Medical Chronicle March 2024

MED

The doctor's newspaper Chronicle

MARCH 2024

Why did you become a doctor?

“How moral, how ethical, how upright are we?” – Dr Imtiaz Sooliman didn’t mince words when addressing delegates at the annual SAMA Conference recently and discussed the five major challenges in SA’s health system.

By Nicky Belseck, medical journalist

TNO DENYING SA’s healthcare sector is in dire straits, and Gift of the Givers founder, Dr Imtiaz Sooliman was quick to acknowledge many of the country’s shortcomings at the annual SAMA Conference held last month in Sandton. “For the last two years everybody has been very concerned about the health crisis in the country. Doctors are unemployed, nurses are short-staffed, infrastructure is not available, patient loads are increasing, catch up surgeries are needed, the challenges of Covid, everyone is severely worried about the healthcare sector. You should be! It’s the most important sector in any country because we deal with lives. We make a mistake, people die. We don't give service, people die. We don't act efficiently, people die. Those people could be us, could be our children, could be our families, could be anybody we know, and that's why it's so critical that in the health sector, we must be the best in everything that we do,” Dr Sooliman opened.

LOOKING IN THE MIRROR

However, he then turned the tables on delegates: “While doctors complain, we really need to look at ourselves first. Everybody's talking about fixing the system, but compared to the old days, unfortunately many of us have moved away from our promises. Ask yourself, why did you become a doctor?”

He challenged doctors whether they’d thought about this in the last 10 years. “Because today when you go to specialists and doctors in private practice, they first want to know if you can pay 300% of medical aid rates. Is that why you became a doctor? Is healing not critical? Is saving lives not critical?

This materialism becomes so supreme that often the patient doesn’t even know why they went for the tests. They don't get the results. What the tests are for? You’re just a number. “Sadly, we've lost the human touch,” Dr Sooliman said.

“We look at the government, infrastructure, healthcare workers, the management. But look at yourself first,” he urged. It’s important to establish whether you’re genuinely part of the solution, or part of the problem.

A QUESTION OF ETHICS

Describing Covid as an equaliser Dr Sooliman said, “People die normally, its normal to die, but in Covid you died lonely, you died alone. A wife couldn’t say goodbye to her husband. A child couldn’t say goodbye to their father. From the hospital you go straight to the cemetery. You died a very lonely death.

“Healthcare workers saw how their friends died. They saw patients die in numbers. They’re hyper hypoxic, they’re smiling, happy, laughing, then they drop dead in the car park, in the ambulance, in the casualty, in the ward. And suddenly healthcare workers are thinking, is there something wrong with us? What are we doing to patients that they’re smiling one minute and dead the next?

“Patients needed compassion, but healthcare workers were suffering from secondary traumatisation because the volume and number of people dying was just too enormous.”

Acknowledging that resources were a huge challenge Dr Sooliman said, “Yes, there was not enough oxygen, it was difficult, but people came to the fore. But it’s a question of ethics, as in many cases, those who were supposed to be on the front lines of Covid, the

physicians and the GPs, disappeared. Instead, it was orthopaedic surgeons, gynaecologists, and the general surgeons who came to the front line. You knew who was ethically right, was moral, was dedicated, and was committed. “We really need to take stock of ourselves. Only then can we sort out the system.”

LESSONS FROM COVID

“During the pandemic, we learned critically that there are five major challenges in the health system in this country,” said Dr Sooliman highlighting management, maintenance, infrastructure, non-functioning equipment and non-medical supplies, and lastly, the lack of healthcare workers, nurses, doctors, and all allied disciplines.

1. “Management is a serious problem in this country. You’ve got people are not qualified, not skilled. I’m sorry to say, political parties put their friends and their grandfather, and brother in positions and they are not skilled. They're not supposed to be there because you are not dealing with averages you're dealing with life. If you’re not skilled, you should not be there. Because you could be responsible for someone

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HERE’S

dying. We need to relook at the system and fix the system. Thank God Momentum Life has put money towards retraining CEOs of hospitals. So, management is critical,” Dr Sooliman stressed.

2. “In our lives and everything else, maintenance is a major issue. We don’t maintain the hospital wards. We don't look after the aircons. We don’t look after MRI machines. We don’t look after the bloodwork machines. We just take them out when the machines are not working. We need to relook at our ethics, at our commitment and our function.”

3. “The third travesty is our infrastructure,” said Dr Sooliman. “Helen Joseph can’t work, Raeema Moosa can’t work. You’d think they were in some God-forsaken rural area in Africa not the economic hub of the African continent, the City of Johannesburg! We need people who are active, who want to fix the system, can think on their feet, because in the civil service, among politicians and governments, three words are not in their vocabulary – urgency, emergency, and disaster. It doesn't mean that everybody is bad. There are good people in government, there are good politicians, there are good civil servants, but unfortunately, the system, the bureaucracy, and the red tape, tie your hands.

4. Non-functioning equipment and non-medical supplies. “In so many areas machines are not working. How do you deal with the backlog which was created by Covid and even before that without equipment?” Dr Sooliman asked. “We’re busy clearing the backlog at McCord Provincial Eye Hospital in Durban from 4 000 to under 2 000. But what's so tragic is for eight years, people are not economically active. They have a poor quality of life. They can't see. Dr Sooliman described the instance of a husband and wife: “You open the bandage of the wife, and she says to the husband, ‘you got old’. You open the bandage of the husband, and he says to the wife, ‘you got old too’. Eight years for something that takes seven minutes, there’s something seriously wrong. And then the doctors don’t want to work after hours, they don’t want to work on weekends, they don’t want to donate their free time because they’re busy making millions. You need to consider that it could be you on the other side.

5. Lack of healthcare workers, nurses, doctors, and all allied disciplines. “Registrar posts are frozen, the most illogical decision I've ever heard of,” Dr Sooliman said. “Registrars do the research, they become qualified and move upwards. They

train the junior doctors. They're the main frontline care for the patients. They treat 30 critical patients a day. And all we need is one million rand a year for four years. One registrar will see 9 000 critically ill patients in the year. That’s 9 000 lives. How complicated could it be? And we need the buy-in from the private sector.

CORRUPTION, COLLUSION, ETHICS, AND MORALS

While recognising the problem of corruption and collusion within the government, Dr Sooliman also highlighted concerns about hospitals and corporate SA. “When I say corporate SA, I don’t mean all of corporate SA, just like I don’t mean all of government, I mean people who work in corporate SA, people within the health services, people within the government with no morality.”

He described how the government sends medicine to hospitals and on arrival the person receiving the medicine will sign for delivery and give the person delivering the medicine R100 000 to sign saying medicine to the value of R5 million was delivered, when only R2 million is delivered. “But you signed for R5 million, that’s R3 million instant profit. And then what do you say? Oh, the government is very bad. They don't send medicines, they don't send supplies, what happened to the health budget?

“What happened to the ethics? What happened to the healthcare system?” Dr Sooliman asked delegates. “Then you get people like us who moonlight and say they’re providing a service in the hospital. They’re paid by government, they take a nice fat salary, and they go home. You never find them in the wards and when you call them from their private practice, they tell you don't disturb me, I'm busy. Who’s funding your salary?

It’s taxpayers’ money! Those poor people, they came at 4am in the morning, on broken roads, taxi rides, hours waiting outside the clinic, eventually with a sick child they get inside but you are too busy at your private practice, for which you've taken R2 million or more in, and you can't come see the child. What kind of ethics is that? We seriously need to look at ourselves.

“And that's why I asked you at the beginning, why did you become doctors? Just to make money? To serve the people? It's not impossible to do both. All it requires is a bit of commitment. We can solve the problems. We can fix the system. We can deal with any crisis. It doesn’t need money, it requires spirituality, morality, values, and ethics,” Dr Sooliman concluded.

Economic impact of NHI

DEAR READER

Welcome to our March issue. Dr Imtiaz Sooliman's poignant question, “How moral, how ethical, how upright are we?” underscores the fundamental principles guiding our profession amid the challenges within our health system.

The debate surrounding the National Health Insurance Bill continues to intensify, with business groups advocating for a thorough review of its constitutional integrity. Understanding the economic implications of this legislation is paramount as we navigate through turbulent economic times. A report on the NHI states that Bill, in its current form, is not economically viable.

Additionally, the discourse on medically assisted dying sheds light on the complexities of endof-life care, emphasising the importance of balancing compassion with ethical considerations. DignitySA's legal efforts and the ensuing discussions underpins the evolving landscape of medical ethics in our society.

The integration of digital health applications in oncology presents

promising opportunities for enhancing clinical efficiencies and patient outcomes. The collaboration between Altron HealthTech and Dischem Oncology highlights the potential of technology in revolutionising healthcare delivery.

Need CPD points?

We have the following opportunities in this issue. We have webinars to register for on the topics of multiple sclerosis, ENT, and asthma, and vitamin D. There are also webinar replays available (come of which are also for CEUs). Look out for the following articles offering CPD points from online quizzes:

• Navigating ocular infections

• Besifloxacin's role in treatment and combating antibiotic resistance

• Understanding, managing comorbidities in adult ADHD

• Long-term diosmectite use does not alter the gut microbiota in adults with chronic diarrhoea.

Happy reading

BUSA / B4SA call on President to test constitutional integrity of NHI Bill

BUSA and B4SA call on the President to act in accordance with his commitment in late November 2023, to test the constitutionality of the NHI Bill.

GIVEN ITS NUMEROUS substantive and procedural constitutional flaws, the business groups believe the President should refer the Bill back to parliament for reconsideration and amendment prior to him signing it into law.

Cas Coovadia, CEO of BUSA says: “Following the adoption of the Bill by Parliament in November, BUSA submitted a detailed formal petition to President Ramaphosa to send the Bill back to the National Assembly on the grounds of unconstitutionality. We hope that the President considers the long-term impact and risks of assenting to a Bill that so clearly flouts the Constitution.”

BUSA and B4SA have consistently supported the policy direction towards universal health coverage but have reservations about the NHI Bill’s design and implementation. Their inputs have been intended to remedy the constitutional, funding and practical deficiencies in the Bill in the best interests of citizens, the economy and the country.

There have been suggestions that the President only sign certain provisions of the Bill into law. However, BUSA believes that piece-by-piece proclamation of the NHI Bill will not provide the necessary clarity and certainty. This will hamper collaboration, impede initiatives which can put the country on a pathway to universal health coverage, as well as undermine critical investment in the healthcare sector and the economy more broadly.

“What the country needs is an NHI underpinned by the Constitution, and which is affordable and implementable. This Bill does not meet these criteria, and is not ready to be signed into law,” says Coovadia.

The business groups have consistently cautioned that the Bill, as it stands today, will materially delay access to universal health coverage, lead to disinvestment in the healthcare sector, further damage South Africa’s already fragile economy, and create significant risks for the country in terms of the availability, quality, management and governance of healthcare.

Martin Kingston, chair of the B4SA steering committee says: “We recognise that the country is in pre-election mode, and that the adoption of the NHI Bill is a cornerstone of the Government’s policy platform and its election campaign. However, the weaknesses and the material negative implications of the NHI Bill, in its current form, will have devastating consequences for the country and her people for generations to come. There is a significant obligation on the President to ensure the Bill passes

constitutional muster.”

Summary of key procedural and substantive constitutional issues raised by BUSA in its petition to the President:

Procedurally, BUSA noted that Parliament’s socio-economic impact assessment process was inadequate, that the Nedlac process in respect of the Bill was not followed through, that public participation inputs were not properly considered, and that multiple constructive inputs from business and other stakeholders were ignored. Parliament’s Portfolio Committee on Health also ignored an opinion by Parliamentary Legal Services, which highlighted several areas of the Bill that are unconstitutional.

BUSA highlighted the fact that the process conducted by the NCOP Select Committee on Health and Social Services was rushed, inadequate in terms of its mandate, and that it failed to properly deal with reports submitted by the provinces. Importantly, the NCOP Committee failed to incorporate amendments, provincial public submissions and technical flaws noted by several provinces and even the Department of Health itself.

BUSA noted that section 33 is unconstitutional in giving the Health Minister unfettered power to determine the restricted role for medical schemes, especially as this power is unnecessary for achieving the policy objectives of the Bill. This is damaging to the private health sector as a whole and there is no rational basis for this approach. BUSA noted that the single fund model (where Government will buy and pay for all healthcare services for everyone) introduces significant concentration risk and adversely impacts people’s ability to seek care in the private sector. This is also likely to result in significant strain being placed on the public sector. The amendments proposed by BUSA seek to allow for the role for medical schemes to be determined in a consultative process, in measured phases in a manner that is consistent with the policy objectives.

BUSA highlighted that the procedures for accessing healthcare and appealing treatment denied by the NHI, could potentially hinder or violate the right to access health services, making them unconstitutional.

The Bill provides for the adding of new taxes and altering tax policies, tasks that should be handled by the National Treasury in a Money Bill as per the Constitution. Additionally, the Bill breaches the separation of powers by giving the Minister of Health judicial discretion.

BUSA also believes that the contracting

provisions in Sections 11 and 26 of the Bill are unsustainable and inconsistent with the principles of value-based care and strategic purchasing, which is the global trend for sustainable healthcare contracting that is patient centred. They focus on price in an unsophisticated manner which contradicts the Constitution’s criteria for lawful procurement.

The roll-out envisaged in Section 57 of the Bill needs to be linked to milestones that are workable and relevant to South Africans having reasonable access to quality healthcare services, rather than dates which are arbitrary and unrealistic, and already outdated.

Section 58 of the Bill introduces legislative changes that seem to take immediate effect. However, this conflicts with Sections 31 and 32 of the Bill, leading to the immediate removal of health functions from the Provinces. This affects approximately R196bn in funding from Provincial Equitable Share allocations

and Conditional Grants. Additionally, the alterations to the Medical Schemes Act contradict Section 33.

There are conflicts with the Competition Act and the Protection of Personal Information Act which are unnecessary to give effect to universal health care.

