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call to action We need your opinion! If you want a health system that works for you, GET INVOLVED! Post your views on our website www.medicalchronicle.co.za MEDICAL CHRONICLE The Doctor’s Newspaper Est 1965 | Circ 15 000 May 2012 HPCSA’s ‘Report a Doc’ Campaign likely to Hike Medical Costs Both the SA Private Practitioners Forum (SAPPF) and SAMA anticipate a rise in defensive medicine following the HPCSA’s launch of its patients’ rights awareness campaign. The campaign, announced in March by Dr Kgosi Letlape, the then acting CEO and registrar of the HPCSA, involves a series of national radio advertisements, broadcast in all official languages, which encourage patients to report doctors to the HPCSA if they feel their rights to good health or ethical standards have been breached. Dr Franco Colin, chairperson of the SAPPF, commented: “It is important to emphasise that no Dr Franco Colin, group of specialists SAPPF chair should ever find fault with the fact that any patient has the right to complain and the SAPPF stands firmly behind existing regulations in this regard. “However, this is an already extremely litigious era, with lawyers shifting from chasing Road Accident Fund cases to advertising their services to sue medical professionals. “By adding its voice to this call, I believe the HPCSA is effectively facilitating the whole process, which will lead to doctors practising medicine defensively in order to protect themselves.” Lack of logic He questioned the logic behind the HPCSA’s campaign. At its launch, Dr Letlape gave statistics of complaints lodged with the HPCSA, which showed no dramatic rise in complaints against doctors - in fact, complaints in 2011 had come down from those of the previous year and had remained relatively static for the past four years. “If you look at the ratio of doctors reported and Preferential Procurement SA Has What it Takes SA drug manufacturers are well geared to compete against the prices of imported generics, which account for roughly half of the generics supplied to the government. According to Stavros Nicolaou, chairman of Pharm aceuticals Made in SA (Pharmisa) and senior executive of Aspen Pharmacare, a large number of drugs used in the public health sector are generics, approximately 55% of Stavros Nicolaou, which are produced Pharmisa chair and locally. senior executive of It is likely, then, Aspen Pharmacare that generics will make up the bulk of the 70 oral solid dosage medicines (OSDs) that will be designated for local procurement under the Preferential Procurement Policy Framework Act. In terms of a joint announcement by the Department of Trade and Industry (DTI) and the Department of Health (DoH), the DoH will issue designation tenders for R2.5bn over the next two years where at least 70% of the tenders have to be procured from local manufacturing. Countering the perception that imported products are, by definition, cheaper than those produced in SA, Nicolaou commented: “Multinational generic companies that operate out of SA, like Aspen, have shown their competitiveness globally. Aspen is the ninth largest generic company globally by turnover. If you have a look at who is importing generics into the country, many of those companies don’t rank in the top 10, which is a clear indicator that SA producers are competitive.” He added: “Having said that, there are many other things that should be brought into the equation when looking at preferential procurement - it is not as simple as a price shootout. “When procuring for the public sector, it can be justified to pay a premium to buy something locally because of the added value to the economy, such as tax that would be coming into the fiscus and skills development, among others. Most of the BRICS (Brazil, Russia, India, China and SA) countries adopt this approach.” They also subsidise their exporters, giving them around a 15%-20% advantage. However, Nicolaou noted that the SA fiscus is not going to be paying more for the drugs than it did two year ago. “The DTI has worked with the DoH to produce internationally benchmarked reference prices for its tender released end April, that are going to be equal to or lower than the tender prices of two years ago.” The pros of preferential procurement The local drug manufacturing industry has existed in a rollercoaster environment until now, with an inability to predict volume impacting negatively on investment in capital expendure and technology, skills development and training, he said. “Preferential procurement will see companies becoming more competitive and improving productivity and efficiency. “It is all about improving economies of scale and when that happens, the platform will be created for exports, which is an extremely important factor to take into consideration,” he added. Vicki St Quintin, chief operating officer for the Pharmaceutical Industry Association of SA (PIASA), said that PIASA supported initiatives that benefit SA-based business and noted that, if necessary, companies will have to adapt their businesses in order to compete. “In terms of access to quality medicines, the system should be administered to ensure that prices do not rise,” she cautioned. Not all players happy Not all industry players are happy with the announcement. The National Association of Pharmaceutical Manufacturers (NAPM) believes it ... to page 2 doctors found guilty, it is a fraction of a percentage, which really makes this whole thing stick in the throat,” said Dr Colin. He added that Dr Letlape had displayed a similar ‘lack of logic’ when, at the recent Third Healthcare Summit, he accused doctors of overcharging their patients. Overcharging is another cause to lodge complaints against doctors and, while not a common reason for litigation, adds to the image of doctors as being untrustworthy. “The flaw in that statement is that for the past eight years, there has been no official fee in this country against which overcharging can be measured,” Dr Colin pointed out. “There was therefore no frame of reference for his allegations and, despite his official capacity, Dr Letlape could supply no statistics to describe the scope of the problem.” ... to page 4 // Highlights // Informed Consent Practice New Management Forum ADHD and Diet Are you Keeping up with doing it right? technology Fact or Focus on Thrombosis fallacy? P13 P27 P18 P51 Follow us on Twitter: @MedChronicle Visit our webpage: www.medicalchronicle.co.za page 2 | medical chronicle | May 2012 // News Capsules Aspen buys GSK drugs Local pharmaceutical company, Aspen, has reached an agreement with GlaxoSmithKline (GSK) to buy a portfolio of the international company’s over-the-counter brands for R2.1bn, subject to approval from the Competition Commission. The therapeutic areas of the products are analgesic, gastro-intestinal, respiratory, dermatology, infant care, vitamins and minerals, and include brands such as Philips Milk of Magnesia, Borstol, Zantac and Dequadin, sold in sub-Saharan countries, Australia and Brazil. The transactions will be funded from existing cash resources, existing credit facilities and new debt, the latter funding approximately 50% of the transaction, Aspen said. Sanofi to make cheap ARVs in SA French pharmaceutical giant Sanofi has signed a partnership with Indian company, Hetero, to manufacture cheap antiretroviral (ARV) drugs in SA. “The agreement with Hetero will allow Sanofi to produce ARVs locally and contribute to the government’s objective to secure 80% locally supplied ARVs,” said Christopher Viehbacher, chief executive of Sanofi, in a statement. Sanofi, which has seven factories in African countries, recently upgraded its factory north of Pretoria in order to meet the increased production. Circumcisions scale-up Right to Care will perform 125 000 medical male circumcisions in 18 months and help the Department of Health’s efforts to scale up circumcision countrywide, with technical experts, through support from USAID and funding from PEPFAR. The new Right to Care agreement builds on USAID investments in 15 high-quality, high-volume MMC sites servicing the Free State, Gauteng, KwaZulu-Natal and Mpumalanga. SAMA slams ANCYL CEO comments SAMA has slammed the ANC Youth League in Limpopo’s public criticism of health minister Dr Aaron Motsoaledi’s intention to recruit hospital CEOs with a healthcare management background, saying it was both disingenuous and unfortunate. “As the medical profession, we are not entirely sure what informed the league’s position on this particular issue. We know, however, that the minister’s decision was informed by a qualitative study into effectiveness and efficiencies in hospitals, coupled with several consultations with health practitioners and medical bodies,” SAMA said. SA HCT tool named for global award A local HIV/AIDS management programme is the only SA finalist in the Technology for Health category of the prestigious GBCHealth’s 2012 Business Action on Health Awards, which recognise exceptional programmes focused on long-term sustainability and achieving results. Developed by Metropolitan Health Risk Management’s HIV department, the HIV Counselling and Testing (HCT) webtool has sparked a dramatic increase in enrolment rates on HIV treatment programmes, as it enables healthcare providers to drive point of diagnosis enrolment, with the patient’s consent. Alzheimer’s test approved Pharmaceutical company, Eli Lilly, has received approval from the US Food and Drug Administration on a chemical that would enable doctors to detect a biological marker for Alzheimer’s disease. They can detect the marker now, but currently quantifying it can only be performed during autopsy. Detecting it early has the potential to not only identify people at risk for Alzheimer’s before they show symptoms, but it could help researchers searching for a cure. Outrage Mounting over DSP ‘Illegal’ Dispensing Fees The Independent Community Pharmacy Association (ICPA) is adamant that the setting of fixed dispensing fees by some designated service providers (DSP) appointed by medical schemes to deliver chronic medicines to their members is illegal, despite assertions to the contrary by the Government Employees Medical Scheme (GEMS). The apparent disregard of regulated dispensing fees, finalised in 2011 after years of discussion and debate among stakeholders, and the lack of action by regulatory agencies including the Department of Health (DoH), the Competition Com mission, Council for Medical Schemes (CMS) and SA Phar maceutical Council (SAPC), is a source of concern, according to Sham Moodley, ICPA chairperson. Sham Moodley, The government’s ICPA chairperson four-tier model clearly indicates the parameters for dispensing fees. However, GEMS’ DSP, Medipost, charges a composite fee of R24.73 for each line item. “The regulations are clear. Dispensing fees should be transparent and should be free of nonhealthcare costs. In the case of GEMS, patients are paying for a range of nonhealthcare costs, including data fees, administrative call centre, extensive data analysis, comprehensive reporting on prescription usage and compliance trends and IT capability, among others,” Moodley pointed out. The precedent set by Medipost may lead to other pharmacies following suit. “Indeed, we have already also received another complaint for similar application of a flat dispensing fee by Clicks Direct, which charged R29.64 per item irrespective of the single exit price of the item,” he noted. Freedom to choose Moodley sketches a scenario in which the plight of independent pharmacies fighting for survival in an increasingly anticompetitive market is as much a fight for the consumer’s freedom to choose. “If a doctor prescribes a certain medicine, the pharmacist is obliged to offer a generic, which is more cost effective for the patient, and the patient Preferential Procurement - SA Has What it Takes ... from page 1 has been sidelined by the DTI, as it drew up plans for preferential procurement for domestic medicine makers. The association is one of several local trade bodies for pharmaceutical companies and represents about half of those selling generic drugs, many imported from India. NAPM CEO Charles Mothata said: “We are not saying there should not be incentives for local manufacturers, but the way the list has been structured compromises cheap and affordable medicines. We support incentives but not to the detriment of importers.” He said NAPM would be meeting with the DTI to discuss the matter. Val Beaumont, executive director of Innovative Medicines SA, believes a more formalised and rigorous process of stakeholder engagement may have resulted in a more balanced and implementable Val Beaumont, policy. IMSA executive director can then make a choice as to which he or she prefers,” said Moodley. Doctors in the disadvantaged community where he works tend to make a habit of prescribing cheaper alternatives, he said. “However, I recently had a patient who went to a specialist and was prescribed four items. This was faxed to Medipost; he wasn’t offered a cheaper alternative and he ended up paying more than if he had brought his prescription to us. “He also had the inconvenience of having to collect his medicine from the post office, and not being able to pay at the point of purchase.” “When patients are not offered the cheapest alternative, as required by the regulations, we’ve seen how this can result in them having huge outof-pocket payments, examples of which we have previously provided to the DoH,” said Moodley. Responding to an apparent conflict in its document: GEMS’ position on chronic medication relating to whether or not its fixed fee is outside of the regulated requirements, GEMS principal officer, Dr Eugene Watson, said: “With regard to the perceived contradiction, it is noteworthy that Dr Eugene Watson, two separate points principal officer, GEMS are made. “Specifically, the DoH is aware that the fee paid by GEMS to its chronic DSP is a composite fee per line item on all four tiers, which is inclusive of a dispensing fee, courier costs and other nonhealthcare service elements that the DSP is required to provide to GEMS under the contract between the parties. The DoH is aware of the extent to which the fee paid to the DSP extends beyond dispensing, as defined in the medicine regulations. “In addition, the scheme believes that it has not contravened the medicine pricing regulations, as was alleged in the media and by way of the related complaints submitted to the CMS, Consumer Commission and health department,” Dr Watson told Medical Chronicle. However, Moodley pointed out that patients are not aware that they are paying for these services and that any courier costs or fees ‘beyond dispensing’ must be defined and charged for separately, in accordance with the South African Pharmacy Council Board Notice 193 (2010) Rules: Services for which a pharmacist may levy a fee and guidelines for levying such a fee or fees. “Furthermore, nonhealthcare service costs are not for the patient’s account. It cannot come out of patient funds - least of all if they are Prescribed Minimum Benefit conditions,” he said. “As these nonhealthcare costs are catered for in the Medical Schemes Act related to administration fees that schemes are entitled to charge, this can be construed as double dipping.” “The sustainability of the imperative with respect to the capacity of the relatively limited pool of local manufacturers to supply 70% of tenders for designated products must pose a risk for the security of the supply of prescribed medicines to patients,” she said. “Application of the policy will be a challenge for all parties due to apparent contradictions within the drafting in relation the SABS standards and BBBEE legislation, which all need to be aligned. There is also lack of clarity on defining parameters. “At this stage, and until we see how effective the measure is in achieving the access objectives of the DoH, the medicines importers will continue to supply medicines and to be involved in consultative processes.” to decentralise manufacture from traditionally favoured locations such as Singapore and Puerto Rico, and start reinvesting in this country.” For example, he said, if a company like Aspen, which owns factories all around the world, had greater certainty and incentives, it could increase its investments in SA and consider manufacturing here, for other countries such as Australia and Brazil. If the total public and private pharmaceutical market is currently worth around R29bn, Nicolaou believed that, given the right circumstances, the company could grow to the size of the entire SA market within the next two-to-three years. “That’s the benefit of building these linkages and international platforms,” he said. “Designating products for local procurement is a first step and shows the government’s intention,” he continued. “Hopefully, they can build on that and if they do, multinationals will eventually start being attracted back to SA. If multinationals invested in SA, it would be for those products that treat diseases and epidemiologies, like infectious diseases, that are specific to SA and the region. Manufacturing in SA would provide an opportunity for companies to start supplying the sub-Saharan region and once they start exporting, additional revenue will be generated that can be invested into other areas. “People underestimate the role that exports can play,” he concluded. Multinationals in ‘neutral position’ Nicolaou does not believe that multinational pharmaceutical companies are going to be affected badly by the announcement. “They contribute very little to public sector procurement where comparatively few innovative drugs are used. When they are, they are not usually produced in this country anyway.” However, he added: “I would personally hope to see the government beginning to address multinational production, and research and development in this country, by offering incentives such as tax breaks. “This could see more multinationals beginning Patients not getting full services “There is sufficient data available suggesting that in order to improve the healthcare status of chronic patients, they need constant interaction with their healthcare professional such as the pharmacist to ensure that they not only get their medicines, but that they take them,” Moodley continued. However, Dr Watson noted: “The chronic DSP is a registered pharmacist and has been registered as such by the SAPC. The scheme’s managed care provider, clearing house and chronic DSP all play an active role in implementing managed care tools to contain medicine expenditure. Drug reviews, utilisation reviews, clinical interactions and contraindications, and the use of generic medicines are among the various elements managed by way of real-time clinical rules, management intervention and claim and authorisation analyses.” Responding to concerns over patient inconvenience and the fact that quality of medicine may be compromised by being left in a post office for too long before collection, he said: “Members choose whether they would like their medicine delivered to their home, place of work, local post office or any other preferred destination. “Medicines requiring the maintenance of a cold chain are managed with due regard to the need to ensure that these medicines are not exposed to unwanted temperatures. Importantly, members requiring these medicines are encouraged to use the door-to-door service. “The maintenance of cold-chain capabilities forms part of the contractual requirements that the chronic DSP are required to adhere to and as such, special delivery and packaging processes apply to these medicines. When a parcel is not collected within 24 hours, it is returned and reissued at no cost to the member.” medical chronicle | May 2012 | page 3 News // Doctors the ‘Whipping Boys’ of So-called Rampant Healthcare Inflation: SAMA Doctors are getting a raw deal, both in terms of their share of money spent on healthcare in SA, as well as their public image as fuelled by the HPCSA and the general press. Although not stated as such, this was a key message at the recent SAMA press conference in Pretoria, where the association presented its views on three critical challenges facing doctors and healthcare in general in SA: the attitude of the HPCSA, NHI and the need for more doctors, and what it termed “the true cost drivers” of healthcare in the private sector in SA. Acting chairperson and spokesperson, Dr Mark Sonderup, spent some time analysing allegations contained in a recent press statement by the HPCSA, wherein the council made several assertions based on the fact that it believes there is a decline in professionalism in the medical profession in SA. “We noted that with extreme concern,” he said. The first reason for the HPCSA’s assertion was the number of complaints it had received over the past four to five years, which, it claimed, showed a year on year increase. “When one analyses the hard core data, however, they are processing about 2500 complaints per year and although there was a chance increase in 2010‑11 to about 2900, this came down again to around 2400 again for the 2011-12 cycle, so we’re not sure of the basis of this allegation.” HPCSA’s reasons for the alleged decline in professionalism, being an increase in inappropriate relationships between doctors and their patients, was unethical and should not be tolerated, but pointed out that the numbers were in fact ‘not stark’. The third reason given by the HPCSA was that medical insurance groups such as the Medical Protection Society (MPS) have been noting a rise in the amount of money they are paying out to people claiming medical negligence. Dr Sonderup responded: “I’ve had personal Pricing vacuum cause of most complaints interaction and discussions with the head of the MPS based in London and they have assured me that this is not unique to SA. It is the same trend that they are seeing in other countries such as Australia, New Zealand and the US. So this is not unique to SA, and reflects an unfortunate worldwide trend.” Referring to the HPCSA’s patients rights campaign, he said: “As SAMA we have no issue with those who feel aggrieved in terms of the way they have been dealt with by a practitioner, having the right of access to complain. “But the HPCSA’s mandate is to protect the public and guide the profession. It is not there to tout for people to lay complaints. We would rather say it is the role of the HPCSA to guide the profession and the question I have to ask is, what have they done to increase professionalism? With all due respect, we find that somewhat wanting.” He further pointed out that the majority of complaints to the council relate to issues of billing and overcharging. The lack of a benchmark for what constitutes an ethical tariff is the core reason for this phenomenon, and can be blamed on the Competition Commission ruling in 2004. This effectively destroyed the previous method of publishing guidelines, which up until then, was working well and provided an accepted yardstick against which to gauge the fairness of fees. “Once this decision is reversed and the