strategy. Given increased economic globalisation, urbanisation and mobility, the next pandemic will spread further and faster, and could lead to significant disruptions. Despite significant medical advances over the past 100 years, there will still be populations that have limited access to care and will be likely to experience high mortality rates during a pandemic. The 2019 influenza season started earlier than previous years in Australia, Chile, South Africa and New Zealand. Influenza A(H3N2) viruses predominated in Oceania and South Africa. In South Africa, influenza activity continued to increase with influenza A(H3N2) viruses predominating. The rate of influenza positivity among ILI cases was reported as moderate based on epidemic thresholds calculated on 2008-18 data (excluding the 2009 pandemic). Influenza transmission is currently moderate and impact is high. In Western Africa, influenza detections were low across reporting countries, except in Côte d’Ivoire where detections of influenza A(H3N2) increased. Burkina Faso, Côte d’Ivoire, Guinea, Mali, Mauritania, Nigeria, Sierra Leone, and Togo provided updates for this reporting period. ▪ In Middle Africa, there was no influenza activity among reporting countries. Central

18 SEPTEMBER 2019 | MEDICAL CHRONICLE

African Republic, Chad, and Democratic Republic of the Congo provided updates for this reporting period. ▪ In Eastern Africa, influenza detections continued to be reported with influenza A(H1N1)pdm09 predominating, followed by A(H3N2). In Madagascar, ILI activity continued to decrease with influenza B predominating. OVERVIEW The Global Influenza Strategy for 20192030 provides a framework for WHO, countries and partners to approach influenza holistically through tailored national programmes – from surveillance to disease prevention and control – with the goal of strengthening seasonal prevention and control, and preparedness for future pandemics. To achieve this, the strategy places a large focus on the following: • The development of better global tools, such as vaccines, antivirals and treatment that would benefit all countries and instil public confidence and uptake • Stronger country capacities that are integrated within national health security planning and universal health coverage efforts. Influenza prevention, control and preparedness are functional building blocks for capacity-building and can

enhance core capacities across the health spectrum; a country-level approach and country ownership are vital for ensuring sustainability of national influenza programmes, which serve as an investment for greater health system strengthening and pandemic preparedness. With its focus on country impact, the strategy is aligned with the goals of WHO’s 13th General Programme of Work for achieving universal health coverage, addressing health emergencies and promoting healthier populations. Pandemic preparedness is a vital component of the global movement to strengthen health security through the attainment of core capacities to prevent, detect and respond to infectious disease threats, including influenza. Linking efforts on influenza prevention, control and preparedness with those on national health security planning can establish political commitment and leverage key resources to support sustainability. Capacity-building and financing improve a country’s ability to respond more rapidly and nimbly to influenza and other infectious diseases. Look out for Medical Chronicle’s Respiratory Focus, sponsored by Cilpa, coming to your inbox soon References available on request.

CLINICAL | ALLERGY

Saluting saline

rinses and sprays Simple saline is a wonderful non-medicated addition to the management of many conditions involving the nose and the chest, from simple colds to annoying allergies

INTER BRINGS WITH it a potentially never-ending web of colds, sniffles and sneezes, sometimes complicated by sinusitis and middle ear troubles. In addition, reactions to ‘indoor’ allergens such as house dust mites and mould, as well as animal dander allergies, can peak during the winter as more time is spent indoors and household ventilation is reduced. Fluffy blankets are hauled out and pets spend more time indoors. And then…. comes the spring, bringing a peak in tree and grass pollen levels, the bane of a hay fever sufferer’s existence.

allergens out of the nasal mucosa, reducing the efficacy of this natural air purifier.

Prof Claudia Gray Paediatric allergy consultant, Red Cross Children’sHospital, UCT, Vincent Pallotti Hospital

If the openings to the sinuses and Eustachian tube, both situated deep

inside the nasal cavity, are crusted up and dry, they will block up more easily leading

DON’T JUST TOLERATE YOUR ALLERGIES

Nasal saline can be used as a first line treatment for colds, flu and sinusitis, and may help reduce the severity, duration and complications of these infections

THE IMPORTANCE OF MAINTAINING A HEALTHY RESPIRATORY MUCOSA Inside the nose and sinuses is a lining of membranes that filters, humidifies and heats the air we breathe. It is part of the non-specific immune system and the first line of defence against germs, inhaled dust, allergens, extreme air temperatures or very dry air. A healthy nose relies on moist, clean mucous membranes. Any drying, crusting or other interference can make patients more susceptible to infections. A dry, crusted nasal mucosa will also reduce flushing of

UN-BOX THEM WITH... IT’S MORE THAN JUST A SALINE SPRAY. www.allerguard.co.za

A myriad of cold and flu remedies are available over the counter, few of them particularly evidence-based or effective. Often, the side effects outweigh the benefits. For allergic rhinitis sufferers, intranasal corticosteroids and antihistamines are available and largely effective, but the rhinitis sufferer may still have inadequate symptom relief. How can we better these treatments without causing undue side effects? The answer is simple – it’s simply saline. Saline can be used at any age and as a great add-on to the treatment of allergic rhinitis as well as sinusitis.

A range of sea salt nasal preparations WITH ADDED ECTOIN ® , which forms a protective barrier 1,2,3

• KEEPS THE NOSE CLEAN 1 • PROTECTS FROM ALLERGENS 1 PROTECTS, PREVENTS & PROVIDES RELIEF so you can get on with your normal day Suitable for the whole family*

SNEEZING

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*From 2 years of age References: 1. Allerguard package insert, July 2016. Proprietary name (and dosage form): Allerguard Allergy Nasal Spray. 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. www.inovapharma.co.za. For full prescribing information, refer to the Instructions For Use. Further information is available on request from iNova Pharmaceuticals. IN3052/19

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MEDICAL CHRONICLE | SEPTEMBER 2019

CLINICAL | ALLERGY

to complications such as sinusitis and otitis media (middle ear infection). In addition, if the nose is filled with crusty mucus and debris, other topical nasal therapies such as medicated sprays will not work as effectively.

Nasal saline can be used as a first line treatment for colds, flu and sinusitis, and may help reduce the severity, duration and complications of these infections

SOME BENEFITS OF INTRANASAL SALINE Saline is simply salt water. Nasal saline can be used as sprays or rinses. The saline can be isotonic or hypertonic. Isotonic saline refers to saline with a physiological concentration of saline (0.9%), whereas hypertonic saline has a higher saline concentration. Some benefits and uses of saline are summarised below: Saline solution restores moisture to dry nasal passages and sinuses, reducing irritation and inflammation of mucous membranes

Saline can help to thin the mucous, making ‘effective nasal blowing’ possible, to rid the nose of mucus as well as to cleanse the nasal passages of bacteria and viruses

Saline sprays and rinses can help keep the cilia moisturised and healthy. Cilia help humidify air that goes into the lung, and trap bacteria to protect the airways. Hypertonic saline is an effective agent to optimise muco-ciliary clearance

Saline sprays and rinses can help to remove allergens such as pollen from the nasal lining, hence are useful to use after a day outside

Using saline first before steroid nasal sprays helps to rid the nose of thick mucus and debris, which can keep the steroid from working optimally. Hypertonic saline can act as a solvent to help clear the nose of debris and thick mucus. ‘Saline-then blow- then steroid spray’ is a good rule to use for daily allergic rhinitis treatment. Nasal saline can be used as a first line treatment for colds, flu and sinusitis, and may help reduce the severity, duration and complications of these infections. Rinsing with hypertonic saline is recommended above cold and flu medicines. Cold and flu medications dry up the cold, which often leads to even thicker secretions. These secretions then become too thick to be effectively cleared by the membranes, increasing the risk of secondary infections. In addition, saline is safe at all ages and can be used as often as needed. CONCLUSION Simple saline is a cost effective, readily available and safe addition to any treatment regime for colds as well as allergic rhinitis and sinusitis. In spray or drop form, it is suitable at all ages; whereas saline rinses are generally better tolerated in those over five-six years of age. Improvement of nasal mucosal lubrication, muco-ciliary clearance and debris removal are documented benefits.

REFERENCES 1. Head K, Snidvongs K, Glew S et al. Saline irrigation for allergic rhinitis. Cochrane Database Syst Rev 2018; 6: CD012597 2. Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: allergic rhinitis. Otolaryngol Head Neck Surg. 2015;152(1 Suppl):S1-S43. 3. Dykewicz MS, Hamilos DL. Rhinitis and sinusitis. J Allergy Clin Immunol. 2010; 125(Suppl 2):S103-S115. 4. Hadley JA, Derebery MJ, Marple BF. Comorbidities and allergic rhinitis: not just a runny nose. J Fam Pract. 2012; 61(2 Suppl):S11-S15. 5. Greiner AN, Hellings PW, Rotiroti G, Scadding GK. Allergic rhinitis. Lancet Lond Engl. 2011; 378(9809):2112-2122. 6. Allan GM, Arroll B. Prevention and treatment of the common cold: making sense of the evidence. CMAJ. 2014; 186(3):190-199.

20 SEPTEMBER 2019 | MEDICAL CHRONICLE

CLINICAL | PSYCHIATRY

Treating schizophrenia symptoms Antipsychotic medications have proven effective at treating positive symptoms, but unfortunately, have offered little benefit for improving the negative symptoms of the disorder.

IVEN THE CLINICAL PARALLELS between depressive and negative symptoms in schizophrenia, the use of antidepressants has also been explored as a potential adjunctive therapy to antipsychotics; although evidence for their efficacy has generally been inconclusive, with findings suggestive of some small positive effects unlikely to translate into meaningful clinical improvements.15,16 The use of stimulant, glutamatergic, and cholinergic augmentation has similarly failed to demonstrate consistent benefits for treating negative symptoms in schizophrenia.15,17 Beyond pharmacological interventions, psychosocial strategies have been examined as potential treatments for negative symptoms. In light of the promising findings of cognitive-behavioural therapy (CBT) for depression and anxiety, there has been increasing interest in the potential of CBT interventions that target negative symptoms in schizophrenia, with recent meta-analyses revealing potential benefits for negative symptoms, albeit with small effect sizes.15,18 Moreover, cognitive remediation, although primarily designed to target the cognitive deficits of the disorder, has also been shown to have some moderate associations with negative symptom reduction.19 Lastly, non-invasive brain stimulation therapies including repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) has gained momentum in the past decade as potential treatments for negative symptoms. rTMS has been extensively investigated in schizophrenia, with a number of studies and meta-analyses revealing small to large improvements, though not consistently. Research on the application of tDCS is still in its nascent stages, although early findings suggest that tDCS may offer some benefit for negative symptoms.15,17 CONCLUSION Negative symptoms – of which motivation deficits are a core feature – are prominent and pervasive in schizophrenia and currently represent an unmet therapeutic need. While several treatment modalities have been explored, their lack of broad efficacy to date may be attributed to a number of factors. 1. Most studies evaluating treatments for negative symptoms have relied on overall symptom severity scores as their primary outcome; however, this may be too crude a method to capture meaningful differences in specific symptom domains. That is, negative symptoms are not a unitary construct, but rather, a broad cluster of multi-faceted symptoms, and must therefore be examined and treated as such. 2. We continue to be faced with the challenge in distinguishing between

primary and secondary negative symptoms. Moreover, our limited understanding of the pathophysiological underpinnings of negative symptoms inevitably restricts our ability to develop treatments targeting the specific underlying set of causes. 3. It is important to acknowledge the possibility that negative symptoms may be

caused by a complex interaction of biological and environmental factors, and as a result, no single treatment may act as a panacea for negative symptoms. 4. Complementing symptom-targeted pharmacological therapy with psychosocial interventions may offer the most effective treatment strategy for ameliorating negative

symptoms, and ultimately improving functional outcomes for individuals with schizophrenia. Source: Da Silva S, Saperia S, Remington G et al. Negative Symptoms in Schizophrenia: Etiology, Hypotheses, and Treatment Implications Psychiatric Times 2019.

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MEDICAL CHRONICLE | SEPTEMBER 2019

CPD | INFECTION CONTROL

Screening for sepsis Sepsis is a leading cause of mortality and morbidity globally. Early diagnosis of sepsis and early initiation of evidence-based bundle care can greatly improve the outcome of sepsis.