"All the constitutional concerns mentioned above were raised by BUSA and B4SA in its submissions, and during various engagements with relevant stakeholders and parliamentary committees. BUSA has also brought these issues to the President's attention in its petition. This is to ensure that, as part of due process, proper consideration is given to the fundamental procedural, and substantive constitutional flaws in the current version of the Bill.

“BUSA and B4SA are confident that, in a constitutional democracy, these views will be taken into account by the President when he assesses the constitutionality of the Bill prior to his assent,” concludes Kingston.

2024 SAMA conference

Held last month at the Sandton Convention Centre, the theme for SAMA’s annual convention was ‘Towards strengthening health systems’

By

DESCRIBING THE 2024 SAMA conference as a landmark event,

SAMA chairman Dr Mvuyisi Mzukwa said it presented a platform for knowledge sharing among medical professionals working at every level, bringing together experts from a wide variety of healthcare fields to contribute to, influence, and reflect

on the policies that shape our medical landscape. “It’s an invaluable chance for doctors and other health professionals to strengthen their strategic networks and reinforce sector wide collaborations and high-level conversations about how to advance quality healthcare coverage as a fundamental human right,” he said.

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This year’s conference focused on sustainability and health care in SA, including research, pandemic prevention, funding, ethics, digital innovation, how to use data, how data and informed decision-making go hand in hand, the criminalisation of the medical profession, how doctors interact with patients, as well

as the mental health and sustainability of doctors going forward. Distinguished medical professionals and keynote speakers from around the world ensured interesting and informative presentations and talks throughout the conference.

and Pamela Njamela (Discovery Health).

Dr Rhulani Edward Ngwenya (SAMA vice chairman), Dr Imtiaz Sooliman (Gift of the Givers founder), and Dr Magome Masike (HPCSA CEO).

Dr Dumisani Momela (HASA), Dr Mvuyisi Mzukwa (SAMA chairman), and Dr Pino Maqhawe Mavengere (BHF).

Dr Maurice Goodman (Discovery Health), Dr Angelique Coetzee (SAMA),

Dr Zenande Mbembeni and Dr Sizwe Mxenge.

Goitsemodimo Winfred Seaketso and Thembekile Zikhali.

Dr Sharon Harbor (SAMA) and Prof Dominique Sprumont (Institute of Health Law, University of Neuchâtel, Switzerland).

Tshibeshi Katembwe (Fezi Ngubentombi Hospital) and Dr Mmaselloane Kgomojoo (FS Health)

Dr Sithule Siyotula (Nelson Mandela Academic Hospital) and Dr Percy Mahlathi (NDoH).

Eric Rantsho (BHF), Dr Magome Masike (HPCSA CEO), Dr Kgabane Moloto (SAMA), and Christopher Tsatsawane (HPCSA).

Dr Tshokolo Modise, Dr Johnny Moroe, and Dr Lerato Richard Monyobo.

Prof Jacques Snyman (SAMA) and Efthimia Tzetis (Fujifilm).

Dr Muana Mputu Muka-Makiangi (Ekurhuleni Health District).

Dr Mark Colin Human (SAMA), Dr Mahomed Faruk Mahomed (SAMA), and Dr Virginia Wilson (Netcare Rehabilitation Hospital).

Hotensia McMaster (MCO), Kgaotsang Samore (GEMS), and Philly Masopha (SAMA).

Dr Benny Choeu (SAMA Limpopo) and Colleen Qvist.

Economic impact of the NHI Bill

he implementation of National Health Insurance (NHI) comes at a crucial juncture marked by significant economic challenges in SA.

While everybody agrees that the

reform, and that this should provide access to universal health coverage, the NHI Bill, in its current form, is not economically viable. This according to a report authored by FTI Consulting which provides an overview of

The Department of Health, in its 2017 White Paper on the NHI and the NHI Bill flagged sources such as VAT, personal income tax, and payroll taxes for raising additional funding. However, the report

By Nicky Belseck,

(DoH) has outlined funding requirements amounting to an additional R200 billion per year, necessitating a closer examination of the economic landscape to assess the feasibility of such an endeavour.

The proposed funding, equivalent to 12.8% of the country's current gross tax revenue, underscores the magnitude of financial resources needed. To put this into perspective, it represents 36.1% of personal income tax, 62.4% of corporate income tax, or 51.2% of VAT. However, these figures only scratch the surface of the economic complexities at play.

Theimplementation of National Health Insurance(NHI) comes at a crucial juncturemarkedby significanteconomic challengesinSA

Considering the existing fiscal constraints and the absence of detailed information on NHI's cost and benefit structure, projections in the report are based solely on the illustrative value of R200 billion. Calculations reveal daunting scenarios for taxpayers, with potential VAT hikes to 21.5%, a 31% across-the-board increase in personal income tax rates, or the introduction of a payroll tax estimated at R1 565 per month for those in the formal sector. Such substantial tax adjustments would unfold against a backdrop of sluggish economic growth, exacerbated by the adverse impacts of the Covid-19

take-home pay registering an 8.3% decline in February 2023 compared to the previous year.

Similarly, consumer confidence indices reflect pervasive concerns about future economic prospects, stifling investment and expenditure. Furthermore, the tax base itself is shrinking, evidenced by a decrease in the number of taxpayers from 5.9 million in 2018 to 5.5 million in 2021.

This dwindling base, coupled with subdued economic growth, limits the government's capacity to raise additional revenue through taxation.

Amid these challenges, the imperative to fund NHI remains pressing. However, the feasibility of raising R200 billion amidst economic headwinds and a shrinking tax base raises pertinent questions about the sustainability of proposed tax increases. Any such measures must be carefully calibrated to avoid unintended consequences such as reduced consumer spending, job losses, and decreased tax revenues.

In navigating these economic challenges, the Organisation for Economic Co-operation and Development (OECD) recommends a multifaceted approach that prioritises fiscal

sustainability, identifies cost-effective healthcare services, and broadens the revenue base. Addressing systemic issues of inequality and bolstering governance frameworks are essential steps toward achieving universal healthcare access while ensuring financial prudence. As SA grapples with the complexities of funding NHI, a delicate balance must be struck between meeting healthcare needs and safeguarding economic stability. The path forward necessitates thoughtful policy interventions that reconcile competing priorities in a dynamic economic landscape.

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pandemic. Despite a brief rebound postpandemic, economic growth in 2022 failed to sustain momentum, reflecting underlying vulnerabilities in SA's economic framework.

Household purchasingpower haseroded,with realtake-homepay registeringan8.3% declineinFebruary 2023comparedtothe previousyear

GDP growth, a key indicator of economic vitality, has been on a downward trajectory since 2011, further exacerbated by a 6.34% contraction in 2020, the most severe since the global financial crisis. While a rebound to 4.91% growth in 2021 offered a glimmer of hope, it was primarily a statistical rebound from the preceding downturn. Prospects for sustained recovery remain uncertain, with the IMF projecting meagre growth of 0.1% in 2023, hampered by challenges such as electricity outages and external economic pressures. Unemployment, another critical metric, remains stubbornly high, hovering at 33.5% and 48.7% by narrow and broad definitions, respectively, in 2022. This persistent joblessness reflects deep-seated structural weaknesses in the economy, exacerbating income disparities and reducing the tax base. Declining disposable incomes, coupled with diminishing consumer and business confidence, compound the economic woes. Household purchasing power has eroded, with real

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Digital health application in oncology: An opportunity to seize

A collaboration between Altron HealthTech and Dischem Oncology in improving clinical efficiencies, cost reduction, improved safety, and standardisation in the oncology practice domain through a leading digital health technology.

Gerard Augustine, Executive sales, and business development, Altron HealthTech

DIGITAL HEALTH ADVANCES

have transformed many clinical disciplines.

However, digital health innovation is relatively nascent in cancer care, which represents the fastest growing area of healthcare spending.

Various opportunities for digital health innovation in oncology include patient-facing technologies that improve patient experiences, safety, and patientclinician interactions, clinician-facing technologies that improve their ability to diagnose pathology and quality of care, and technology infrastructure to improve clinical workflows and documentation.

AccordingtoCancer ResearchUK,the costofcancerdrugs isincreasingby10% per year

OPERATIONAL CHALLENGES IN CANCER CARE

Oncologists spend most of their time in diagnosis and treatment of cancer patients and face many operational challenges in cancer care delivery daily.

Resource intensive cancer care delivery demands leaders to take charge of their operations. An operation focused delivery with the aim to reduce costs, increase safety, improving clinical outcomes will allow an organisation to compete effectively in an aggressive marketplace.

According to the American Institute of Cancer Research, cancer costs the world approximately US$895bn a year. This means that while advancements in cancer treatments are increasing, so are costs.

And, according to Cancer Research UK, the cost of cancer drugs is increasing by 10% per year. Alongside drugs, the cost of diagnosis, radiation, chemotherapy, imaging, pathology, surgery, and end-of-life care are also increasing exponentially.

The Independent Clinical Oncology Network in South Africa estimates that, depending on the type of cancer, treatment locally can cost anything between R10 000 and R1m per patient, per year.

KEEPING MEDICAL COSTS UNDER CONTROL

Owing to the vast potential for digital health technologies to improve quality and reduce spending in cancer care it is incumbent upon all players in the value chain to envision new ways to deliver oncology care and to facilitate broader, patient-centric integration of digital health in cancer care.

A collaboration between Altron HealthTech and Dischem Oncology aims to provide clinicians the opportunity of standardising electronic health record (EHR) data to

enable interoperability, increased patient access to and control of health data, and establishing payment reforms to offset the costs of digital health infrastructure.

Keen to know more?

Contact Altron HealthTech to book a demo today or drop us an email at healthtech. sales@altron.com.

The case for medically assisted dying in SA

It is imperative to strike a balance between compassionately addressing end-of-life suffering and safeguarding ethical principles within the realm of medical practice.

By Nicky Belseck, medical journalist

DOCTORS HAVE RALLIED behind

DignitySA in their legal efforts to decriminalise and legalise medical assistance in dying (MAID) in a recent article published in the South African Medical Journal (SAMJ). The movement, aimed at advocating for patients' rights to bodily autonomy and dignity, has sparked discussions surrounding medical ethics, legal frameworks, and the role of healthcare professionals in end-of-life care.

The crux of the argument put forth by the doctors is rooted in the principles of medical ethics: “Since our sole concern is to enable responsible practice of medicine, we are professionally committed to the four fundamental guiding principles of medical ethics for doctors' treatment of their patients, namely: refraining from doing harm (non-maleficence); promoting their best interests (beneficence); respecting their self-determination (autonomy); and treating them fairly (justice),” Van Niekerk JP et al wrote. The authors contended that MAID, when practiced responsibly, aligns with these principles by providing patients with a compassionate option to alleviate suffering in the face of terminal illness. The distinction between physician-assisted suicide (PAS) and physician-administered euthanasia (PAE) is drawn, highlighting the patient-driven nature of MAID as a response to individual initiative and free choice.

Drawing insights from countries where MAID is legalised, such as the USA, Canada, Colombia, the Netherlands, Belgium, and Australia, the authors emphasised the importance of adopting a tailored approach that suits local conditions and respects patients' preferences. Acknowledging the feasibility concerns surrounding the implementation of MAID, particularly within the existing healthcare infrastructure, the focus remains on the ethical imperative to address end-of-life suffering through compassionate and dignified means.

The discourse extends to the intersection of palliative care and MAID, with an emphasis on ensuring that no patient endures unbearable and intractable suffering. “As medical practitioners, we should assist patients to have as gentle and peaceful a death as possible. Therefore, medically assisted dying should be allowed as an end-of-life medical treatment option, together with others, such as palliative sedation, terminal sedation, and withdrawal or withholding of life-sustaining treatment. A general legal prohibition of medical assistance in dying in the appropriate circumstances means abandoning patients in their final and dire need. The time has come for medical assistance in dying to be recognised as a compassionate, humane, and caring end-of-life medical treatment option.”

The authors explained that the current legal landscape, characterised by a prohibition of MAID, poses challenges for healthcare professionals who may feel morally compelled to assist patients in dying despite legal risks. Instances of doctors discreetly providing such assistance underscore the moral complexity inherent in end-of-life care decisions and the need for legal reforms that align with evolving societal values.

Reflecting on the ongoing public debate surrounding MAID in SA, which has gained momentum in the past decades, the authors emphasised the need for responsible legislative action guided by empirical evidence and ethical considerations. The role of the courts in adjudicating the legality of MAID is recognised as part of a broader legal process that may ultimately lead to parliamentary legislation.

Van Niekerk JP et al believe that medical professionals are poised to play a pivotal role in shaping future legislative frameworks for MAID, ensuring the implementation of robust protocols, safeguards, and

oversight mechanisms. While respecting individual conscience rights, the focus remains on upholding patient autonomy, safeguarding the vulnerable, and fostering a compassionate approach to end-of-life care.

The authors’ support for decriminalising and legalising MAID in SA underscores a commitment to ethical, patient-centred care, and the recognition of individuals' rights to a dignified death.

Ogilvy Health launches SA's first patient-led cancer registry using data power

As a market leader in health communications, Ogilvy Health is thrilled to support the launch of South Africa's first patient-led cancer registry.

THIS GROUND BREAKING initiative signifies a major breakthrough in the fight against cancer, highlighting the critical importance of data-driven healthcare strategies. With approx. 120 000 people diagnosed with cancer

annually, this innovative approach significantly enhances our understanding of the disease.

The registry provides cancer patients a central platform to manage their health and find community support, highlighting

how research and treatment advancements are making cancer a manageable condition.

Supported by Ogilvy Health's cutting-edge modern marketing, the patient-led cancer registry is a joint effort launched by Living with Cancer (LWC) and the National Cancer

Registry (NCR), which operates under the National Institute of Communicable Diseases (NICD).

The goal of this landmark initiative is to enrol one million registrations in the registry, creating a robust platform for cancer research and surveillance, policy-making, and patient support.