issue effectively dealt with, I believe we will see the numbers of complaints of overcharging drop quite dramatically,” said Dr Sonderup. He added that the overall number of doctors that have been struck off the role (an average of four per year) represents just 0.001% of SA doctors. “This is an extremely small number and has remained pretty much constant, so I’m not quite certain how, again, this indicates a decline in professionalism within the country.” Dr Sonderup agreed that another of the Dr Mark Sonderup, SAMA’s acting chairperson and the chairperson of the association’s public sector doctors’ committee, Dr Phophi Ramathuba at the media conference Administrators taking lion’s share Cost drivers in private healthcare were the second arena in which doctors were being unfairly targeted, according to Dr Sonderup. “We are all too aware of the fact that we’re often the whipping boys or girls of the so-called rampant healthcare inflation that exists in the private healthcare sector.” He called for more ‘cat-footedness’ when analysing the so-called not-for-profit nature of medical schemes. “We all know there are many aspects to managing healthcare, through subsidiary companies and management companies that are in fact for-profit companies - and they are turning a very healthy profit in this country.” Data from the Council for Medical Schemes showed that, in 2010, approximately 13% of all expenditure in private healthcare, amounting to just under R12bn, was spent administering healthcare, which was almost two thirds of the amount paid out to specialists (19.5% of expenditure). “When you look at the amount paid out to GPs, who are the cornerstone of any healthcare delivery system, the situation is appalling. They accounted for 5.5% of the total expenditure, a figure that has been in real terms, declining over many years. The raw amount of money paid out to GPs amounts to just under R5bn, which is less than 50% of the amount spent on administering healthcare. “I think the facts speak for themselves and our position is quite clear. We do not believe doctors are responsible for this so-called rampant inflation in healthcare costs. There are many other players in the system; it is a monolithic bureaucracy in which doctors really are just bit-players. “From our perspective, it is an increasingly regulated area and the ability of the doctor to do what he or she is trained for and wants to do, to look after patients to the best of their ability, is becoming increasingly difficult in the private sector.” Doctor shortage a serious issue for NHI Finding ways to train more doctors and keep them in the country was the second most important message at the briefing, which was addressed under the subject of NHI. According to Dr Sonderup, the number of doctors registered in SA was, at best guess, around 26 000, which was almost equal to the numbers of SA-trained doctors working overseas (23 400). “If the ideal doctor-to-public ratio is around 1:1000, the ratio in Brazil, which compared well to SA, is approximately 1.85 per 1000 population, whereas SA is sitting at 0.77:1000. So we are really quite far off the mark and this is an area of big concern for us - this is a very serious issue,” he said. While the Cuban training programme Contents News Opinion 1 22 Clinical Cardiac Medicine 23 Thrombosis & Haemostasis Forum 27 Aesthetic Medicine 28 Spine 32 Tuberculosis 34 Asthma / Allergies 37 Gastroenterology 38 Fertility Forum 41 HIV 42 Oncology 44 Pain Management 46 Sexual Health Forum 48 Psychiatry 49 Winter Ailments 53 Women’s Health 58 Wound Care 61 Periscope 62 introduced around a decade ago was commendable and achieved some ends, he asked whether, in 2012, these resources would not be better spent on training doctors in SA, where the burden of disease was very different from that in Cuba. Dr Sonderup noted that NHI was but one factor in the government’s 10-point turnaround strategy, and that unless all other nine points were addressed, which would involve all departments in the SA government, NHI would not succeed. SAMA’s public sector doctors’ committee chairwoman Dr Phophi Ramathuba, emphasised that improved infrastructure was critical to the success of NHI. More training institutions - ideally, one in every province - and improved incentives for doctors to work in rural areas was something the government would have to address, she said. She felt more needed to be done to highlight the role of doctors in SA, whose sacrifices and commitment went largely unnoticed. As part of that, SAMA is planning to hold a national Doctor’s Day later in the year, when patients will be encouraged to share positive stories about their doctors. Surgical Groupings Unite to Bolster Bargaining Power Recognising the power of unity when dealing with issues of common interest, surgical societies, associations and affiliated groups have established an umbrella organisation tasked with representing them in negotiations with government, medical schemes and other stakeholders in the healthcare industry. The main objective of the Federation of South African Surgeons (FoSAS) is to foster cooperation between the different surgical disciplines and allied groupings to strengthen their bargaining power on matters concerning their future and the wellbeing of their patients, explained Dr Elmin Steyn, FoSAS president and until recently, president of the Trauma Society of South Africa. “Although professionals in the surgical field face similar problems, many of the groupings such as those in trauma, hepatobiliary and transplantation fields are too small to carry much weight when it comes to negotiations on issues such as funding, billing, working conditions in the public sector and the shortage of equipment,” said Dr Steyn. Growing support Since the launch of FoSAS earlier this year, 10 organisations have signed up as members and it is hoped that more will join to make it a force to be reckoned with, not only in negotiations with the Department of Health and funders but also in creating partnerships with other stakeholders such as the medical devices and pharmaceutical industries. But Dr Steyn stressed that FoSAS is not a selfserving organisation focused only on improving the practices, income and working conditions of its members. “Uniting all these multifaceted groups can make a big difference to the care we offer our patients, improving clinical practice, and preventing injury, complications and poor outcomes in surgical care irrespective of whether it is a trauma, cancer or transplant patient,” she said. FoSAS general secretary and head of the Department of Surgery at Wits, Prof Martin Veller, said the federation has already met with the Board of Healthcare Funders on issues related to the cost and coding of surgical services in the private healthcare sector and the future availability and sustainability of surgical services in the country. Referring to the proposed National Health Insurance system and the HPCSA’s plans to revive its ethical tariff, Dr Steyn noted that a united organisation will be much more effective in ensuring that members’ input and rec om mend at ions are taken seriously in consultations on these crucial issues. Prof Martin Veller, FoSAS general No threat to secretary and head of the department of nonsurgical surgery at Wits organisations However, Dr Steyn emphasised that FoSAS should not be seen as opposition to SAMA or the SA Private Practitioners’ Forum, but as a group representing the specific interests of all surgeons and practitioners linked to surgery, including emergency medicine doctors, paramedics and nurses. “The aim is to unite groupings involved in the surgical field and not to alienate nonsurgical organisations,” said Dr Steyn. Current members include the Association of Surgeons of SA (ASSA), the Vascular Society of Southern Africa, the College of Surgeons, Surgicom, the Trauma Society and organisations representing endoscopic and paediatric surgeons, and surgeons in training. The brainchild of Prof Veller and ASSA chairperson, Prof Sats Pillay, the development of FoSAS started five years ago at a meeting of general surgical societies. It was then agreed that the mandate of the federation would be to address issues of common interest including surgical education and congresses, professional affairs, patient advocacy and private practice affairs, Dr Steyn said. To prevent the domination of bigger organisations over smaller ones, its executive committee is made up of two senior members of each member organisation with the presidents of these organisations appointed as chairperson on a rotational basis. For more information, contact Susan Parkes on 011-717-2080 or email [email protected] page 4 | medical chronicle | May 2012 // News New State Hospital Opened in Western Cape A new 240-bed public hospital has been opened in Khayelitsha in the Western Cape, which will provide healthcare to between 500 000 and 1.5 million people in the area. According to the provincial Department of Health, the new facility is expected to lighten the load of the overburdened GF Jooste and Tygerberg hospitals. The construction of the R632m hospital was approved in 2005 and building started in 2009. Services provided at the facility include surgical, medical, paediatrics, obstetrics and a medical day ward that is used predominantly for ARV referrals. Apart from a large accident and emergency unit that is 30% larger than that of a standard district hospital trauma unit, it also has a large maternity ward and obstetrics unit. It is also the first hospital in the Western Cape to have an e-filing content management system that will allow staff and medical practitioners to access patient folders electronically. Describing it as is one of the best public health institutions in Africa, Western Cape Premier Helen Zille highlighted the Khayelitsha Hospital’s significance in advancing redress and promoting equity. “For the longest time, there has been inequitable access to quality health services across society. This hospital is one of many interventions undertaken by the Western Cape Government to overcome the legacy of our past so that all people in the province have access to quality healthcare,” she said. According to Theuns Botha, the provincial health minister, the opening of the hospital marked a milestone for improved service delivery in the Western Cape as it finally provides the people of Khayelitsha with access to a hospital in their immediate vicinity that ‘compares with the best in the world’. HPCSA’s ‘Report a Doc’ Campaign likely to Hike Medical Costs system by which they can make complaints or seek redress, it needed an effective system to run such a system. “In our experience, we have noted that there can be a significant lag between when a complaint is lodged and when it is actually resolved. In light of this, we would be concerned that a ‘surge’ in complaints which could be triggered by this type of campaign would only lengthen resolution times. This would be frustrating for the doctor and for the patient.” He said MPS would be happy to work with the HPCSA on how efficiencies to the current complaints system could be made. ... from page 1 At that conference, Dr Letlape publicly stated that the lack of a pricing structure led to doctors ‘acting like healthcare idiots instead of healthcare professionals’, a statement which Dr Colin believes added insult to injury and was in conflict with the HPCSA’s own of Ethical Rules of Conduct. “Doctors are not allowed to in any way belittle, slander, insult or undermine their colleagues to patients, and we are considering reporting Dr Letlape to the HPCSA for unethical behaviour,” said Dr Colin. Doctors already acting defensively Helen Zille, Western Cape Premier, and health minister Dr Aaron Motsoaledi at the opening of the Khayelitsha Hospital Get Medical Chronicle on your Phone ... Medical Chronicle is moving with the times and is now providing its readers with easy access to all its webbased content through a Quick Response (QR) code. All that you need is a smart phone with a camera and an installed QR code reader application (app) that is available on most of the newer mobile phones or can be downloaded for free from any app store. In the future, as you browse the magazine, keep an eye open for the codes inserted at the end of articles scanning these will allow you to access some unique related information; be it video, audio, pictures, interviews or references. The process of reading a QR code is similar to taking a photo. Look for the QR code in Medical Chronicle, open the code reader app on the phone and point the camera at the code. Some apps will automatically scan the code but others require the user to press the phone’s camera button. After you have scanned the code, it will only take a few seconds to load the link to our website (www.medicalchronicle.co.za) on the phone where it can be saved for use whenever or wherever you want to access Medical Chronicle’s up-to-date news, clinical content or archived articles. Medical Chronicle hopes readers enjoy this new innovation and looks forward to being able to offer more depth, value and interactivity through it. ... or on Your iPad Medical Chronicle is now also available on your iPad! For more information, visit www.medicalchronicle.co.za He believes that doctors were already acting increasingly defensively and were feeling the effects of a rising number of complaints from patients. “The HPCSA’s campaign is certainly going to fuel this trend,” he said. Dr Colin noted that despite the fact that most complaints against doctors are thrown out as unjustified, doctors are never pronounced ‘not guilty’; rather, they receive a notification that ‘no further action will be taken against them’. “This creates tremendous anxiety for the doctor and inevitably he or she will go to greater lengths to avoid this kind of stress again. So they start ordering more blood tests or scans just to safeguard themselves against a possible complaint. Although we are very aware of the costs of these interventions, we feel increasingly compelled to do them.” Increasing litigation also drives up practitioners’ overheads. For example, the annual malpractice insurance for an obstetrician is R180 000. “This means that an obstetrician will have to do more than 20 deliveries before that cost is covered,” he pointed out. “The day will come when no one will want to deliver babies.” Minister aware of problems According to Dr Colin, these problems were raised with the health minister at a meeting with the SAPPF at the beginning of the year. Although they have not yet received feedback, they strongly suggested that a ceiling be set on the amounts that can be claimed for malpractice, as is the case in Australia, in order to avoid a situation where the healthcare system becomes financially bankrupted by claims. “Three months later, however, the minister’s own HPCSA is launching a media campaign that will encourage litigious behaviour among patients and fan the flames of healthcare costs.” At a recent press briefing, Dr Mark Sonderup, acting spokesperson for SAMA, described the HPCSA’s campaign as being tantamount to touting, which is increasingly prevalent among ‘ambulance-chasing’ attorneys. “We need to tread carefully before encouraging the public to lay complaints,” he said. “We are a country with an enormous burden of disease. We also have a very proud heritage of our doctors practising common sense medicine that is appropriate for the patient’s needs. If we deviate from that, I think the healthcare system in this country will implode.” He described the US as a prime example of how litigious medicine drives up costs in a healthcare system. “Encouraging willy-nilly reporting among patients is a dangerous path to start treading for a healthcare system that certainly cannot afford that.” (For the full story on the press briefing, see page 3) Dr Graham Howarth, the Medical Protection Society’s (MPS) head of medical services in Africa, pointed out that while it was important for patients to be aware of and have access to a clear and efficient We are aware of the costs of these interventions but feel increasingly compelled to do them No drop in professionalism among doctors “It’s also important to reiterate that we don’t believe there has been a drop in the level of professionalism among doctors, nor have we seen diminished levels in the quality of patient care. If anything, there has been an increase in patient awareness and willingness to raise issues, and this is one factor for the rise in clinical negligence costs that we have seen in recent years.” “We know that the risk of a complaint is a reason that doctors practise defensively. In 2010, the MPS surveyed more than 3000 members in seven different countries, including SA. The survey revealed that 73% practised defensively to avoid complaints and claims and 78% noticed their colleagues practising defensively, e.g., ordering more tests than were medically necessary. “This sort of behaviour is not always in the patient’s best interests and could lead to further complaints, for example, requesting unnecessary, invasive tests. So, as well as introducing additional and avoidable costs, in an already financially pressured health system, there is a risk that doctors who practise defensively would only exacerbate complaints and claims. It could also affect the relationship of trust if patients feel their doctors are trying to ‘cover themselves’.” Dr Letlape dismissed the profession’s fears as ‘hearsay and speculation’. “Litigation has nothing to do with optimal care. If you know the issues relating to your profession, keep up with your knowledge and know what constitutes the international clinical guidelines or protocols for management of particular illnesses in SA and stick to those, there is no problem. “As long as you are treating according to what the reasonable doctor considers is best practice, that will be enough.” To view the full media conference, go to http://www.medicalchronicle.co.za/sama-slamshpcsa%E2%80%99s-%E2%80%98report-adoctor%E2%80%99-campaign/ page 6 | medical chronicle | May 2012 // News Docs Urged to Familiarise Themselves with New Drug Schedule Changes A number of changes to the schedules of the Medicines and Related Substances Act, 101 of 1965 were recently published by the Minister of Health and are effective immediately. According to Lorraine Osman, head: public affairs at the Pharmaceutical Society of SA (PSSA), all prescribers and suppliers of medicines need to be aware of the changes and the implications for both consumers and healthcare professionals. Scheduling status of nicotine “In cases where a substance appears in more than one schedule, the default schedule for the substance is the highest schedule in which it is listed,” explained Osmond. All entries of the same substance in lower schedules indicate an exception to the default schedule. To illustrate this point, the scheduling status of nicotine becomes easier to understand if read from Schedule (S) 3 to S1. S3 states that nicotine, when intended for human medicinal use as an aid to smoking cessation or as a substitute for a tobacco product (as defined in the Tobacco Products Control Act, 1993, as amended), is an S3 substance, except when registered and presented as nicotine gum or lozenges (S0, S2), metered sprays containing 1mg per dose or less (S2), nicotine transdermal patches for continuous application to the skin (S1, S2), oral solid dosage forms containing 2mg or less (S2) or as inhalers containing 10mg or less per cartridge (S2). “In other words, nicotine is an S3 substance if it is intended as an aid to smoking or as a substitute for a tobacco product,” she said. Exceptions are however made for products that comply with the requirements for sale in a pharmacy as S1 or 2 substances, and for those that may be sold as S0 products, i.e. in general retail outlets. “One of the interesting aspects of this change is that there has been a lot of debate about whether or not the electronic cigarette (e-cigarette) is now scheduled and may only be sold on a doctor’s prescription,” noted Osmond. The Pharmaceutical Society of SA requested the Medicines Control Council (MCC) to clarify the scheduling status of nicotine, with particular respect to so-called e-cigarettes. The response pointed out that nicotine, when sold as a substitute for a tobacco product, will be classified as an S3 substance, unless the product is registered by the MCC after consideration of its safety, quality and efficacy. All other nicotinecontaining e-cigarettes that are used as a tobacco substitute, whether registered with the MCC or not, may therefore be sold only on prescription.” Ibuprofen - a case of down-scheduling In some cases, use for a particular indication has resulted in a schedule change, with the remaining indications continuing to be controlled by the existing schedule. For example, ibuprofen, because of its use for conditions that require accurate diagnosis and appro priate monitoring, such as osteoarthritis or rheumatoid arthritis, is listed in S3. When intended for the treatment of a haemodynamically significant patent ductus arterious in infants less than 34 weeks of gestational age, however, the MCC has placed it in S4. Ibuprofen may be sold in a pharmacy without a prescription for schedule-defined conditions, primarily mild to moderate pain or fever of inflammatory origin, posttraumatic conditions and acute gout attacks. Patient age, daily dose, pack size and maximum treatment period are defined in S2. Single ingredient, solid-dosage forms of ibuprofen have moved from S2 to S1. These products, which contain ibuprofen as the only active therapeutic substance, and intended for the treatment of mild to moderate pain or fever of inflammatory origin or for the treatment of posttraumatic conditions in adults and children over 12 years of age, may be sold as S1 products, provided that the pack does not exceed 24 dosage units and the recommended daily dose does not exceed 1.2g for adults or 20mg per kilogram of body weight for children of <12 years. Combination products, oral liquid products and those intended for children aged 1-12 years, if for these indications, remain in S2. Up-scheduling Until the middle of March, alginatic acid and its salts could be sold as S0 products. Because of new evidence, however, the MCC has placed products containing these substances in S4 when they are intended for use in gastric regurgitation, gastrooesophageal reflux and reflux associated with hiatus hernia in infants and young children <6 years. For all other uses and indications for children >6 years and adults, the products remain S0. “A matter of concern is that although alginatic acid can now no longer be used for children under six years old unless on instruction of a medical practitioner, there are currently a number of products available as S0 that have packaging and package inserts indicating that they may be used from the age of two years,” Osmond pointed out. Correspondence with the MCC has indicated that pharmaceutical companies normally have six months to implement any new packaging and regulatory