NFORTUNATELY, EARLY AND accurate diagnosis of sepsis is difficult. Sepsis is a complex clinical syndrome with a wide range of manifestations. Although the systemic inflammatory response syndrome (SIRS) criteria were part of the prior definition of sepsis, it has been shown to be unable to differentiate severe from uncomplicated infections. The latest Sepsis-3 definition describes sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection, with life-threatening organ dysfunction defined as a change in the sequential organ failure assessment (SOFA) score of more than two points in intensive care unit (ICU) patients. In clinical settings outside the ICU where calculating the SOFA score is not routine, a simplified score â€“ quick sepsis-related

organ failure assessment (qSOFA) was introduced as a screening tool for patients with sepsis. Since the introduction of qSOFA, concerns have been raised. None of the elements in qSOFA are specific for the detection of infection, and subsequent validation studies showed suboptimal overall discrimination and sensitivity (reported sensitivity 32%) under the recommended cut-off. In addition, diagnosing sepsis relies on the accuracy of the physicianâ€™s clinical suspicion of infection. Infectious disease biomarkers such as C reactive protein (CRP) and procalcitonin (PCT), on the contrary, have been shown to accurately predict infection and mortality. These two markers were accepted as part of the diagnostic criteria in Sepsis-2, but were not included in the Sepsis-3

definition. Combining biomarker information with the qSOFA score would potentially enhance its ability to predict the mortality risk from sepsis. In this study, the authors sought to evaluate whether adding either CRP or PCT to the qSOFA score would improve its ability to predict in-hospital mortality in a multicentre cohort of patients who presented with clinical symptoms of systemic infection. PCT is a biomarker used to diagnose bacterial infections and shows a high correlation with sepsis severity. The biomarker is expressed upon stimulation of cytokines such as IL-6, TNF in almost all parenchymal cells. Distinct algorithms have been defined through several thousand studies in order to use PCT as a diagnostic and prognostic tool in indications such as sepsis, respiratory

Safe reduction of antibiotic exposure with B-R-A-H-M-S PCT Learn more >

22 SEPTEMBER 2019 | MEDICAL CHRONICLE

infections, paediatric and neonatal sepsis. The biomarker test is often run in the ICU wards where sepsis prevalence is high. In addition, PCT has shown to play a pivotal role in antibiotic stewardship by reducing the number of antibiotic treatment days. The gold standard for sepsis and bacterial infection diagnosis rely on blood cultures, which has been deemed highly unspecific. Advantages of PCT over other biomarkers such as CRP and presepsin include high specificity and sensitivity, rapid increase (three-four hours after onset of infection), and half-life of 24 hours. Multiple clinical trials have shown positive outcomes using a PCT approach compared to traditional approaches in relation to hospital length of stay, reduction in antibiotic exposure and overall improvement of the clinical outcomes

CPD | INFECTION CONTROL in patients. PCT have been included in numerous clinical guidelines where adherence plays a crucial role in the clinical outcome of PCT subjected patients. The following observational study highlights the use of PCT in conjunction with other sepsis diagnostic tools such as the quick sepsis-related organ failure assessment (qSOFA) score. It is shown that by using the qSOFA score and PCT in parallel, sepsis diagnosis is increased to 90%. OBSERVATIONAL STUDY Yu et al (2019) investigated whether PCT can improve the performance of quick sequential organ failure assessment (SOFA) score in predicting sepsis mortality. They conducted a retrospective multicentre cohort study with independent validation in a prospectively collected cohort in three tertiary medical centres. Patients with presumed sepsis were included. Serum PCT levels were measured at admission. qSOFA score and systemic inflammatory response syndrome (SIRS) criteria were calculated for each patient. PCT levels were assigned into 0, 1, and 2 points for a serum level of <0.25, 0.25 to 2, and >2ng/ mL, and added to the quick sepsis-related organ failure assessment (qSOFA) score. The incremental value of PCT to qSOFA was then evaluated by logistic regression, receiver-operating characteristic (ROC) curve, and reclassification analysis.

STUDY POPULATION Patients were enrolled retrospectively using consecutive sampling of cases from each hospital from January 1, 2015 to December 31, 2016. All adult patients (≥18 years old) who presented to the emergency department or were admitted to the hospital floor were eligible for inclusion. Patients were included if they had symptoms that indicated systemic infection; and PCT (VIDAS BRAHMS PCT) and blood culture tests within 24 hours of admission. Exclusion criteria were missing data, transfer from other hospitals, leucopenia, do-not-resuscitate (DNR) orders, lost to follow-up, or history of pre-existing thyroid disease that may affect procalcitonin levels.

Participating investigators from the three sites independently reviewed all retrieved medical records to confirm the presence of infection as a reason for admission. The study focused on qSOFA score, which targeted the sepsis patients outside the ICU. So, patients who developed sepsis in ICU were excluded. A cohort that prospectively collected 493 consecutive emergency department (ED) patients with presumed sepsis was used for independent validation. Patients with presumed sepsis was defined patients who fulfilled at least two of the three SIRS criteria (temperature >38°C or <36°C, pulse rate ≥90 beats per minute, and respiratory rate ≥20/min) upon ED admission with a

presumed diagnosis of systemic infection by treating physicians. This study was approved by the Research Committees and Institutional Review Boards for all institutions, and it met criteria for exemption from informed consent. RESULTS Patient characteristics and outcome During the study period, 604 patients from NTUH, 503 from SCPH, and 515 from FSFPH fulfilled the inclusion criteria. After the exclusion of 304 ICU patients, the final cohort included a total of 1 318 patients. In all, 867 (65%), 208 (15%), and 752 (53%) patients were diagnosed with sepsis according to the SIRS criteria and

In clinical settings outside the ICU where calculating the SOFA score is not routine, a simplified score – quick sepsisrelated organ failure assessment (qSOFA) was introduced as a screening tool for patients with sepsis In all, 1 318 patients with presumed severe infection were enrolled with a 30day mortality of 13%. Serum level of PCT showed a high correlation with qSOFA score and 30-day in-hospital mortality. The area under the ROC curve was 0.56 for SIRS criteria, 0.67 for qSOFA score, and 0.73 for qSOFA PCT in predicting 30-day mortality. The risk prediction improvement was reflected by a net reclassification improvement of 35% (17%–52%). METHODS Study design and locations This was a multicentre retrospective cohort study performed at the Sichuan Provincial People Hospital (SCPH) in Chengdu City, First People’s Hospital of Foshan (FSFPH) in Guangdong province of China, and National Taiwan University Hospital Yunlin Branch (NTUH) in Douliou city. All three hospitals are tertiary-care urban medical centres. MEDICAL CHRONICLE | SEPTEMBER 2019

CPD | INFECTION CONTROL qSOFA score, respectively. In all, 205 (15%) patients had clinical significant bacteraemia, with a higher prevalence of gram-negative bacteraemia (7%) than gram-positive bacteraemia (6%). The median age of the study sample was 64.0 (interquartile range 47–75) years old. The overall in-hospital mortality rate was 13%. The mortality of patients with clinical significant bacteraemia was 19%. In general, non-survivors were older, had a higher burden of comorbidities and organ dysfunction, had lower respiratory tract infections, more bloodstream infection and polymicrobial infection, and had a greater proportion of patients with PCT, SIRS, or qSOFA scores higher than reference levels.

Distinct algorithms have been defined through several thousand studies in order to use PCT as a diagnostic and prognostic tool in indications such as sepsis, respiratory infections, paediatric and neonatal sepsis

DISCUSSION In the retrospective validation of the Sepsis-3 definitions using multicentre cohorts, the authors confirmed that the qSOFA score is superior in mortality prediction compared with SIRS in terms of discrimination, model fit, reclassification, and calibration statistics. They also demonstrated that PCT has better correlation with clinical severity than WBC count or CRP. They found that combining PCT and the qSOFA score by simply adding the ordinal scale of PCT to the qSOFA score can significantly enhance its mortality prediction capability in all dimensions of model performance indicators. Clinically, PCT enhanced qSOFA, or qSOFA PCT, has the best sensitivity (86%) and can be served as a screening tool to quickly identify patients with sepsis who may benefit from early intervention. qSOFA alone has the best specificity (87%) and can subsequently serve as a quick confirmation tool to aid in the decision to pursue more invasive treatment. The original Sepsis-3 definitions proposed using the simple qSOFA score as the initial screening tool, followed by the comprehensive SOFA score as the confirmation tool for sepsis. In the original work, the sensitivity of a qSOFA score ≥2 was reported to be low at 55%, albeit with a high specificity (84%), whereas a change of SOFA score of ≥2 had a higher sensitivity (68%), but a lower specificity (67%). The sensitivity and specificity profiles of qSOFA and SOFA, however, are contradictory to

their proposed clinical use. A screening tool requires high sensitivity, whereas a confirmation tool requires high specificity. This study, like other external validation studies, confirmed the low sensitivity and high specificity of the qSOFA score. The authors propose incorporating PCT levels into qSOFA to correct for its low sensitivity. The high sensitivity (86%) and high NPV (95%) of qSOFA PCT ≥2 justify the combined score as an initial screening tool. They would like to preserve the qSOFA as a confirmation tool for two reasons. First, it is validated as a simple but highly specific tool with a specificity (84%) higher than the proposed delta SOFA greater than two (specificity 67%). Second, in clinical settings outside the ICU such as the ED, the comprehensive SOFA score may not be easily obtained. In summary, the study authors believe the newly proposed algorithm, using high-sensitivity qSOFA PCT as a screening tool and the highspecificity qSOFA score as the confirmation tool, is the most optimal use of biomarker information and the best clinical decision rule in clinical settings outside of the ICU.

In addition to the contradiction between the sensitivity and specificity profiles of qSOFA and SOFA, another major concern regarding replacing SIRS with qSOFA is the absence of clinical indicators of infection in the qSOFA score. PCT has been shown to be a reasonably sensitive marker in differentiating sepsis from sterile SIRS. In a large meta-analysis with 3 244 patients, PCT alone had a sensitivity of 77% and a specificity of 79% in the diagnosis of sepsis. The accuracy of PCT has been shown to be valid for various sites of infection and for different populations such as the elderly, patients with renal impairment, and patients with autoimmune disease. Therefore, the addition of PCT to the qSOFA score may complement its lack of infection indicators. However, the accuracy of PCT may be compromised in patients with neutropenia, hyper functioning thyroid cancer, and in patients with certain subacute infectious diseases such as infective endocarditis. The qSOFA PCT should be used cautiously in these specific populations. In clinical settings where testing for

24 SEPTEMBER 2019 | MEDICAL CHRONICLE

PCT is not readily available, the SIRS criteria would retain its value as a simple and lowcost screening tool. In multiple validation studies, SIRS ≥2 consistently demonstrates a higher sensitivity than qSOFA. The authors propose that when PCT cannot be obtained, SIRS should remain as a screening tool with qSOFA as the confirmation tool. Although they showed that the AUC of qSOFA PCT is higher than qSOFA alone, the confidence intervals overlapped. The limitations of the c-statistic, or AUC, as a measure of clinical model performance, have been discussed extensively in the literature. AUC is based exclusively on ranks, and it only measures how well the predicted values can rank order the responses. It may not be as sensitive as the likelihood function in choosing between models, and it is less clinically relevant as a calibration measure that directly cross-classifies the predicted risk categories with the observed risk. The magnitude of IDI, defined as the difference in discrimination slopes, has a direct interpretation. In this study, qSOFA PCT, compared with qSOFA, had an IDI of 0.0097. This indicates that the new model increases the mean difference of predicted probabilities for death and non-death by 0.97%. In the reclassification analysis, NRI is calculated as the sum of the net percentages of correctly reclassified patients with and without the event of interest. NRI is the favoured metric when assessing the true discriminatory potential of a new predictor compared with other predictors.