"I am proud of the powerful impact our partnership with Living with Cancer has made in supporting this initiative. This collaboration anchors Ogilvy Health's commitment to driving positive change, offering hope and tangible benefits to those affected by cancer," says Gillian Bridger, managing director at Ogilvy Health. "Our contributions can significantly alleviate the South African cancer crisis. By enhancing patient data, we are addressing a crucial element for advancing cancer care for everyone."

According to Netcare Cancer Care, one in four South Africans are affected by cancer, with many succumbing to the disease undiagnosed. The most common cancers in men are prostate, lung, and colorectal, whereas in women, they are breast, cervical, and colorectal. Additionally, childhood cancers are treatable with success rates between 70%-80% in well-resourced countries, while approximately 80% of children with cancer in Africa die without access to adequate care.

This initiative is a call to action for patients, healthcare providers, and the broader community to join forces to collate data in the fight against cancer. “People impacted by cancer deserve a place where they can learn about their diagnosis and access a safe network to share their emotions and experiences, support one another, and foster courage and hope,” says Belinda Wager, managing director of Living with Cancer. "Each registration advances us towards a future where cancer is a chapter of triumph, not a death sentence. The registry allows meaningful contributions to research, aiding the battle against cancer."

For more information on the patient-led cancer registry and how to register, please visit https:// livingwithcancersa.co.za/countmein/

Dr Dion Craig Opperman

Date: 9 April 2024

Time: 7:00pm

Topic: Introduction into understanding and when to suspect Multiple Sclerosis in General Practice

Speaker: Dr Dion Craig Opperman

CLICK TO REGISTER https://bit.ly/ActivoWebinar9Apr24

Fellow of the College of Neurologists of South Africa (FC Neurol) by peer review since 2008.

Research: MMed dissertation on Myotonic Dystrophy

Clinical Trials: We took part in various clinical trials including: Alnitidan, Aricept, SP511, Lamictin, Elitriptan, Zomitriptan, Topiramate (for migraine prophylaxis), Epilepsy, 3 Migraine trials, Devco D.

Specific Fields of Interest

• Multiple Sclerosis

• Parkinson’s Disease

• Dystonia (I run a Botox clinic for dystonia)

• Headache

• Epilepsy

• Peripheral Neurology (Nerve Conductions and EMG)

Publications

Co-author: Giampaolo, D., Bhigjee, A., Retief, C., Isaacs, M., Britz, M., Opperman, D., Govender, R., & van Rensburg, M. (2013). Guideline for the diagnosis and management of multiple sclerosis: A Southern African perspective. South African Medical Journal, 103(9), 670-691.

Save and protect your data and finances through medical software

The healthcare industry is data sensitive and technological improvements, such as medical software, have enabled healthcare professionals to use this data to improve their productivity. However, the question comes to mind: how safe is all this data?

IN THIS ARTICLE, we will be focusing on data security, which includes patient information and the protection of the healthcare professional’s finances as well as the benefits of making the use of a medical software application that will facilitate the protection of information. Using secure medical software, the healthcare professional can not only protect their data and finances but also save it through best-practice internal controls.

1. DIGITAL TRANSFORMATION

Healthcare professionals are looking for a more secure digital solution. Medical software is transforming and simplifying the way medical practices operate. Healthcare costs are on the rise, and it can be a struggle to find a balance between quality patient care and the costs to maintain such a status.

The primary benefits of digital transformation are changing how patients and doctors interact with each other, altering how data is managed, saving time and cost by transforming processes that were previously heavy manual-driven and paper-intense processes. Most healthcare professionals will opt for a web-based medical software.

1.1 WEB-BASED

A web-based application is any application that uses a website as the user interface. Users can easily access the application from any device connected to the internet using a standard browser.

This contrasts with traditional desktop applications, which are installed on a local computer. Storing the information in the cloud allows you to access it anywhere and anytime regardless of the machine making it a highly accessible and flexible technology.

With the benefit of being cost-efficient, easily manageable, and facilitating in backups and restoring data, the installation and maintenance process is easier, cloud-based medical software can give you a strategic edge. However, there are cons such as limited control, network connectivity dependency, and downtimes where providers are implementing maintenance.

2. IMPLEMENTING SECURITY

2.1 ACCESS CONTROL

It’s important to limit access to computers at your medical practice. This includes the different users that will have access to the medical software. A patient’s data is on a need-to-know basis and needs to be protected. Ensure that you have a role and responsibilities guideline to facilitate you as the practice owner.

2.2 PASSWORDS

Of course, not everyone likes to remember multiple passwords for multiple accounts, however, for a medical practice using medical software, it is quite mandatory. It’s especially important when considering the access controls as mentioned above. At your medical practice, it is a good idea to have a policy that requires a strong password and a change of password every 90 days.

2.3 POPI COMPLIANCE

Compliance with the Protection of Personal Information Act (POPIA), also known as the POPI, is mandatory for most organisations in South Africa. This means that we should consider privacy implications in all our processes and systems and build security and privacy concepts into the day-to-day operation of our organisations. POPI is all about privacy, and this means security.

2.4 BACKUP

Backing up your medical practice’s data regularly will help you in the situation of damage, theft and loss. Regular backups will give your medical practice something to fall back on so that not all your data is lost. Finding a medical software company that is web-based ensures automatic backups of your data and they will have backup and disaster recovery plans to help protect against data loss during a natural disaster or other unexpected events.

2.5 CLOUD SECURITY

A medical software company that monitors network traffic to the cloud will help ensure that you will always have access to the software. This includes the identification of

unauthorised attempts to upload or change information or to otherwise cause damage to the Cloud in which any possible criminal activity will be reported, together with any evidence which may be gathered, to the appropriate authorities.

2.5 EDUCATION

Employees of the medical practice require ongoing education to stay on top of data security risks. Employees need to be equipped with the necessary processes and steps necessary to take to protect the practice’s data. Staying vigilant in keeping sensitive information out of bounds for visitors, other patients, and any other role that has no responsibilities regarding a patient’s sensitive information.

3.BENEFITS OF MEDICAL SOFTWARE

3.1 REDUCES OFFICE SPACE

One will notice that once you start shifting to a medical software, your practice starts to transform. Going from stacked files and various cabinets to all of it being saved onto a web-based application. Your office space will significantly increase.

3.2 PAPERLESS

As mentioned above, all of your files such as debtor files, accounts, and clinical information will now transform from physical to digital. Using medical software that has paperless capabilities will not only save you space, but it will also save costs related to office supplies and give your practice an environmentally conscious edge.

3.3 ELECTRONIC MEDICAL RECORDS

Electronic Medical Records (EMR) software is a digital file cabinet for patient files –storing medical history, scripts, medications, lab results, treatment plans and patient billing information. Implementing an EMR system increases medical practices’ productivity and the quality of medical care given to patients.

3.4 PRODUCTIVITY, EFFICIENCY AND PROFITABILITY

Following the first few benefits is the increase in productivity and efficiency

through medical software that provides easy and fast patient input and billing, real-time medical aid claiming, smooth scripting, electronic pathology test and integrated clinical notes. Such software better leverages staff time by automating standard tasks. Other benefits here include accuracy and error reduction.

3.5 DATA BACKUP

With regular data backups, there is no need to worry about any natural disaster obliterating your records and the disastrous financial results thereof, because all you need to retrieve them is a device and internet connectivity. Very importantly, no one has to consciously think of updating records, because they are updated in real-time.

3.6 EFFECTIVE COLLABORATION

With the correct employees given access to the software, medical software promotes outstanding collaboration and sharing amongst teams in a medical practice as well as doctors from other medical practices.

3.7 MORE FOCUS ON QUALITY PATIENT CARE

Through automating processes and administrative tasks, a smart medical software enables healthcare providers to focus more on their patients and servicing them with quality care. The less practitioners have to worry about the different tasks and processes, the more time they will devote to their patients, building a loyal and strong patient base.

CONCLUSION

As a practitioner and/or medical practice owner, investing in a complete medical practice management software will prove to be of great benefit to you, your practice, and your patients. Invest in a software application that enables you to have security measures in your practice. Make data protection a priority through using medical software that not only gives you security tools and/or features, but one that selfcomplies with the Protection of Personal Information Act.

Navigating ocular infections Besifloxacin's role in treatment and combating antibiotic resistance

CHARACTERISED BY INFLAMMATION of the conjunctiva with mucopurulent discharge, bacterial conjunctivitis requires prompt treatment to shorten the disease course, prevent contagious spread, and eradicate causative organisms. However, the rising prevalence of antibiotic-resistant ocular isolates

necessitates the development of novel therapeutic agents for effective treatment.

PHARMACOKINETIC PROPERTIES

Understanding the pharmacokinetic properties of topical fluoroquinolones, such as besifloxacin, is crucial for optimising treatment regimens.

Recent studies have shown that besifloxacin exhibits excellent penetration and retention in conjunctival tissue, with a longer mean residence time compared to other fluoroquinolones.

This sustained presence allows for effective bacterial eradication and improved clinical outcomes.

TARGET SPECIFICITY

Besifloxacin's mechanism of action involves targeting bacterial DNA gyrase and topoisomerase IV, essential enzymes for DNA replication and cell viability. Unlike traditional fluoroquinolones, besifloxacin demonstrates balanced inhibition of both enzymes in clinically relevant pathogens like Staphylococcus aureus and Streptococcus pneumoniae. This dual targeting approach reduces the risk of resistance development and enhances besifloxacin's efficacy against a wide range of ocular pathogens.

CLINICAL EFFICACY

Clinical trials evaluating besifloxacin's efficacy in treating bacterial conjunctivitis have yielded promising results. Administered twice daily for three days, besifloxacin has demonstrated superior bacterial eradication and clinical resolution compared to vehicle and other topical fluoroquinolones. Moreover, besifloxacin's convenient dosing regimen enhances patient adherence and mitigates the development of antibiotic resistance, making it an ideal treatment option for both adults and children.

BACTERICIDAL ACTIVITY

Besifloxacin exhibits potent in vitro bactericidal activity against common ocular pathogens, including methicillinresistant Staphylococcus aureus (MRSA) and fluoroquinolone-resistant strains. Its rapid and concentration-dependent killing mechanism ensures efficient bacterial eradication, even in challenging cases of antibiotic resistance. By targeting multiple essential bacterial enzymes, besifloxacin maintains its efficacy against a broad spectrum of ocular pathogens, making it a valuable addition to the armamentarium against bacterial conjunctivitis.

COMBATTING ANTIBIOTIC RESISTANCE

The escalating issue of antibiotic resistance underscores the importance of judicious antibiotic use and the development of new therapeutic agents like besifloxacin. Surveillance studies have highlighted persistently high resistance rates among ocular pathogens, emphasising the need for effective treatment strategies. Besifloxacin's potent bactericidal activity and low propensity for resistance development position it as a promising solution to combat antibiotic resistance in ocular infections.

CONCLUSION

Besifloxacin's favourable pharmacokinetic properties, target specificity, clinical efficacy, and potent bactericidal activity make it an ideal choice for the empirical treatment of ocular infections.

References available on request.

Understanding, managing comorbidities in adult ADHD

Attention-deficit hyperactivity disorder (ADHD) is a multifaceted neurodevelopmental condition recognised by symptoms such as inattention, hyperactivity, and impulsivity.

THOUGH HISTORICALLY STUDIED in children, the acknowledgment of ADHD in adults is growing, especially regarding its comorbidities. Adults with ADHD often face additional challenges due to comorbid psychiatric disorders such as substance use disorder (SUD), mood disorders, anxiety disorders, and personality disorders. These comorbidities complicate diagnosis and treatment, necessitating a comprehensive approach. Studies consistently show elevated rates of comorbid psychiatric disorders in adults with ADHD compared to those without. For instance, the prevalence of mood disorders like major depressive disorder and bipolar disorder is significantly higher in ADHD populations. Similarly, anxiety disorders and substance use disorders are more prevalent among adults with ADHD. Notably, antisocial personality disorder is also commonly associated with ADHD.

Sex differences exist in the prevalence of comorbidities, with women more prone to anxiety, mood, and bipolar disorders, while men tend to have higher rates of substance use disorders. However, overall comorbidity rates remain similar between sexes, indicating that ADHD amplifies existing sex differences in psychiatric disorders.

The association between adult ADHD and psychiatric comorbidities is well established. Anxiety disorders, including generalized anxiety disorder and panic disorder, are highly prevalent in individuals with ADHD, exacerbating symptoms and increasing clinical severity. Similarly, mood disorders like depression and bipolar disorder frequently co-occur with adult ADHD, leading to poorer functional outcomes.

SUD represents a significant comorbidity in adults with ADHD, necessitating integrated treatment approaches due to the bidirectional relationship between ADHD and SUD. Personality disorders, particularly cluster B personality disorders, further complicate diagnostic and treatment strategies. Recognising comorbid psychiatric conditions in adults with ADHD is crucial for personalised treatment planning.

A holistic approach that addresses ADHD symptoms and associated comorbidities is essential in improving outcomes. Integrative interventions, including pharmacotherapy, psychotherapy, and psychosocial support, play a pivotal role in managing adult ADHD and its comorbidities.

Pharmacological management of adult ADHD primarily revolves around increasing catecholaminergic transmission. Stimulants such as methylphenidate and amphetamines are considered first-line agents, but non-stimulant options like atomoxetine and bupropion are also viable,

especially for patients with comorbid substance use disorders.

Challenges in treatment include the risk of stimulant misuse, exacerbation of anxiety or psychosis, and potential drug interactions. Tailored medication choices based on specific comorbidities are

This is a summary of a CPD article available on www.medicalchronicle.co.za

necessary, with considerations for mood stabilisers or antipsychotics in certain cases.

Despite advancements, challenges remain, including diagnostic heterogeneity and limited consensus on treatment guidelines. Future research should focus

on understanding the neurobiological mechanisms linking ADHD and psychiatric comorbidities and evaluating the efficacy of integrated treatment approaches.