requirements. medical chronicle | May 2012 | page 7 News // Change of Qualifications May Exacerbate Shortage of Radiographers Concern has been raised over a pending shortage in radiographers available for community service, following a decision to change their qualifications from a three-year radiography diploma to a fouryear degree. Radiographers have already been declared a scarce resource by both the Department of Health and Department of Labour. This year alone, 64 radiographers will qualify from the University of Johannesburg, one of the major producers of radiographers in Gauteng, the province with the greatest demand for these skills. If that number alone were to be unavailable for community service next year, it would significantly impact on the skills required in government hospitals, which rely on a steady intake of newly qualified radiographers to perform day-to-day x-rays in theatres, emergency departments and wards, and provide general assistance for more complex imaging procedures under the supervision of hospital radiologists. However, Mable Kekana, head of the Professional Board of Radiography and Clinical Technology at the HPCSA and head of the University of Pretoria’s radi ography department, has played down the concerns. “Not all of the eight institutions in SA that offer radiogra- Mable Kekana, phy have yet made head: radiography application to run department, UP the courses. Once they have done so, they will have to go through an accreditation process, whereby the HPCSA will inspect and approve the curricula before the institutions can commence with offering the degrees. “I would imagine the first would only be ready to commence with the four-year courses in 2014,” she said. “Accreditation will not happen at the same time, but will likely be staggered over a few years, so it is not as though there will be no radiographers available for community service in a particular year.” The new degree courses will enable students to register to qualify on one of four different areas: diagnostic radiography, ultrasound, nuclear medicine or radiation therapy. There will be no bridging courses from one qualification to another, but students may receive credit for certain common modules. According to Kekana, the decision was taken after several years of consultation, based on the changes in the Department of Education, the SA Qualifications Authority and National Qualifications Framework. “Members of professional bodies, radiographers and all eight institutions sat together with the standard regulating body and saw fit to move from the three-year diploma to a four-year degree,” she explained. Private hospitals must become more involved She added that increasing the number of clinical training facilities will also help to generate more students. “For us to be able to produce the large numbers that are needed, the private sector must also become more involved. Private radiology practices can approach the universities close by and become accredited to have students training there from as early as first year.” However, training facilities are dubious about the benefits of the new qualifications. Radiographer Wendy Biggins, who now works for a medical imaging company, said: “There are a limited number of training opportunities that can be sustained by any training facility. “There is currently a high need for diagnostic radiographers with an extra ultrasound qualification. Now, the facility will have to make space for two separate people, one qualified in diagnostics and the other, in ultrasound.” Other radiology practices have expressed dissatisfaction in that, having trained students for four years, many leave and do not return after their year of community service, so the practices do not benefit from their years of input into the students. Advanced Prostate Cancer Treatment Finally Available in SA Legal Action White South African males’ chances of developing prostate cancer are one in 11. Until recently, only standard treatment options were available to local patients, which include external beam radiotherapy, prostatectomy, low-dose-rate (LDR) seed brachytherapy and/or drug therapies. The good news is that temporary interstitial high-dose-rate (HDR) brachytherapy is now available in SA. The procedure is currently only available at the Charlotte Maxeke Johannesburg Academic Hospital, but it is something that he hopes will soon change, said Prof Vinay Sharma, head of radiation technology at the hospital and the University of the Witwatersrand. Brachytherapy or closed-source radiation has been in use since the early 1950s. Radiation is administered using different intensity levels including LDR, medium-dose-rate and temporary HDR. LDR brachytherapy is most commonly used. With LDR, the source of radiation stays in place for one to seven days and patients are hospitalised for the duration of this treatment. With HDR brachytherapy, the radiation source is in place for 10-to-20-minute periods and then taken out - thus not only limiting the patient’s exposure to radiation, but also his/her hospital stay. The treatment can also be offered on an out-patient basis. Over the past few years, the use of temporary HDR has gained popularity thanks to the development of the Syed-Neblett Prostate Implant set by Prof Nisar Syed in the late 1980s. Prof Syed, who is based at the department of radiology oncology at the University of California, Irvine (US) and director of the department of oncology at Long Beach Memorial Hospital, is considered the world’s leading expert in the field of HDR brachytherapy and has performed more than 2000 prostate cancer procedures to date. The set, however, is not only suitable for use in prostate cancer, but is also used in the treatment of breast, rectum and cervical cancer, and has become the international standard of care in the use of brachytherapy treatments. To demonstrate the use of the ‘revolutionary’ Syed-Neblett Prostate Template Implant set to local public sector radiation oncologists, Prof Syed and his team presented workshops at the Charlotte Maxeke Johannesburg Hospital in March. The workshops were organised by Prof Sharma and were attended by more than 100 radiology oncologists, urologists and physicists. As part of the presentation, two patients underwent the procedure. According to Prof Sharma, they are doing ‘extremely well’ and have not reported any side effects to date. He did not want to speculate why it has taken this long for the procedure to be introduced in SA. In fact, he said, he was very surprised when he first arrived in SA from India in 2003 to find that the technique was not used locally - especially in light of the fact that research indicates that the fiveyear disease-free survival rate of patients who have undergone this technique is 90%. Syed-Neblett set Prof Nisar Syed, inventor of the revolutionary Syed-Neblett Prostate Implant Set, demonstrated the use of the device to local oncologists, urologists and physicists, during a workshop held at the Charlotte Maxeke/ Johannesburg Academic Hospital The set comprises a template or guide, an applicator (catheter) as well as steel, plastic or titanium needles and plastic tubes. The tubes are used to connect the needles to the HDR remote after-loader. The template or guide is made from silicon, has a hole in the middle which allows for the placement of the catheter/tube if needed and is 2cm thick and 6cm × 5cm in dimension. The template makes provision for the placement of up to 18 needles. The placement of the needles is guided by a transrectal ultrasound probe, which makes it possible for the radiation oncologist and urologist to insert the silver or gold marker seeds to outline the prostate gland and accurately delineate the areas that need to be radiated. Before the treatment is started, dummy catheters are inserted into the needles and scans are done. This allows the radiation oncologist to review the placement and adapt his/her treatment strategy accordingly, explained Prof Sharma. Advantages Not only is this procedure much safer because it allows for effective dose escalation of radiology while minimising toxicity, but it also significantly shortens treatment and recovery times. The procedure can be done under spinal or general anesthesia, which takes approximately 45 minutes to complete. Depending on the extent of the disease, four or five treatments are delivered over two days - one in the morning and once in the evening. Patients are given epidural blocks to manage pain. Another advantage is the fact that the template does not have to be removed between treatments, thus causing the patient less discomfort. What makes this technique even more attractive is the fact that no additional capital expenses are required. Standard equipment used in radiation oncology such as a computer tomography imaging scan or x-ray machine, an ultrasound machine and an HDR remote after-loader are all that is needed. It is also much cheaper than LDR brachytherapy (R120 000 inclusive of seeds, treatment planning, CT scans etc. vs R16 000 for the template and needles as planning is done by the present staff), which makes it ideal for use in public hospitals. Other advantages include the fact that the template and needles can be reused and the position of the seeds can be altered, something which is not possible in LDR brachytherapy. Not suitable for all patients The technique is suitable for patients with low-, intermediate- and high-risk prostate cancer, but not for patients whose cancers have metastasised, explained Prof Sharma. He believes that this technique will become one of the gold standards in treating low-, intermediate- and high-risk prostate cancer with or without combination with external beam radiation, within the next two to three years. A video of the demonstration is available from Prof Sharma. Contact him at 011-488-4911 or send an e-mail to [email protected] to order a copy. over Cancer Drug Patent The constitutional right of ‘everyone to have access to healthcare services’ will be soon be put to the test if the Treatment Action Campaign (TAC) succeeds in its bid to be heard in an upcoming legal dispute over the cancer drug, docetaxel. If successful, it will be the first time in SA that a court will weigh up the respective rights of patent holders of lifesaving drugs, vs the rights of citizens to access healthcare. Docetaxel is the active ingredient in a secondline drug for cancer and is registered in SA and other countries for the treatment of non-AIDSdefining malignancies such as breast, prostate and lung cancers. It is recognised as a safe and effective treatment for advanced-stage AIDS-related Kaposi’s sarcoma. The patent on docetaxel is held by Aventis Pharma. It was registered in SA in 1993 and expires in November 2013. Aventis is seeking relief against generic drugs manufacturer, Cipla, which has manufactured and is marketing a generic version of docetaxel, which costs 50% of the original drug. In a press statement, the TAC clarified: “TAC is arguing that when the Supreme Court of Appeal hears this case, it should take into consideration arguments about the public interest and the constitutional right to health. “TAC is not leading evidence or making any arguments about how effective the drug is, or about the numbers of people who will benefit from the drug, or the types of cancers it may be useful for. Our intervention aims to establish as a principle something the Court has not considered before, and that is that Constitutional rights must be factored into the adjudication process when deciding patent infringements.” The organisation said that poor people are diagnosed and treated late, if at all. One of the reasons for this is the ‘prohibitive cost’ of medicines that treat cancer. According to the TAC, experts believe the mortality rate of cancer may be twice as high as that reported and that there could be as many as 120 000 new cancer cases per year in SA. page 8 | medical chronicle | May 2012 // News Private Sector to Tackle Lack of Human Resources, Management Skills in State A public health enhancement fund that will see roleplayers from across the private healthcare spectrum coming together to work with the Ministry of Health on projects aimed at building human resources and management capacity in the public health sector is to be launched later this month. Describing the establishment of the fund as ‘a breakthrough development’ in healthcare, Pharmaceuticals Made in SA (Pharmisa) chair and senior executive at Aspen, Stavros Nicolaou said it will be first time that stakeholders from different sectors in the private healthcare industry, including pharmaceutical and private hospital companies, will be working together towards improving the healthcare system as a whole. ‘Health isn’t a commodity but a public good that must be provided publicly for the majority of people’ The idea to set up the fund was first mooted at the end of last year at a meeting between health minister, Dr Aaron Motsoaledi, and 16 CEOs of some of the biggest private healthcare companies in SA that looked at ways the two sectors could collaborate to address the lack of human resources and management skills in the state and alleviate the burden of HIV/AIDS and tuberculosis. The most important functions of the fund, Nicolaou said, will be the establishment of a Health Professions’ Intelligence Centre and an Institute for Leadership Management. Pointing out the anomaly that exists between the numbers of health professionals registered with the different professional councils and the actual numbers practising their profession in SA, Nicolaou said the intelligence centre will be tasked with mapping out where the resources are residing, if they are in fact ‘active’ resources and where the biggest shortages are. The Institute of Leadership Management will assist with the improvement of management skills, qualifications and productivity in public institutions in a bid to cut wastage and promote better usage of available budgets and resources. “In some of the big state hospitals, CEOs are running budgets of between R2bn and R3bn. If you can gain 5% on R2m with improved management and productivity, you could save R100m with which much more can be done to improve service delivery,” Nicolaou said. He was one of the speakers at the launch of the African Institute for Healthcare Development (see article below), a new think-tank aimed at promoting dialogue between roleplayers in the private and public healthcare sectors on the creation of a common national strategic agenda in healthcare. The meeting saw the minister and representatives of the SA Private Practitioners Forum (SAPPF), private hospitals, the pharmaceutical industry, medical schemes and nursing union, Denosa, sharing a platform to discuss their ideas around the implementation of the proposed National Health Insurance (NHI) scheme and attaining universal health coverage. sector should not be construed as a ‘fight against the industry’ but should be seen as based on the assertion that ‘health is not a commodity but a public good that must be provided publicly for the majority of people’. Calling the NHI the wrong cure for a misdiagnosed problem, SAPPF CEO, Dr Chris Archer, said it was an example of what can happen when political considerations take precedence over the country’s economic realities. He said private doctors unequivocally support the concept of universal access and believe that a common strategic agenda is possible if it is ‘pragmatic, affordable, carefully considered and correctly researched prior to implementation’. “However, we do not need the complexity nor can we afford the cost of the envisaged NHI system and there is no evidence provided in the Green Paper to suggest that such a financing model would in any manner or guise deal with the real problems of remedying the poor delivery of health services in public sector.” Private sector not a ‘monster’ Slamming recent statements by the minister that the private sector was a ‘monster that needs to be reined in’, Dr Archer said that while it is true that private healthcare is not affordable to a lot of South Africans, it does deliver healthcare services of a very high quality at affordable prices compared to other countries. “The problems in the public sector, in our opinion, are not caused by a lack of funds or the twotiered system but by poor management, leadership and organisation,” he added. Describing the move towards universal coverage as a ‘sensible’ thing to do, Hasa chair, Dr Nkaki Matlala, warned that all South Africans will suffer if the two sectors don’t work together and contribute positively to the direction government has taken. “We [private hospitals] are ready to play our role in NHI, work together with those who want to improve health services and we are prepared to provide our services to government as we are providing our services to other governments in other countries where we have hospitals.” But he stressed that governance institutions within an NHI system, including the Office of Health Standards Compliance, must be independent of political influence, transparent and that their decisions should be scientifically motivated. Is NHI the solution? Pointing out that SA spends more than any of the BRICS (Brazil, Russia, India, China and SA) countries on healthcare (apart from Brazil) but that it has the worst health outcomes, Dr Motsoaledi reiterated government’s position that the NHI was the appropriate tool to remedy SA’s ailing healthcare system. However, the effectiveness of the NHI, he said, will depend on government’s success in improving the quality of care in the public sector and bringing down prices in the private sector. “When we talk about NHI, people think we want to introduce something funny. The truth is that most developed countries are moving towards mandatory pre-payment health systems to make healthcare more accessible,” Dr Motsoaledi said, stressing that his statements about the private Debating a common national strategic agenda for healthcare: Left to right Thembeka Gwagwa (Denosa secretary general); Dr Chris Archer (SAPPF CEO), Dr Nkaki Matlala (HASA chair), health minister, Dr Aaron Motsoaledi and Stavros Nicolaou (Pharmisa chair) New Institute Set on Bridging Gap between Health Policy and Practice The African Institute of Health and Leadership Development (AIHLD) is in the process of finalising appointees to a board of trustees who will ensure that the institute achieves its goal of bridging the gap between health policy and health practice in SA. Executive director of AIHLD, Dr Percy Mahlati, said the trust will comprise five members. Three have been appointed to date: Dr Fazel Randera, member of SAMA’s Board of Directors; Dr Brigalia Bam, former chairperson of the Dr Percy Mahlati, Independent Electoral AIHLD executive Commission and for- director mer agriculture and public works minister, Thoko Didiza. “We are very meticulous about who we bring on board. The trustees’ purpose is to make sure that we remain true to the mandate of the institute. Also to make sure that we act within the law and that all the required governance issues are adhered to.” Asked whether either of the remaining two positions on the trust might go to private sector players, Dr Mahlati commented: “Appointment to the board of trustees is not necessarily on a representation basis. Having said that, we took a decision that we need someone with business experience on the board and we are currently talking to some private sector people in this regard.” He envisaged the private sector as ‘contributing immensely’ to the agenda of the institute in terms of participating in its activities, engagement in its public dialogue series, focusing on the goal of creating lasting partnerships between the public and private health sectors and assisting with funding various initiatives, including commissioning relevant research to the Institute. “We are saying unashamedly that we want the proper development of the national health sector, which includes the public and the private sectors. “In this partnership between the public and private health sector leadership, the respective strengths of these sectors should be exploited and complement each other, not only regarding financial management issues but also in the sharing of data and skills,” Dr Mahlati said. Funding for the institute will come from various sources - mostly donations from those who share its vision and wish to see the national health system becoming strengthened by supporting its activities. “Another major source will be health systems research projects that the institute will be commissioned to undertake within SA, the African continent and elsewhere.” Topics for discussions in the public dialogue series will focus on a particular topic that requires attention. The first, held on 28 March and themed ‘Towards a common national strategic agenda’, was a starting point. “Now the challenge is going to be really on government to make sure that they make the environment conducive for people to be able to contribute practically, not just in words. “In my own experience in government, sometimes we have good policies but people who are appointed to implement the policy are lacking, or they may be good but don’t have the systems enabling them to implement policy,” said Dr Mahlati, the former deputy director-general of Human Resources in the Department of Health and a CEO of SAMA. Dr Mahlati said that the AIHLD will make itself available to assist government in the implementation of the proposed National Health Insurance (NHI) system. “Nobody said NHI is a totally bad idea - even some of the people in the private sector have said there has to be coverage for all citizens. “However, it is the modality that people are questioning - is this the right way to go? We are saying, rather than pointing at deficiencies, opinions should be provided on solutions to achieve the goals.” Dr Randera added that the dialogue series is hoped to be a platform to start building the necessary trust and respect that will enable all roleplayers, including the private and public sectors, NGOs and others, to meet the healthcare needs of South Africans. Asked how the AIHLD could assist on overcoming the private sector’s fears of corruption in the NHI, Dr Randera said: “If it is found to be necessary, this could also form a topic for a future public dialogue session.” A date for the next in the series has yet to be set, but he said that it would take the form of a fullday workshop, which the Minister of Health has indicated he would attend. medical chronicle | May 2012 | page 9 News // Ethical Rules Remain Intact after Competition Commission Ruling The Health Professions Council of SA (HPCSA), has issued a statement to settle any remaining confusion surrounding perceived anticompetitive restrictions in ethical rules following the Competition Commission’s ruling on the matter. The misunderstanding arose after the Competition Commission did an advisory opinion on the ethical rules, and found that some were likely in breach of the Competition Act. This led in 2008, to the HPCSA submitting an application to the Commission seeking