The incremental value of PCT to qSOFA was then evaluated by logistic regression, receiver-operating characteristic (ROC) curve, and reclassification analysis It captures the incremental strength of the new predictor after accounting for correlations with variables included in the baseline model. NRI values above 0.6 are considered strong, 0.4 intermediate, and below 0.2 weak. In this case, the NRI comparing qSOFA PCT with qSOFA is 0.35, which suggests a medium number of patients were reclassified to more appropriate risk categories. This change was

found to be significant (P=.00011). Since its publication of Sepsis-3 criteria and qSOFA in 2016, numerous attempts have been made to assess the performance of qSOFA. A recent meta-analysis collecting 45 studies showed low sensitivity and good specificity when the qSOFA is used as a screening tool for sepsis (pooled sensitivity was 61%, and specificity was 72%). In contrast, SIRS criteria resulted in a pooled sensitivity of 88%, but with only 26% specificity. This study demonstrates that combing PCT and qSOFA, rather than PCT and SIRS, can achieve the best sensitivity. The simple qSOFA PCT score will help clinicians identify at-risk patients and those with high likelihood for deterioration. A prospective external validation of this simple score is needed to verify the generalisability of this modified score. This work has both strengths and limitations. The study authors were the first in the literature to prove the added prognostic value of PCT to the qSOFA score by a rigorous statistical analysis. They proposed a practical strategy for clinical use: The highly sensitive qSOFA PCT score used as a screening tool, followed by the highly specific qSOFA score used as the confirmation tool. In addition, this multicentre design has a relatively large population, which increases the generalisability of this work. A key limitation of this study was the retrospective nature of this work. However, the patient characteristics of the study cohort are comparable with prospectively collected continuous samples. In addition, as these sepsis patients were not enrolled in ICU, common severity scores such as SAPS, APACHE II, or SOFA score were not available. Incorporation of PCT into the qSOFA model could raise the sensitivity to 86.5% (95% confidence interval 80%– 91%). In the validation cohort, qSOFA PCT greatly improved the sensitivity to 90%. A simple modification of qSOFA score by adding the ordinal scale of PCT value to qSOFA could greatly improve the suboptimal sensitivity problem of qSOFA and may serve as a quick screening tool for early identification of sepsis. CONCLUSIONS This work confirmed that qSOFA has low sensitivity and high specificity in predicting sepsis mortality. The incorporation of the ordinal scale of PCT to the qSOFA model could enhance sensitivity and reclassify patients into risk groups that better reflect their actual short-term mortality risk. The authors propose using qSOFA PCT as a screening tool followed by qSOFA alone as a confirmation tool for the identification of patients with sepsis in settings outside of the ICU. REFERENCE Yu H et al. Combining procalcitonin with the qSOFA and sepsis mortality prediction. Medicine 2019:98:23(e15981).

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CPD | OSTEOARTHRITIS

Efficacy and safety

of hyaluronic acid in knee osteoarthritis Osteoarthritis (OA) is one of the leading causes of disability in the elderly. Changes in the lubricating properties of synovial fluid leads to significant pain and functional disability.

steoarthritis is a form of arthritis that features the breakdown and eventual loss of the cartilage of one or more joints. Cartilage is a protein substance that serves as a â€˜cushionâ€™ between the bones of the joints. Among the over 100 different types of arthritis conditions, osteoarthritis is the most common joint disease. Osteoarthritis occurs more frequently as we age. Before age 45, osteoarthritis occurs more frequently in males. After 55 years of age, it occurs more frequently in females. In the United States, all races appear equally affected. A higher incidence of osteoarthritis exists in the Japanese population, while South African blacks, East Indians, and Southern Chinese have lower

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rates. Osteoarthritis is abbreviated as OA or referred to as degenerative arthritis or degenerative joint disease. Osteoarthritis commonly affects the hands, feet, spine, and large weightbearing joints, such as the hips and knees. Osteoarthritis usually has no known cause and is referred to as primary osteoarthritis. When the cause of the osteoarthritis is known, the condition is referred to as secondary osteoarthritis. SYMPTOMS Osteoarthritis is a disease that is isolated to the cartilage of the joints. Unlike many other forms of arthritis that are systemic illnesses (conditions that affect multiple areas of

26 SEPTEMBER 2019 | MEDICAL CHRONICLE

the body apart from the joints), such as rheumatoid arthritis and systemic lupus, osteoarthritis does not affect other organs of the body. The most common symptom of osteoarthritis is pain in the affected joint(s) after repetitive use. This can lead to knee pain, hip pain, finger joint pain, ankle pain, foot pain, wrist pain, and shoulder pain with loss of range of motion and function. Joint pain of osteoarthritis is usually worse later in the day. There can be swelling, warmth, and creaking of the affected joints. Pain and stiffness of the joints can also occur after long periods of inactivity. In severe osteoarthritis, complete loss of the cartilage cushion causes friction between bones, causing pain even at rest or pain with

limited motion. Symptoms of osteoarthritis vary greatly from patient to patient. Some patients can be debilitated by their symptoms. On the other hand, others may have remarkably few symptoms in spite of dramatic degeneration of the joints apparent on X-rays. Symptoms also can be intermittent. It is not unusual for patients with osteoarthritis of the finger joints of the hands and knees to have years of pain-free intervals between symptoms. Osteoarthritis of the knees is often associated with excess upper body weight, with obesity, or a history of repeated injury and/or joint surgery. Progressive cartilage degeneration of the knee joints can lead to deformity and outward curvature of

2019/04/15 11:00 AM

CPD | OSTEOARTHRITIS the knees, which is referred to as being 'bowlegged.' People with osteoarthritis of the weight-bearing joints (such as the knees) can develop a limp. The limping can worsen as more cartilage degenerates. In some patients, the pain, limping, and joint dysfunction may not respond to medications or other conservative measures. Therefore, severe osteoarthritis of the knees is one of the most common reasons for total knee replacement medical procedures in the US. TREATMENT Viscosupplementation based on the injection of hyaluronic acid (HA) into the knee joint represents an important part of current therapeutic regimen of pain in knee OA. Intra-articular HA and hylan have proven to be an effective, safe, and tolerable treatment for symptomatic knee OA. In an effort to limit cardiovascular, gastrointestinal, and renal safety concerns related to COX-2 selective and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) and maximise HA efficacy, it is even proposed using HA earlier in the treatment paradigm for knee OA and also as part of a comprehensive treatment strategy. Our study reconfirmed efficacy and safety of intra-articular use of hyaluronic acid in the treatment of knee osteoarthritis. OA is a lifestyle disease. Due to an increase in average life span, more individuals are at high risk of having the condition. Basic problems of these patients include pain and decreased quality of life. OA involves destruction of the articular cartilage. Damage on the collagen network and an increased production of proteoglycans by chondrocytes cause inflammation and thickening of the cartilage. The course of the disease involves a decreased content of water and proteoglycans, metalloproteinase activation, an increase of pro-inflammatory cytokine activity, subchondral degenerative bone cysts (or “geodes”) and development of subchondral sclerosis. Osteophytes (bone projections) are formed on the bonecartilage border. Joint capsule and ligaments become harder and lose elasticity. OA may affect multiple joints; most commonly (in order of frequency): spine, knee, hip, shoulder and hand joints. Aetiology of osteoarthritis has not been completely known. However, the chronic inflammation due to excessive metabolic activity of the affected joint seems to be the basis of the pathological process. Current treatment is mostly focused on reducing the symptoms intensity: Reduction of inflammation and pain relief using nonsteroid anti-inflammatory drugs, other analgesics and steroids. Besides the pharmacological treatment, physiotherapy including physical therapy and surgical treatment are applied. Recently, Intra-articular injections of HA have become one of the most popular therapies. HA is a natural component of the synovial fluid responsible for its elastic properties; thus, it is essential for the regular function of articular surfaces. Symptoms of knee OA are primarily related to inflammation of the synovial membrane and other articular structures,

as well as in the synovial fluid, where hyaluronate level decreases. Administration of HA in injections efficiently supplements its deficit and prevents its depolymerisation, a process that facilitates leukocyte migration into the synovial fluid. The restoration of rheological properties of the synovial fluid reduces the development of inflammation through the inhibition of leukocyte migration from synovial membrane capillaries into the synovial fluid. However, mechanism of action of the hyaluronic acid is not completely understood. Modifications in physicochemical properties of synovial fluid after HA administration cannot explain longterm reduction of symptoms, considering

Suplasyn Advert Medical Chronicle.indd 1

HA short half-life. Probably HA also has some biological effect on the inflammatory cells and stimulates HA production by synovial cells. Administration of hyaluronic acid, as proven by many authors, reduces the symptoms and development of the pathological process, as well as improves patients’ development in daily activities. MATERIAL AND METHODS An observational study was carried out from 2007 to 2008. Overall, 4 519 patients (59% females, 41% males) diagnosed with osteoarthritis, with a mean age of 54.2 years (SD 13.2). Affectation of the right knee was present in 39% of OA patients.

The left knee affectation represented a 39%, and in 21% both knees were affected. The study was conducted by orthopaedic, rheumatology and internal medicine specialist doctors. Each patient received a mean of three intra-articular injections of Suplasyn (20mg of sterile hyaluronic acid) and followed for a 30-day period. During the study, measures of intensity of symptoms were checked before and after treatment, including pain at rest and pain during walking (using VAS score). Changes in pain intensity (basic scored characteristic for OA degree) and symptoms like morning stiffness, after rest stiffness, pain after ascending stairs and walking on the surface level

2019/04/15 10:55 AM

MEDICAL CHRONICLE | SEPTEMBER 2019

CPD | OSTEOARTHRITIS

Patients scored improvement in a similar pattern, and the proportions were 59% and 32%, respectively. Treatment tolerance was evaluated as very good and good in 68% and 29% of patients, respectively

were evaluated. Evaluation also included changes in the range of motion of the knee joint based on evaluation of extension and flexion restrictions. According to their disability degree, patients were classified into five groups: regular mobility, slightly impaired mobility, moderately impaired mobility, severely impaired mobility and extremely impaired mobility. The study also evaluated the use of orthopaedic appliances (elbow crutches, orthoses). Besides all these parameters, doctors and patients opinions on efficacy and safety of HA were recorded. Each case of adverse reaction was registered. The analysis involved all the patients enrolled to the study (n = 4519). The data gathered was presented using descriptive statistics. Quantitative variables were expressed with sample size, minimum, maximum and median values, arithmetic mean and standard deviation (SD). For qualitative variables, absolute numbers and relative numbers for particular classes were provided. Questionnaires with missing data were provided. To make a comparison of selected variables between diagnostic and follow visits, t-Student, Wilcoxon and McNemar tests were followed respectively. RESULTS Patients scored the pain level at rest and during walking before treatment as 3.4

and 5.0, respectively. After treatment the scores for pain level at rest and during walking decreased to 1.5 (SD 1.5) and to 2.2 (SD 1.7), respectively. Mean scores of the morning stiffness intensity before and after treatment were 3.5 (SD 2.2) and 1.8 (SD 1.6), respectively. Score of stiffness at rest also decreased from 3.0 (SD 2.2) to 1.5 (SD 1.5). The treatment also showed some improvement in walking on surface level and walking up and down stairs; results are presented in Tables 5 and 6. Ability to extend and range of flexion after treatment changed significantly compared to the baseline. After treatment the use of orthopaedic appliances decreased. According to the 59% of doctors, mean patient condition improved significantly, and 34% of them scored it as moderate. Patients scored improvement in a similar pattern, and the proportions were 59% and 32%, respectively. Treatment tolerance was evaluated as very good and good in 68% and 29% of patients, respectively. Adverse effects, such as oedema, exudate, pruritus, redness and pain occurred in 1% of the patients; association with some of these effects with the injection itself cannot be excluded. No serious adverse effects were reported. DISCUSSION Numerous previous multicentre trials

28 SEPTEMBER 2019 | MEDICAL CHRONICLE

confirmed the efficacy of hyaluronic acid in knee osteoarthritis treatment, including the American College of Rheumatology (ACR) and European League against Rheumatism (EULAR). These study results confirm the benefits from the administration of HA in the treatment of knee osteoarthritis. Short- and long-term pain relief and mobility improvement are of great importance to patients because there is a significant improvement in quality of life. Despite short half-life of hyaluronic acid, its confirmed long-term action, produce some improvement on patientâ€™s quality of life for longer periods. The study confirms beneficial effect of HA. The functionality of the affected knee after treatment with HA improved, with the resolution of pain at rest and during walking. Extension ability and flexion range were improved. Patients reported fewer complaints on morning stiffness and stiffness after rest. Also, problems with daily activity, such as walking on flat surface and walking up and down stairs were reduced. A very important feature of the product is its extremely low rate of adverse effects. Good tolerance of HA also was confirmed in numerous studies. Very good and good tolerance of the treatment was noted in 68% and 29% of the patients, respectively. Adverse effects, such as oedema, exudate, pruritus, redness and pain occurred in 1%

of the patients. However, association with some of these effects with the injection itself cannot be excluded. No severe adverse effects were reported. Considering low rate of adverse effects, HA seems to be particularly indicated in the osteoarthritis treatment in individuals with bad tolerance to NSAIDs (such as elderly patients) or for whom NSAIDs are contraindicated (eg patients with peptic ulcer). CONCLUSION The study confirmed high efficacy and good tolerance of HA in the treatment of knee osteoarthritis. Due to adverse reactions related to the treatment with NSAIDs, treatment with hyaluronic acid is increasingly considered as the therapy of choice in patients suffering from osteoarthritis.