In conclusion, managing comorbidities in adult ADHD requires a comprehensive and multidisciplinary approach.

NO

VYVANSE®

adult attention deficit hyperactivity disorder (ADHD) symptoms for up to 14 hours 1

VYVANSE® is the FIRST prodrug stimulant 2,3

Offers improvement in real-life executive function deficits and self-reported quality of life 3,4

Convenient once-daily dosing with a well-established safety profile 3,5,6

placebo-controlled, crossover study of the efficacy and safety of lisdexamfetamine dimesylate in adults with attention-deficit/hyperactivity disorder: novel findings using a simulated adult workplace environment design. Behav Brain Funct. 2010;6:34. Available from: http://www.behavioralandbrainfunctions.com/content/6/1/34 [Accessed 18th August 2021]. 2. Pennick M. Absorption of lisdexamfetamine dimesylate and its enzymatic conversion to d-amfetamine. Neuropsychiatr Dis Treat. 2010;6:317-327. 3. Frampton JE. Lisdexamfetamine: A Review in ADHD in Adults. CNS Drugs 2016: 30(4):343-54.DOI 10.1007/s40263016-0327-6. 4. Adler LA, Dirks B, Deas PF, Raychaudhuri A, Dauphin MR, Lasser RA, et al. Lisdexamfetamine Dimesylate in Adults With Attention-Deficit/ Hyperactivity Disorder Who Report Clinically Significant Impairment in Executive Function: Results From a Randomized, Double-Blind, Placebo-Controlled Study. J Clin Psychiatry. 2013;74(7):694-702. 5. VYVANSE 30,50,70. SAHPRA approved professional information. Takeda (Pty) Ltd. 24 July, 2020. 6. Coghill DR, Caballero B, Sorooshian S, Civil R. A Systematic Review of the Safety of Lisdexamfetamine Dimesylate. CNS Drugs 2014;28:497–511.

S6 VYVANSE 30

References: 1. Wigal T, Brams M, Gasior M, Gao J, Squires L, Giblin J, for 316 Study Group. Randomized, double-blind,

DIOSMECTITE IS USED in the symptomatic treatment of chronic functional diarrhoea and pain associated with functional bowel diseases in adults. Numerous randomised controlled trials

and meta-analyses have demonstrated its efficacy, attributing its benefits to its potent coating properties on the gastrointestinal mucosa, thanks to its leaflet structure and high plastic viscosity.

Pharmacological studies have elucidated diosmectite's mechanisms of action, which include stabilising mucus and protecting the gastrointestinal mucosa against aggressive agents like hydrochloric acid and bile acids.

Diosmectite also exhibits high adsorption capacity against enterotoxins, bacteria, and viruses, decreases inflammation mediators, reinforces intestinal mucosa barrier, and restores epithelial barrier defects induced by proinflammatory cytokines. Moreover, it reduces hypersensitivity to colorectal distension, making it effective in treating chronic functional diarrhoea and diarrhoeapredominant irritable bowel syndrome (IBS) when administered at doses of 3g three times a day for 2-8 weeks.

Given the prevalence of chronic diarrhoea associated with microbiota alterations, researchers sought to assess diosmectite's impact on the gut microbiome during long-term use. A prospective, open-label, non-comparative, multi-center international study administered diosmectite 3g three times a day over five weeks to evaluate its effect on elemental impurities and the bowel microbiota composition in subjects with chronic functional diarrhoea.

The study confirmed diosmectite's clinical benefit in reducing overall Bristol Stool Scale (BSS) scores, particularly in cases of more severe baseline symptoms. Despite its efficacy in improving transit, there was no observed alteration in the microbiota composition even at the highest resolution attained by complete shotgun sequencing-based metagenomic gene scans. This contrasts with treatments for other chronic conditions like type-2 diabetes or neuropsychological disorders, where drug-microbe interactions can significantly alter the microbiota.

The lack of impact on the microbiota suggests that diosmectite can be safely administered for extended periods (up to five weeks in the study) without causing microbiota-mediated gut symptoms such as bowel distension or intestinal inflammation. However, further investigations are warranted to assess potential modulation of microbiome functions through assessments of gene expression (metatranscriptome) or metabolome. Nonetheless, the study's findings highlight diosmectite's safety and efficacy in chronic diarrhoea management, providing reassurance for its long-term use in clinical practice.

CONCLUSION

In conclusion, diosmectite demonstrates efficacy and safety in managing acute and chronic gastrointestinal transit disorders. Its long-term administration in chronic diarrhoea does not appear to adversely impact the intestinal microbiota composition, as evidenced by this study's findings. Thus, diosmectite stands as a viable treatment option for chronic diarrhoea without posing risks associated with microbiota-mediated gut symptoms.

Increase in drug resistance to DTG

While an antiretroviral with absolutely no potential for the development of resistance is probably impossible, the barriers to resistance vary.

RECENT FINDINGS REVEAL a concerning rise in HIV drug resistance to dolutegravir, as outlined in the latest HIV Drug Resistance (HIVDR) Report by the World Health Organization (WHO). While there's positive news regarding high levels of HIV viral load suppression among populations undergoing dolutegravir (DTG)based antiretroviral therapy (ART), there's also cause for alarm. Observational data indicates that levels of HIV drug resistance to DTG are surpassing those observed in clinical trials.

Since 2018, WHO has recommended dolutegravir as the preferred first- and second-line HIV treatment due to its effectiveness, ease of administration, and minimal side effects compared to other drugs. However, resistance to dolutegravir has been observed in varying degrees, ranging from 3.9% to 8.6%, and reaching 19.6% among individuals transitioning to DTG-based ART with high HIV viral loads. This highlights the urgency for heightened vigilance and efforts to enhance the quality of HIV care delivery.

The report underscores the necessity for standardised surveillance of HIV drug resistance to effectively prevent, monitor, and respond to these challenges. While progress has been made in implementing WHO recommendations globally, targets for Sustainable Development Goals (SDGs) related to HIV have not been met due to continued new infections and deaths from HIV-related causes.

Only a fraction of countries have conducted surveys or integrated HIV drug resistance monitoring into routine systems. Many struggle with optimising retention in care, viral load suppression, and ensuring uninterrupted drug supply, impacting patient adherence. WHO emphasises the importance of routine surveillance of HIV drug resistance to guide treatment guidelines and improve treatment programmes.

Moreover, the report highlights cases of resistance to integrase-strand transfer inhibitors (INSTIs) following exposure to cabotegravir (CAB-LA), urging prompt detection of HIV infection to minimise resistance risks. Despite this, WHO supports the rollout of CAB-LA for preexposure prophylaxis (PrEP) but calls for standardised resistance surveillance among PrEP users testing positive for HIV.

Routine monitoring of quality-of-care indicators at both clinic and national levels is crucial for the success of ART programmes. Strengthening data reporting systems and engaging ART clinics to utilise indicator data for tailored solutions are vital steps in optimising service delivery quality and reducing the emergence of drug-resistant HIV. “The new HIVDR report emphasises the importance of strengthening data

reporting systems so that countries can effectively monitor and report qualityof-care indicators. It underscores the active engagement by ART clinics and programmes in use of indicator data to develop locally appropriate and sustainable solutions. These efforts are crucial for optimising service delivery quality, thereby

reducing the emergence of drug-resistant HIV,” the WHO stated.

Addressing HIV drug resistance is integral to the broader global response to antimicrobial resistance, requiring coordinated action across all government sectors and societal levels.

The HIV Drug Resistance report for

2024 is available here: https://rb.gy/ e291hd

REFERENCE

WHO. New report documents increase in HIV drug resistance to dolutegravir. https://rb.gy/7gz45o Accessed 6 March 2024.

Dexlansoprazole modified release vs esomeprazole in gastric acid control

Dexlansoprazole and esomeprazole, both belonging to the proton pump inhibitor class, are pivotal in managing acid-related gastrointestinal disorders (GORD). However, incomplete acid suppression remains a challenge with once-daily dosing.

PROTON PUMP INHIBITORS (PPIS)

are cornerstone therapies for various acid-related gastrointestinal conditions. However, challenges persist, including incomplete acid suppression and delayed onset of action with once-daily dosing.

GORD DEFINITION

The definition of GORD has been an evolving one. Initially felt to be synonymous with tissue damage, it has been recognised that many patients with GORD experience a strong symptom-based component (including heartburn and regurgitation) in the absence of endoscopic and histologic evidence of injury.

With the rise in prevalence of reflux disease, as well as varying manifestations of the disorder, a concise definition was felt to be necessary both to define the problem and to address management recommendations for patients and providers. In 2006, the Montreal consensus defined GORD as, “A condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications.” Using this unifying definition, treatment for patients with GORD should focus on management of both complications from reflux and significant symptoms relative to the disorder.

Pharmacology and formulation:

Dexlansoprazole and esomeprazole inhibit the (H+,K+)-ATPase enzyme, thereby

suppressing gastric acid secretion and elevating intragastric pH. Dexlansoprazole modified-release employs a dual delayedrelease (DDR) system, ensuring drug release at proximal and distal small intestine segments, leading to distinct plasma concentration-time profiles. Initial drug release in the proximal small intestine is followed by subsequent release in distal regions several hours later. Conversely, esomeprazole's delayed-release formulation achieves peak plasma concentrations approximately 1.6 hours post dose, necessitating ingestion before meals for optimal efficacy.

Unfortunately, many patients continue to suffer from symptoms related to GORD despite appropriate use of PPIs. Dexlansoprazol MR addresses limitations with short plasma half-life and need for meal-associated dosing, characteristic of conventional PPIs. In addition, it has been shown to be effective in several specific clinical situations. These include:

• Coadministration with clopidogrel

• Healing of all grades of erosive esophagitis

• Improvement in reflux-related quality of life

• Step down to once-per-day dosing

• Induces symptom improvement in patients with:

- Nonerosive oesophageal reflux disease

- Nocturnal heartburn

- GORD-related sleep disturbance

- Regurgitation.

Dexlansoprazole dual delayed-release technology releases drug in two phases:

Granule 1 comprises 25% of total dose and is released at pH5.5 within 1-2 hours of dosing.

Granule 2 comprises 75% of total dose and is released at pH6.75 4-5 hours after dosing.

The formulation of dexlansoprazole utilising dual delayed release technology results in a dexlansoprazole plasma concentration-time profile with two distinct peaks. The first peak occurs one to two hours after administration, followed by a second peak within four to five hours. Dexlansoprazole can be taken without regard to food or the timing of food.

Comparator pH study: single-dose pharmacodynamics of dual delayed-release dexlansoprazole 60mg vs delayed-release esomeprazole 40mg compared the pharmacodynamic effects of dexlansoprazole modified release and esomeprazole, utilising doses approved for erosive esophagitis healing. Intragastric pH measurement serves as a reliable indicator of PPI efficacy. This study assessed the pharmacodynamic effects of single doses of dexlansoprazole modified-release 60mg and esomeprazole 40mg on 24-hour intragastric pH in healthy subjects.

Study design and methodology: The study employed a randomised, crossover design, with each subject serving as their control. Dosage strengths chosen mirror those approved for healing erosive esophagitis. Intragastric pH measurement serves as a reliable indicator of PPI efficacy, allowing for a head-to-head comparison of dexlansoprazole modified release and esomeprazole.

Results: Dexlansoprazole modified-release exhibits prolonged gastric acid control compared to esomeprazole, especially evident in the 12-24-hour post dose interval. The percentage of time with intragastric pH >4 over 24 hours significantly favours dexlansoprazole. Dexlansoprazole exhibits significantly greater pH control over 24 hours, with dual-peaked pharmacokinetics enhancing its efficacy.

While both drugs show comparable pharmacodynamic activity in the initial 0-12 hours post dose, dexlansoprazole's extended duration of action underscores its clinical advantage.The study's crossover design

enhances reliability, although its single-dose nature limits extrapolation to multipledose regimens.

While clinical efficacy assessment in healthy volunteers is constrained, the study highlights the pharmacological implications of PPI formulation characteristics. Dexlansoprazole modified-release demonstrates extended gastric acid control compared to esomeprazole, particularly evident in the 12-24-hour post dose interval.

Conclusion: A single dose of dexlansoprazole modified-release 60mg demonstrates superior gastric acid control over a 24-hour period compared to esomeprazole 40mg.

The extended duration of acid suppression with dexlansoprazole, particularly in the latter half of the post dose interval, underscores its potential clinical advantages. Although both drugs exhibit comparable efficacy within the initial 0-12 hours post dose, dexlansoprazole's dual delayed-release formulation offers promise in optimising acid suppression in acidrelated gastrointestinal disorders.

This highlights its potential in optimising acid suppression. While limitations in the study design preclude extrapolation to multiple-dose regimens, the comparison underscores the pharmacological significance of PPI formulation characteristics. Dexlansoprazole's dual delayed-release formulation exhibits extended gastric acid control compared to esomeprazole, offering potential advantages in clinical practice.

REFERENCES

Frye JW, Peura DA. Managing gastroesophageal reflux disease - comparative efficacy and outcomes of dexlansoprazole MR. Ther Clin Risk Manag. 2015:30;11:1649-56. doi: 10.2147/TCRM.S66680.

PMID: 26586949; PMCID: PMC4634831.

Metz DC, Howden CW, Perez MC, Larsen L, O'Neil J, Atkinson SN. Clinical trial: dexlansoprazole MR, a proton pump inhibitor with dual delayed-release technology, effectively controls symptoms and prevents relapse in patients with healed erosive oesophagitis. Aliment Pharmacol Ther. 2009:1;29(7):742-54. doi: 10.1111/j.1365-2036.2009.03954.x. Epub 2009 Feb 7. PMID: 19210298.

Howden CW, Larsen LM, Perez MC, Palmer R, Atkinson SN. Clinical trial: efficacy and safety of dexlansoprazole MR 60 and 90 mg in healed erosive oesophagitis - maintenance of healing and symptom relief. Aliment Pharmacol Ther. 2009:1;30(9):895-907.

doi: 10.1111/j.1365-2036.2009.04119.x. Epub 2009

Aug 14. PMID: 19681809.