exemption of certain ethical rules considered in conflict with the Act. The application was rejected. Restrictions on the naming of practices remain in force The HPCSA’s senior manager: public relations and service delivery, Bertha Peters-Scheepers, explained: “Many in the profession, particularly the SA Optometric Association, interpreted the declining of our application as a ruling that our ethical rules were in contravention of the Competitions Act. “However, the reasoning behind the rejection of our application was that the rules did not qualify for exemption on the basis that they were not found to be anticompetitive; or that they did not constitute a contravention of the Competitions Act due to their broad wording.” In short: ethical rules of the HPCSA remain intact; indeed the definition of ‘touting’ has been strengthened by the words ‘but is not limited to’. Restrictions on naming of practices, fee sharing (lay ownership) and acceptance of payment of commission, sharing of consulting rooms and supersession, remain in force. Similarly, the current ethical rules on formation of other forms of practice models; employment of Claims against Gauteng DoH Skyrocketing The news that Gauteng Premier Nomvula Mokonyane has been ordered by the court to pay R12m in yet another medical negligence case shows that medical lawsuits will hit the Gauteng health budget hard, according to Jack Bloom, the DA’s spokesperson for health in the province. Last month, Justice Kathy Satchwell of the Johannesburg High Court found several acts of negligence by the Edenvale Hospital that resulted in Tanya Khumbalo being brain-damaged and paralysed during birth. In 2011, the Gauteng Department of Health (DoH) lost all 10 medical negligence cases against it in court, and had to pay out R16.9m, Bloom said in a statement. So far this year, R15.5m has already been paid in two cases: R9.25m to Prince Sibusiso Khanyi who was brain-damaged at birth at the Pholosong Hospital, and a R6.25m court order to Shabbier Nagel who had a leg amputated when he went for heart surgery at the Steve Biko Academic Hospital in Pretoria. According to a report to the Gauteng Legislature’s public accounts committee in July last year, the Gauteng DoH faced 101 medicolegal claims totalling R235m. Courts are granting higher payouts for medical negligence, so every effort must be made to ensure that quality care is provided instead of needlessly injuring patients, Bloom said. practitioners; participation in the manufacture for commercial purposes of medicines and medical devices, practices relating to shareholding in hospitals or other healthcare institutions and formation of partnership and other permissible juristic person by a certain category of practitioners remain unaffected and in force. However, the Competition Commission may assess complaints on a case-by-case basis for anticompetitive, noncompliance with the Competition Act. The only rule that has seen a marginal lift in restrictions is Ethical Rule 4, relating to professional stationery, by the removal of the word ‘only’ to describe information a practitioner may have printed on letterheads, account forms and electronic stationery information. The definition of ‘canvassing’ has also been changed (italics) to read: ‘canvassing’ means conduct which involves direct contact with prospective clients verbally or by inter alia distributing letters, pamphlets, circulars or other means of communication including printed or electronic communication, in which attention is drawn to one’s personal qualities, superior knowledge, quality of service, professional guarantees or best practice in order to secure the prospective clients’ custom. The HPCSA media statement concludes: “(The HPCSA) will continue enforcing our mandate to guide healthcare professionals and protect members of the public by prosecuting complaints where acts contravene these ethical rules.” However, members of the profession still have recourse to complain to the Competition Commission should they feel the rules have resulted in anticompetitive outcomes in their individual case. page 10 | medical chronicle | May 2012 // News New SA HIV Clinicians Society President Says She Has ‘Big Shoes to Fill’ The Southern African HIV Clinicians Society’s new president, Dr Francesca Conradie, is determined to continue the impressive legacy of her predecessor, Dr Francois Venter, to promote evidence-based, quality HIV healthcare in Southern Africa. In particular, she has pledged to work with the Department of Health (DoH) to achieve the goals of its National Strategic Plan for HIV, STIs and TB for 20122016, announced in April this year. In terms of that plan, the Dr Francesca government aims to Conradie, cover 80% of people new president of the who need antiretro- Southern African HIV viral drugs (ARVs) by Clinicians Society 2016. Her interest in HIV was ignited when she realised how infections had burgeoned since her first note in her university medical files, from 1983, which mentioned two airline stewards who had been diagnosed with AIDS in SA. During her internship in 1989, she admitted only two confirmed cases of HIV to hospital. She soon realised, as the numbers of new cases mushroomed, that this was one of the most serious health threats that SA would ever face. This realisation led to her becoming one of SA’s most committed pioneers in HIV treatment and over more than a decade, she has gained extensive experience in ARV therapy and its complications, and in opportunistic infections. Her impressive CV includes, among others, an MBBCh from Wits University in 1988, diplomas in HIV management; tropical medicine and hygiene; and a higher diploma in epidemiology (from the University of London). She is a member of the Human Research and Ethics Committee of Wits University. A joint appointee of Right to Care and the Clinical HIV Research Unit at the Helen Joseph Hospital in Johannesburg, she is also Right to Care’s Clinical Advisor to Sizwe Hospital, a hospital for the treatment of multidrug-resistant TB, where she is involved in research and clinical trials. A changing society The HIV Clinicians Society has undergone radical changes since it was formed in the early days of its existence: “I joined the Society In 2002, while working in the HIV clinic at Helen Joseph Hospital (where I was based from 2001 until 2005). At that stage, it was somewhat of an exclusive organisation for private practitioners who had access to ARV therapy.” That all changed in 2004, when the government commenced with its national ARV rollout programme - in which the HIV Clinicians Society was actively involved, both in terms of advising the government and writing HIV treatment guidelines (which were subsequently adapted by the DoH for its own national guidelines). “Suddenly, HIV was not something that was limited to the domain of specialists; it was for everybody,” she said. She recalls how, prior to 2004, she would treat people for HIV-related TB and they would soon stop coming because they had died. “For the first few months after the ARV rollout began, I would open the cupboard and say: ‘Medicines!’” The drug rollout programme had dramatically changed the SA HIV landscape, offering, most importantly, hope for patients, but also, for the doctors treating them. Dr Conradie is highly supportive of the change in tide since Dr Aaron Motsoaledi’s appointment as health minister: “For the first time in my life I am no longer an adversary of the government; I’m on their side.” One of her roles as president of the society is advocacy - a role with which she is very familiar. But there is also a strong focus on training and education - in particular, of nurses. “More than half of our members now are nurses. Because the government rollout programme employed nurse-initiated monitored ARV therapy, we are trying first of all, to raise the esteem of the nursing profession, and to get nurses up and running as integral members of the ARV rollout programme.” True integration of TB and HIV The second thing she wants to achieve during her presidency is true integration of HIV and TB including diagnostics, infection control and training in medication dosages and their side effects. She referred to the comment of Yogan Pillay, deputy director-general for Strategic Health Programmes in the DoH, that one of the reasons why the HIV mother to child prevention programme works so well is because the bare bones of the programme can be contained on a single sheet of paper. “If you’re a nursing sister, you can have a ticklist, an algorithm that is relatively simple to follow but everyone does the same thing. In TB, however, we all have our own opinions, but there is no algorithm.” Dr Conradie’s goal is to publish a treatment algorithm by the end of the year. “The TB programme got stuck in 1976 and there have been no new developments in the programme since then. About 1% of South Africans get TB every year - which is way higher than when I was an intern. Today, about 80% of medical admissions in Johannesburg are for HIV and most of them are TB-related.” Ignorance among GPs There is widespread lack of knowledge among GPs as to how to recognise and treat TB, according to Dr Conradie. “There are definitions in the TB programme, but most GPs don’t pay enough attention. Anyone who’s coughing, sweating at night, has a fever and weight loss must be investigated for TB, irrespective of their age, gender or socioeconomic status,” she said. HIV-related TB presents somewhat differently to TB in the immune-competent person; and once TB is diagnosed, doctors send patients to clinics where treatment is then taken over by nurses. Most pharmacies do not carry TB drugs and medical schemes have generally opted out of covering TB. According to Dr Conradie, some schemes are now considering capacitating GPs to treat TB. One of the major problems in management of TB is the fact that patients are not educated or encouraged to take ownership of their disease and treatment, as HIV patients are. “Historically, we have treated TB patients as though they are too silly to understand how they should take their medicines. This paternalistic approach has failed. One of my patients ended up with drug-resistant TB after he stopped treatment for the third time - no one had warned him of the side effects, such as dizziness, or the fact that his urine would turn bright orange. If he had known this, he may not have ended up with drug-resistant TB, which requires a 24-month course of medication and a daily injection for six months.” Also, few people know that 12% of patients go deaf from the medication. “If patients were informed, adherence would improve, as it has with HIV.” New treatments offer hope “TMC207, a new drug that is in clinical trials stage, is the first new medicine for the treatment of TB in my lifetime,” commented Dr Conradie. “It is highly effective.” However, she believes it will be 10 years before the lethargic approach that has characterised TB research and the development of new drugs will step up and gain sufficient momentum to reverse the epidemic. “The first thing we need to do is to get the basics right, which means intensified case finding, and making sure patients get onto, and complete, their treatment.” Evidence of the SA government’s political will to tackle HIV makes her cautiously hopeful about the future of the disease in SA. “I do think it is possible for this to be the last HIV generation. I would like to be able to read stories to my grandchildren about this terrible scourge of HIV in a time when it was almost unknown to them.” When it comes to TB she is less optimistic. However, the fact that pharmaceutical companies and other organisations are starting to invest in developing TB drugs is a good sign. “Once we have HIV-related TB under control, we will have to start tackling the second most common reason why people get TB, which is diabetes.” Given the dramatic rise in diabetes, the challenge to eradicate TB may even be harder than controlling the spread of HIV - particularly since the disease is airborne, making it impossible for people to take ownership of protecting themselves from contracting the disease. NCD Burden Cannot be Managed by Health Department Alone The Department of Health (DoH) has called for greater collaboration in reducing the impact of chronic and noncommunicable diseases (NCDs) by 2020. It has set ambitious goals in this area, including reducing premature mortality by 25%, reducing tobacco and alcohol use by 20% each, and increasing the number of patients effectively controlled for asthma, hypertension and diabetes. And, it says, intersectoral cooperation is the first crucial step. According to Prof Melvyn Freeman, chief director of the NCD Cluster at the DoH, the department would like to have an intersectoral structure in place within the next four years. “We are working Prof Melvyn on a plan that will Freeman, facilitate healthier chief director of the lifestyles, and this Non-communicable will include collabo- Disease Cluster at the ration in the sectors National DoH of agriculture, trade and industry, sport and education.” He added that this would have far-reaching positive effects - ranging from greater access to affordable, healthy foods to a greater focus on physical activity, as well as allowing an interministerial committee to deal with substance abuse by combining legislation in health, sport, transport and other areas. Prof Freeman was speaking at the 6th SemiAnnual Steering Committee Meeting of the UnitedHealth Group and National Heart, Lung and Blood Institute’s Global Health Initiative Preventing Chronic Disease in Cape Town last month. The event brought together 11 centres of excellence from developing countries worldwide, including the Chronic Diseases Initiative in Africa (CDIA), which hosted the event, and is a network of chronic disease researchers representing universities in the Western Cape, the Medical Research Council, Harvard University and researchers in Tanzania. Prof Freeman noted that managing lifestyle risk factors remains a challenge, although it is clear from past interventions - such as the laws surrounding tobacco use and advertising - that enormous improvements are possible. “We achieved a reduction of 34% in the smoking rates in the country since 1994 and the consumption has decreased by 30%. Taking it further will be a challenge.” Furthermore, he noted that it was important to ensure the existing systems were working properly. “We can reduce mortality from cancer by increasing efficiency,” he said. “For example, we have government-sponsored testing for cervical cancer. But for Pap smears to be useful, they must be administered properly. That is the first step.” Health minister, Dr Aaron Motsoaledi, revealed SA’s Declaration for Prevention and Control of Noncommunicable Diseases at last year’s United Nations summit on NCDs, which set several targets to be met by 2020, including the reduction of salt, regular screenings for cervical cancer, reduction of alcohol consumption and reducing mortality and morbidity for people under 60 by 25%. “Meeting these targets requires addressing the primary causes of mortality and morbidity or the broad ‘social determinants’ of NCDs,” Prof Freeman said. “It means preventing the specific behavioural risk factors and ensuring that the health system is geared to early detection, good treatment and control.” !!! Thank You - Thank You - Thank You !!! 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There are no contraindications associated with the use of the unit, as all efforts are active and not forced. The Mediflo Duo allows for comfortable adjustments of flow by simply rotating the cap. The use of the unit continuously motivates the patient due to the noticeable improvement of performance. The one-ball system makes it safe to use and the fact that the patient is always in control of the device further ensures the safety of the Mediflo Duo. An additional added advantage is that the same unit may be used for both adults and children. The Mediflo Duo is the perfect device for use postoperatively, post ventilation, in chronic obstructive pulmonary disease patients and asthmatics. The device is designed for single patient use but will last for years with proper care. With an average of 1300 new patients in SA using the Mediflo Duo on a monthly basis, isn’t time you afforded your patients the same opportunity? Contact Medloyd Healthcare on 011-397-2717; order code: 700 000 000. 12 Bravo Road Hughes, Jet Park 1459 Tel: +27 11 397 2717 page 12 | medical chronicle | May 2012 // News Priorities Identified for Improving Health Research Initiatives in SA In the third article in our series on the state of clinical trial research in SA, we look at the seven priorities for the improvement of clinical research that were identified at last year’s National Health Research Summit (NHRS). The final report will appear in this month’s issue of the South African Medical Journal. “The findings of the report represent the culmination of a lot of work undertaken to identify what needs to be addressed in healthcare in SA,” said Prof Bongani Mayosi, head of the department of medicine at the University of Cape Town and Groote Schuur Hospital. He is also the chair of the National Health Research Committee (NHRC), a body established by Parliament to advise the Minister of Health on matters related to health research policy, coordination and funding. The report’s abstract underscores that the national Department of Health (DoH) recognises the essential role of health research in achieving a long and healthy life; one of the strategic focus areas of the DoH’s 10-point Prof Bongani Mayosi, plan for 2009-2014 head of the department health sector priori- of medicine at UCT and ties. Strengthening Groote Schuur Hospital of research and development has been identified as a priority in helping to achieve this. Prof Mayosi describes the report as the ‘manifestation of our task to identify priorities for health research initiatives’. “As chair of the NHRC, I am more than pleased with the seven priorities identified in this report,” he said. “The NHRS took place in response to our legislative mandate to set priorities for health research, and to address the strategic priorities of the DoH and government. It was informed by two key earlier studies and its recommendations align very well with what we anticipated based on those reports. The ‘Health in SA’ series published in The Lancet in 2009 was written by a group of South African researchers, physicians, public health specialists and care providers. It comprised six papers and six linked comments examining the historical roots of current health challenges, presenting an overview of the burden of disease in SA and identifying priority interventions and actions. “It was highly concerning to find that after 15 years of democracy, an increasing burden of disease consequent on four colliding epidemics (HIV/ tuberculosis; violence and injury; chronic diseases and childbirth-related deaths) had seen the average lifespan of South Africans fall by 20 years in just one generation,” observed Prof Mayosi. The Academy of Science of SA’s ‘Revitalising Clinical Research in South Africa’, published later the same year, provided a review of the overall state of clinical research in SA. The NHRS successfully brought together 271 stakeholders from government, industry, academia and civil society to identify the key priorities for strengthening health research, innovation and development over the next three to five years, and to assist the NHRC and DoH accordingly. Its seven findings have a similar number of actionable recommendations, which promise to significantly enhance health research in SA. The first five priorities are as follows and are implementable in the short- to medium term: • Increased funding for health research by the DoH to achieve the 2% target of the national health budget. According to Prof Mayosi, “Both health research and the public health sector overall are currently underfunded and the 2% target applies not only to government, but also to private healthcare companies.” He underscored, though, that all funding requires a clear purpose and should not simply be funding for its own sake. It needs to be focused on solving problems and challenges, e.g. the need for an HIV vaccine. • Addressing the shortage of health researchers by training a new generation of investigators, especially black people and women through a proposed National Health Scholars Programme that will offer scholarships to degree-based healthcare professionals. • Developing health research infrastructure in the academic health complexes to facilitate researchbased reengineering of primary healthcare (through funding of clinical research centres). • Funding of research projects designed to increase the lifespan of South Africans (through a National Priority Research Projects Fund). • Improving the national regulatory framework for health research. “Increased efficiency in this regard will make SA more competitive in the international clinical trials arena,” noted Prof Mayosi. The remaining two priorities are rather less straightforward and will require more policy work by the NHRC. They are: • Creating a national mechanism for the prompt incorporation of research findings into guidelines, policy, programmes and clinical practice, so that they translate into treatment and prevention benefits for patients. • Developing a national system for evidencebased planning, monitoring and evaluation of the effectiveness and impact of the health research system on the burden of disease in SA. “We have recognised that we do not measure what we do and that we need to monitor investments and outputs much more closely.” As someone involved in training and research himself, Prof Mayosi is confident that the report’s findings will lead to improvements across all areas of research. “We need to maintain high standards and addressing the priorities identified in the report will allow us to do this better,” he concluded. Advanced MRI System Installed at Pretoria Hospital A breakthrough Ingenia 3.0 Tesla MRI system that combines advanced technology and ambient lighting effects for a much-improved patient experience has been installed at the Life Little Company of Mary Hospital (LCM) in Groenkloof, Pretoria. Manufactured by Philips, the system delivers crystal clear images and rapid results. According to Dr Mark Velleman, radiologist and and specialist in musculoskeletal imaging at LCM, it enables better image quality and faster imaging protocols, and lessens patient movement and distress during examination. It also provides a wide range of new and advanced applications, which were not previously possible. The system’s ‘ambient experience’ feature uses ambient lighting to help patients feel more at ease and relieves anxiety levels. The Pretoria MR Trust, a joint venture between the practices of Dr Labuscagne and partners, and Dr Bezuidenhout, Van Niekerk and partners, which own and manage MR installations at the LCM, Faerie Glen and Zuid-Afrikaans Hospitals, were responsible for this new installation. Dr