REFERENCE Gydek A et al. Efficacy and safety of intra-articular use of hyaluronic acid (Suplasyn) in the treatment of knee osteoarthritis. Przegl Lek 2011;68(6) 307-10.

This article is a CPD article that you can find on www.medicalacademic.co.za

CLINICAL | WOMEN'S HEALTH

Obs and Gynae Society intervenes to improve quality of women’s health in SA

The South African Society of Obstetricians and Gynaecologists has announced the introduction of ‘BetterGyn’, a new clinical care and governance programme aimed at significantly improving the quality of healthcare for South African women in both the public and the private health sectors.

HE BETTERGYN PROGRAMME will complement SASOG’s existing initiative, the BetterObs programme, which was established during 2015, and is aimed at reducing the number of maternal deaths in South Africa. Prof Greta Dreyer, President of SASOG explains that women’s health and the prevention of maternal deaths has always been a key focus for the society. “The implementation of the BetterGyn programme means that we will have covered the entire spectrum of women’s health issues and not just those associated with pregnancy and childbirth”, she said. The BetterGyn programme provides gynaecologists and other practitioners with a set of protocols aimed at the prevention and management of serious surgical complications and important conditions affecting women. Once development for the first phase is complete, a total of 32 conditions and procedures will be covered. Surgical procedure guidelines include conditions such as hysterectomies, urinary incontinence, pelvic organ prolapse and surgical complications. Importantly, attention will also be given to cancer screening and contraception, both of which are national priorities. The programme

includes information for patients to assist in the communication between practitioner and patient. The BetterObs programme is aimed at reducing the number of maternal deaths and complications and consists of a set of protocols for best practice for 19 of the most frequent and high-risk complications occurring during childbirth, including excessive bleeding, preterm labour and caesarean section deliveries. Already introduced into all labour wards in South Africa, these guidelines, which must be adhered to by all members of the delivery team, are aimed at standardising and raising the quality of care in the labour ward. Dreyer says that for every 100 000 live births, 134 women are losing their lives during childbirth, many from causes that could be prevented by improving infrastructure, health care systems and clinical know-how. “Although as a country we are making progress in bringing down the number ofwomen dying during pregnancy and childbirth, we are still losing far too many women from preventable complications such as those resulting from HIV, severe bleeding after childbirth, high blood pressure during pregnancy and infections”, she says.

The BetterObs programme is a holistic approach to improving quality and outcomes, and involves commitment from the obstetrician, the hospital, the attending paediatrician and the patient. Under these guidelines, obstetricians are expected to adhere strictly to the protocols and must comply with set peer review processes. Attending paediatricians are expected to complete detailed discharge summaries on each newborn and must notify the delivering obstetrician if the infant is readmitted, be it either to the same or another hospital. Also included in the programme are compulsory mortality and morbidity (M&M) meetings attended by obstetricians and paediatricians, where complications and quality of care are scrutinised and monitored. Hospitals must ensure that meetings take place regularly and consider withdrawing delivery rights of an obstetrician not attending these meetings. Upon admission, hospitals must make patients aware of the programme and of the procedure to follow in the case of a complaint. Dr Johannes van Waart, BetterObs programme leader, says that a handbook, compiled by the society, has been presented to every obstetrician

in the country and has also been made available for maternity nursing staff at all hospitals. He adds that, in the case of an adverse event, the Expert Opinion Panel are requested to study all the facts and provide recommendations on their findings, and the way forward to the SASOG Executive committee and the doctor involved. This panel will also refer potential litigation cases for mediation. The functions of the panel extend beyond obstetrics to the entire field of gynaecology. “Childbirth is a dangerous process of transition with many individuals – including nurses, midwives, hospitals and obstetricians – involved in assisting a safe journey for mother and child. The aim of the BetterObs programme is to make sure that excellent patient care becomes the priority for each member of the team involved in the delivery of a baby, in order to avoid complications and death. Similarly, we strive for quality in gynaecology via BetterGyn”, concludes Dreyer. ABOUT SASOG: The South African Society of Obstetricians and Gynaecologists was formed in 1946 and is a representative organisation for the majority of Obstetricians and Gynaecologists in South Africa. SASOG’s vision: Excellence and equity in women’s health. SASOG’s mission is to represent and support its members in pursuit of: • Improvement in women’s health in South Africa • Maintenance of high ethical standards • Promotion of excellence in clinical practice, training and research in Obstetrics and Gynaecology • Representing the discipline of Obstetrics and Gynaecology within the country, on the continent and internationally • Continuous professional development • Co-operation with the College of Obstetricians and Gynaecologists of South Africa, the Royal College of Obstetricians and Gynaecologists, the International Federation of Obstetrics and Gynaecology (FIGO) and other societies with similar goals.

MEDICAL CHRONICLE | SEPTEMBER 2019

CLINICAL | CENTRES OF EXCELLENCE

Making nuclear medicine patient friendly

TheraMed Nuclear is a general Nuclear Medicine/PET-CT facility based in Midstream, Gauteng and deals with scanning for various cancers and diseases.

S DR GEORGE BENNIE, nuclear physician states, “If you’re at nuclear medicine, you’re usually pretty sick.” Surrounded by nature-themed murals and light wooden furniture the atmosphere is calm and soothing. In patients newly diagnosed with cancer, this is imperative according to Dr Bennie. This theme is evident throughout the practice from reception to the imaging rooms. The practice is unique in that it has the only three-in-one PET-CT-SPECT camera in Africa. This allows the facility to perform both PET-CT (positron emission tomography) and SPECT-CT (single phone emission computed tomography) making it one of only three private facilities in South

Africa, and the only one in Gauteng with single-sitting whole-body co-registered SPECT-CT hybrid imaging capabilities with diagnostic quality CT scanning to boot. The two datasets, namely the 3D SPECT images are automatically fused to conventional CT allowing for better image processing and accurate localisation of lesions that is otherwise difficult in most studies (without some anatomical reference points). This obviates the need for a separate CT to be performed at additional cost and does not require the use of costly co-registration software to achieve similar results. TheraMed Nuclear is an example of a practice embracing hybrid (or dual-modality) molecular imaging, which until recently was

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limited to PET-CT. SPECT-CT allows for a cheaper and yet still competitive alternative to PET-CT in cancer diagnosis and treatment decisions. It is especially popular amongst referring oncologists because the cost of the scan allows for more funds to be retained for treatment purposes, especially where scheme oncology benefits are limited. SPECT-CT Where SPECT-CT has proved useful of late is with Technetium-99m iPSMA wholebody scans for prostate cancer skeletal and soft-tissue staging and follow-up. A third of the cost of the PET-CT alternative, the benefits outweigh the marginally lower sensitivity – a margin their referring

doctors are happy with, providing the CT scan is included. Without the CT the iPSMA scan is difficult to interpret as the radiopharmaceutical doesn’t distribute to fixed anatomical reference points as it does with a bone scan for example – limited to only skeletal staging. Other indications for SPECT-CT include pre-surgical localisation of excisable lesions eg sentinel lymph nodes for melanoma and breast cancer, and parathyroid adenoma in primary hyperparathyroidism. In addition to surface markings and gamma probe use, the addition of CT into the mix allows the surgeon to better strategise. The practice has largely abandoned its conventional ventilation-perfusion

CLINICAL | CENTRES OF EXCELLENCE

(VQ) scans for pulmonary embolism diagnosis in favour of hybrid perfusiononly SPECT-CT scan as it yields more information regarding other lung pathology and is cheaper (compared to traditional VQ scan or CTPA – the ubiquitous standard) making it very cost-effective. Literature shows that SPECT-CT, while not yet universally available, is the best-performing investigation for acute pulmonary embolism diagnosis and has been well received by the hospital’s specialists due to the additional information it provides. PET-CT PET-CT has largely become the de-facto method of staging various malignancies and the service provided at TheraMed Nuclear is no different to any of the world’s leading oncology centres. The multi-slice

CT provides diagnostic quality images and allows for accurate staging and follow-up of patients. PET-CT is also indicated in the diagnosis/prognostication of various other conditions such as cardiac viability, dementia and epilepsy, infection localisation, sarcoidosis and large-vessel vasculitis – all of which are performed at TheraMed Nuclear. ATMOSPHERE AND FACILITIES The friendly yet professional staff guides patients seamlessly through what would be described as an otherwise intimidating disposition (including the scan preauthorisation hassles with the medical schemes etc.). This is not the case at TheraMed Nuclear, where patients are taken care of from referral-to-report.

The decor and large spaces are welcoming and reassuring. This extends to the camera rooms, which have scenic murals and large windows allowing the technologist to monitor and communicate with the patient – all small considerations that help settle the nerves. Each PET-CT patient has a private waiting cubicle that is kept dimly lit to limit unwanted brain activity that may affect scan interpretation –each equipped with a comfortable lazy-boy chair. Patients feel relaxed and often fall asleep, which is ‘firstprize’ according to the technologists. The procedure room is stocked with all the examination-room essentials as well as a treadmill for myocardial perfusion testing, which the doctor performs personally. In case of emergency, the unit is also has a fully-stocked resuscitation trolley and ample

space for performing emergency measures. Other considerations include an onsite ablution facility for injected patient use while waiting, and an all-youcan -drink coffee counter to rejuvenate the spirit (and blood sugar levels) after a long night of fasting. TheraMed Nuclear truly believes in their promise of being ‘Patient-centred and doctor-tailored.” NUCLEAR MEDICINE & PET-CT “Conventional nuclear medicine (incl. SPECT – the 3D-version), and PET are two sides of the same coin,” says Dr Bennie. “Effectively you are injecting a pharmaceutical that has known chemical properties that determine its pharmacokinetic and pharmacodynamic processes. By adding a low dose radioactive isotope – lower than most x-rays – you can detect these pharmaceuticals and the process each one undergoes in the body. Essentially we are imaging the functional or physiological state of body, its organs, disease processes or malignancies as opposed to just its anatomy, as is the case in conventional radiology. Since these pharmaceuticals interact with their targets at a molecular level, nuclear medicine forms part of the broader field of molecularimaging. Of all the molecular imaging methods currently available, Nuclear Medicine has proven the most sensitive, with the most literature to support this, and depending on the specificity of the radiopharmaceutical, is also very specific. The only real difference between SPECT and PET is the type of radiation emitted and the detection method – requiring two different cameras.” While all the services provided are beyond the scope of this article, more information can be found at www.theramednuclear.co.za

MEDICAL CHRONICLE | SEPTEMBER 2019

CLINICAL | ONCOLOGY

A clinical case

for value-based care in oncology A shift from the fee-for-service model to VBC is in the patient’s best interest.

HE RISING INCIDENCE and prevalence of cancer, along with the increasing cost of new oncology drugs and treatments has major financial implications for funders, oncologists and cancer patients alike. The need for both professionals and funders to work together to manage this issue constructively is urgently needed. A shift from fee-for-service to value-based care (VBC) is considered a pragmatic way forward. In the private healthcare sector, Icon Oncology is leading the way in this field. This increasing financial burden of cancer care results in delays in funders granting authorisation for cancer treatment. Apart from the potential impact this has on the efficacy of treatment, it also leads to frustrations and anxiety on the part of oncologists and their cancer patients. High costs results in the depletion of the annual cancer care benefits of patients often before treatment can be completed. This then means the transfer of the financial burden onto the patient. One of the leading causes of this situation identified by Icon Oncology is the fee-for-service model. Simplistically, this model funds the volume of treatment given without taking clinical outcomes into consideration. Almost 10 years ago Icon Oncology was founded as a network-driven solution to bridge this gap between funders and practitioners, while placing the patient at the centre. Icon Oncology has advocated

for the VBC model in local oncology and this has shown itself to be an innovative solution to this issue. Icon’s studies have shown that VBC, using evidence-based treatment protocols, developed by the Icon oncologist network, can reduce oncology costs without compromising patient care and clinical outcomes. TWO STUDIES CONDUCTED Two recent retrospective studies done by Icon using matched anonymised patient authorisation and claims data have shown that protocol compliance drives significant cost savings and improved patient outcomes. Study 1. Cost Impact of Protocol Compliance for Cancer Treatment Plans in the Private Healthcare Environment (1; 2) The first study, published in 2017, assessed the cost and clinical impact of VBC in a third-party funder environment. A retrospective analysis of cancer treatment plan requests to funders over a period of 24 months was done. This study found that the cost of treating patients using Icon clinical protocols was 27% less compared to those patients treated in a non-protocolised environment. The validity of the results was confirmed by performing the same analysis on data from a previous year. Most importantly the analysis showed

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no evidence of denial of care. These findings then formed the basis on which a further study was conducted.

significant benefit without compromising the care given. These results were again validated by using data from a previous year.