Kukulka M, Eisenberg C, Nudurupati S. Comparator pH study to evaluate the singledose pharmacodynamics of dual delayed-release dexlansoprazole 60 mg and delayed-release esomeprazole 40 mg. Clin Exp Gastroenterol. 2011;4:213-20. doi: 10.2147/CEG.S24063. Epub 2011

Sep 14. Erratum in: Clin Exp Gastroenterol. 2011;4:255. PMID: 22016582; PMCID: PMC3190289.

•

• TRUE once-daily

#the only dexlansoprazole available in South Africa. DDR: dual delayed-release; PPI: Proton pump inhibitor; QoL: quality of life.

doi: 10.2147/TCRM.S66680. 6. Dexilant Professional Information. Takeda (Pty) Ltd, South Africa; August 2021. 7. Sharma P, Shaheen NJ, Perez MC, et al. Clinical trials: healing of erosive oesophagitis with dexlansoprazole MR, a proton pump inhibitor with a novel dual delayed-release formulation--results from two randomized controlled studies. Aliment Pharmacol Ther. 2009;29(7):731-41. doi: 10.1111/j.1365-2036.2009.03933.x. 8. Fass R, Chey WD, Zakko SF, et al. Clinical trial: the effects of the proton pump inhibitor dexlansoprazole MR on daytime and nighttime heartburn in patients with non-erosive reflux disease. Aliment Pharmacol Ther 2009;29(12):1261-72. doi: 10.1111/j.1365-2036.2009.04013.x.

S4 DEXILANT 30 mg modified-release capsules, Reg. No. 48/11.4.3/0695. Each capsule contains 30 mg of dexlansoprazole. S4 DEXILANT 60 mg modified-release capsules, Reg. No. 48/11.4.3/0696. Each capsule contains 60 mg of dexlansoprazole. For full prescribing information refer to the professional information approved by the medicines regulatory authority. TAKEDA (Pty) Ltd. Reg. No.: 1982/011215/07.

Dr Johan Grobbelaar

Date: 16 May 2024

Time: 7pm

Topic: Sinus solutions: The nose knows best Speaker: Dr Johan Grobbelaar

CLICK TO REGISTER: https://bit.ly/AustellWebinar16May24

Dr Johan Grobbelaar is currently the Head and Department of ENT, Tygerberg Hospital, Stellenbosch University. His interests include head and neck surgery, combined open and endoscopic sinus and skull base surgery, and balance disturbances. After an initial academic

career for 3 years, he went into private practice from 2008 till 2022. Since then, he has been the HOD at Stellenbosch University. He enjoys training the next generation of doctors and ENTs and has a special interest in setting up databases for research purposes.

E

Turning anger into motivation

ANGER CAN BE a highly destructive force or a powerful motivator, depending on how we decide to use it. Occupational therapist Kersha Singh, COPE manager at Netcare Askeso Kenilworth, explains how this emotion can be channelled more constructively to become your superpower. “Anger is a natural feeling that affects everyone. It is a normal emotion with a broad range of intensity from mild irritation and frustration to rage and aggression,” she says.

“Getting angry may be in reaction to a perceived threat or pent-up frustration, and it can be helpful to take note of what triggers your feelings of anger and try to identify the underlying cause. Anger can be triggered in many spaces, such as when sitting in traffic or at home with your family, and if it’s not dealt with in a healthy way, it can have potentially devastating, life changing consequences.”

Often people are more guarded about expressing anger in the workplace, even though stress at work may be a significant underlying contributor to these feelings. The anonymity of being in traffic, or the relative freedom to express emotions in the home environment, may manifest this anger as road rage or irritation – potentially even violence – with loved ones.

“If we allow anger to get out of control, it can cloud our thinking and judgement and may lead to irrational and destructive behaviours that can harm our relationships, health, work and ultimately our quality of life. The good news is that it is not too late for adults to learn to control their anger. This can be a very empowering experience when instead of reacting angrily, we can learn to transform our approach to respond to the situation more positively,” Singh says.

“If we are willing to acknowledge our triggers, even if we cannot fully control them, we can learn how to cope more healthily. The more we identify situations, environments and people that trigger angry feelings, the better we can manage these scenarios and hopefully learn to

respond calmly and constructively in challenging situations.”

“Anger management is a set of skills; if we practise, we get better at mastering it. For instance, with dialectical behavioural therapy (DBT), we help teach people practical coping skills to manage their anger both in the moment and on a long-term basis to reduce the intensity of the feelings.

“The first step is often impulse control. Identifying that our anger is in response to specific triggers, and what it is about the situation that consistently makes us feel this way is helpful towards managing the temporary distress, knowing it will pass,” she says. “With the right tools, it is possible to break the cycle of anger, and there are very effective non-pharmaceutical ways of redirecting the emotion more productively and, ultimately, more satisfyingly.”

TOOLBOX TO HELP COOL A HOT TEMPER

Singh recommends the following short-term techniques to help reduce intense feelings such as anger. “When something makes you angry, try to work towards responding rather than reacting to the situation. When we start to feel triggered or overwhelmed, STOP,” she says.

S – STOP. Pause, don’t react in the heat of the moment. Count to 10.

T – Take a step back. Remove yourself from the situation by taking a walk or bathroom break.

O – Observe. There is no need to respond when you feel overwhelmed; wait until you have a more objective perspective.

P – Proceed mindfully. Try deep breathing, in through your nose for the count of four, and out through your mouth more slowly.

“The physical feelings of being hot and flustered that come with being angry can exacerbate our perception of the situation, and actively cooling the body temperature can help us feel better. Drinking cold water, splashing your face and wrists, having a cool

shower, or stepping into an airconditioned room can all break the experience of feeling ‘hot under the collar’,” Singh says.

When a situation is out of your control and triggering angry feelings, she recommends distracting yourself for a mental break. Read a magazine, listen to relaxing music, play a game, or get absorbed in something creative.

“Intense exercise is an ideal way to let off steam. If you’re feeling annoyed with a loved one, try going for a run instead of reacting angrily. Increasing your heart rate for 10 to 20 minutes will help relieve some tension so you can return calmer.

“If you find you are bringing anger from work stress home, try stopping at the gym on your way home to release some of the day’s tension and frustrations before you get home. This can also improve the quality of your leisure time at home with your loved ones,” Singh suggests.

“If we feel angry, we can use it as motivation to channel our behaviour into more assertive or constructive communication. Proceed mindfully, as being assertive and respectfully

communicating your feelings toward the situation by having a discussion or writing a letter about what has upset you, and suggesting how your needs could be better met, can be productive.

“As well as these short-term strategies for responding better to anger, it is important to address the underlying factors to resolve the source of our discomfort in the long term. Use the energy from that anger and redirect it to work towards creating a lasting solution, whether working towards building a different career that may reduce your stress or freeing yourself from a toxic relationship, for example.” If you or someone you know is struggling with anger control or any other emotional or mental health difficulties, Netcare Akeso’s range of services, including occupational therapists, psychologists, and psychiatrists, are available to provide professional support. Netcare Akeso’s 24-hour crisis line is always here for you. Call 0861 435 787 any time of day or night, 366 days this leap year, trained counsellors are available to listen and can guide you on the options available to assist you.

Date:

Time: 7pm

Topic:

Presenter: Dr Alan Peter

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Understanding allergic conjunctivitis Symptoms, mechanisms, and treatment

Allergic conjunctivitis is a common allergic reaction affecting the eyes, triggered by exposure to various allergens such as pollen, pet dander, dust mites, or certain foods.

ALLERGIC CONJUNCTIVITIS

RESULTS from an immune response in which histamine and other inflammatory mediators are released, leading to characteristic symptoms including itching, redness, tearing, and swelling.

ROLE OF HISTAMINE

Histamine plays a pivotal role in allergic reactions, particularly in allergic conjunctivitis. When an allergen comes into contact with the eye, mast cells in the conjunctiva release histamine. This histamine binds to histamine H1 receptors, causing vasodilation, increased capillary permeability, itching, and smooth muscle contraction, ultimately leading to symptoms like redness and tearing.

TYPES OF ALLERGIC CONJUNCTIVITIS

Allergic conjunctivitis encompasses several conditions triggered by exposure to environmental allergens. These include seasonal allergic conjunctivitis (SAC), perennial allergic conjunctivitis (PAC), atopic keratoconjunctivitis (AKC), vernal keratoconjunctivitis (VKC), and giant papillary conjunctivitis.

These conditions affect a significant portion of the global population, with an estimated 20% grappling with some form of allergies.

SEASONAL ALLERGIC CONJUNCTIVITIS (SAC)

SAC is the most prevalent form of ocular allergy, typically triggered by airborne pollens during spring and summer. It involves an IgE-mediated type-I hypersensitivity reaction, with symptoms lasting clinically for about 20-30 minutes initially. Subsequent late-phase reactions result from inflammatory cell infiltration into the conjunctival mucosa, leading to prolonged symptoms including redness, itching, burning, swelling, and tearing.

TREATMENT STRATEGIES

Current therapeutic approaches for allergic conjunctivitis aim to prevent and alleviate symptoms. These methods include allergen avoidance, cold compresses, artificial tear usage, immune system modulation, and pharmacological inhibition of chemical mediators responsible for immune responses.

Various drugs are used for treatment, including topical antihistamines, nonsteroidal anti-inflammatory drugs (NSAIDs), mast cell stabilisers, steroids, corticosteroids, and artificial tears. However, each of these treatments has its limitations, including potential adverse effects like conjunctival hyperaemia, corneal stinging,

and burning. Newer-generation topical antiallergic agents with multiple modes of action, such as ketotifen, are recommended as primary treatment options for allergic conjunctivitis due to their efficacy and tolerability.

CONCLUSION

In conclusion, understanding the mechanisms and treatment options for allergic conjunctivitis is essential for effectively managing this common allergic condition affecting the eyes. By targeting

inflammatory mediators and alleviating symptoms, individuals can experience relief and improved quality of life despite the challenges posed by allergen exposure.

References available on request.

Extra-oesophageal presentation of GORD

Gastro-oesophageal reflux disease (GORD) is a prevalent gastrointestinal condition characterised by troublesome reflux of stomach contents into the oesophagus, leading to various tissue damages ranging from esophagitis to potentially severe conditions like Barrett's oesophagus and oesophageal adenocarcinoma.

SYMPTOMS OF GORD can manifest as typical oesophageal (heartburn, regurgitation) or extraoesophageal (EO), posing diagnostic challenges due to their diverse presentations involving the lungs, upper airways, mouth, and even non-cardiac pain.

Approximately one-third of GORD patients may experience atypical or EO symptoms, with non-cardiac chest pain being the most common complaint, followed by pulmonary manifestations such as bronchitis and asthma, as well as head and neck symptoms like hoarseness. While the

prevalence of EO symptoms is higher in erosive reflux disease (ERD) compared to non-erosive reflux disease, between 20% and 60% of GORD patients may present with head and neck symptoms despite minimal heartburn. Diagnosis of GORDrelated EO manifestations necessitates

collaboration among specialists to exclude alternative causes.

Two main mechanisms explain GORDrelated EO manifestations: direct damage induced by gastric material aspiration and indirect damage mediated by the vagus nerve. While the empiric proton pump inhibitor (PPI) therapy (PPI test) is a diagnostic tool, its sensitivity and specificity are limited. Additionally, GORDrelated EO manifestations show less responsiveness to standard PPI therapy, necessitating alternative diagnostic approaches like ambulatory 24-h oesophageal pH monitoring and upper gastrointestinal endoscopy.

Pulmonary manifestations of GORD, including chronic cough and asthma, present significant diagnostic and therapeutic challenges. Chronic cough, often attributed to GORD, exhibits varying prevalence rates worldwide, with proposed mechanisms including vagalmediated reflex and micro-aspiration of gastric contents. Similarly, asthma, which may exacerbate due to GORD-induced bronchial hyper-responsiveness, requires an empiric trial of PPIs for diagnosis and subsequent monitoring through pH testing or impedance–pH monitoring.

Laryngitis resulting from laryngopharyngeal reflux (LPR) showcases various symptoms, including hoarseness, sore throat, and cough, with the laryngeal mucosa being more susceptible to injury compared to the oesophagus. Empirical PPI therapy serves as the first-line treatment for suspected LPR, supplemented by impedance or pH monitoring if unresponsive.

Reference: 1. Data on File. 2. Generics Dictionary South Africa. Available from: http://www.generic.co.za/frontend/generics?utf8=%E2%9C%93&q%5Bactive_ingredient_ name_eq%5D=ESOMEPRAZOLE&q%5Bmanufacturer_name_cont%5D=AstraZeneca Accessed [14 July 2022]

S4 TRUSTAN® 20 mg. Reg. No. 45/11.4.3/0777. Each gastric resistant tablet contains 20 mg esomeprazole (as magnesium trihydrate) in the form of a multiple unit pellet system (MUPS). S4 TRUSTAN® 40 mg. Reg. No. 45/11.4.3/0778. Each gastric resistant tablet contains 40 mg esomeprazole (as magnesium trihydrate) in the form of a multiple unit pellet system (MUPS). For full prescribing information, refer to the professional information approved by the medicines regulatory authority (03/2021). Trademarks are owned by or licensed to the Aspen Group of companies. HCR: Pharmacare Ltd. Co. Reg. No. 1898/000252/06. Healthcare Park, Woodlands Drive, Woodmead, 2191. Marketed by: Acino Pharma (Pty) Ltd. Reg. No.: 1994/008717/07. 106 16th Rd, Midrand, 1686, Gauteng, South Africa. (011) 516 1700. www.acino.co.za. ZAR-ESO-06-22-00002 08/2022 LP4248 Exp: 05/2024.

In the oral cavity, reduced salivary flow volume in GORD patients leads to dental erosions and other oral symptoms, necessitating collaboration between dentists and gastroenterologists for diagnosis and management.