Velleman said he foresees that the system will take current MR imaging a step further with new and advanced applications for neurospinal work, musculo-skeletal imaging and whole body imaging. “The oncology community will also benefit JJ van Dongen, vice president of Philips Africa and CEO of Philips SA, Christa BothaViljoen, regional account manager for Philips Healthcare and Nithasha Megnath, marketing specialist Philips Healthcare: Africa Region with the Ingenia 3.0 Tesla MRI system at LCM through increased image clarity and the capabilities now possible, with specific regard to the abdomen and pelvis, whole body diffusion imaging as well as breast and prostate imaging.” Device to Warn Patients of Impending Heart Attack It is estimated that around 30% of heart attack victims die before seeking medical attention. Although widespread educational campaigns describe the warning signs of a heart attack, the average time from the onset of symptoms to arrival at the hospital has remained at three hours for more than 10 years. In an article in Ergonomics in Design entitled: ‘This is your heart speaking. Call 911’, authors Mary Carol Day and Christopher Young studied the benefits of an implantable medical device currently undergoing clinical trials that alerts users about a potential heart attack through a combination of vibrations, audible tones and visual warnings. What makes the device distinctive is this combination of alert modes. Although vibrotactile (vibrating) alarms are sometimes used to warn medical personnel in operating rooms or ICUs of an emergency, very little research has focused on their potential as a self-monitoring device for patients. Auditory alarms are provided with selected implantable heart defibrillators, but research indicates that some patients - particularly the elderly are unable to hear the alarms. “A vibrotactile alarm provided by the implanted device has two major advantages,” said Day. “Firstly, the implanted device can’t be left behind like a portable device. Secondly, a vibrotactile alarm from the implanted device is more likely to be felt than an auditory alarm is to be heard because, for example, the patient may be wearing heavy clothing, have hearing loss, or may be in a noisy environment.” The device called the AngelMed Guardian offers two levels of alarm urgency: A high-priority alarm that indicates that the patient may be having a heart attack and should call for emergency help, and a low-priority alarm that indicates that a condition has been detected that requires a doctor’s visit within 48 hours. The alarms are provided by an implanted medical device, similar in size to a pacemaker that is placed in the upper left chest, plus an external device, similar to a pager, that emits an auditory alarm and flashes a red or yellow warning light. In a series of studies with older adults designed to test the device’s design and user-friendliness, participants were able to tell the difference between the low-priority and high-priority vibration patterns and respond appropriately. They also reported that they liked the vibrating alarms and the redundancy of the auditory, visual, and vibrotactile warnings. •••Source: Human Factors and Ergonomics Society medical chronicle | May 2012 | page 13 News // Law in Practice Elsabé Klinck Informed Consent: Old Rules in New Formats? Informed consent and the Constitution The duty of healthcare professionals to obtain, and the right of patients to provide, informed consent have been well established in South African law, even prior to the constitutional dispensation. Apart from being a legal concept, underpinning the agreement between healthcare professional and patient to specific healthcare interventions, informed consent is a well-known and important ethical requirement set by the HPCSA, the Pharmacy Council, the Nursing Council and international bodies, such as the World Medical Association. It should be borne in mind that, since 1994, informed consent has human rights (constitutional) roots. Hence, the failure to obtain proper consent could have repercussions beyond a complaint to a professional body, or to the Consumer Commission. Section 12 of the Bill of Rights in the Constitution protects the right to bodily integrity in general, and specifically awards reproductive rights to all persons. Legislation giving effect to the principle of informed consent The National Health Act of 2003 (NHA) sets out the sequence of steps to be taken when obtaining informed consent, and has to be integrated with the more recent Consumer Protection Act of 2008 (CPA): Firstly, a healthcare provider must inform a patient of his/her ‘health status except in circumstances where there is substantial evidence that such disclosure would be contrary to his/her best interests’. Case law has established that withholding a person’s HIV status from him/her could have serious implications not only for that patient, but also for the practitioner deciding to withhold such health status information from the patient. The NHA allows the withholding of information on the basis of what is known as therapeutic privilege, but then this clearly has to be in the best interest of the patient (e.g. where sharing further information on a person’s health status would be pointless, such as when a patient is dying). It is, however, strongly advised that practitioners seek the assistance of an ethics committee prior to making a decision to withhold information. Any patient can use the Promotion of Access to Information Act of 2000 (PAIA) to obtain healthcare information about him/herself. In such circumstances, healthcare information about oneself cannot be withheld, even if it is deemed to be potentially not in the patient’s interest. In this case PAIA requires that the patient (the so-called ‘requester of information’) nominates a healthcare professional to whom the sensitive information is then disclosed, and who can support the patient in dealing with the information. Secondly, the provider must inform the patient of the ‘range of diagnostic procedures and treatment options generally available’. This means that, irrespective of whether the practitioner regards the treatment as the best option, or as expensive and unlikely to be funded by schemes or facilities, the options have to be disclosed and discussed with the patient. In the public sector options may be limited to what is available on state tender and what constitutes public sector hospital practice (in the form of treatment guidelines, for example), whereas treatment options may offer more choice in the private sector. If these limitations (e.g. limited formulary options on employer-funded healthcare) are in place, they should be disclosed to the patient. Thirdly, the patient must be informed of the benefits, risks, costs and consequences generally associated with each option. The CPA goes further in requiring more than the ‘generally associated risks’ should be discussed: it requires written consent in all cases where the risk is serious, or could place the patient’s life or limb at risk, and verbal disclosure for all other risks. It requires the disclosure of risks prior to consent being given, and also requires that patients’ attention is drawn to the risks in a conspicuous manner. The CPA also requires all communications with patients to be in plain and understandable language. Just providing a patient with a written consent form that lists types of possible adverse events and side effects is unlikely to withstand CPA scrutiny. Discussing costs is important, as the CPA now requires disclose of price, or a specific cost estimate that contains disclosure of the variables of the estimate, up front and before services are rendered. The only exemption, obviously, is in the provision of emergency care. It is important that, if a patient seems to be refusing treatment based on the risk profile, the NHA requires a patient to be informed of the implications of such a refusal. Patients should also understand that all healthcare interventions (as with many other goods, such as motor vehicles) carry risk. This means explaining to patients that there may be an even graver risk if they do not undergo treatment. Allowing a refusal to receive care without checking whether the patient understands the implications of that decision is not advised. Fourthly, then, the patient must be informed of the right to refuse health services, bearing in mind that they should understand the implications of such a decision. The NHA requires patients to be informed in a language that they understand and in a manner that takes their levels of literacy into account. The HPCSA Ethical Rules by and large correspond with the legal framework created by the NHA, as it requires consent to medicines and medical devices to be obtained by the practitioners provided that s/he ‘has ascertained the diagnosis of the patient concerned through a personal examination of the patient or by virtue of a report by another practitioner under whose treatment the patient is or has been and such medicine or medical device is clinically indicated, taking into account the diagnosis and the individual prognosis of the patient, and affords the best possible care at a cost-effective rate compared to other available medicines or medical devices and the patient is informed of such other available medicines or medical devices’. Written consent? A question frequently asked by practitioners is whether consent must be in writing. Apart from the CPA’s requirement of written consent to risks that are serious, there is no general requirement that consent should be written. It is, however, in cases where patients may complain, advisable to have a note in the patient’s file indicating that informed consent has been obtained. A practice can also have a policy statement that encapsulates the elements of informed consent, and that could be used as proof that the note in the file indicates compliance with the practice’s policy. This is also useful when the practice uses locums, or in health facilities such as pharmacies where various professionals are involved in the delivery of healthcare services. Where children are concerned, the very specific provisions of the Children’s Act of 2005 should be followed. There are compulsory, prescribed forms to be used in all surgical interventions on children. Who consents? The patient must provide the informed consent. However, there may be circumstances where consent cannot be provided by the patient, because it is an emergency or if the patient is unconscious. The NHA states that patients can mandate someone in writing to consent on their behalf in such cases, or if they have not mandated someone, the patient’s spouse or partner, adult children, parents, brother or sister, etc. can provide the required consent. In cases of emergency, practitioners can proceed without consent, but must inform the patient afterwards of the healthcare services that were provided. In the following circumstance, treatment can commence without consent: • Where a law or court order authorises treatment without consent. • Where a delay in the provision of treatment might result in death or irreversible damage and the patient has not refused such service previously or implicitly. It is good practice to obtain the written mandate from patients upon admission, as to who they would like to consent on their behalf, should they be unable to. This would then guide staff should further treatment be required and the patient is unable to consent, as to whom to approach. In three circumstances the person who consents are prescribed by other, specific laws. These are the Mental Healthcare Act of 2002, the Children’s Act of 2005 and the Sterilisation Act of 1998. The situation of children deserves specific mention: A child at the age of 12, who is mature enough to understand the risks, benefits and implications of treatment, can consent thereto, without parental support or consent. For children below 12, or immature children 12-18 years, the parent or caregiver can consent to the treatment. HIV testing is singled out, and any 12-year-old can consent, irrespective of their level of maturity, and even mature children under 12 can consent to an HIV test. A child of 12, who is mature and understands the implications thereof, can consent to an operation, but must be supported by a parent or legal guardian, and the forms prescribed in the regulations to the Children’s Act should be used. An important practical advance in the Children’s Act is that the caregivers (i.e. grandmothers, family members or others) can consent to treatment of children. They can, however, not consent to operations. Who must obtain the consent? The healthcare professional must obtain the consent for the services s/he would be rendering. In the case of surgery, it would mean three consents. For example: one to the hospital relating to the provision of the theatre, nursing staff and so forth (this consent should also include a consent should a third party, such as a device company representative be present in theatre); one for the anaesthetist, and one for the surgeon. Conclusion The codification of the ethical principles of informed consent in the NHA, and now with further requirements provided by the CPA, ensures consistency in the manner in which consent to testing and treatment is obtained. The CPA also requires purposefulness in services and goods used by suppliers (i.e. practitioners), and merits a review of practice forms and policies, to ensure alignment across the various laws discussed above. page 14 | medical chronicle | May 2012 // News The Risky Business of Medicine: Protecting Yourself against Possible Litigation In this article in our series aimed at helping doctors to protect themselves against possible litigation, Sarah Whitehouse from the Medical Protection Society (MPS) looks at the steps practitioners can take to reduce their own risk and the risk of their colleagues - and what to do if something goes wrong. communication.2 “The experience of MPS is that poor communication between two or more doctors providing care to a patient lies at the heart of many complaints, claims and disciplinary actions against members,” explained Dr Graham Howarth, MPS head of medical services (Africa). Increasingly complex investigations and treatment options, time pressures and changing work patterns have resulted in more frequent mistakes when communicating with colleagues, particularly: • When care of a patient is passed from one doctor to another. • When there is significant disagreement about the diagnosis and/or management of a patient. Poorly communicated referrals and handovers lead to abnormal investigations being missed, wrong diagnoses being made and predictable complications going unrecognised. MPS has developed two checklists to help aid the referral process: ‘Referring a patient to a colleague’ and ‘Referring patient care back to a colleague’. They can be used as a memory aid, or integrated into referral and reply letters. The checklists and other tools to reduce risk are discussed in depth in the MPS Mastering Professional Interactions workshops. Healthcare professionals like to get things right. Making a mistake can often be interpreted as failure, but human nature is fallible. Emphasis must be placed on ensuring appropriate systems are in place to help reduce errors. Why do we make mistakes? Stretched resources, a stressful working environment, tiredness and other human factors can all cause mistakes. Cognitive psychologist, Dr James Reason, began to explore how mistakes happen after he put cat food in his teapot while making tea and feeding his cat - the two components became mixedup. Mistakes happen because of two elements: • Active failures - unsafe acts committed by people who are in direct contact with the patient or system, e.g., slips, mistakes and violating procedures. • Latent conditions - decisions made by management etc., which have the potential for introducing failure into the system, such as time pressure, understaffing and inadequate training.1 Dr Reason proposed a ‘Swiss cheese’ model to illustrate the trajectory of an accident. We put multiple defensive barriers between a risk and damage, but like slices of Swiss cheese, these barriers may have holes in them. If all the holes line up, a risk can pass through. Disagreements between colleagues In addition, disagreements between doctors can influence a patient’s belief that he/she has received poor care. Hickson found that doctors urging patients to sue was a factor in one third of litigation cases.3 Reducing the risk To reduce risk, good communication is paramount. Poor doctor-patient communication can lead to complaints or claims, but so too can doctor-doctor Medical Chronicle welcomes D-Days medical congress announcements. Please email to [email protected] To view a comprehensive list of congresses, please visit www.medicalchronicle.co.za May Hospital Major Incident Medical Management & Support 17-18 May, Emergency Care Institute of SA, UCT Faculty of Health Sciences. Contact Janet Sirmongpong, 021-406-6348, [email protected] ACAPAP Roadshow - Managing Difficult Children and Adolescents 18-19 May, Wits Medical School, Johannesburg. Contact Lizl Fyff, 041-374-5654, [email protected] Consulting physicians of SA 1st Annual Congress 18-20 May, Cape Town ICC, Contact Stacey Coetzee, 011-768-4355, [email protected] 9th North West Anaesthesia Refresher Course 19 May, Siverstar Conference Centre, Muldersdrift. Contact Dr Paul Abrahams, 011-933-1843, [email protected] SAMED Conference 24 May, Wanderers Club, Illovo. Contact Roz, 012-661-9229, [email protected] SAGS Congress 25-27 May, Protea Hotel, Kruger Gate. Contact Charmaine Watkins, 011-468-5339, [email protected] Continuing Nutrition Education Update 30 May-1 Jun, Faculty of Health Sciences, Tygerberg Campus. Contact Nelda Rousseau, 021-938-9651, [email protected] Aesthetic Medicine Congress of SA 31 May-2 Jun, CSIR, Pretoria. Contact Mareli van Rensburg, 012-548-7152, [email protected] June SA Spine Congress 13th Congress 7-9 Jun, CSIR, Pretoria. Contact Hendrika van der Merwe, 021-910-3322, [email protected] Case Management Course 12-14 Jun, FNB Training Centre, Johannesburg. Contact Institute for Health Risk Management, 0861-112-751, [email protected] 3rd SA TB Conference 12-15 Jun, ICC, Durban. Contact Layton Beard, 012-816-9125, [email protected] Pharmaceutical Society of SA Congress 12-15 Jun, Emperors’ Palace, East Rand. Contact Anri Gagiano, 012-301-0850, [email protected] Whatever the cause of the disagreement, the doctor should always act in the patient’s best interests, treat colleagues with respect and dignity, and try to negotiate an agreed way forward. You should continue to take action until you are satisfied. This could include involving another colleague for a third opinion, checking the validity of your position, or seeking expert advice from another colleague or the doctor’s medical defence organisation. During this process, doctors should explain to the patient that differences of opinion are not uncommon and that they are acting in the patient’s best interests. The doctor should offer the patient an appropriate range of options and allow them to make an informed decision. Handling complaints Sometimes, in spite of your best efforts, patients will be unhappy with the care they have received, and it is important to handle their concerns properly. This is especially true given that complaints are on the rise - the HPCSA received more than 2700 complaints in 2009 and 2010, compared to 2310 in the previous year.4 Complaints can feel personal - many doctors describe how they feel angry, hurt and betrayed. The first step is to take some of the emotion out of the situation. Try not to react defensively by avoiding the issue or making counter-threats. Remember, however good a doctor you are, in your career you will receive complaints. When receiving a complaint, firstly, talk the situation through with a colleague or contact your medical defence organisation for advice. Follow your practice’s or hospital’s complaints procedure, which will normally include the following steps: • Acknowledge the complaint promptly. • Establish what happened - be open about what went wrong. • An apology may help diffuse the situation and it is not necessarily an admission of liability. • Offer a meeting to discuss the problem or give a written response. • Identify what can be done to stop the problem happening again. • Ensure lessons are learned - share with colleagues and the patient. Often, small complaints can be dealt with on the spot. If the complaint is acknowledged, (‘Sorry that you’ve had to wait a while’) and the patient addresses his/her concerns (‘I hope you won’t be late for another appointment?’), the patient will feel more at ease, relax, and the consultation can get underway. Drug errors Some complaints are more complex, for example, if a patient has an allergic reaction to drugs prescribed in error. Such instances must be thoroughly investigated to ensure that the mistake doesn’t happen again. Give the patient a rough timeframe of how long the investigation will take and when he/ she should expect a response. Once the investigation has been completed, the doctor should provide the patient with a letter outlining the details of the results, an apology if necessary, and an option to discuss the matter in further detail. Being open when things go wrong means sharing the incident and how you will learn from it with your colleagues and the complainant. The best doctors openly admit to making mistakes and see the process as a learning tool. All health professionals should feel they can report incidents without the fear of reprimand. Open communication, mutual trust, good relationships with colleagues and a recognition of the potential for risks all help to create a positive patient safety culture. Mastering Professional Interactions and Mastering Adverse Outcomes workshops are offered free of charge to MPS members. For more information visit: w w w.m e d i ca l p r o t e c t i on .o r g /s o u t h a f r i ca / risk-management-workshops References 1. Reason, J. Human Error: Models and Management, BMJ 2000;320:768-770. 2.Government of Western Australia Department of Health, Delivering Saver Healthcare in Western Australia: WA Sentinel Event Report 2007-2008, p11-13. 3.Hickson GB et al. Obstetricians’ Prior Malpractice Experience and Patients’ Satisfaction with Care, JAMA 1994;272:1583-1587. 