Study 2. Hospitalisation Rate As A Proxy Outcome For Clinical Value In A Protocolised Cancer Treatment Environment (3.) Protocolised treatments have been criticised for possible cost shifting and compromising on appropriate care. Using the hypothesis that unscheduled hospitalisation during oncology treatment is considered a negative clinical outcome, this study aimed to prove that patients treated in a protocolised environment had at least equivalent outcomes to those treated in a non-protocol setting. The results showed that unscheduled hospitalisation events were reduced in the patient group that received treatment from oncologists treating in a protocolised environment – 16.07% – compare to those patients treated in a non-protocolised setting – 17.64%. The average hospitalisation stay of 1.62 days for patients in the protocolised environment was also shorter than the 1.95 days of the non-protocolised group. The average hospitalisation cost was lower in the protocolised group at R14 114 versus R21 405 for the non-protocolised group. The results of this study, using hospitalisation metrics as a proxy for clinical outcomes, indicated that the patient cohort in the protocolised setting demonstrated

A CLINICAL CASE FOR VBC These two studies, presented as poster presentations at international conferences, and published in peer reviewed journals (1; 2; 3), gives a strong indication that the implementation of VBC does not result in inferior quality of care to oncology patients. In the 10-year period of championing VBC as an alternative to the fee-for-service model, Icon Oncology has convincing evidence that patients receiving protocolised treatment will receive excellent care without compromising on clinical outcomes. The results of the two studies support Icon Oncology’s vision of placing the cancer patient’s needs at the forefront and ensuring that they receive the appropriate care at an appropriate cost without compromising on quality of care.

REFERENCES 1 Kotze, L. 2017. Cost Impact of Protocol Compliance for Cancer Treatment Plans in the Private Healthcare Environment. Value in Health, vol 20, issue 9, A426-A427. 2. Kotzé, L., Izzett, M. and Snyman, JR. (2017). Cost Impact of Protocol Compliance for Cancer Treatment Plans in the Private Healthcare Environment. African Journal of Clinical and Outcomes Research. 01 (01), 15-18. 3. Izzett, M et al. 2018. Hospitalisation Rate as a Proxy Outcome for Clinical Value in a Protocolised Cancer Treatment Environment. Value in Health, vol.21, S121.

THE RIGHT CARE IS VALUE-BASED CARE Icon is pioneering the move to value-based care, ensuring that cancer patients receive the appropriate care leading to better health outcomes. With our integrated network of oncologists, programmes and facilities, we provide cost-effective and quality cancer treatment that enables oncologists and medical schemes to deliver the right treatment to the right patient at the right time. With Icon - oncologists and medical schemes put the patient in the centre and the benefit is shared.

Oncology | Network | Managed Care www.iconsa.co.za

CLINICAL | NUTRITION

Nutritional care for surgery patients

Malnutrition affects up to 50% of hospitalised patients and contributes to adverse health and economic outcomes, but often remains unrecognised or undertreated.

N ORDER TO MAKE proper plans for the nutritional support of patients undergoing surgery, it is essential to understand the basic changes in metabolism that occur as a result of injury, and that a compromised nutritional status is a risk factor for postoperative complications. Starvation during metabolic stress from any type of injury differs from fasting under physiological conditions. Surgery itself leads to inflammation corresponding with the extent of the surgical trauma, and leads to a metabolic stress response. To achieve appropriate healing and functional recovery a metabolic response is necessary, but this requires nutritional therapy especially when the patient is malnourished and the stress/ inflammatory response is prolonged.

Postoperative management of metabolism and gut function Insulin resistance is a response mechanism to starvation predominantly caused by the inhibition of glucose oxidation The negative effect of long term caloric and protein deficits on outcome for critically ill surgical patients has been shown again recently. The success of surgery does not depend exclusively on technical surgical skills, but also on metabolic interventional therapy, taking into account the ability of the patient to carry a metabolic load and to provide appropriate nutritional support. In patients with cancer, management during the perioperative period may be crucial for long-term outcome Patients undergoing surgery may suffer from chronic low-grade inflammation as in cancer, diabetes, renal and hepatic failure. Other non-nutritional metabolic factors interfering with an adequate immune response have to be taken into account and, whenever possible, corrected or ameliorated before surgery. These are diminished cardio-respiratory organ function, anaemia, acute and chronic intoxications (eg alcohol, recreational drugs), medical treatment with anti-inflammatory and cytotoxic drugs. The surgeon has to balance the extent of surgery according to nutritional state, inflammatory activity and anticipated host

response. Severe pre-existing inflammation and sepsis influence healing negatively (wounds, anastomoses, immune function) but also decrease the benefit of nutritional therapy. Severely malnourished patients may exhibit an adynamic form of sepsis with hypothermia, leukopenia, somnolence, impaired wound healing and pus production, altogether leading to slow deterioration and mortality. In this situation nutritional therapy will not maintain or build up muscle mass but may restore an adequate stress response, promoting the chances of recovery. Awareness for the impaired inflammatory stress response means limiting the extent of the surgical trauma and may lead to uneventful recovery. Severely compromised patients should receive perioperative nutritional therapy of longer duration or when acute intervention is required, surgery should be limited or minimally invasive interventional techniques should be preferred to relieve infection/ischaemia. In order to optimise the mildly malnourished patient short term (7-10 days), nutritional conditioning has to be considered. In severely malnourished patients longer periods of nutritional conditioning are necessary and this should be combined with resistance exercise.

In the truly infected patient immediately dealing with the focus of sepsis (‘source control’) should have priority and no major surgery should be performed (risky anastomoses, extensive dissections). Definitive surgery should be performed at a later stage when sepsis has been treated adequately. Postoperative management of metabolism and gut function Insulin resistance is a response mechanism to

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starvation predominantly caused by the inhibition of glucose oxidation. It is a protein sparing evolutional ‘survival’ mechanism. Some degree of insulin resistance develops after all kinds of surgery, but its severity is related to the magnitude of the operation and development of complications eg sepsis. Several measures, with additive effects, may contribute to a reduction in insulin

resistance, including pain relief, continuous epidural analgesia using local anaesthetics, and preparation of the patient with preoperative carbohydrates two to three hours before surgery. This has implications for nutritional management since patients with marked insulin resistance cannot tolerate feeding without developing hyperglycaemia, necessitating the use of insulin to limit hyperglycaemia.

CLINICAL | NUTRITION

According to Mullin et al (2019), in a large cohort of malnourished adult inpatient ONS intervention was associated with 38% fewer 30-day readmissions. This association was more pronounced for oncology encounter

EVIDENCE OF NUTRITIONAL THERAPY There is evidence that malnutrition is associated with worse outcome, and it is evident that major surgical stress and trauma will induce catabolism. The extent of catabolism is clearly related to the magnitude of surgical stress but also to the outcome. In complex medical conditions like the perioperative patient undergoing major surgery, the geriatric patient or in the critically ill the outcome will be clearly related to multiple associated factors. Regarding a nutritional intervention an existing effect may be too weak to show significant impact in a prospective controlled randomised study with a feasible number of patients to be included, even in a multicentre setting. However, the combination of the nutritional intervention with some other therapeutic items as a ‘treatment bundle’ like in the ERAS programme may show significant benefit. According to Mullin et al (2019), in a large cohort of malnourished adult inpatient ONS intervention was associated with 38% fewer 30-day readmissions. This association was more pronounced for oncology encounters. Shorter length of hospital stay was observed when the interval between admission and ONS initiation was shorter. Reduced length of stay and readmissions rates could result in financial

benefits for health care systems prioritising hospital nutrition care, in addition to informing significant medical benefits for their patients.

There is evidence that malnutrition is associated with worse outcome, and it is evident that major surgical stress and trauma will induce catabolis KEY POINTS Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, eg for cancer, and

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of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include: • Integration of nutrition into the overall management of the patient • Avoidance of long periods of preoperative fasting • Re-establishment of oral feeding as early as possible after surgery • Start of nutritional therapy early, as soon as a nutritional risk becomes apparent • Metabolic control eg of blood glucose • Reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function • Minimised time on paralytic agents for ventilator management in the postoperative period • Early mobilisation to facilitate protein synthesis and muscle function.

REFERENCES Mullin G, Fan L, Sulo S, Partridge J. The Association between Oral Nutritional Supplements and 30-Day Hospital Readmissions of Malnourished Patients at a US Academic Medical Center.J Acad Nutr Diet. 2019;119(7):1168-1175. doi: 10.1016/j. jand.2019.01.014. Weimann A, et al. ESPEN guideline: Clinical nutrition in surgery. European Clinical Nutrition 2017:623e650.

CLINICAL | DERMATOLOGY

Sustaining AK and sBCC clearance

The prevalence of actinic keratosis (AK) and superficial basal cell carcinoma (sBCC) make them some of the most commonly encountered dermatological conditions in a primary care setting. While they are easy to treat, concerns remain about their long-term clearance.

ASAL CELL CARCINOMA (BCC) is the most common cancer, accounting for nearly 75% of all skin cancers worldwide. Although it rarely results in death or metastatic disease, BCC can cause significant morbidity due to destructive local spread. Luckily, the accessibility of skin and the high prevalence of BCC have allowed a thorough characterisation of its pathogenesis, clinical presentation and histopathology and the course of BCC treatment is generally well understood. Rates of BCC have been reported to be increasing in many countries around the world as a result of the increasing longevity of the general population and sun exposure behaviours. A similar affliction, the chronic skin condition actinic keratosis (AK), also known as solar keratosis, is characterised by the formation of keratotic lesions of variable thickness that are poorly delimited. These represent focal areas of abnormal keratinocyte proliferation and differentiation. AK occurs on areas of the skin that have had long‐term exposure to

the sun or UV radiation, predominantly on skin of the head and dorsa of the hands, in fair‐skinned individuals. Although AKs may regress, they usually persist and can progress to squamous cell carcinoma (SCC). Most patients with AK can be diagnosed and managed in primary care. AKs are generally considered to be premalignant lesions with low individual potential for invasive malignancy and potential for spontaneous regression. AKs present as discrete, sometimes confluent, patches of erythema and scaling on predominantly sun‐exposed skin, usually in middle‐aged and elderly individuals. RECURRENCE RISKS The disease progression of BCC is usually that of a slow-growing skin cancer starting from a tiny, hardly visible papule, growing usually for years without any aggressiveness into a nodule or a plaque, sometimes ulcerated, leaving time to be diagnosed and managed correctly. A few forms of common BCC, such as superficial, nodular, morphoeic and ulcerated, are clinically

ACTINIC KERATOSIS

recognised, although common BCCs are highly polymorphic and sometimes difficult to classify into one of these standard subtypes. More than 95% of BCCs are easy to treat through standard surgery or a range of alternative blind treatments at least during the initial months or years after diagnosis. Difficult-to-treat BCCs include all locally advanced BCCs and also common BCCs which, for any reason, pose specific management problems. These reasons may be: * The technical difficulty of maintaining function and aesthetics due to the size or location (eyes, nose, lips and ears) of the tumour * The poorly defined borders often associated with morphoeic subtype or prior recurrence * Multiple prior recurrences on the face (often requiring much larger excision) * Prior radiotherapy * Patient’s reluctance to accept the consequences of surgery and patient’s comorbidities interfering with surgery.