Finally, GORD-related chest pain, often classified as non-cardiac chest pain, requires exclusion of cardiac causes and may be alleviated by a trial of PPI therapy after ruling out non-oesophageal causes.

In summary, the extra-oesophageal manifestations of GORD present complex diagnostic and therapeutic challenges, requiring a multidisciplinary approach for accurate diagnosis and effective management. Collaboration among specialists, along with judicious use of diagnostic tools and tailored therapeutic strategies, is essential in addressing the diverse array of symptoms associated with GORD.

REFERENCE

Durazzo M, Lupi G, Cicerchia F, et al. ExtraEsophageal Presentation of Gastroesophageal Reflux Disease: 2020 Update. Journal of Clinical Medicine. 2020; 9(8):2559. https://doi.org/10.3390/ jcm9082559.

Phospholipids are the unsung heroes of cellular function, constituting vital components of cell membranes with an astonishing turnover rate.

PHOSPHOLIPIDS INCLUDING phosphatidylcholine, phosphatidylethanolamine, phosphatidylinositol, and sphingomyelin, are indispensable for maintaining cellular structures, regulating physiological functions, and orchestrating immune responses. Particularly within neuronal membranes, phospholipids play critical roles in nerve impulse conduction, neurotransmission, and brain maturation.

However, various conditions can disrupt phospholipid synthesis or lead to their loss, resulting in impaired cell function and pathophysiological consequences. Such disruptions are implicated in conditions ranging from cerebral oedema and traumatic brain injury to neurodegenerative diseases like Alzheimer's. Enter citicoline, also known as cytidine-5’-diphosphocholine (CDP-choline), a pharmaceutical substance identical to the natural precursor of phospholipid phosphatidylcholine. CDPcholine is integral to the synthesis of structural phospholipids and serves as an exogenous source of choline and cytidine, crucial for neurochemical processes and membrane integrity. Recent experimental and clinical studies have highlighted citicoline's potential neuroprotective effects, particularly in glaucoma.

Glaucoma, a condition characterised by progressive neuronal degeneration along the visual pathway, poses significant challenges in treatment and management. Citicoline emerges as a promising adjunct to conventional therapies, offering both neuroprotection and improved quality of life for patients. A ground breaking study led by Rossetti et al (2023) investigated the efficacy of citicoline oral solution in enhancing vision-related quality of life (QoL) in glaucoma patients. The study, employing a placebo-controlled, crossover design, demonstrated significant improvements in QoL metrics with citicoline treatment, particularly in patients with more severely affected baseline QoL scores. Notably, citicoline's effect was primarily related to visual function, as evidenced by improvements in visual field parameters and electrophysiological measures.

Moreover, citicoline's neuroprotective potential extends beyond glaucoma, with promising results observed in various neurodegenerative diseases. Studies have shown improvements in visual acuity, contrast sensitivity, and electrophysiological function in conditions such as amblyopia and non-arteritic ischemic optic neuropathy.

CONCLUSION

In conclusion, citicoline represents a valuable addition to the armamentarium of treatments for glaucoma, offering not only neuroprotection but also potential improvements in quality of life. As research continues to unveil its mechanisms and efficacy, citicoline holds promise as a neuroenhancer and prophylactic agent

against neurodegenerative diseases, paving the way for enhanced patient care and management strategies.

REFERENCES

Rossetti, L., Goni, F., Montesano, G. et al. The effect of citicoline oral solution on quality of life in patients with glaucoma: the results of an international, multicenter, randomized, placebocontrolled cross-over trial. Graefes Arch Clin Exp Ophthalmol 2023:261, 1659–1668. https://doi.

org/10.1007/s00417-022-05947-5.

Jünemann AGM, Grieb P, Rejdak R. Bedeutung von Citicolin bei der Glaukomerkrankung [The role of citicoline in glaucoma]. Ophthalmologe. 2021 May;118(5):439-448. German. doi: 10.1007/ s00347-021-01362-z. Epub 2021 Mar 17. PMID: 33730306; PMCID: PMC7967777.

Grieb P. Neuroprotective properties of citicoline: facts, doubts and unresolved issues. CNS Drugs. 2014 Mar;28(3):185-93. doi: 10.1007/s40263-014-01448. PMID: 24504829; PMCID: PMC3933742.

Despite the promising findings, the study acknowledges limitations such as sample size constraints and the absence of a washout period between cross-over phases. Future research should aim to address these limitations and explore citicoline's potential in patients with more advanced glaucomatous damage.

We need to talk about piles

Piles, also known as haemorrhoids, is a common yet often overlooked condition that affects a significant portion of the South African population, with one in two individuals experiencing it at some point in their lives.

DESPITE ITS PREVALENCE, the stigma surrounding piles persists, leading to reluctance to seek treatment and unnecessary suffering.

Recent research reveals that 52% of people avoid seeking treatment altogether, while 44% delay seeking help due to feelings of embarrassment and discomfort.

As healthcare professionals, pharmacists and doctors can play a crucial role in breaking this cycle of silence and providing much-needed support and guidance to patients dealing with piles.

Understanding the emotional Impact: Piles can evoke feelings of fear, embarrassment, and social isolation due to symptoms like blood loss and anal pain. Patients may also harbour concerns about underlying health conditions. By approaching the subject with empathy and understanding, healthcare professionals can help alleviate patients' anxieties and provide reassurance.

Initiating conversations: Research shows

that many patients only disclose their piles condition when prompted by their healthcare provider.

Thus, healthcare professionals need to initiate open-ended discussions during consultations, creating a safe space for patients to share their concerns and seek appropriate treatment.

Targeting high-risk groups: Certain demographics, such as pregnant women and individuals with specific lifestyle factors, are more prone to developing piles. Healthcare professionals should proactively discuss the risk of piles with high-risk groups, offering preventative advice and early intervention strategies.

Providing self-care recommendations: Empowering patients with self-care strategies can promote healing and reduce the likelihood of recurrent episodes. Healthcare professionals should advise patients on dietary modifications, fluid intake, exercise, and lifestyle adjustments

to alleviate symptoms and improve overall well-being.

Respecting treatment preferences: Patients experiencing piles often prioritise symptom management over cure. It's key for healthcare professionals to respect patients' treatment preferences and provide clear, understandable information about available options, including over-thecounter products like AnuSol, the UK’s No. 1 selling treatment for piles. It contains a soothing astringent that effectively reduces swelling and provides relief. Available in various forms, including suppositories, ointments, and wipes, the AnuSol range offers a gentle yet effective solution, enabling individuals to resume their daily activities comfortably.

Despite its prevalence, piles remain a taboo subject, as indicated by search engine trends. Medical professionals are uniquely positioned to challenge this stigma and foster open dialogue about piles, promoting early detection and

effective management.

REFERENCE

Van Tol R, Kimman M, Breukink S, et al. Experiences of patients with haemorrhoidal disease – a qualitative study. J Coloproctol (RIO J). 2019;39(1):41-47. https:// doi.org/10.1016/j.jcol.2018.10.005.

Sheikh P, Regnier C, Goron F, et al. The prevalence, characteristics and treatment of hemorrhoidal disease: results of an international web-based survey. J Comp Eff Res. 2020;9(17):1219-1232. Doi: 10.2217/cer2020-0159

Ray-Offor E, Amadi S. Hemorrhoidal disease: predilection sites, patterns of presentation and treatment. Ann Afr Med. 2019;18(1):12-16. doi: 10.4103/ aam.aam_4_18: 10.4103/aam.aam_4_1

Sheikh P, Regnier C, Goron F, et al. The prevalence, characteristics and treatment of hemorrhoidal disease: results of an international web-based survey. J Comp Eff Res. 2020;9(17):1219-1232. Doi: 10.2217/cer2020-0159

Merchant L, Brown L, Burton J. Case-based learning: Haemorrhoids. The Pharmaceutical Journal, PJ, January 2022, Vol 308, No 7957;308(7957):DOI:10.1211/ PJ.2021.1.121181

1. Van Tol R, Kimman M, Breukink S, et al.

Experiences of patients with haemorrhoidal disease – a qualitative study. J Coloproctol (RIO J). 2019;39(1):4147. https://doi. org/10.1016/j.jcol.2018.10.005.

2. Anusol. How to treat piles. https://www.anusol. co.uk/ piles-advice/treatment (accessed March 2022)

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Credit: KATERYNA KON/SCIENCE PHOTO LIBRARY

Expert: Stop killing smokers by protecting combustible cigarettes

Tobacco use continues to be one of the most primary contributors to the global burden of disease. It is estimated that smoking kills eight million people around the world and yet more than a billion people are currently smokers with 80 per cent of these living in low-to-middle income (LMIC) countries.

MOST ADULT SMOKERS want to quit but too many find it challenging to quit successfully. It is for this reason that as a harm reduction advocate, we continue to challenge the World Health Organisations dictatorial policies and their position that non-combustible products should be regulated the same way as cigarettes.

The unequivocal message here is – stop killing smokers by protecting combustible cigarettes. It is a fact, scientifically proven that non-combustible products produce fewer and lower levels of toxicants than cigarettes, in fact even by their own admission the National Library of Medicine says that the use of combustible tobacco products is the leading cause of preventable mortality and morbidity, substantially reducing such use represents one of the most significant opportunities to improve global health.

Reducing the harm caused from smoking is inextricably linked to the United Nations Sustainable Development Goal 3: Ensure healthy lives and promote well-being. One-in-two smokers will die from smoking related-diseases, we need to embrace smokers so that millions of deaths can be prevented, smoking reduced, and health can be improved.

A report by the International Commission to Reignite the Fight Against Smoking states: “If the world can take full advantage of new cessation and tobacco harm reduction solutions, about 3.5 million people will die from tobacco in 2060 – a reduction of three to four million annual deaths from tobacco within four decades.

The report also states that widespread misinformation that Tobacco Harm Reduction (THR) products are as risky as cigarettes and that nicotine is a substance that causes illness and death, prevents smokers from switching to less harmful alternatives. The scientific evidence demonstrates that the burning of tobacco is what releases most of the harmful chemicals, and by delivering nicotine through less harmful ways for example, through non-combustible products such as e-cigarettes, heat-not-burn and snus, or nicotine replacement therapies, the harms of smoking can be greatly reduced.

South Africa has an opportunity to become a leader in tobacco control through regulating non-combustible products differently from cigarettes, no one said it would be easy to achieve this in South Africa, but it is something worth fighting for and will be achieved, just like health activists fought to provide antiretroviral therapy in the country. Regulators need

to look at the science and see where alternatives to smoking have entered other markets and how the prevalence of smoking declines with these entrants.

Why do medical professionals promote and supply nicotine replacement therapies to people if nicotine was the problem? Nicotine is a stimulant; combustion is the problem. Remember people who smoke are human too. All nations that embrace this have seen significant declines in the prevalence of smoking combustible cigarettes. These include Sweden, Japan, UK, USA and New Zealand amongst others. Even Australia despite being hostile to risk reduced products have a faster decline of smoking with vapes and more than 70% are from the illicit market.

Theunequivocal messagehereis–stopkillingsmokers byprotecting combustible cigarettes

It is presumed that LMIC countries do not have the capacity to regulate less harmful nicotine products and that we should therefore follow the dictates of the WHO in regulating these products in the same way as combustible cigarettes. We do not want to do the hard work of asking questions and doing research. Why should our governments buy in to the fact that we can’t think for ourselves, that we can’t make up our minds, or that we can’t do research?

The newly tabled Control of Tobacco Products and Electronic Nicotine Delivery Systems Bill, unfortunately already reflects the WHOs position. The bill opens with a cautionary statement and then in its simplest form it says everything that produces a ‘cloud’ will be treated as a combustible cigarette.

or reducing their consumption of tobacco products and exposure to tobacco smoke.

We must save LMIC’s and engage the WHO on the scientific evidence to differentiate THR products from cigarettes, as we have a duty to ensure that it does its job properly without fear or favour.

We need to speak truth to power, engage with one another and be accountable. It’s a fight we all must come together to win. By embracing harm reduction and promoting these products you are also encouraging people to make responsible decisions to take care of their lives.

Common sense should not escape us; government should provide information and access to harm-reduction initiatives to reduce the harms of smoking. When the WHO FCTC was created many years ago, there were few alternatives to smoking and now years later there are a plethora of scientifically proven alternatives, but the approach remains the same. It needs to be brought up to date and leverage the potential of harm reducing products.

FCTC Article 1 d states: ‘tobacco control’ means a range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating

Dr Kgosi Letlape, an ophthalmologist from South Africa, is a former president of the Health Professions Council and chairman of the Medical and Dental Board of South Africa. He is the current president of the Africa Medical Association and the president of the Association of Medical Councils of Africa. He is also past chairman of the board of the South African Medical Association (SAMA) and past president of the World Medical Association (WMA), the global representative body for physicians.

He is the former executive director of the Tshepang Trust (2002 to 2013), a not-forprofit organisation that pioneered the provision of treatment for HIV and AIDS patients in partnership with state hospitals, an initiative he initiated through the SAMA at the request of the late President Nelson Mandela with a bequest from the Nelson Mandela Foundation and funding from the Presidential Emergency Programme for AIDS Relief through the Centre for Disease Control and Prevention. Letlape is a healthcare activist who believes that everyone in South Africa has a right to and deserves to receive equal health care, and that a lot of today’s illnesses can be prevented. To that end, he co-founded the Africa Harm Reduction Alliance, whose aim is to create awareness and educate about the need to reduce harm and promote well-being. He also consults to the private sector on harm reduction

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Credit: Sorin Banica / 500px

gettyimages Credit: Tachjang

Dr Kgosi Letlape, president and co-founder of the African Harm Reduction Alliance

The combination of migraine and persistent hot flashes could prove deadly

New study suggests that women with both migraine and persistent hot flashes face double the risk of heart disease and triple the risk of stroke.