4.Medical Chronicle, Litigation and Disciplinary Actions Feared Most by Doctors (March 2011). Automated Medicine Dispenser for Urology Hospital Pharmacy The first automated storage and dispensing system, which provides an innovative solution to space and stock management problems that are often experienced in hospital pharmacies, was officially commissioned at the Urology Hospital in Pretoria last month. The system makes provision for compact storage and easy stock input in an energy-efficient manner. According to PW Liebenberg, pharmacy manager at the Urology Hospital, the system allows them to store and dispense a full range of products - including those that require refrigeration and scheduled control. Storage and dispensing is enabled by the precise picking-head technology, which requires only an extremely small distance between rows of packs. This means that the system has double the capacity of ordinary storage systems over the same length - up to 4000 packs per running meter. It stores and retrieves up to eight packs of medication at the same time. “Automatic inventory reporting allows for simple, user-friendly stock management, increases in supply availability and expiry date administration. It also leads to more effective use of staff and a faster service to the customer,” said Sarel van der Walt, director of the Urology Hospital Pharmacy. Dr Izak van Heerden (right), chairman of the Urolocare Hospital’s board of directors and PW Liebenberg, pharmacy manager, did the honours at the official commissioning of the automated medicine dispenser medical chronicle | May 2012 | page 15 PIASA Attends Launch of East African Community Medicines Registration Harmonization Project T he NEPAD Agency, on behalf of the African Medicines Regulatory Harmonization (AMRH) Programme partners - the World Health Organization (WHO), the Bill & Melinda Gates Foundation, the World Bank, UK Department for International Development, and Clinton Health Access Initiative - launched the East African Community Medicines Registration Harmonization (EAC MRH) Project on 30 March 2012 in Arusha, Tanzania. The EAC comprises Kenya, Tanzania, Uganda, Rwanda and Burundi. The vision of the EAC health sector is to attain a healthy and productive population in East Africa. All five member countries are affected by similar infectious disease problems such as HIV/AIDS, meningitis, tuberculosis, malaria, cholera and meningitis. Kirti Narsai, head: Scientific and Regulatory Affairs at the Pharmaceutical Industry Association of South Africa (PIASA), attended the event. “PIASA strongly supports the AMRH Programme, which aims to address concerns about the lack of standardised approaches in medicine registration regulation in Africa. PIASA congratulates the EAC on its trailblazing achievement of being the first region to launch its harmonisation project,” she said. The AMRH Programme aims to address concerns about the lack of standardised approaches in medicine registration regulation The AMRH Programme has been created to assist African countries and regions to respond to challenges posed by medicines registration as an important, but neglected, area of medicines access. Narsai explained further, “The EAC is one of four regional communities in Africa - the other three will roll out their harmonisation initiatives in due course,” she continued. “Initially the projects will work to promote co-operation and collaboration within each community. Under the programme, each community was required to put together a business plan, which then went through a process of review and approval. The EAC’s was the first to be approved. The ultimate goal will be inter-regional collaboration, which will harmonise medicine regulation across the continent.” She underscored, however, that this is a long-term vision requiring putting in place of interim measures, pointing out too that it took 35 years for Europe to achieve a similar aim. The EAC MRH Project will promote the harmonisation of medicines registration in the region, which is a key contributor to public health and leads to faster access to good quality, safe and effective medicines for priority diseases. Essential medicines save lives and improve health when they are available, affordable, of assured quality and used rationally. According to NEPAD Agency CEO, Dr Ibrahim Assane Mayaki, “The regulation of medicines and harmonisation of technical standards and legislative frameworks have emerged as important components of the regional economic integration efforts.” Delegates attending the programme The launch of the EAC MRH Project marks the beginning of the implementation phase of the AMRH Programme across Africa. Moreover, it is also a milestone in improving access to essential medicines for priority diseases in Africa. Speakers including ministers, high-level representatives from the African Union Commission, the NEPAD Agency, EAC officials, representatives of EAC National Medicines Regulatory Authorities, regional pharmaceutical associations, international organisations and donors all graced the event. The main goals of the EAC MRH Project are as follows: • Quicker patient access to affordable, essential medicines of assured quality • Improved public health outcomes • More effective medicines control by strengthened national drug regulatory authorities • Improved procurement practices for securing priority medicines • Cost efficiencies for governments. Attendees at the launch of the AMRH Programme Guideline for Optimal Cold Chain Management Sought by Newly Established Forum T he need for a clear guideline on optimal cold chain management in SA and other African countries has led to the recent establishment of the Cold Chain Forum of SA. The Pharmaceutical Industry Association of South Africa (PIASA) has played a leading role in the facilitation of the forum. “PIASA is the convenor of the forum, the main objective of which is to establish an African guideline for cold chain management that regulators can adopt,” said Kirti Narsai, head: Scientific and Regulatory Affairs at the association. Working groups have been formed and these are intended to assist and guide the industry to better manage the challenges faced in the receipt, storage and distribution of temperature-controlled products. The forum will serve as a platform to share professional and technical information pertaining to the cold chain and temperature control of pharmaceutical and related products; to prioritise challenges in the pharmaceutical industry throughout the supply chain; to facilitate costeffective, compliant, total supply chain solutions, including the control of last-mile distribution of all pharmaceutical and related products; and to educate all roleplayers in order to continue to deliver safe, effective and quality pharmaceutical products. “The main objective is to establish an African guideline for cold chain management that regulators can adopt” The chairperson of the forum’s steering committee is Theano Kosmas, managing partner of Strategnos, a supply chain and business management consultancy with extensive experience of the pharmaceutical industry. She explained further, “Over the last five years or so, we at Strategnos have received an ever-increasing number of enquiries from people seeking guidance in respect of understanding cold chain requirements, especially with regard to the transport of vaccines. The intention is to harness and align all resources and knowledge to inform this proposed guideline, which will be something that all roleplayers can understand and adhere to. In addition, we’re reviewing all the literature on the subject that we’re aware of.” Contrary to what some might think, ensuring adequate cold chain management and maintaining temperatures at the requisite 2-8 degrees Celsius cannot be guaranteed merely by transporting a product in an insulated container. “One also needs to take into account the ambient temperature, seasonality and the mode of transport,” continued Kosmas. The four working groups that have been formed are technical operations; compliance; regulatory; and education/PR. The technical operations group is determining the current status quo and comparing it to international guidelines, with a view to ensuring standards that are practical, cost effective and repeatable. The compliance group is analysing and comparing current global regulations, standards and guidelines in order to marry what everyone else is doing with SA’s requirements. The regulatory group will liaise with the Department of Health and industry bodies to make them aware of what the Cold Chain Forum is and to ascertain their expectations thereof. The Education/ PR group is committed to ensuring that the enduser is informed and empowered by strengthening the partnership between the pharmaceutical and logistics industries. “It’s often the so-called last mile that is problematic,” observed Kosmas. “We maintain the cold chain in the truck, but what happens to that vaccine, say, when it finally reaches the hospital or pharmacy? If we can educate at all levels, embracing logisticians and the people on the warehouse floor, we will be able to guarantee that the product reaches its final destination with its quality intact.” “If we can educate at all levels, we will be able to guarantee that the product reaches its final destination with its quality intact” Kosmas is confident that towards the end of the year, a draft standard will exist for discussion. “There is such an encouragingly high level of interest and engagement. We’re all doing it for the love of the cold chain,” she concluded. medical chronicle | May 2012 | page 17 Company News // Culture of Inclusivity Key to Success Generic drugs are the future. Affordable, high-quality medicines are defining the industry. The first thing most CEOs do when appointed is move to that big corner office on the top floor. Not Carnie van der Linde, generic medicines manufacturer Sandoz SA’s former commercial director, and now country head. He is still in the same office he occupied when he joined the company. “I decided not to move offices because where I am enables me to stay close to the business, see people and feel the culture of the organisation. I don’t want to lose that connection.” Van der Linde (43) was appointed country head, in January 2012, after Carnie van der Linde, just 15 months with country head, Sandoz the world’s second-largest manufacturer of generic drugs and the fourth largest in SA. He joined Sandoz in October 2010. Sandoz is well known for acetylcysteine (ACC), its largest-selling over-the-counter drug. In SA, the company manufactures 80 different products. The company employs about 200 associates in the commercial division and about the same number in manufacturing. Sandoz SA has its headquarters in Ekurhuleni. Priority areas include TB drugs, which account, among others, for the biggest share of government spending Why Sandoz? On why he chose to join Sandoz, Van der Linde said: “I truly believe generics have a place in SA, where there is a genuine demand for high-quality, affordable medicines, and that is why I have always wanted to get involved in this space. But I didn’t want to join just any company. I wanted to get into an organisation that has a good global footprint, where there’s room for growth and learning.” “Patients are our priority and are at the heart of our work at Sandoz. The fact that each day, we work together to help create a healthier world in which everyone has access to the medicines they need, made it the most obvious choice.” His role so far Van der Linde’s first 90 days in office have been something of a rollercoaster - challenging but fun. A veteran with a career that spans over two decades in the pharmaceutical industry, he has had to deal with redefining Sandoz SA’s strategic business direction, an exercise that includes making sure that he spends the same amount of time with all departments and those who report directly to him. Organisational culture Van der Linde has also been engaged in efforts to build the organisation’s culture, which he believes is crucial if the firm is to achieve its objective of improving its market share to being number one within a couple of years. “I wanted to build a culture in the organisation where the business is not run by the CEO and the executive team but by everybody,” said Van der Linde. “I want people in the business to know that everybody is important, but that also means you have to contribute, and that includes making decisions and not waiting to be told what to do. People are paid to think. I would rather see a person make a mistake than doing nothing at all.” Growth strategy As part of its growth strategy, the next couple of months will see Sandoz restructure its portfolio. Its last big new product launch in the market was Sandoz® Levofloxacin in 2007. The lack of new product launches over the years has led to it losing some ground, something that Van der Linde is determined to reverse. “What we want to do right now is identify and manufacture those drugs that are in demand in our key market, which is SA. The factory needs to be able to produce 10 of our biggest-selling drugs. We want to produce a high volume and sell at the most affordable prices.” Priority areas include TB drugs, which account, among others, for the biggest share of government spending. Focus is also on manufacturing so-called complex molecules. Globally, the company is a pioneer and leader in biosimilars. While common medicines such as ibuprofen can be manufactured cost efficiently, complex molecules require additional clinical studies, which increase time to market and cost. In his spare time, Van der Linde enjoys cycling and judo. He cites Sandoz Global CEO, Jeff George as a business role model. Outside the sector, it is Apple co-founder the late Steve Jobs, whom he admires for his passion for innovation. *Content provided by Sandoz. page 18 | medical chronicle | May 2012 // Practice Management Digital Dose Dr Karen Koch Is your Practice Keeping Up with the Latest Trends in Health Technology? The merging of health technology and IT has sparked a torrential flood of smartphone applications software (apps), devices, programmes and interfaces - all of which could help or hinder doctors in everyday practice. Find out more about the latest trends with our new monthly column, Digital Dose. Want to track your patient’s heart rhythm 24/7? Perform surgery in another country while still in your own? Monitor your patient’s ICU monitor from your home? Technology has brought both benefits and drawbacks to the health profession. On the one hand, we face an ever-increasing number of ‘Google doctors’ every day. On the other, genuinely time-saving tools such as e-scripting, electronic radiology and pathology results, and billing systems can improve efficiency and accuracy. In 2008, the South African government awarded a R1bn 10-year contract for the development of a nationwide Department of Health electronic health record known as eHR.co.za. For private practitioners, the decision to go digital depends entirely on personal needs. Tools need to be convenient, cost effective and demonstrably improve patient care before they are likely to adopt them. As Dr Kobus Kotzé, a GP working with Medicross, pointed out, “There isn’t a single integrated solution that currently caters for the South African practitioner in private practice in an entirely user-friendly and secure manner.” What this means is that Dr Kotzé uses multiple tools, each with its own benefits. “E-scripting and PrescribingMedicines…TheWayForward World-class electronic prescribing technology is now available to all medical practitioners in South Africa at NO COST. This enables a hassle-free transition from hand-written to electronic scripts and helps the South African medical practitioner to take the next step in moving their practice and patients into the future. Medical practitioners are encouraged to visit the Health-Soft website (www.health-soft.co.za) for more information or to download the software for free. Alternatively, contact Health-Soft on 011-214-1707 or email [email protected] to obtain an installation disk. Since the launch of the new e-scripting version in October 2011, hundreds of practitioners have successfully installed the software and are now proudly supporting the e-scripting initiative in South Africa. This is what some of the practitioners are saying about their experience of the application: Dr Nicola Rains (General Practitioner, NHC Health Centre Northcliff) I’m enjoying the benefits of e-scripting. It’s an innovative software solution leading towards a paperless system. It has the advantage of efficiency, for example storing and reproducing of chronic scripts with one easy step and other additional features such as price of generic options and documents such as sick notes and referral letters. It is in the best interest of you, your practice and your patients to consider using e-scripting. Dr Wynand Mouton (Paediatrician, Medicross Centre Rustenburg) I use the software everyday. The program is very user friendly and totally removes the problem of my unreadable handwriting at pharmacies! Potential mistakes are eliminated and I have the peace of mind that my scripts won’t be misinterpreted. All of this and it doesn’t even take me longer to prescribe. Dr Johan Kruger (General Practitioner, Health-WorX Family Medical Centre, Cresta) Using electronic scripting saves me up to one and a half hours each day. This allows me the freedom to spend more quality time with patients when necessary or see more patients. MAKE THE CHANGE THIS YEAR AT NO COST – SWITCH TO e-PRESCRIBING Some of the main benefits: ✓ Complete scripts in seconds ✓Save all scripts and other documents to be retrieved instantly ✓Building of prescriber’s own favourite scripts, medicines and ICD‑10 code lists ✓Generic alternatives and medicine cost price (SEP) look-up ✓Sick notes, referrals, WCA and many other forms completed electronically Join the global drive to electronic prescribing ✓Integration with prescriber’s PMA (Practice Management Application) software ensures smooth integration of billing and prescribing ✓ Increased patient satisfaction, safety and compliance ✓ Eliminate script interpretation errors at pharmacies ✓ No monthly fee ☎011-214-1707 (Support/Helpdesk) www.health-soft.co.za [email protected] electronic sick notes are great examples of how technology can save you time and improve accuracy.” The software used in his practice allows for script templates to be saved, which include details such as NAPPI codes and additional patient instructions when the medication is prescribed. “Obviously, this improves the accuracy of dispensing by the pharmacist and, in the long run, saves you time.” The application can’t be used for Schedule 6 or 7 medications, which require a handwritten script. Laboratory results Another good example of technology at work is the availability of laboratory results electronically. Lancet, Ampath and Pathcare have electronic interfaces to access patient results. Pathcare has gone so far as to develop an iPad app for downloading results. “This speeds up delivery of lab results and is certainly better than any paper-based system,” said Dr Kotzé. The drawback is when it comes to integrating lab results from more than one laboratory. “You unfortunately have to purchase additional software to display results from multiple laboratories.” Technology has brought benefits and drawbacks to the profession “Electronic radiology results do allow you to view x-rays and scans in greater detail; the only drawback is that each radiology practice uses different display software. This is not normally a problem, as the CD on which the results are copied includes the software. Obviously, the difficulty is for doctors to have to learn to use multiple viewing programmes when technology is not normally our strong suite.” In addition, the files are often very large, making it difficult to store online in a patient record. ... to page 20 medical chronicle | May 2012 | page 19 Practice Management // Who Measures the Measurers? Provider profiling and peer review - is this really necessary? What do I do if my profile is simply wrong? South African medical schemes and their actuaries are wisening up to the fact that primary healthcare, prevention and disease management are the key factors in sustaining medical schemes. We are seeing many initiatives being aimed at improving the focus on primary healthcare and prevention. Many of these initiatives include the setting up of GP networks where participation requires GPs to allow their practices to be profiled and subject themselves to a peer review if required. Schemes aim to use provider profiling and peer review to identify which providers to work with. Is practice profiling and peer review necessary? In tackling this subject and in trying to ensure that we provided a balanced view on provider profiling and peer review, Lifechoice commissioned a survey that was forwarded to all the principal officers of the 90-odd medical schemes in SA. We had a reasonable reply, receiving feedback from 12 schemes, including GEMS. Perhaps it’s time that schemes profiled themselves so that GPs can know which ones to work with The survey provided some interesting insight: Firstly, measures aimed at improved member care and clinical outcomes were rated as being more important than financial and operational efficiency measures (see Figure 1). All of the respondents (100%) indicated that profiling needs to measure primary care and preventative care while 78% of respondents believe that both provider profiling and peer review should be mandatory. The participants also felt strongly about corrective measures (see Figure 2). Participants were divided about whether schemes or professionals should take responsibility for and fund provider profiling and peer review. Some participants indicated that the Council for Medical Schemes (CMS) should be involved. 