SUPERFICIAL BASAL CELL CARCINOMA

All difficult-to-treat BCCs are at high risk of recurrence mainly because of difficulty in the management that often leads to compromise with regard to ideal treatment and recommended safety margins of excision. All BCCs managed by ablative procedures without histopathological control instead of surgical excision are at high risk of recurrence. It must however be mentioned that not all recurrences have the same implications. A recurrence of an invasive BCC on eyelids, nose, lips and ears significantly increases the risk of deleterious consequences, while a recurrence of a superficial BCC (sBCC) on the back will be easily managed. In the case of AK, the presence of a single lesion is a marker of excessive sun exposure and is associated with the development of further lesions. Point‐ prevalence studies demonstrate that lesions regress and relapse over time (especially in the case of so-called grade 1 and 2 lesions). Figures range wildly between 25% and 70% for apparent resolution of AKs over a period of one to four years.

EXTERNAL GENITAL WARTS

WITH ALDARA YOUR PATIENTS HAVE EFFECTIVE SUSTAINED CLEARANCE FOR AK, sBCC AND EGW1-4 References: 1. Krawtchenko N, et al. Br J Dermatol 2007; 157(Suppl.2):34-40. 2. Stockfleth E et al. Arch Dermatol/Vol 140, Dec 2004:1542. 3. Gollnick H, et al. Eur J Dermatol 2005; 15(5):374-381. 4. Edwards L, et al. Arch Dermatol 1998; 134:25-30. Scheduling status: S4 Proprietary name and dosage form: ALDARA Cream. Composition: Each 2,0 g cream pump contains 5 % Imiquimod (100 mg). ALDARA Cream Sachet. Composition: Each 250 mg cream sachet contains 5 % Imiquimod (12,5 mg). Preservatives: Methyl hydroxybenzoate 0.2 % m/m, Propyl hydroxybenzoate 0.02 % m/m, Benzyl alcohol 2 % m/m. Pharmacological classification: A 34 Other. Indications: ALDARA Cream is indicated for the topical treatment of superficial basal cell carcinoma (sBCC), and of external genital/perianal warts (condyloma acuminata) and clinically typical, non hyperkeratotic, nonhypertrophic actinic keratosis (AKs) on the face or scalp in adult patients. Registration number: 32/34/0541. Name and business address of the holder of the certificate of registration: iNova Pharmaceuticals (Pty) Ltd,. 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 package insert approved by the MCC (Medicines Control Council). Further information is available on request from iNova Pharmaceuticals. IN2659/18

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CLINICAL | DERMATOLOGY This is cause for concern since AKs could, in some circumstances, be seen as a precursor condition to SCC. Despite the proximity of AKs and SCC when they occur on chronically sun‐damaged skin, and the histological and molecular similarities between them, debate continues concerning whether they are separate but similar pathologies developing in tandem or whether one leads directly to the other. In one prospective photographic monitoring study over five years, it appeared that 65% of SCCs arose at a site of previously documented AK. TREATMENT TO PREVENT RECURRENCE Most primary BCCs can be easily treated by surgery or by non-surgical methods for certain subtypes, but BCCs with a high risk of recurrence need to be treated more aggressively. Risk of recurrences increases with tumour size, poorly defined margins, aggressive histological subtype or previous recurrences. Certain tumours can be locally advanced with destruction of adjacent tissues or difficult to treat for other reasons which might need discussion regarding appropriate therapy in a multidisciplinary board. Surgical excision is a very effective treatment for primary BCC treatment, with recurrence rates varying from less than 2% to 8% at five years after surgery. Scalpel excision is performed using either a standard (2D) excision with safety margins or a microscopically controlled stepwise procedure (3D excision). Alternatively, surgical removal by destructive (blind) treatments and nonsurgical modalities including topical treatments or photodynamic therapy (PDT), either alone or combined, may be used for low-risk BCCs when surgery is contraindicated or impractical. Histological examination of damaged tissue is not possible using topical or destructive treatment techniques. Moreover, deeper parts of tumours might not be reached because of methodologyinherent penetration limits or only with an inappropriate risk of tissue scarring. As a rule, blind techniques should be avoided in BCCs, in which a deeper tissue invasion cannot be ruled out and in those at increased risk for subclinical spread or local recurrence. In summary, data suggests the possibility of regression and a low risk of malignant progression for any given AK. The presence of AK (particularly in high‐risk patients with multiple AKs or field change) predicts an excess risk for subsequently developing melanoma compared with a matched population. NON-SURGICAL TREATMENT WITH IMIQUIMOD Given the variety of nonsurgical treatment options available for BCC, physicians must take into account numerous factors in order to determine which therapy, or combination of therapies, would best meet the goals of the patient. As a general rule of thumb, nonsurgical modalities, such as topical creams and phototherapies, are superior to surgical therapies for non-advanced BCCs in cosmetically sensitive areas, albeit at the

cost of higher recurrence rates and longer treatment times. Additionally, nonsurgical therapy is usually more effective for superficial BCCs than nodular BCCs. In cases of deep or infiltrating BCC, nonsurgical modalities should be used with caution and clinicians may want to consider a combination of therapies to minimise recurrence. Imiquimod functions as an immunomodulatory drug that stimulates both the innate and cell-mediated arms of the immune system while simultaneously exhibiting direct pro-apoptotic effects

on tumour cells. It has also been shown to inhibit the Hedgehog signalling pathway whose activation is crucial for the development and propagation of BCCs. Treatment with imiquimod is generally well-tolerated, even in sensitive areas. Adverse effects are usually limited to application-site reactions and include erythema, oedema, weeping and pruritus. The incidence and severity of these effects are reported to increase with application frequency. Cosmetic outcomes are generally excellent with imiquimod therapy.

CONCLUSION There is a risk of recurrence with both AK and sBCC. While surgical treatments are clinically optimal and are almost guaranteed to prevent recurrence, they leave much to be desired in terms of their cosmetic effect on a patient’s skin. Non-surgical therapies are often a better choice, and among these imiquimod 5% cream has a demonstrably positive effect on short-term and long-term clearance rates.

References available on request.

This is a synopsis of a longer, CPD-accredited article available on www.medicalacademic.co.za

MEDICAL CHRONICLE | SEPTEMBER 2019

CLINICAL | GASTROENTEROLOGY

Testing for functional diarrhoea and IBS-D

A new guideline provides recommendations for the laboratory evaluation of adults with suspected FD or IBS-D.

HE AGA INSTITUTE process for developing clinical practice guidelines incorporates GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology2 and best practices as outlined by the Institute of Medicine.3GRADE methodology was used to prepare the background information for the guideline and the technical review that accompanies it.4 Optimal understanding of this guideline will be enhanced by reading applicable portions of the technical review. The guideline panel and the authors of the technical review met face-to-face on September 8, 2017 to discuss the quality of evidence and consider other factors relevant for the risk–benefit assessment of the recommendations. The members of the guidelines panel subsequently formulated the recommendations by consensus. Although quality of evidence was a key factor in determining the strength of each recommendation, the panel also considered the balance between the benefit and harm of interventions, patients’ values and preferences, and resource utilisation. BACKGROUND AND OBJECTIVE Functional diarrhoea (FD) and diarrhoeapredominant irritable bowel syndrome

(IBS-D) are highly prevalent disorders that can be difficult to distinguish from organic causes of chronic diarrhoea (ie, lasting >4 weeks) based on symptoms alone. Clinicians often use an array of biomarkers to assist diagnosis; however, there is little available guidance regarding the appropriate use of available diagnostic tests. This guideline provides evidence-based recommendations addressing these gaps. KEY RECOMMENDATIONS Test for celiac disease with immunoglobulin A (IgA) tissue transglutaminase. In the case of IgA deficiency, immunoglobulin G (IgG) tissue transglutaminase and IgG or IgA deamidated gliadin peptides can be measured. TEST FOR GIARDIA INFECTION USING ANTIGEN TEST OR POLYMERASE CHAIN REACTION Consider testing for bile acid diarrhoea. If assays are unavailable, empiric treatment with a bile acid binder is reasonable. Use either faecal calprotectin (threshold, 50μg/g) or faecal lactoferrin (threshold range, 4.0–7.25μg/g) to screen for inflammatory bowel disease (IBD). Do not measure erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to screen for IBD, although

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CRP can be considered as an alternative to faecal calprotectin or lactoferrin if these cannot be measured. Do not test for ova and parasites in the absence of a suggestive travel or immigration history. The routine measurement of serological markers of IBS (antibodies to cytolethal distending toxin B and the gut mucosal protein vinculin) awaits additional supportive data. IBS Diarrhoea-predominant irritable bowel syndrome (IBS-D) is a major cause of chronic watery diarrhea. Several tests have been proposed to identify those with IBS-D and who might benefit from IBS-D–specific therapy. Specifically, it has been postulated that a strategy of measuring antibodies to cytolethal distending toxin B and the gut mucosal protein, vinculin, might be used to identify persons who have postinfectious IBS-D. The available data are sparse but suggest that the contemporary tests lack the diagnostic accuracy needed for routine use. In addition, the case–control design of the studies and the study setting used (secondary and tertiary care) likely inflate the estimates of the test characteristics compared to what is expected in a general population. The specificity in the 2 studies available for the technical review was in the

90% range, meaning that a positive test would indicate a high likelihood of IBS-D. However, the low sensitivity (20%–40%) would not be sufficient to employ these tests in routine use. More data will be helpful in determining the proper roles of these and similar tests. COMMENT These guidelines are based on an informative technical review of each diagnostic test (Gastroenterology 2019 Jul 25; [e-pub]) and provide practical guidance for primary care and GI providers. Takehome points are to avoid the “kitchen sink” approach where multiple tests are done simultaneously in patients with suspected FD or IBS-D, and rather to focus first on celiac disease, Giardia infection, and stool inflammatory markers. An empiric trial of bile acid binders is a reasonable concomitant or subsequent step, as diagnostic tests for bile acid diarrhoea are either not available or not widely used. Older patients with chronic watery diarrhoea should be considered for endoscopic evaluation with biopsy to exclude microscopic colitis.

REFERENCE Charles J. Kahi, MD, MS reviewing Smalley W et al. Gastroenterology 2019 Jul 11.

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CLINICAL | WOUND CARE

The role of silver

in healing DFUs The use of an antimicrobial dressing instead of a non-antimicrobial dressing may increase the number of diabetic foot ulcers (DFUs) healed over a medium-term follow-up period.

ÁZARO-MARTÍNEZ J et al recently evaluated the clinical and microbiological efficacy of silver foam dressings in the management of diabetic foot ulcers. They conducted a single-centre; prospective, open, noncontrolled study involving 21 outpatients with diabetic foot ulcers with mild infection. All patients received standard of care for their wounds and a silver foam dressing with silicone adhesive was applied twice per week for wound management during a six-week treatment period. Soft tissue punch biopsies were taken every second week for qualitative and quantitative microbiological analysis. Wounds were assessed at patient admission, and wound bed tissue was evaluated for presence, quality, and consistency of granulation tissue. FINDINGS The study demonstrated that the use of a silver foam dressing with silicone adhesive has a clinical and microbiological efficacy in a case series of patients with DFUs. The main arguments against using topical antiseptics are the lack of adequate proof of efficacy and residual concerns about their potential toxicity to healing wounds. Regarding the clinical effectiveness, in our study population wound scores improved significantly, from a mean score of 3.9 ±1.6 points at inclusion to 6.1 ± 1.3 points at the end of the study (n = 19, P <.001). Furthermore, we observed a significant decrease in exudate levels (38.8% of patients with high exudate levels at inclusion vs 5% at the end of the study, P = .0031) and in the mean ulcer size (2.27 cm2 at inclusion vs 0.99 cm2 at the end of the study, P = .001). The stand-out feature of this study is that patients in their study received systemic antibiotics and our patients did not receive systemic antibiotic treatment during the study. The authors consider that the more positive effects of a silver dressing on overall wound condition for the patients initially prescribed antibiotics might be expected from use of a dressing, which absorbs and holds wound exudate. The capacity to absorb, retain, and kill bacteria in infected wound fluid in the silver dressing may work in synergy with systemic antibiotics, which may not always reach microorganisms on the wound surface. In this study, patients did not receive systemic antibiotic treatment because the authors also analysed the microbiological effects of the silver dressing, and the systemic antibiotic treatment could have

The use of a silver foam dressing with silicone adhesive significantly reduced the pathogenic bacterial load.