HOT FLASHES AND migraine

(particularly with aura) have been shown to be individual risk factors for cardiovascular disease because of associated poorer heart disease risk-factor profiles. A new study, however, is the first to examine the joint influences of migraine and hot flashes/night sweats (vasomotor symptoms) independent of traditional heart disease risk factors and oestrogen use. Research results are published online in Menopause, the journal of The Menopause Society.

Specifically, the research shows that women with migraine and persistent vasomotor symptoms were 1.5 times as likely to incur heart disease and 1.7 times as likely to have a stroke compared with women without both symptoms, after adjustment for age, race, oestrogen use, oophorectomy, hysterectomy, and cardiovascular disease risk factors. In contrast, women with either migraine history or persistent hot flashes over time did not face a significantly increased risk of heart disease outside of the effect of traditional risk factors such as tobacco use and levels of lipids, blood pressure, and fasting glucose.

These results are noteworthybecause migraineandhot flashes are both so common

Nearly 2 000 women participated in the study that began data collection at ages 18 to 30 years up until roughly age 61 years. These results are noteworthy because migraine and hot flashes are both so common. It is estimated that hot flashes affect nearly 80% of women transitioning through menopause, although these symptoms can vary greatly in severity, frequency, age of onset, and accompanying symptoms. Migraines are particularly common in women of late-reproductive age, affecting approximately 17.5% of women.

Survey results are published in the article ‘Migraines, vasomotor symptoms, and cardiovascular disease in the Coronary Arter Risk Development in Young Adults study’.

"This study highlights the importance of considering female-predominant or female-specific factors such as history of migraine and persistent vasomotor symptoms when assessing cardiovascular risk in women. There is a critical need to further refine existing cardiovascular disease risk-prediction models to identify women more accurately at future risk. In the interim, risk factor optimisation is important for women with both conditions," says Dr

Stephanie Faubion, medical director for The Menopause Society. For more information about menopause and healthy aging, visit www.menopause.org. The Menopause Society (formerly The North American Menopause Society) is dedicated to

empowering healthcare professionals and providing them with the tools and resources to improve the health of women during the menopause transition and beyond. As the leading authority on menopause since 1989, the non-profit, multidisciplinary organisation

serves as the independent, evidence-based resource for healthcare professionals, researchers, the media, and the public and leads the conversation about improving women's health and healthcare experiences. To learn more, visit menopause.org.

Heinemann Medizintechnik –Revolutionising ENT Healthcare since 1983

Heinemann Medizintechnik stands as a beacon of excellence in the field of ear, nose, and throat (ENT) medical technology. With a legacy dating back to 1983, the company has consistently delivered equipment and services to ENT practices worldwide.

FROM

MANUFACTURING HIGHQUALITY treatment units to offering comprehensive practice planning solutions, Heinemann Medizintechnik is a trusted partner for medical professionals seeking top-tier ENT equipment.

THE MEDSEAT TREATMENT CHAIR

At the heart of Heinemann Medizintechnik's offerings lies the renowned Medseat treatment chair. With its extensive range of variants, the Medseat has become the preferred choice for ENT practitioners globally. Praised for its unparalleled

versatility to meet the diverse needs of medical professionals. Optional features like the Quick Assist quick coupling for head restraints further enhance efficiency, making patient positioning seamless and ergonomic.

GREINER WORK STOOLS

In addition to treatment chairs, Heinemann Medizintechnik also offers a range of Greiner work stools designed to support medical professionals in their daily routines. Crafted with the renowned German precision, these stools are synonymous with quality, durability, and ergonomic excellence.

Whether in examination rooms, treatment areas, or operating theatres, these work stools provide unmatched support and comfort for healthcare professionals. With features such as hygienic upholstery, adjustable heights, and a choice of base parts and castors, these stools are tailored to meet the demanding requirements of medical environments. The use of premium materials ensures long-term durability and comfort, promoting healthier posture and reducing strain on the back during long hours of work.

INNOVATIVE ENT INSTRUMENTS AND MICROSCOPES

The company has a comprehensive range of ENT instruments and microscopes. Partnering with industry leaders such as Karl Kaps and Zeiss, the company provides state-of-the-art equipment for diagnostic and surgical procedures.

FIBRE OPTIC AND LED HEADLIGHTS

Completing the company's product portfolio are fibre optic and LED headlights, designed to provide optimal illumination during medical procedures. Whether it's the precision-focused fibre optic OTheadlight or the mobility and efficiency of the high-performance LED headlight, Heinemann Medizintechnik ensures that medical professionals have access to the best-in-class lighting solutions for their practice needs.

Webinar replay: Neuvysi –for predictable outcomes

Prof Chetty explains the intricate nuances of neuromuscular blocking agents and their impact on predictable outcomes in anaesthesia.

WATCH THE WEBINAR to learn about:

• Physiology of neuromuscular blocking agents

• Postoperative residual curarisation (PORC)

• To reverse or not to reverse?

• Reversal options

If you missed the live webinar on Neuvysi – For Predictable Outcomes with the esteemed anaesthesiologist, Prof Sean Chetty, fret not. The replay is available at: https://rb.gy/bvboap. This webinar is sponsored by Dr. Reddy's. Please note that this webinar will mention brand names and is therefore not for CPD points.

• Neostigmine

• Sugammadex.

The age-old dilemma of whether to reverse neuromuscular blockade is thoroughly examined by Prof Chetty. With patient safety at the forefront, he navigates the complexities of this decision-making

process. Sugammadex is emerging as a novel alternative to traditional reversal agents, offering a glimmer of hope in mitigating the risks of PORC.

Prof Chetty explores the evidence supporting Sugammadex's efficacy and safety, paving the way for its adoption into clinical practice.

In the timeless words of Shakespeare, "To reverse or not to reverse... that is the question."

This webinar provides a comprehensive framework for answering this pivotal question and navigating the complexities of neuromuscular blockade reversal in anaesthesia.

How do we use levetiracetam to manage epilepsy?

On 12 February 2024, Medical Chronicle and Dr. Reddy’s hosted a webinar entitled ‘Levetiracetam A Paediatric Perspective,’ which was presented by specialist paediatric neurologist Dr Debbie Pearce.

HOW DO THESE factors affect the development of peripheral neuropathic pain? Could peripheral neuropathy be due to other factors? What’s better, duloxetine or pregabalin? To find out, watch a recording of this webinar here: https://rb.gy/ihb4q7.

Ifautonomicfibresareaffected,lossoffunctionwillbeexperienced,forexampledigestive, urogenital,cardiovascularandsudomotordysfunction

Dr Debbie Pearce

Specialised paediatric neurologist

Prof Sean Chetty MBChB(Natal), DCH(SA), DA(SA), FCA(SA) Cert.Crit.Care(SA) PhD

Dr Gary Hudson

Date: 15 April 2024

Time: 7pm

Topic: Optimising Vitamin D Deficiency Management:

Understanding the Superiority of Vitamin D3

Presenter: Dr Gary Hudson

CLICK TO REGISTER: https://bit.ly/AustellWebinar15Apr24

Dr Hudson has a special interest in Immunity and Metabolic Disorders. He graduated MBBCh (magna cum laude) 1987 from the University of Witwatersrand. An internship followed at Hillbrow hospital. He was placed onto the Johannesburg registrar circuit in 1989. He completed MMed exam in 1993 and he initiated the immune and rheumatology clinics at the then JG Strydom / Coronation Hospital as a consultant.

Dr Hudson is a founding member of the HIV Clinicians society. In 2003 he completed FCP (SA). He is a senior lecturer for the FPD and he practiced as a private practitioner in Johannesburg North for many years and relocated to Pringle Bay, where he now practices. He is a guest lecturer for numerous pharmaceutical companies with related topics metabolic syndromes, obesity, thyroid disease and immune diseases. The

Cancer prevention in SA Upping our game

On 29 February Medical Academic and Activo Health were proud to host a webinar entitled ‘Cancer prevention in SA: Upping our game.’ The webinar was presented by CANSA’s Prof Michael Herbst.

PROF HERBST BEGAN by clarifying that cancer cannot in fact be prevented, but that the risk of cancer can be reduced significantly. “Cancer is the second most prolific cause of death in the world,” Prof Herbst said.“

“This might come as a surprise to some people, but when one conflates all the available mortality stats and one treats the various forms of cancer as one disease, the true scale of the condition becomes apparent.”

The most important characteristic of cancer is that an abnormal and uncharacteristic multiplication of cells occurs. This runaway multiplication results in the formation of a tumour. Cancer also causes inflammatory and septic responses in the tissue surrounding affected areas. According to the National Cancer Registry’s 2019 statistics, there were 7903 deaths from cancer in 2019.

CANCER CANNOT BE PREVENTED

“The stats revealed that over 500 children aged 0 to 9 years died of cancer-related

causes in 2019, as confirmed by pathology reports,” Prof Herbst pointed out. “It should be clear that cancer asks no questions, does not care what population group one belongs to or what language one speaks. As recent reports have made clear, even a king can get cancer.” According to Prof Herbst, the confusion surrounding whether cancer can be prevented or not started with the interdisciplinary ‘borrowing’ of concepts surrounding the prevention of disease from the discipline of infectious diseases. “People talk about primary prevention, or intervening before health effects occur; secondary intervention, or patient screening to identify diseases in the earliest stages; and tertiary prevention, which is implemented in symptomatic patients and aims to reduce the severity of the disease as well as any associated sequelae.”

“If one examines the guidelines on cancer prevention published by the Union for International Cancer Control,” Prof Herbst stated, “then it becomes clear that what they are talking about is more aligned with cancer control than any sort of prevention

effort.” Cancer control initiatives must take the form of risk reduction.

REDUCING RISK

Cancer risk can be reduced by several practical measures, including the avoidance of alcohol. “Alcohol is a toxic, psychoactive, and dependence-producing substance and has been classified as a Group 1 carcinogen in the 1980s by the International Agency for Research on Cancer (IARC),” Prof Hersbt emphasised. “Group 1 is the highest risk group, which also includes asbestos, radiation and tobacco products.”

Prof also indicated that smoking was a significant risk factor, as was the sedentary lifestyle people tend to lead. Perhaps the most unpopular measure in a braai-loving culture like South Africa is the avoidance of red meat. “IARC has classified consumption of red meat as a Group 2A risk factor, or ‘probably carcinogenic to humans.’ In making this evaluation, IARC took into consideration all the relevant data, including the substantial epidemiological data showing a positive association between consumption

of red meat and colorectal cancer and the strong mechanistic evidence. Consumption of red meat was also positively associated with pancreatic and prostate cancer,” Prof Herbst said.

VAPING

Regarding the relatively recent vaping craze, Prof Herbst did not mince words: “It took decades for IARC to classify tobacco products as a Group 1 risk factor, and we may just be seeing the same delayed response with vaping products. We do not have a clue what the effects, in isolation or combined, of the chemicals in vaping products will be 10 or 15 years down the line.”

What’s so great about Fotofinder mole analysis? Is biltong a processed meat? What is radon gas, why is it the second leading cause of lung cancer, and why is there so much of it in Paarl?

For the answers to these and other questions, watch a recording of this webinar at https://vimeo.com/event/4040442 to claim 1 CPD point.

Anxiety disorders and recommended treatments: Insights from Dr Christian Schüler

In the realm of mental health, anxiety disorders stand as some of the most prevalent and impactful conditions affecting millions worldwide.

ANXIETY IS A NATURAL response to stress, often serving as a beneficial mechanism to alert us to potential dangers and help us focus. However, when anxiety becomes excessive and uncontrollable, it can morph into an anxiety disorder. These disorders, which encompass conditions like generalised anxiety disorder (GAD), panic disorder, phobias, and more, affect nearly 30% of adults at some point in their lives. Dr Schüler emphasises that anxiety disorders manifest in various forms, each with its own set of symptoms and challenges. For instance, GAD is characterised by persistent and excessive worry that interferes with daily activities, while panic disorder involves recurrent panic attacks accompanied by overwhelming physical and psychological distress.

Phobias, including specific phobias and agoraphobia, entail irrational fears of specific objects, situations, or environments, often leading individuals to extreme measures to avoid them. Social anxiety disorder, on the other hand, involves intense anxiety and discomfort in social interactions, hindering daily functioning and lasting for extended periods.

Separation anxiety disorder and selective mutism are unique conditions, particularly affecting children, with symptoms revolving around excessive fear or avoidance of separation from loved ones and difficulty speaking in certain social situations, respectively. Posttraumatic stress disorder (PTSD), another anxiety-related disorder, stems from exposure to traumatic events and is characterised by intrusive thoughts, avoidance behaviours, and alterations in cognition and mood. Obsessive-compulsive disorder (OCD), marked by recurrent obsessions and compulsions, further adds to the complexity of anxiety disorders.

Understanding the risk factors contributing to anxiety disorders is crucial for effective management and treatment. Genetic predispositions, neurobiological factors, environmental stressors, and personality traits all play significant roles. Additionally, childhood experiences, such as trauma or adversity, can heighten vulnerability to these conditions later in life.

The impact of anxiety disorders extends beyond individual suffering, affecting various aspects of life, including quality of life, social interactions, occupational performance, and physical health. Recognising these consequences underscores the importance of early intervention and comprehensive treatment approaches.

Anxiety disorders, despite their prevalence, often remain unaddressed as many individuals may not recognise their symptoms as a treatable condition. Driven by various factors, including genetic predispositions, neurobiological alterations, and environmental stressors, anxiety disorders require comprehensive diagnostic and therapeutic strategies for effective management. Exploring the diverse array of treatment options sheds light on how individuals grappling with anxiety can find relief and regain control over their lives.

While anxiety disorders pose significant challenges, they are treatable with a combination of psychotherapeutic and pharmacotherapy interventions.

DIAGNOSIS AND TREATMENT

One of the primary challenges in addressing anxiety disorders is the failure of many affected individuals to seek help. Often, individuals may not recognise their symptoms as indicative of a diagnosable condition, leading to delays in seeking appropriate care. It is crucial to first exclude

any physical causes for the symptoms before proceeding with treatment. However, once diagnosed, anxiety disorders typically respond well to two main types of treatment: psychotherapy and pharmacotherapy. These treatments can be utilised independently or in combination to tailor the approach to each individual's needs.