56% of respondents believe that profiling should be a confidential process, with 90% believing the results should be available to members. This is interesting in the slight contradiction communicated. Suggested strategies for GPs to add more value to schemes included: improving the accuracy of billing, improved focus on clinical outcomes and playing an increased role in referral to specialists and the costs generated by specialists. In summary, the overriding view from the principal officers is that profiling and peer review should be a mandatory process that focuses on clinical outcomes and improved healthcare, must include measures that look at preventive care and primary care, should be funded mainly by schemes and professional associations and poor performance must be addressed by punitive corrective measures. Given these strong thoughts, should we expect that it is only a matter of time before principal officers set up a principal officer professional association, or ask their schemes to fund a mandatory profiling and peer review process for them that should carry financial sanction for them? Let’s watch this space. ... to page 20 Measures aimed at improving delivery of care to scheme members Clinical quality measures Financial measures Member satisfaction measures Operational efficiency measures 0 1 2 3 4 Figure 1: Importance of aspects in profiling (rating of importance on a scale of 1-5) 5 page 20 | medical chronicle | May 2012 // Practice Management Who Measures the Measurers? ... from page 19 As we mentioned in our first article in the series, three rules of life are: Life is not always fair, don’t rely on anyone else to look after you and learn to look after yourself. Thus, as we move into an environment where profiling and peer review will become the norm, we should celebrate this process, as it will assist us in improving the quality of care we can provide for our patients. We can also take into consideration the suggestions coming from the survey i.e. improving our focus on clinical outcomes and managing downstream costs. However, we must engage with the process to ensure it is transparent, accurate, fair and focused on improving care. The subject of who measures the measurer is controversial - are provider profiling tools being peer reviewed? Is the methodology behind these tools in the public domain so that we can be comfortable with how we are measured? Are profiles created by nonclinical parties who carry scant knowledge of the nuances of general practice? Are these tools easily understandable? Are these tools always run on sample sizes that are significant? We are not aware of any formal peer-review process of the profiling tools used or that any profilers publish their profiling methodology for public scrutiny and input. If your profile is simply wrong, your first port of call is your IPA. They should be able to explain how your profile is calculated and rectify any errors. Should this approach fail, feel free to drop Lifechoice a line to see how we can assist. Decreased remuneration Reporting to professional or regulatory bodies Contractual exclusion 0 0.2 0.4 0.6 0.8 1 Figure 2: Corrective measures to be taken (percentage agreeing) To ensure the success of GP private practice, we need to work together and support schemes that fund primary healthcare and schemes that focus on controlling nonhealthcare costs. Perhaps it is time that schemes profiled themselves against their peers so that GPs can know which schemes to work with. If you would be interested in seeing scheme profiles based on publically available information or would like to give further input on this matter, please feel free to mail [email protected] For further information or queries, contact Dr Andrew Good on 072-797-7279 or email [email protected] Is your Practice Keeping Up with the Latest Trends in Health Technology? ... from page 19 EHR concerns When it comes to uploading and storing patient health records electronically, there are several pros and cons. “A paper-based system is clumsy, vulnerable to tampering and can be lost in floods, fire and so on, but changing to an electronic system also needs consideration. Security, offsite back-up and access in case of power failures and theft are just some aspects to consider.” If an entirely electronic system is just too daunting, Dr Kotzé recommends a compromise. “Scanning in records is a good alternative at this point, especially for those of us who write faster than we type.” The date stamp on the records allows them to be sorted, making access to a timeline history more convenient for the doctor. Newer technology featuring touch screens allows doctors to write records on the screen rather than typing in entries, another possible solution for a GP. “Most importantly, South African doctors are concerned about security when it comes to accessing patient records. We need to be able to rely on software or app developers to ensure that data is ultra-secure.” First prize is to have an impenetrable system. “Failing that, who takes responsibility if patient records are breached?” With novel approaches including patient biometrics (such as fingerprint scanning) in accessing records, proper data encryption and secure storage back-up systems solutions are being developed, especially since electronic health records are becoming mandatory in the US. “We’re going to see improvements in the software options available to doctors to capture integrated records, but this is an ongoing process,” observed Dr Kotzé. “In the meantime, practitioners should consider using specific tools to save them time and improve patient service delivery.” Even if you aren’t techno-savvy, there are literally thousands of tools out there designed to improve patient interaction and care. It’s all about finding technology that works for you. *Next month, we look at the Apple apps that doctors rate most highly for everyday use and why. page 22 | medical chronicle | May 2012 // Opinion Practice Matters Doctor’s Voice ... Prof Morgan Chetty Dr AM Levin Managed Care: The Roots of Discontent Denying Rights in a Democracy Healthcare providers are becoming increasingly irate with techniques employed under the guise of managed care to disallow or prevent care or to employ nonevidence-based reasons to control healthcare. Sadhina Vora (Harvard University) stated that, “Complaints about managed care hang thick in the healthcare atmosphere of the US.” There is a belief that the implementation of managed care has become unstoppable and that it may be too late for change. Another observation is that the corporate invasion into healthcare has resulted in a situation of: ‘when money talks, truth is silent’. Richard CW Hall, of the University of Florida, noted in one of his publications practices in the US that have come under scrutiny as representing a breach of contract or fraud. These include the routine disallowance of claiming for costs of certain modalities of care, routine tests, (that may be medically necessary) and drug costs. Does this not sound familiar? To further support how the financial outcomes have taken precedence over healthcare endpoints, Prof Uwe Reinhart of Princeton University pointed out that health insurance companies thrive on the dollars that flow through them, not the number of people they insure. The view of health professionals in SA, especially GPs, of managed care is very similar to that of their US counterparts. Many of them believe that managed care programmes are designed to intimidate or harass doctors and that they make appropriate care difficult or impossible. If appropriate standards are employed, managed care plans can work with reasonable success. They can provide systems that encourage an effective and longstanding relationship between patients and primary care providers. They can commit to provide quality medical care to their patients and they can ethically assume a population-based approach that incorporates public health concerns. Of concern to healthcare providers is the fact that healthcare delivery decisions are regulated by ‘managers’ who have no training or experience in providing healthcare. How often do we see nonclinicians making decisions on healthcare indicators and quality endpoints for clinicians? The true source of discontent is often not just the financial aspects. For instance, have you recently tried to put a patient at risk for hyperlipidaemia supported by a family history, age and gender, on a statin? The medical scheme rule book or the Framingham score is extracted in isolation and used to deny the patient preventive care which could decrease morbidity or mortality. Doctors are worried that the complexities introduced by managed care companies into healthcare are complicating healthcare delivery, increasing risk to practitioners and compromising care. They are often forced to accept one-sided ‘risk ridden’ contracts that shield managed care companies from financial risk and assure them a return on investment. The reimbursement is not market-related at all and doesn’t take into consideration a practitioner’s intellectual skills and years of experience. It’s my view that no one is involved in healthcare delivery management because of philanthropic reasons or a calling to serve the sick. This is now a business and perhaps the reason why SA has so many medical schemes. They have researched how to squeeze what there is to be squeezed out of the 7% of the healthcare pie paid to primary healthcare providers. Towards a Common National Strategic Agenda in Health Dr Chris Archer, CEO, SAPPF The SA Private Practitioners Forum (SAPPF) supports unequivocally the need for health reform and believes that a common strategic agenda for healthcare reform is possible. However, such a strategy should be pragmatic and recognise that any proposal that seeks a radical overhaul of the healthcare system should be carefully considered and empirically researched prior to implementation. Reforms should thus only be pursued if they are practically implementable and affordable. Rehabilitation of the public sector is clearly the central task of such an agenda, but it is crucial that the role that the private sector could and should play in this task of rehabilitation is not ignored or underestimated. NHI not a cure The government has made it clear through its Green Paper on National Health Insurance (NHI) what it believes such a common national strategic agenda should be. The agenda (as represented by the proposals contained within the Green Paper) would, in the view of SAPPF, be neither wise nor implementable, and would therefore not be in the broader interests of South Africans. It is critical, in my opinion, that a common strategy for health should not be tainted by political ideology but should rather concentrate on finding proven, pragmatic and affordable solutions that can and will work. South African healthcare does not need the complexity, nor can we afford, the cost of the envisaged NHI model put forth in the Green Paper, and there is no evidence provided to suggest that such a financing model will, in any manner or guise, deal with the real problem in the public sector, which is the poor delivery of healthcare. SAPPF also does not accept the premise of the Green Paper that it is the existence of the twotier system of healthcare in SA that is the cause of the problems affecting the public sector, nor do we accept that pricing in the private sector is out of control, or that the private sector is a ‘monster’ that needs reigning in. That is not to say that we do not acknowledge that the private sector itself is in need of reform. We accept that, but the truth is that the private sector consistently delivers quality healthcare the equal of anywhere in the world, and at highly competitive prices. Reform of the private sector and of the market in which it operates, as noted by the Centre for Development and Enterprise in its submission on the Green Paper; “Will be a positive step forward on the long road to universal access to quality healthcare, and not, as some of the private sector’s detractors believe, a step backwards.” Two interconnected systems under one caring ministry, public and private, with a shared agenda of working together in unison towards the goal of improving access to quality healthcare for all South Africans, is a common agenda that the SAPPF would support. Elements of such an agenda Private sector reforms Private sector reforms that will make medical scheme membership and private healthcare accessible to more South Africans include: • Mandatory medical scheme enrolment of all in formal employment. • Establishment of the mooted, but inexplicably abandoned, Risk Equalisation Fund for medical schemes. • A fair and transparent system of setting realistic pricing in the private sector that pays adequate attention to the costs of providing the service. • The establishment of large single or multispeciality group practices, to create economies of scale and to enable private sector specialists to participate more easily in the public sector. • The abolition of remunerative work outside the public service. • The integration of private sector GPs into the rural public service. Public sector reforms • Reforms as per the 10-point plan minus NHI. • The depoliticisation of health with zero tolerance for corruption, together with the insistence on good management and oversight mechanisms. • The devolution rather than centralisation of decision making. • The establishment of a limited NHI fund to finance the indigent patient’s use of a basic benefit package (BBP) via either the public or private service (i.e. a tax-funded medical scheme for the poor). General reforms • The establishment of a BBP. • Mandatory copayments to discourage abuse of an otherwise free service. These copayments should be affordable to all and not be an impediment to accessing essential or emergency care. • Corruption, which is draining the very lifeblood out of the service, must be ruthlessly rooted out, wherever it is found and the perpetrators dismissed. The medical profession continues to be bombarded by surreptitious endeavours cleverly disguised in order to reinforce government’s determination to denigrate, minimise and perhaps eventually remove the private health sector. The latest manifestation of this obsession is government’s obvious salvo of destruction in closing both the additional health and ‘gap’ insurance facilities whereby private patients have elected to secure, and thereby insure the availability of private healthcare. Forgotten is that in this so-called democratic society that SA purports to enshrine, citizens have the freedom of choice in securing any, and all, private market proposals that enhance their standard of living, both medical and otherwise. Attempts to deny these rights once again illustrate the government’s socialist tendency to regulate and control citizen entitlements despite the enforcement of the noninterference being the fundamental ethos of a democracy. Indeed, the above government ‘butting in’ is merely a clever ploy to enforce patient attendance at government hospitals and clinics as an essential component of the forthcoming NHI, a health concept that has as yet to receive approval by the majority of patients in major overseas countries. Furthermore, it is interesting to note that the Department of Health and the HPCSA are suddenly encouraging patients to know their rights, responsibilities and the tariffs for private medical treatment as detailed by the medical schemes to which they have willingly subscribed. Furthermore, doctors must explain the costs of consultations and procedures with the patients, irrespective of the method of payment, as failure to do so would make them guilty under the Consumer Protection Act. The Department of Health and the HPCSA are now unwittingly, but finally, ‘broadcasting on the same wavelength’. Bearing in mind the above scenario, and thus the important need to prolong the use of financing private health through medical schemes, medical practitioners should be made aware of the long-term financial pitfalls of the much-lauded Prescribed Minimum Benefits (PMB) concept. This is an acceptable and perhaps muchneeded method of ensuring financial reliability in covering the costs of many critical diseases and injuries. Medical schemes are obliged to accept responsibility for these PMB conditions under clearly defined circumstances. However, what is not readily appreciated by private medical practitioners is that in the payment of these medical pathologies, the medical scheme member’s daily benefit account is first used to pay the PMB expenses with any additional outstanding balance being funded through the medical scheme’s own risk management facility. In many situations, the above dual method of payment of PMBs may leave the patient without any daily benefits for future medical therapy. The patient will then be obliged to seek treatment at the government hospitals for any non-PMB medical problems that may arise in the future. High PMB payments in the short term may ultimately affect the long-term private remuneration for medical attention outside of the ambit of the PMB programme. The above information is purely a financial consideration, and under no circumstances does it cast aspersions on the integrity of the providers of private medicine. Rather, it underlies the importance of negotiation in a democratic free market system of private enterprise. Adherence to a fixed price regulation is totally unacceptable. Visit our webpage: www.medicalchronicle.co.za cardiac medicine Get the free mobile app at http://gettag.mobi Thiazide Diuretics in Hypertension Not What they Seem to Be? A debate that seems never ending is the one the value or not of thiazide diuretics in the treatment of hypertension. Thiazide diuretics have been used for a very long time and at a low cost, a feature which enhanced their usefulness. Just as it seemed that these diuretics have assumed their leading role, concerns on their use have emerged. The major concerns come from the adverse effects of thiazide diuretics such as their ability to cause hypokalaemia, impair glucose tolerance (increase in new-onset diabetes mellitus) increase in serum cholesterol and increase in uric acid. Medical practice responded to this adverse effect profile by advocating the use of low-dose thiazide diuretics (typically 12.5mg). One of the issues now is whether there is sufficient evidence to warrant the use of low-dose diuretics. Thiazides and the thiazide-like diuretics, chlorthalidone, have been important drugs in the management of hypertension for more than 50 years. When using a thiazide, most clinicians will prescribe hydrochlorothiazide, a drug that was launched in the market in 1958. In SA there are at least three products of hydrochlorothiazide and some where hydrochlorothiazide is combined with potassiumsparing diuretics. Adherence to therapy Antihypertensive drugs remain the cornerstone of the medical management of hypertension. Adherence to medication is crucial in the reduction of blood pressure and the reduction of cardiovascular events. A meta-analysis of 17 studies on adherence to medications showed that adherence to diuretics was the lowest compared to any other antihypertensive drug class. Sexual dysfunction Diuretics are the class of drugs that apparently impair sexual function the most of all classes of antihypertensive drugs. This effect may also contri bute to the worst adherence of patients on diuretics. Antihypertensive efficacy In a recent meta-analysis, all randomised clinical trials (n=19) using 24-hour ambulatory blood pressure monitoring, the antihypertensive efficacy of hydrochlorothiazide was compared to the blood pressure efficacy of other drugs. The result of this meta-analysis showed that showed that when given as monotherapy, the blood-pressure-lowering ability of hydrochlorothiazide was significantly lower than with any other drug class. This was in the dose range of 12.5-50mg per day. This confirmed the concept that hydrochlorothiazide is an inferior antihypertensive agent. In another meta-analysis, the systolic blood pressure reduction achieved in the current low-dose range (12.5-25mg) is not equivalent when hydrochlorothiazide is compared to chlorthalidone. Chlorthalidone was superior. The low-dose thiazide practice has been called a myth that has evolved over time without any real evidence. Thiazides: morbidity and mortality There are no data to show that low-dose thiazide diuretics reduce cardiovascular events or mortality. All the studies that did show favourable outcome were done with a much higher dose (50-100mg per day) or in combination with a potassium sparing diuretic. Combination therapy with hydrochlorothiazide (HCTZ) There are numerous combination products on the market using 12.5-25mg HCTZ with angiotensinconverting-enzyme (ACE) inhibitors, beta blockers, angiotensin receptor blockers. There is little doubt that the combination of thiazide with these drugs improves the blood-pressure-lowering efficacy. The question is whether these combinations have a superior outcome. However, in the ACCOMPLISH trial, the combination of the same ACE inhibitors plus HCTZ was inferior to the combination of ACE inhibitor plus calcium channel blocker. There was a 20% reduction in morbidity/mortality in the ACE inhibitor/calcium channel blocker. Even in combination with an ACE-inhibitor, HCTZ is inferior to a calcium channel blocker. Hydrochlorothiazide and chlorthalidone There are many arguments on the interchange ability of HCTZ and chlorthalidone. At least four large trials with chlorthalidone have shown a reduction in mortality, stroke, cardiovascular events and heart failure. There were the Hypertension Detection and Follow-up Program Cooperative Study, SHEP study, ALLHAT study and MRFIT study. In all of these, the dose of chlorthalidone was 25-50mg. Yet, there has never been a head-to-head trial with a thiazide diuretic (e.g. HCTZ) and chlorthalidone, so there is no direct answer that is best. In the MRFIT trial, those patients who received HCTZ had a 46% increase in mortality compared with patients who received usual therapy. In contrast, those patients who received chlorthalidone had a 56% decrease in cardiovascular mortality. The safety committee then recommended a switch from HCTZ to chlorthalidone whereupon the switched group now on chlorthalidone had a 26% reduction in cardiovascular mortality. These findings strongly suggest that chlorthalidone has superior efficacy over HCTZ with regard to cardiovascular mortality. Chlorthalidone is twice as potent as HCTZ. HCTZ and indapamide There are a number of outcome-based trials with Indapamide. Indapamide has been combined with perindopril in two mechanistic cardiac studies: PICXL and REASON demonstrating better reduction of left ventricular mass than enalapril and in one ... to page 24 Consulting Editor ... Prof James Ker What Diuretics do for the Heart Diuretics have been used for the treatment of hypertension for over 50 years, yet there is still much debate and controversy about their use. The current debate is whether there is any evidence for the use of low-dose thiazide diuretics - evidence is lacking that the low dose can reduce morbidity/mortality. Higher doses can increase the development of diabetes and have other negative metabolic adverse effects. Hydrochlorothiazide given as monotherapy has an inferior antihypertensive action when compared to other antihypertensive drugs evaluated by 24-hour ambulatory blood pressure monitoring. It seems that some guidelines are now switching to thiazide-like diuretics such as chlorthalidone and indapamide. This controversy is far from being resolved. Drug-induced hypertension It is important to consider drug-induced hyper tension as a type of secondary hypertensive when evaluating a patient. There is a very long list of drugs and chemical compounds that can increase blood pressure. These drugs may also contribute to resistant hypertension. Lifetime risks Clinicians are used to evaluate and calculate the global cardiovascular risk by using calculators such as the Framingham risk chart. These calculations typically calculate the absolute risk over a short term such as 10 years. The majority of patients in a population may be in the lowrisk category, yet have high lifetime risks of cardiovascular disease. There is an article on lifetime risks with a clear message: normal risk factors lifelong lead to low lifetime risk. New Insights into Hypertension - How to Deal with Borderline Blood Pressure Dr Danushka Lipinska Nearly 50 million people in the US have hypertension with three quarters of hypertensive individuals being older than 50 years. Almost one third of adults presenting for noncardiac surgery and some two thirds presenting for coronary bypass surgery report a history of hypertension. The clinical consequences of chronic hypertension have been well characterised being highly associated