altered the microbiological results. They observed that use of the silver dressing resulted in significant decreases at week six (P =.0148) in the bioburden of classically considered DFU pathogenic organisms. These results demonstrate efficacy of the silver dressing against several common wound pathogens in DFUs, and in this sense, this dressing may also prove helpful with the increasing problem of multidrugresistant microorganisms that are untreatable with most systemic agents. Although mechanical debridement before sampling should reduce, if not eliminate, the biofilm formed, the authors assumed that, under the assumption that most of DFUs presented in our study exhibited biofilms, the dressing was also active against bacteria embedded in biofilms. However, this should be specifically assessed in a future study since we did not perform a direct measure of biofilm occurrence. On the other hand, the treatment with silver dressing contained the basal bioburden of DFUs in all patients who completed the study period irrespective of the clinical evolution during the followup (0.0 and 0.5 Log drop for patients with favourable and unfavourable clinical outcome, respectively). We know that the healing in DFUs will occur due to three conditions: Adequate arterial inflow,

42 SEPTEMBER 2019 | MEDICAL CHRONICLE

appropriate control of infection, and offloading of the site of wound and immediate surrounding area is satisfied. In this regard, one of the patients with unfavourable clinical evolution developed critical limb ischaemia and required a revascularisation treatment and another patient required surgical treatment due to diabetic foot osteomyelitis. In the study population, two patients were excluded due to the presence of cellulitis during the treatment period because they requested systemic antibiotic treatment. It is uncertain whether use of an antimicrobial dressing affects the risk of adverse events compared with use of a nonantimicrobial dressing over a medium-term observation period in patients with DFU. Regarding the potential toxicity of silver dressing to healing wounds, we know that the amount of silver release can be controlled by various means, most notably by increasing the surface of the incorporated silver preparation. Nanocrystalline silver dressings have been shown to release high amounts of silver ions over a short period of time and this could be associated with significant cytotoxicity. Ziegler et al and Dong et al have reported that low-silver–releasing ointment dressing has less toxicity than other dressings surrounding wound tissues. The silver dressing used in the present study has a sustained silver release profile up to seven

days in the presence of exudate. A similar sustained silver-release dressing has shown positive clinical results in non-healing wounds with signs of infection in several comparative clinical studies. Currently, the balance between antimicrobial activity and cellular toxicity remains a challenge for developing new products, which may interfere less with normal wound healing processes. Given that unlike antimicrobials the resistance to antiseptics containing silver is rare and sporadic, the authors think that the balance between the benefit, that is, reduction of pathogenic bacterial load and prevention of the emergence of resistant organisms, and the risk for adverse effects or toxicity on the patient is favourable to the use of this silver dressing. CONCLUSION The authors conclude that the use of a silver foam dressing with silicone adhesive significantly reduced the pathogenic bacterial load and markedly improved the clinical outcome in patients with diabetic foot ulcer with mild infection over a six-week treatment period. REFERENCE Lázaro-Martínez J et al. Clinical and Antimicrobial Efficacy of a Silver Foam Dressing with Silicone Adhesive in Diabetic Foot Ulcers With Mild Infection. The International Journal of Lower Extremity Wounds 2019: 1–10. doi/10.1177/1534734619866610.

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CLINICAL | WOUND CARE

Care of the burn patient after discharge

Most doctors are familiar with the acute management of burns. However, after the immediate burn wounds have healed and the patient is discharged from the hospital, many problems can occur and re-adjustments may be necessary.

ROBLEMS MAY ARISE months or even years after the initial injury. It is therefore recommended to follow up adults whose burn wounds required more than three weeks to heal or who required a skin graft for a minimum of two years, and children through puberty. Scar tissue does not grow at a pace with normal tissue, and therefore an insignificant contracture at age four may pose a serious functional impairment at age 14. CARE OF THE BURN WOUND Once the burn wounds have re-epithelialised and the patient has been discharged from hospital these wounds go through a prolonged process of ‘remodelling’ that can last up to two years. During this period the patient can develop typical complaints and complications that may need attention. I will list a few of these: Although the epithelium has resurfaced the wound, skin appendages such as sweat and sebaceous glands take much longer to recover. The result is that the skin is often dry and scaly, and is damaged quickly. A moisturising or emollient cream needs to be applied several times a day. Simple creams, such as aqueous cream, Vaseline, virgin coconut oil or coconut butter may be used. The area needs to be washed thoroughly with water and soap before application to remove any dissipated cream which may block pores and cause infection. The surface area must be dabbed rather than rubbed with a drying towel to prevent damage and itching (see below) Burn scars are extremely sensitive to sun damage, and direct exposure to the sun must be avoided at all costs. This means staying out of the sun during the hottest hours of the day (usually between 10.00 and 16.00 hours), and covering the burn scars with clothing (long sleeves, hats, etc). If exposure to direct sunlight is unavoidable (such as when doing outdoor labour) the burned area must be protected with a thick layer of high-quality sunscreen. (Sun Protection factor SPF 30) Itching is a common problem after burns, and may interfere with sleep. Washing the skin with soap and water, followed by followed by gentle massage using a moisturising cream is the first step and can be taught to the patient or his/her relatives. As itching is related to histaminerelease, further stimulation of the skin by scratching (or even rubbing with a towel) should be avoided, for instance by keeping a child’s nails short. The best medication is gabapentin (300 mg tds, children 5 mg/ kg) or pregabalin. An H1-blocker, such as Vallergan, may be used as alternative but is

less successful. All these medications can make the patient drowsy, and it is advisable to start with a once-daily night dose and slowly building up to the tds dose The most important complication of burn wounds is hypertrophic scarring, especially if the original burns were infected, took longer than three weeks to heal or were grafted. Hypertrophic scarring can result in cosmetic deformities, ectropions and contractures. Although massaging the wound has been recommended, there is little evidence that it does any good in preventing hypertrophic scarring. The hallmark of hypertrophic scar prevention is compression therapy, where pressure garments are worn over the scars for most of the day and night (they are only taken off for bathing and scar care) and for the duration of the remodelling stage (ie, when the scar is soft, pliable and flat, which usually takes any time from six months to two years). The garments are custom-made by the occupational therapist, and should exert a pressure of about 24-40 mmHg. Pressure therapy should start as soon as the wounds have healed. Pressure garments can successfully be combined with soft silicones, which can be applied as a gel or sheet Physiotherapy in the form of passive or active exercises is traditionally regarded as an important treatment modality to prevent contracture formation. Although it is certainly beneficial for the patient to exercise the muscles and joints underneath a burn scar, the role of passive exercises and of splinting that puts the scar tissue under passive stretch has recently become controversial. Stretching scar tissue has been shown to increase the number of myofibroblasts in the scar, the very cells responsible for the contractures that one aims to prevent. It has been suggested that passive stretching of scar tissue might actually increase contracture formation rather than prevent it If hypertrophic scarring develops or persists after a period of three months of pressure therapy, the patient is usually referred for laser therapy. Laser therapy for burn scars is a relatively new modality, and is rapidly replacing the dreaded intralesional injections with steroids or cytostatic agents. Deep settings for laser beam cause small cylindrical burns to move into the hypertrophic scar tissue, thus disrupt the tight fibrous bands that are responsible for the contracted tissue. These usually heal without further scarring. Superficial settings are used to improve the appearance of the scar. The modality is usually combined with a steroid

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cream, which gains access to the deeper tissues through the cylinders of burnt tissue created by the laser If laser therapy is unsuccessful, surgery is advised. Thin, tight bandlike contractures are usually managed by a form of plasty (V-Y, Z or 7-flap). The aim is to interrupt the band by placing unburned, pliable tissue along its line. This operation is can be combined with laser therapy. Larger areas of hypertrophic scarring causing contractures often require more advanced plastic surgical techniques. These surgeries are preferably carried out after maturation of the scar tissue.

CARE OF THE PATIENT Patients who are discharged from hospital after a major burn (ie, more than 15-20% in an adult, and even smaller in a child) may have a number of typical sequelae, that might have to be addressed by those who look after the patient.

The hypermetabolic/hyperdynamic response that frequently plagues in particularly children with major burns while in hospital, carries on after discharge, and may last for up to two years. Burns survivors therefore often suffer from weight loss – or growth retardation in children – muscle weakness and a decreased resistance against infection. If the hyperdynamic response persists after discharge with a persistently high heart rate, the patient may be started or continued on propranolol (0.5-4 mg/kg daily to bring the HR down by 15-20%). Attention to nutrition is important, and post-burn patients should be encouraged to eat protein-rich food such as cheese, milk, eggs, custard, yoghurt, baked beans, fish, meat etc. The burns survivor must be encouraged to eat as much of these foods as possible. As burn patients develop intolerance to fat the so-called Banting diet is not a good option. Exercise has been shown to decrease the hypermetabolic response, and to strengthen muscles and increase endurance. Post-burn patients must therefore be encouraged to exercise from early on in the recovery stage. Although isometric exercises have been shown to be most beneficial, any form of exercise will have a positive effect

Burns are threatening injuries that leave the patient with unsightly scars and functional deformities. When Hollywood wants to depict a particularly heinous villain it often chooses a burn survivor. Furthermore, the treatment of a major burn is often associated with painful

Dr Daan den Hollander Consultant Trauma Surgeon, HOD Provincial Burns Unit; Inkosi Albert Luthuli Central Hospital, Durban

wound dressings, multiple operations and a slow recovery with many disappointments. It is no wonder that many burn patients develop psychological problems after their injury, with post-traumatic stress disorder (PTSD), major depression and problems with social adjustment being the most frequent. PTSD is reported in 15-45% of burn survivors at 12 months. It is defined as the combination of intrusive re-experiencing of the traumatic event, either in the form of nightmares or of flash-backs, avoidance behaviour and symptoms of increased arousal, occurring for more than three months after the injury. In burns survivors the syndrome may be incomplete (eg only nightmares). Treatment is with an SSRI (which will reduce nightmares and improve sleeping patterns) and psychotherapy. Cognitive Behavioural Therapy has proven to be beneficial for both adults and children with PTSD. About 4-7% of burn survivors suffer from major depression one year postburn, but up to half experience depressive symptoms. SSRIs need to be continued for at least nine months. Body image dissatisfaction is often multifactorial and not directly related to appearance. The trap is to offer repeated corrective cosmetic surgery indiscriminately while leaving other issues unexplored.

A neglected area in burns survivors is sexuality. Scarring around the genitalia may interfere with intercourse or cause dyspareunia. A high percentage of male survivors of burns around the genital area suffer from impotence. But these are relatively rare. Much more common are sexual problems as a result of body image dissatisfaction. These are more common in adult women. Teenagers who were burnt as children, and managed and followed up in the Shriner’s Hospital for Sick Children in the US, on the other hand, were not different from their non-burned peers with regards to sexual behaviour, while they on average demonstrated better sexual adjustment. These children, however, are extensively followed up by a multidisciplinary team, including life-coaches and psychologists. As burns survivors will rarely volunteer sexual problems, it is important for the health care worker to ask about them. Management of the burn patient does not stop when the patient is discharged from hospital and the wounds have healed. Problems often carry on for months after the injury, and new problems may arise – often years later. The medical practitioner must be ready to address these at any time.

ETHICS

Doctors in the spotlight What you should and shouldn’t do when approached by the media News coverage may result from patients complaining directly to the media if they feel there have been lapses in their care, or if a journalist considers a high profile HPCSA hearing to be in the wider public interest.

Dr Graham Howarth, head of Medical Services, Africa at Medical Protection

to do so in a public forum. You may like to keep contemporaneous records of all dealings with the press, as they could assist in defending your actions if you receive a complaint about the information you disclose later.

Avoid saying ‘no comment’, as this can be perceived as you having something to hide

T’S NOT HARD to see why reallife stories about alleged poor care and consequent personal suffering make the headlines. Readers can relate to experiences of medical care, and doctors are generally held in high regard within society. This perception and the trust placed in the profession can be challenged when a patient is harmed or a doctor is caught behaving badly, and is often considered ‘newsworthy’. Understandably, it can be very daunting for doctors – who generally have no or limited media training – if they are thrust into the public eye, with criticisms directed at their patient care. Journalists can be inventive when attempting to seek comment, as they can try to catch people off-guard in the hope that it will prompt a response. This could be an unexpected phone call or a reporter ‘door-stopping’ a doctor at their home or place of work. Journalists may also seek comment through colleagues, friends or family, and make contact via email and social media. If you find yourself in this situation, the following points may help to prepare you for the experience: REMAIN PROFESSIONAL If approached by a journalist, the first thing you should do is maintain your composure. It is important to appear calm and professional and not say something that you might later regret.