THERAPIES

Psychotherapy: Psychotherapy encompasses a variety of approaches aimed at addressing the cognitive and behavioural aspects of anxiety disorders. Techniques such as cognitive-behavioural therapy (CBT), dialectical behaviour therapy (DBT), psychodynamic psychotherapy, and rapid trauma therapy offer valuable tools for challenging maladaptive thought patterns, regulating emotions, and addressing unresolved conflicts contributing to anxiety.

Psychedelic-assisted therapy: While still in its nascent stages, psychedelicassisted therapy, particularly involving substances like Ketamine, shows promise in treating anxiety-related conditions. However, it requires careful consideration, thorough psychiatric assessment, and medical supervision due to its potent nature and potential risks. Pharmacotherapy: Medications play a significant role in managing anxiety symptoms, although they do not offer a cure. Antidepressants, such as SSRIs and SNRIs, are commonly prescribed to modulate neurotransmitter levels and alleviate anxiety. Additionally, anxiolytic medications like benzodiazepines and beta-blockers may be used for short-term relief of acute symptoms. However, careful monitoring and adherence to treatment guidelines are essential to minimise risks and optimise outcomes.

Dr Christian Schüler Specialist Psychiatrist MBChB, MMed Psychiatry

UNDERSTANDING NEUROTRANSMITTERS

Neurotransmitters, the chemical messengers of the brain, play a crucial role in anxiety regulation. Excitatory neurotransmitters, such as glutamate, augment nerve impulses, while inhibitory neurotransmitters, like GABA, prevent or reduce impulse transmission, thus modulating anxiety levels.

CLOBAZAM: A BENZODIAZEPINE ALTERNATIVE

Clobazam stands out among benzodiazepines due to its unique structural composition and partial agonist activity. With reduced sedative effects compared to other benzodiazepines, clobazam offers a valuable option for managing anxiety, particularly in crisis situations. Its rapid onset of action, linear kinetics, and favourable safety profile make it an effective choice for acute symptom relief.

KEY MESSAGES

Clobazam presents a viable alternative in the management of anxiety disorders, offering rapid relief with minimised sedative effects. Its distinct pharmacological properties and safety profile make it a valuable addition to the treatment armamentarium, particularly in crisis management scenarios. By understanding the diverse array of treatment options available, individuals grappling with anxiety can navigate their journey towards healing and reclaiming their lives from the grips of anxiety disorders.

Dr Schüler's expertise sheds light on the complexities of anxiety disorders and underscores the importance of tailored treatment plans to help individuals lead fulfilling lives despite their struggles.

A calming touch

Introducing CLOBAZAM ADCO

Indicated for the treatment of anxiety in neurotic patients, for pre-operative medication, and it may be effective in relieving the acute symptoms of alcohol withdrawal syndrome1

May be used as an adjuvant in epilepsy*1

• Unlike other benzodiazepines, CLOBAZAM ADCO has less sedative effects2

• Mild to moderate adverse events2

• Cost saving of 15 % versus originator3

Mental health collaborative care and the role of primary care

The healthcare landscape, particularly in the realm of mental health, has been undergoing frequent changes.

IN RECENT TIMES the rate of mental illness has reached an all-time high (especially post-covid), putting increased pressure on the healthcare industry to deliver proper treatment to the sufferers of these disorders. It is estimated that as of 2019 over 43.8 million people would experience a mental illness in any given year. However, with understanding the mental health issues, reaching out for help without shame is becoming easier for those who previously struggled in silence with depression, anxiety, bipolar disorders, or other mental health disorders.

It is common phenomenon that, when people begin suffering from alarming mental health irregularities, their first cause of action is to seek out a family care doctor.

“Under scrutinising debate is the controversial topic of whether primary care physicians should be treating their patients for mental health concerns.” [Solara Mental Health] The decision to visit the family doctor is most likely the smartest and most proper course of action when someone is experiencing abnormal psychological symptoms and then if they need to be referred further.

PSYCHIATRIST VERSUS FAMILY PHYSICIANS

GPs are trained excessively to treat a broad range of illnesses, but psychiatry is as delicate a branch of healthcare as any other specialty. Therefore it requires a comprehensive mental assessment by a healthcare professional and thorough follow-up. “The Human Mind is complex and is still being studied for all its mysteries.”

Therefore MDs who are explicitly trained in psychiatry ought to be sought out for long-term treatment. However, the PCP can screen and make the appropriate care decisions.

MENTAL HEALTH COLLABORATIVE CARE AND THE ROLE OF PCP

Collaborative Care Models (CCMs) provide a pragmatic strategy to deliver integrated mental health and medical care for persons with mental health conditions serviced in primary care settings. CCMs are teambased Interventions to enact system level redesign by improving patient care through organisational leadership support, provider design support and clinical information systems as well as engaging patients in their care through self-management support and linkages to community resources.

These methods are cost efficient strategies for primary care practitioners to improve outcomes for a range of mental health conditions across populations and settings. CCM can help achieve integrated care aims. Successful CCM in routine care

will require alignment of financial incentives to support systems redesign.

Mental health conditions are common and are the leading cause of disability worldwide. In the US, over 25% of the population is affected by one or more of these conditions at any one time.

In a primary care setting, a location where 70% of patients are diagnosed and treated for the most prevalent mental health conditions including anxiety, mood and substance abuse disorders.

With acute and chronic medical conditions (eg chronic pain, COPD, obesity) and psycho-social issues with the potential to exacerbate symptoms or undermine treatment outcomes, primary care is well situated as a medical home for provision of essential behavioural healthcare.

Despite the availability of effective mental health treatment, these interventions rarely employed in a coordinated approach in routine care to yield long-term improvement in mental health outcomes. Among patients with access to primary care who are accurately diagnosed with depression, fewer than 15% receive adequate treatment to achieve remission.

Primary care providers continue to encounter barriers to referring patients to specialty mental health settings while patient uptake to these offsite referrals remain low. Furthermore physicians, physician assistants and nurses often lack the time or training to effectively address mental health needs.

Recent systematic reviews found that CCMs are a cost-efficient strategy for primary care providers to improve mental and physical outcomes for a range of mental health conditions across diverse populations and primary care settings.

“The enactment of the US Mental Health Parity and Addiction Equity Act [MHPAEA] of 2008 and the US Patient Protection and affordable Act of 2010 [ACA] combine to present an opportunity to implement organisational and financial strategies to better integrate mental healthcare into primary care settings through CCMs.”

[David E Goodrich et al – Curr Psychiatry Rep. 2013 August 15/8:383]

Collaborative care is an underlying tenant in healthcare reform including into ACA mechanisms to control costs in complex patient populations.

It is important that mental health providers and PCPs have a vested stake in understanding current issues pertaining to mental health CCMs to better advocate for policies that can promote the uptake of this model to help achieve the Triple Aim of improving health and quality of care in a cost-efficient manner [David E. Goodrich et al].

KEY COMPONENTS OF COLLABORATIVE CARE MODELS FOR MENTAL HEALTH

Simply co-locating mental health professionals into primary care settings has been proven insufficient to improve mental health outcomes.

Collaborative Care Model (CCM) is a multi-component, Health System-level Intervention that re-emphasises the delivery of care so that care managers link PCP more efficiently with patients and mental health providers to improve evidence-based treatment of mental disorders.

CCMs are based on Wagner’s chronic care model that recognises that medical care tends to prioritise the treatment of acute symptoms over the need to properly manage individuals with chronic conditions.

CCMs are described as an iteration of the chronic care model that acknowledges mental health disorders also require longterm and systemic approach to foster access and continuity of care to achieve optimal management.

Mental health CCMs emphasise collaboration among a team of mental health providers and PCP within a practice to effect these changes including coordination of care with specialists and community resources outside of primary care.

Current CCMs for mental health are commonly identified by six components:

1. Organisational support from the healthcare system leaders for resource allocations and workflow restructuring.

2. Delivery systems redesign that emphasises care management.

3. Utilisation of clinical information systems.

4. Provider decision support.

5. Patient support for improved selfmanagement of health risks.

6. Linking patients to community resources.

These components not only empower providers with improved access to information that supports evidence-based decision making, but also serve to help patients take a more active role in treatment decision-making and managing their health outcomes. The basic component of mental health CCMs are predicated by the interrelated principles of populations-based management to identify panels of highrisk patients to track through electronic registries created with electronic medical records (EMR).

These information systems permit care teams to track the status of patients to anticipate the need for services and target preventative services. CCM are believed to improve care through the flow of more timely information to PCPs.

ESSENTIAL TO CCM HEALTHCARE IS ‘CARE MANAGEMENT’

Care managers facilitate the flow of information between patients and providers, also measure mental health symptoms and to track responses and side effects to specific medication dosages, treatment adherence and service dates that are essential to stepped care models. This information improves decision-making by improving PCPs’ ability to follow treatment guidelines to achieve more desirable treatment responses, [‘treat to target’ or patient preference] by adjusting/ switching medication and treatment with psychosocial treatments while empowering patients with better options to avoid the exacerbation of medical conditions. In CCM practice environment, PCP are part of a team and are responsible for screening and diagnosing mental health conditions, prescribing appropriate medications, and referring complex cases to specialist mental healthcare as needed. Collaborative communication between these providers and their patients is facilitated by the care manager usually a nurse, social worker, or other allied health professionals. Care managers also work with PCP by providing self-management support to patients through evidence-based psychotherapies, information provisions, skills training or health counselling or by linking patients to community-based wellness resources.

CCMS FOR MENTAL HEALTH ARE EVIDENCE-BASED CARE

CCM is an evidence-based strategy for management of mental health conditions in Primary Care settings. The increasing evidence also demonstrates the effectiveness of multi-condition/ cross diagnosis CCMs that aim to address depression and one or more medical comorbidities.

CONDITIONS AND FUTURE DIRECTIONS

CCM is a mental health strategy to deliver integrated care in primary care settings. The CCM applies concepts of population-based care, measurement-based care and stepped care to systematically track patients spikes to support improved patient and providerpatient decisions.

Financial and organisational incentives need to be aligned to ensure that both Public and Private Health plans have the capability to adopt and sustain the models effectively. It is also necessary to negotiate changes in the current fee for service and service carve outs to enable mental health providers to support PCPs in carrying out CCM care management and mental health specialist roles.

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

Initiative launched to address student wellbeing

Finally, support for students to thrive academically, emotionally and physically.

IN MARCH A ground breaking healthcare programme which is set to boost student well-being kicked off at Eduvos campuses countrywide. This forward-thinking initiative is set to address the intricate dynamic between students’ mental and physical health needs, signalling a transformative shift in the university’s approach to holistic student support.

Amidst a global surge in mental health challenges and considering alarming statistics from the World Health Organization (WHO) indicating suicide as the second leading cause of death among 15 to 29-year-olds, the imperative to address mental healthcare issues has never been more pressing. Recognising the profound impact of mental health on all facets of life, the need for an integrated, holistic strategy has emerged as paramount.

Dr Riaan Steenberg, executive director at Eduvos, affirmed the institution's commitment to meeting this critical need for comprehensive student support by partnering with leading multi-national full-service healthcare management company Universal Healthcare for the rollout of a tailored healthcare programme designed to address the intersection of mental and physical healthcare needs seamlessly.

"The progressive programme, aptly named u360™, will be deployed campus-wide, harnessing cutting-edge technologies and wellness counselling

EDITORIAL

EDITOR: Claire Rush McMillan

Claire.Rush@newmedia.co.za

NEWS WRITER: Nicky Belseck

Nicky.Belseck@newmedia.co.za

SUB-EDITOR: Gill Abrahams

EDITORIAL CONTRIBUTORS

Gerard Augustine, Dr Kgosi Letlape, Conrad Strydom, Prof Morgan Chetty.

support services in all 11 official languages to equip all students with the tools necessary to excel," stated Dr Steenberg. "By acknowledging the unique challenges confronting today's students, Eduvos endeavours to redefine the landscape of student wellbeing in higher education."

Dr Johan Pretorius, group chief executive officer of Universal Healthcare, underscored the significance of this initiative: "The u360™ programme represents a tried-and-tested model which is a highly adaptable, innovative solution designed to meet the demands of today’s high-pressure environment.

“The well-established elements comprising the service are underpinned by innovative new technology, and the service offering is packaged more effectively. More importantly, it has multiple applications to meet a diverse population’s health and wellbeing needs, where mental and physical wellbeing are intrinsically linked.

“The programme seamlessly integrates five key service offerings, catering directly to the needs of the modern, tech-inclined healthcare consumer. From the convenience of the uWellness™ app, providing around-theclock wellness support, to discounted virtual consultations through uConsult™, thereby revolutionising wellbeing on every level,” explains Dr Pretorius.

In pursuit of ultimate accessibility, the u360™service offering also

introduces mediBucks, a “healthcare payment Top-Up solution” providing seamless access to affordable prenegotiated medical consultations alongside discounted sessions with psychosocial counselling providers. Furthermore, the Universal Rewards programme incentivises holistic health with discounts on gym memberships and healthy eating plans.At the heart of the experience lies the Universal.one App, a centralised gateway to unlock all services. With seamless integration and intuitive navigation, the app ensures instant access to a range of innovative offerings, promoting optimal health and wellness. This comprehensive wellness app transcends the ordinary, addressing all eight dimensions of wellness –emotional, physical, intellectual, social, occupational, financial, spiritual and environmental. Packed with the latest research, uWellness™ offers a holistic, interactive approach to total wellbeing, including daily wellness tips, a mood checker, emergency contacts, self-assessments, calculators, health guides and a breathing coach for relaxation. "We firmly believe that the newly introduced programme will revolutionise student wellbeing.

The Eduvos and Universal Healthcare partnership underscores our steadfast commitment to providing comprehensive support both inside and outside the academic environment,” concludes Dr Steenberg.

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