Avoid saying ‘no comment’, as this can be perceived as you having something to hide. Rather than providing provisional comments or refusing to engage at all, ask the reporter for further details and tell them you will get back to them. It is a good idea to obtain: • The journalist’s name • The name of the publication or the programme they work for • Exactly what they are asking you to comment on • Their deadline • Who else they have spoken to • Their contact details. It is important to remember that there is no such thing as ‘off the record’. If you don’t want to see something in print, it is better to say nothing at all. It is also advisable to discuss the issue with your hospital press office as soon as possible. If appropriate, doctors should inform their colleagues as they may be approached too. SEEKING MEDIA ADVICE FROM YOUR MDO As most doctors are unlikely to have received media training, informing your medical defence organisation (MDO), such as Medical Protection, from the outset is particularly important – even if you feel like you can deal with the query on your own.

The medicolegal adviser dealing with your case will be able to proactively engage the press office and any instructed lawyers required to respond to the query. The Medical Protection press office is available to members 24 hours, seven days a week, has expertise in dealing with the press and will be able to provide specific advice and support relating to your situation. They may also liaise with the journalist on your behalf, assist you to develop a press statement, issue it to the journalist and monitor press activity. DUTY OF CONFIDENTIALITY It will of course be tempting to tell your side of the story, especially if you feel as though you have been cast in a negative light or if the information that has been provided is inaccurate, incomplete or misleading. However, you must remember that you have an obligation to follow the HPCSA’s Guidelines on Ethical Rules on Confidentiality Protecting and Providing Information and that you have a professional duty to protect the patient’s right to confidentiality. Commenting on any specifics relating to your patient’s care is considered to be a breach of confidentiality and could lead to a complaint, disciplinary action or regulatory sanction. Even if a patient informs you of their consent for you to provide a comment about their care, it is usually not appropriate

WHAT CAN YOU SAY? It is a good idea to begin by liaising with others involved in the patient’s care to agree on the approach and key messages. Any comments or statement you provide should be short and factual while not compromising patient confidentiality. Column inches are limited and lengthy statements are likely to be edited, which could distort the meaning or alter the emphasis. As a guide, statements should be no more than 150 words, using plain language that cannot be misconstrued or taken out of context. A standard statement may explain in general terms that you have a professional duty to maintain patient confidentiality and cannot comment further. Depending on the circumstances, it may also be appropriate to offer condolences to the patient’s family. You may also wish to make other comments, for example a reassurance that you always strive to provide the best possible care or that you have learnt from the experience. However, be careful of not breaching patient confidentiality when doing so. PHOTOGRAPHERS It is possible that you may be confronted by a photographer or camera crew outside your home, place of work or at a hearing in which you may be involved. They are likely to obtain an image of you to go alongside any news articles published about you so it is important to maintain your professional composure. Do not cover your face or appear angry, but avoid smiling as this could also give the wrong impression. It is also a good idea to alert any colleagues to the presence of photographers as soon as possible so they can ensure that steps are taken to protect the confidentiality of other patients. Regardless of why the media is interested in your professional life, it can be a very stressful and traumatic experience. Above all, try to remain professional when dealing with the issue, continue to provide your patients with the best care possible, and remember you are not alone – your MDO is there for support.

MEDICAL CHRONICLE | SEPTEMBER 2019

OPINION

Shaping the future of healthcare

The fourth industrial revolution will usher in technological disruption that will fundamentally alter the way we work and relate to each other.

HE SCALE, SCOPE and complexity of the fourth Industrial revolution is bound to lead to a transformation that will be “unlike anything humankind has experienced before." These disruptive technologies and trends such as Internet of Things (IoT), robotics, virtual reality (VR) and artificial intelligence (AI) are changing the way we live and work, and will have a major impact on healthcare. The first industrial revolution in the 19th century, used water and steam power to mechanise production. The second used electric power to create mass production. The third industrial revolution through the 1970s used electronics and information technology to automate production. It was also responsible for the development of mainframe computing, personal computers and the internet.

Now the fourth industrial revolution is building on the third. It is characterised by a fusion of technologies that is blurring the lines between the physical, digital and biological spheres. It has three distinct features – velocity, scope and a systems impact. We will witness the intersection of nanotechnology, AI, 3D printing, IOT sensors, robotics and computing power that will create realities which we have previously thought unthinkable. There will be billions of people connected by mobile devices, with unprecedented processing power, storage capacity and access to knowledge will be unlimited. It has the potential to raise global income levels and improve the quality of life for populations around the world. To mention some of the efficiencies that the fourth industrial revolution has already created – ordering of a cab, booking a flight, buying a product, making a payment, listening to music, watching a film or playing a game – any of these can now be done remotely. HOW WILL THIS IMPACT HEALTHCARE? The technological revolution will facilitate the digitisation of medical records, biometric technology and advances in medical knowledge, leading to new, better medicines and faster care for patients. With the convergence of the life sciences and biological revolutions, physicians will be able to diagnose illness much faster, apply personalised treatment plans and monitor the progress of patients in real-time. As patients become more informed through IT-platforms they will demand to be part of the conversation about their treatment plans. These technological advances will lead to a better relationship between healthcare providers and their stakeholders. The IT revolution will facilitate more data collection. Today, 4% of the world’s data collected is healthcare data. A relatively low percentage of the overall data collected. By 2030 it is predicted that 41% of the world’s data will be related to health. From this data innovations in various stakeholder sectors will emerge increasing medical research, improved patient care, improved hospital infrastructure and patient flow as well as new pharmaceutical development. AI and new data will allow for large scale biological automation. This will lead to a

D E

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breakthrough in human genome sequencing and allow for extraction of information from your genotype profile. Physicians will be able to predict illnesses before they happen. To decode the first genome in 2004, it cost hundreds of millions of dollars, yet by today’s standards, machines can sequence 18 000 genomes for around $1 000. The ethnical concern is that the basic principle of ensuring that we keep the human user at the heart of it all, and to use these efficiencies to solve problems for ultimate good. One should not underestimate the challenges facing innovations, from regulatory barriers to difficulties with digitisation of patient data and its legitimate use. New technologies will improve monitoring of patients, applying personalised treatment plans and predictive medicine. Biometric devices could lead to scanning systems that will fill the void between physician consultation allowing for early treatment and prevention of chronic illness. The faster and more widespread connectivity will have a profound impact on hospital infrastructure. The SG networks will decrease latency from 50 milliseconds to one millisecond allowing for ground-breaking medical procedures such as remote robotic surgery, provided that security and privacy is properly protected. With better data connectivity, researchers could unlock the cure for cancer or the key to fighting obesity and other vital preventable medical ailments if identified early by interrogating the data. Faster and more wide-spread connectivity, as well as new medical technologies will allow world-class healthcare, even remotely, to more people for less cost. This will decrease healthcare inequality. The new technology will contribute to decrease the cost of healthcare worldwide. Two thirds of the healthcare costs come from NCDs, like cancer and heart failure, which if detected early, can be treated more effectively and cost less. The use of biometric sensors will allow for earlier diagnosis and treatment, saving billions of dollars in patients in management of chronic care. Today the greatest challenge and impediment to healthcare in rural areas is a lack of connectivity, which can be solved by SG Networks. There will also be the benefits from creating a universal patient record both at population and individual levels thus decreasing inequality.

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

DISEASE MANAGEMENT Devices could become more seamlessly interconnected through the Internet of Things (IoT) to enhance patient monitoring potentially allowing individuals and their physicians to better manage conditions like NCDs. A sensor connected to IoT will have the potential to engage NCD patients in their disease management, which could reduce incidence of adverse events and associated costs. It is expected that by 2030 the costs of NCDs will be above 70% of the GDP spend on health. There is an urgent need to improve efficient chronic care management, to manage costs and prevent health systems becoming bankrupt. CARING FOR AGEING POPULATION Technological advances have the potential to reduce negative outcomes and rising costs associated with ageing. Robotics is one promising area being explored to provide care to aging individuals. Combined with AI robotics could potentially provide some caregiving services to older individuals such as continuous monitoring and assisting with tasks like keeping track of medicines. This could be especially useful in areas with limited access to care or where family members are unable to attend to ageing patients. MEDICATION AND ADVANCEMENTS Recently we have witnessed innovations in medicine in areas of genomic advances. New technology has made it possible to sequence a person’s genomes within 24 hours, resulting in an explosion of genomic data. This can help in the future for patients to take preventative measures and allow physicians and scientists to develop more personalised treatments. At present we must be aware of some of the ethical issues to be considered, the use of gene editing may offer new hope for some largely untreatable conditions of diseases like Alzheimer’s. The fourth industrial revolution may lead us into a new wave of life changing innovations. “Relatively newer diseases like HIV and Hepatitis C now have medicines that treat and in some cases cure patients suffering from once life-threatening conditions.” (Jimenez) With further advances in the digital age, newer innovations will emerge to deliver a healthier and more connected future for all people around the world. The benefit to healthcare will be significant with technological transformational changes.

PLACEBO

Mixing business

EDITORIAL EDITOR: Claire Rush McMillan Claire.Rush@newmedia.co.za NEWS WRITER: Nicky Belseck Nicky.Belseck@newmedia.co.za SUB-EDITOR: Gill Abrahams

with health

EDITORIAL CONTRIBUTORS Hugo Homann, Prof Claudia Gray, Dr Daan den Hollander, Dr Graham Howarth, Prof Morgan Chetty

Business school Dean challenges healthcare sector.

LAYOUT & DESIGN: Naresh Budraj

HIGH GINI CO-EFFICIENT raises the height of walls, the firepower of private armies and voltage of the electric fences for the privileged few. It also makes their children’s future emotionally harder, less human and more precarious. According to Jon Foster-Pedley, Dean and director of the Henley Business School campus in Johannesburg, there is only one way out. That is by giving education, support and possibilities to those who don’t have. Speaking at Hospital Association of South Africa’s annual conference, FosterPedley said an improved Gini co-efficient was one of the most important measures of progress, stability, and the possibility of thriving and living a decent life. He said those on the right wing disliked the NHI bill because, “they don’t like socialising things, and believe free markets will deliver better health outcomes.”

Those on the left wing, who might be thought of as natural allies of the bill, were sceptical that it would create another well-intentioned government fund, which would be abused and corrupted over time.

Few people argued with the principle of universal healthcare. However, the last time a country transformed its health system like this was in Israel, almost 25 years ago. Global society was currently living in “narrative vacuum’, following the collapse of fascism, communism and in more recent times, a growing mistrust in a liberal democracy underpinned by a capitalist, profit-driven system.

In the absence of information, fantasy reigns and we fixate on doomsday scenarios. It’s all changing. But there is much we can do,” he added. Inequality – whether it was food inequality, health inequality, financial or social inequality – was at the heart of all South Africa’s problems today. Any business or organisation which wasn’t working to reduce the Gini co-efficient was signing its own death warrant, he stressed.

“We’re entering an age of tremendous technical opportunities in which businesses and medical professionals will be able to deliver service excellence through digital tools, artificial intelligence, data analytics and cloud computing.

THE RISE OF THE SIDE HUSTLE In a report called ‘The 100-year Life,” published by researchers at London Business School, it was estimated that today’s 15-year-old would likely have a total of 17 jobs in five different sectors before they retired. In Canada, the number of people who stayed in a single position for less than two years had risen from 16% in 1990 to more than 50% today. In South Africa, 47% of people who responded to a survey by recruitment consultant Kelly said that they had been in their current role for less than a year.

“More people are ‘gigging and jobbing’ simultaneously. These workers are happier, more energised, earn more and create more. They also tend to work more in their main job, as compared to those who don’t have a side business. Employers are finding better use of their talents,” he said.

However, uncertainty, mental health, addiction and NCDs are a concern in this group of people. “We don’t know if NHI will improve access to healthcare. It’s complicated, and requires big systemic changes. “As medical practitioners and execs in the industry, you aren’t just entering an era of precariousness for yourselves. You’re also the ones who will be tasked with dealing with its fallout. NHI may not arrive. You need to be prepared, no matter the consequences.”

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“If we can learn to manage precariousness and uncertainty, we can turn it to our advantage. Your world, in the medical profession, is all about uncertainty. You know, more than anyone else, what we can and can’t predict. You are trained to deal with situations where sometimes, things just go wrong. If you can apply the same thinking that is used to manage a medical procedure to managing your entire infrastructure, however precarious it gets, it will be in safe hands,” he concluded.

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MEDICAL CHRONICLE | SEPTEMBER 2019