with coronary heart disease, stroke, renal failure, retinopathy, peripheral vascular disease and most importantly, mortality and poor quality of life. Dr Prys Robert, well-known US researcher, performed and published some of the groundbreaking studies on the haemodynamic perturbation following induction of anaesthesia and surgery on the patients with severe hypertension. He provided the following recommendation: Untreated elevated arterial pressure constitutes a serious risk to patients undergoing anaesthesia and surgery and therefore antihypertensive therapy should not be withdrawn prior to anaesthesia and surgery. Dr Lee Goldman studied outcomes of patients with mild to moderate hypertension (over 1000 cases) who were operated under general anaesthesia. Study findings Mild to moderate hypertension does not increase perioperative risk of patients. So-called ‘borderline blood pressure’ - 140/100, 150/100 - does not need pharmaceutical treatment. Washington-based well-known nutritionist Jean Carper discovered how natural remedies and diet can help to lower blood pressure without pharmaceutical treatment. Six nondrug ways to reduce blood pressure • The first cure for high blood pressure is to cut down on salt. Cut sodium intake to no more than 2400mg a day. There is evidence that restricting sodium can reduce even normal blood pressure. Prof Malcolm Law of the University of London estimates that eliminating one teaspoon of salt (about 200mg of sodium) a day from your diet can knock systolic pressure down on average 7mmHg and diastolic down 3.5mmHg. One way to cut down on sodium is to limit processed foods, which account for 75% of the sodium in the food supply. • Excessive weight is the most prevalent cause of high blood pressure. A loss of only 3.5-4.5kg reduced systolic blood pressure by 5.8mmHg. • Vitamin C up, blood pressure down. Take 100mg vitamin C daily. Six weeks of Vitamin C supplementation showed, on average, a decrease of 8-10mmHg of the systolic reading and an average of 7mmHg of diastolic blood pressure in those with borderline blood pressure. • Regular physical exercise - even half an hour of brisk walking or aerobic exercise (even in the garden). • Avoid alcohol entirely - is the most effective advice. If patients don’t want to do this, at least limit intake to one glass of red wine daily. • Eat fruits and vegetables. A Harvard nutrition study showed that only 2% of vegetarians had high blood pressure, compared with 26% of meat eaters. Eating two servings of fruit daily and two servings of vegetables will reduce systolic blood pressure on average by 11.4mmHg and diastolic blood pressure by 5.5mmHg in just in two weeks. Diet recommendation for high blood pressure Fish is another must for healthy blood pressure. Its omega 3 fatty acids are essential in keeping blood pressure on a healthy plateau. Fish such as salmon, mackerel, sardines and herrings should be eaten twice a week. Monounsaturated fat in olive oil would lower systolic pressure by about 9mmHg and diastolic pressure by about 6mmHg. Olive oil should be used on salads. Caffeine can drive up blood pressure. Try to reduce coffee to one cup daily, never drink coffee after 5pm. Green tea is also highly recommended. Onion, garlic and celery relax the smooth muscles of the blood vessels, allowing them to dilate. Celery has a mild diuretic effect and detoxifies your body fluids. If patients follow the above instructions for at least a period of six months, they will be certainly satisfied with the results. References available on request. page 24 | medical chronicle | May 2012 Follow us on Twitter: @MedChronicle Cardiac Lifetime Risks of Cardiovascular Disease Current medical practice is concerned with the calculation of global short-term cardiovascular risk to develop heart disease. This risk calculation (typically using Framingham Risk Chart) is used to target therapy in those people deemed to be at risk. The short-term risk is seen as the next ±10 years, but the majority of adults who are considered as being at low risk calculated by the Framingham Risk Chart, and therefore not needing treatment, are actually at high risk to develop heart disease across their remaining lifespan - this is the so-called lifetime risk. The calculation of the lifetime risk of cardiovascular disease in an individual or groups of people is a more comprehensive assessment of overall burden of disease now (short-term) and in future (lifetime) because the calculation of lifetime risk takes into account the risk of cardiovascular disease and competing risks (e.g. death from cancer) until the person reach an advanced age. Most estimates of lifetime risk of cardiovascular disease are restricted to risk factors measured at a single age. These estimates do not take account of, e.g. the widespread use of medications or changes in riskfactor levels (e.g. decreasing levels of ‘normal’ cholesterol). To address these problems, the Cardiovascular Lifetime Risk Pooling Project was started. Baseline characteristics Aim of the study Results The project aimed to collect and pool data from many longitudinal epidemiological cohort studies over the past 50 years and to calculate lifetime cardiovascular risk. There were 17 studies with 67 890 participants and the MRFIT data (n=189 494) were added separately. All had varying cardiovascular risk factors. For the calculation of lifetime risk, a modified version of survival analysis was used. Only 5% of the participants fell into the low-risk category where all the risk factors were optimal. At least two-thirds (2/3) of the participants fell into the high-risk group (having at least one major risk or more factors). There were differences in the burden of risk factors between older and younger birth cohorts e.g. 55-year-old people born before 1920 as compared to 55-year-olds born after 1920: 8.8% vs 4.2% had diabetes, less smoked (29.5% vs 52.3%) mean cholesterol was lower and mean systolic blood pressure was lower (124mmHg vs 137mmHg). The lifetime risks of death from cardiovascular disease were higher among men than among women. Among 55 year old people, those with an optimal risk profile [total cholesterol <4.7mmol/ℓ, blood pressure <120/80mmHg, nonsmoker, nondiabetic) had substantial lower risks of death from cardiovascular disease through to the age of 80 years as compared to people with two or more risk factors. Risk of death was 4.7% in low risk group vs 29.6% in high risk for men and 6.4% vs 20.5% for similar risk groups in women. Fatal coronary heart disease (or nonfatal myocardial infarction): • 3.6% vs 37.5% for men • <1% vs 18.3% for women. Conclusion Differences in risk factor burden translate into marked differences in lifetime risk of cardiovascular disease. These results are the end-result between cardiovascular disease risk and competing risks of death, e.g. cancer. Similar trends were seen among the black population and Caucasians, and across diverse birth cohorts. References available on request. Thiazide Diuretics in Hypertension - Not What they Seem to Be? ... from page 23 study (LIVE) vs enalapril showing better reduction of left ventricular mass. Two studies showed better reduction of albuminuria than enalapril: NESTOR and PREMIER. Indapamide has thus been involved in in five outcomes-based mechanistic studies, with a consistent positive result. Indapamide, combined with perindopril, was involved in three clinical trials with hard cardiovascular endpoints: HYVET, PROGRESS and ADVANCE, all with positive results of better cardiovascular outcomes. There are no such trials with indapamide as monotherapy and nor are there trials that compared head-to-head with HCTZ. Conclusion Despite the use of diuretics over half a century, many questions and uncertainties remain on the exact value for diuretics. It is increasingly clear that not all diuretics are created equal and they differ in adverse effects (e.g. metabolic side effects) and may differ in outcomes. Low-dose HCTZ, although commonly prescribed as monotherapy, has no positive outcome data and has an inferior blood-pressure lowering capacity as compared to other antihypertensives. HCTZ, even in combination with an ACE-inhibitor, is inferior to a calcium channel blocker added to an ACE-inhibitor. Adherence to diuretics is worse than with any other drug class. What do the guidelines say? NICE-guidelines The National Institute of Clinical Excellence [NICE] recommends: • For people under 55 years, offer an Angiotensin Converting Enzyme Inhibitor (ACE-I) or a low cost Angiotensin Receptor Blocker [ARB] • For people over 55 years of age and black people of African or Caribbean origin - offer a calcium channel blocker. If this is not suitable, offer a thiazide-like diuretic • If diuretic treatment is needed - offer a thiazidelike diuretic such as Chlorthalidone (12.5mg to 25mg daily) or indapamide (1.5mg modified release daily or 2.5mg once daily). South African guidelines The choice of diuretic should be a low-dose HCTZ (12.5-25mg) or a thiazide-like diuretic such as indapamide. References available on request. page 26 | medical chronicle | May 2012 Follow us on Twitter: @MedChronicle Cardiac Drug-induced Hypertension: An Unappreciated Cause of Secondary Hypertension It is often not appreciated that there are a number of therapeutic agents or chemical substances that may elevate blood pressure and in that manner cause secondary hypertension - but they can contribute to a patient that presents with resistant hypertension. The following are important groups of drugs/ chemicals that may elevate blood pressure: Drugs that inhibit vascular endothelial growth factor signalling Antivascular endothelial growth factor (VEGF) drugs are used in the treatment of various malignancies. Examples of those drugs are bevacizumab (monoclonal antibodies), lapatinib (inhibits tyrosine kinase stimulated by VEGF), sorafenib, axitinib and pazopanib. Hypertension has evolved as one of the most common adverse effects of these drugs. NSAIDS Nonsteroidal anti-inflammatory drugs (NSAIDS) are known to induce hypertension and, in addition, may interfere with the antihypertensive effect of the antihypertensive drugs. Studies have shown that NSAIDS can increase blood pressure significantly by a mean increase of 5mmHg. The only drugs that are not affected by NSAIDS are calcium channel blockers; all other antihypertensives may lose some of their efficacy. It may be that cyclooxygenase-2 (COX 2) inhibitors increase the blood pressure more than COX1 inhibitors (traditional NSAIDS). Antidepressant agents Venlafaxine hydrochloride, a serotonin/norepinephrine reuptake inhibitor can cause elevation of blood pressure, more pronounced in the elderly and in men. The blood pressure effect is dose-dependent. The mechanism is probably through its noradrenergic mechanism. Several other antidepressant agents may elevate blood pressure, e.g. tricyclic antidepressants, fluoxetine, busipirone, etc. Corticosteroids Hypertension occurs in at least 20% of patients treated with corticosteroids in a dose-dependent fashion. When steroids cause hypertension, a diuretic is the drug of choice to treat because volume overload is the main mechanism by which steroids raise blood pressure. Sex hormones Oral contraceptives can induce hypertensives in ±5% of users of combined high-dose compounds (at least 50mg oestrogen and 1-4mg progestin). Postmenopausal hormone replacement has minimal if any effect on blood pressure in normotensive women. Sympathomimetica Drugs commonly used as upper respiratory tract decongestants such as pseudoephedrine can cause elevation of blood pressure, sometimes severe. The chronic use of these drugs can also contribute to resistant hypertension. Caffeine Caffeine increases sympathetic activity and may increase blood pressure. When caffeine is ingested through coffee, the blood pressure effect is small. Herbal products Some popular herbal products can increase blood pressure and can interfere with antihypertensive therapy. The true incidence of this effect has not been established. Cocaine Cocaine abuse is characterised by adrenergic overactivity with acute elevations of blood pressure that may be life-threateningly high. Immunosuppressive drugs Cyclosporin-induced hypertension post renal transplantation e.g. is present in at least 30% of patients and in bone marrow transplantation it may be >50%. Cyclosporin, when used in psoriasis, also can induce hypertension. Tacrolimus, is also associated with hypertension but it produces less blood pressure elevation than cyclosporine. Recombinant human erythropoietin The use of this compound can cause hypertension. Alcohol Excessive alcohol use can raise blood pressure and can also cause resistance to antihypertensive therapy. HIV treatment Highly active antiretroviral therapy (HAART) can increase systolic blood pressure but it this usually only happens after approximately six months of therapy. It has been found that this blood pressure reaction is more pronounced in the elderly. Conclusion When the diagnosis of hypertension is made, a full detailed medical history should include foods, poisons, all medications even medications that the patient may not consider to be drugs. These substances may cause secondary hypertension. On the other hand, they may contribute to the development of resistant hypertension. For a detailed review, consult the reference: Grossman E, Messerli FH. Drug-induced hypertension: an unappreciated cause of secondary hypertension. Am J Med 2012;125:14-22. medical chronicle | May 2012 | page 27 Visit our webpage: www.medicalchronicle.co.za Thrombosis & Haemostasis Forum New Oral Anticoagulant for Stroke Prevention in Atrial Fibrillation Dr Louis van Zyl, Physician in Private Practice with a special interest in preventive cardiovascular medicine For more than half a century, warfarin and similar vitamin K antagonists (VKAs) have been the mainstay of oral anticoagulation, mainly for the prevention and treatment of venous thromboembolism (VTE) and, for the past two decades, also the cornerstone for stroke prevention in nonvalvular atrial fibrillation. Compared to placebo, warfarin bestows a risk reduction of approximately 64% for preventing recurrent stroke in patients with atrial fibrillation. Despite this formidable legacy, the optimal utilisation of VKA usage is still lacking and its therapeutic profile is not near perfect. For warfarin to exert its desired effect, its anticoagulation intensity has to be maintained within a narrow therapeutic window (INR 2.0-3.0). Outside of these parameters, the risk of thromboembolism or haemorrhage (of which intracranial haemorrhage is the most hazardous) becomes clinically unacceptable. Time in therapeutic range (TTR) is a surrogate marker for the quality of the anticoagulation expressed as the percentage of time that the INR is maintained within a predefined range and the most commonly used is the Rosendaal method. The limitation of VKA therapy is a result of significant inter- and intra-patient variability in dose response due to comorbid conditions, genetic polymorphisms, numerous interactions with food and concomitant drugs and unpredictable pharmacology leading to undesired TTR values and necessitating regular coagulation monitoring and dose adjustment. These and the fear of complications have led to underuse of VKA as required by accepted guidelines and as Deplanque et al highlighted, several of these factors influencing clinicians were misconstrued and unfounded conceptions in as many as 76% of eligible patients not prescribed oral anticoagulation. Attempts to improve this situation would include strategies of improving VKA usage by expanding the array of tools to assist the clinicians in attaining confidence to become assertive anticoagulators. Reducing the Risk of Developing DVT and Pulmonary Embolism after Surgery Venous thromboembolism (VTE) following hip or knee replacement is the cause of one in 10 deaths in hospitalised patients. In 2008, both the European Commission and Health Canada approved the oral anticoagulant, rivaroxaban (Xarelto), followed by the US Food and Drug Administration in 2011. Since then, rivaroxaban, which showed a significant relative risk reduction of more than 50% in those treated with the anticoagulant compared to enoxaparin during clinical trials, has become the most prescribed anticoagulant in the world for thromboprophylaxis in patients undergoing total hip or knee replacements. To celebrate this milestone, Bayer HealthCare recently hosted a dinner for doctors with University of Witwatersrand haematologist, Prof Barry Jacobson; orthopaedic surgeon, Dr Jan de Vos and specialist physician, Dr Roy Spammer as guest speakers. Their presentations focused on the prevention of intraoperative bleeding, the use of rivaroxaban in major orthopaedic surgery of the lower limbs and the importance of anticoagulation. Record trial Dr De Vos briefly discussed the findings of the phase III studies of the Regulation of Coagulation in Orthopaedic Surgery to Prevent Deepvein Thrombosis and Pulmonary Embolism (RECORD) trials in which he was involved. The trials were randomised, double-blind, parallel-group, multicentred and double-dummy studies. Patients involved in Record 1 and 2 underwent total hip replacement surgery, while those in Record 3 had total knee replacement surgery. Inclusion criteria were simply that a patient had to either undergo total hip or total knee replacement surgery. Patients with haemophilia and significant liver diseases, as well as those who showed allergic reactions to the drugs or required ongoing anticoagulant therapy were excluded. More than 12 500 patients participated in the studies. The efficacy end-point of the study was total, major or symptomatic VTE and death from any cause, while the main safety endpoint included the incidence of major bleeding. Record 2 patients received either rivaroxaban for five weeks or enoxaparin for two weeks, followed Guest speakers on DVT and PE (left to right): Dr Jan de Vos, orthopaedic surgeon, Wilgers Hospital Pretoria; Prof Barry Jacobson, head of clinical haematology, department of haematology NHLS, Steve Biko Academic Hospital; Dr David Adler, specialist physician, Sandton Mediclinic; Dr Roy Spammer, specialist physician, Panorama Mediclinic, Cape Town by three weeks of placebo. This was to demonstrate that extended prophylaxis is more effective than short-term prophylaxis. In Record 1, patients received either rivaroxaban or enoxaparin for five weeks while in Record 3, patients received either rivaroxaban or enoxaparin for two weeks. Findings Record 2 patients using rivaroxaban showed a 79% risk reduction in total, 88% in major and 83% in symptomatic VTE. In addition, said Dr De Vos, there was a low incidence of major bleeding. In Record 3, patients using rivaroxaban showed a 50% risk reduction in total, 62% in major and 65% in symptomatic VTE compared to those using enoxaparin. The importance of anticoagulation More than 50% of fatalities due to pulmonary embolism (PE) and 67% of deep vein thrombosis (DVT) can be prevented through the proper use of anticoagulants. PE is the cause of 1% of deaths in hospitalised patients: 80% of patients show no signs of the condition and 66% die within 30 minutes after the incident has occurred, said Dr Spammer. The incidence of DVT in patients who have undergone total hip replacement surgery and who have not received anticoagulation therapy is as high as 42%-57%. In addition, 9%-28% of patients who don’t receive the drug will develop a PE, between 2%-5% of these patients are at risk of VTE and it is the cause of 1%-2% of fatalities. The prevalence of DVT without anticoagulation is 41%-85% while approximately 4% of these patients are at risk of developing PE and it is the cause of 1.7% of fatalities. Dr Spammer stressed that complications such as embolisms or DVTs often only develop after patients have been discharged from hospitals. A UK study has found that the patients who have undergone total hip replacement surgery generally only develop complications 21.7 days after discharge. Patients who have undergone total knee replacement surgery develop complications on average after 9.7 days. More than 15 000 patients on the UK’s orthopaedic registry were part of the study. Guidelines drafted by the American Academy of Orthopaedic Surgeons recommend that patients undergoing total hip replacement surgery must be put on anticoagulants for a duration of 35 days, while those undergoing total knee replacement surgery should be on anticoagulants for 14 days. However, according to Prof Jacobson, the latest guidelines on the prevention of VTE published by the American College of Chest Physicians were completely misguided. Identifying patient-level predictors of oral anticoagulation control in the outpatient setting, is one example and personalising warfarin therapy by means of pharmacogenetics, patient’s self-testing and self-management or the use of low-dose vitamin K for patients with unstable INRs. The promise of simplified dosage regimens, no dietary restrictions, predictable anticoagulation and no need for routine monitoring held by the new novel oral anticoagulants: apixaban, edoxaban, rivaroxaban (Factor Xa inhibitors) and dabigatran (direct thrombin inhibitor) may be a major leap forward, which could eclipse VKA usage. Clinicians need to sharpen their skills to recommend the best approach for individual patients However, it may not be as simple as it seems to replace VKA with a new oral anticoagulant. Despite all of them demonstrating noninferiority to warfarin for reducing the risk of stroke and systemic embolisation (edoxaban trial still ongoing) there are distinct differences to be considered when selecting a specific agent in clinical application. For example: 1. The TTR of Warfarin for the different trials should not be utilised as a differentiator because of the numerous factors influencing the variability of TTR’s between the trials (i.e. CHADS2 score, age, presence of CHF, location and VKA naivety. 2. Renal elimination of an agent may especially be of importance specifically in the high risk population warranting OAC. 3. The reversibility or availability of an antidote. So where do we stand? Warfarin will remain a viable option in the foreseeable future. Clinicians will need to sharpen their skills and apply them with increased responsibility so as to recommend the best approach for an individual patient through a tailored approach. This will assist them to promptly identify those patients who may predictably not be ideal candidates for VKA, thus prompting the use of a new novel oral anticoagulant in a rational and well-informed manner. References available on request. Thrombosis Forum Aimed at educating and informing doctors about the latest advances and developments in the prevention and treatment of thrombosis and pulmonary embolism, Medical Chronicle will from this month feature a regular Thrombosis & Haemostasis Forum, written by SA’s leading experts in the field. page 28 | medical chronicle | May 2012 Aesthetic Medicine Congress of SA (AMCSA) CSIR International Convention Centre, Pretoria 1-2 June 2012 Aesthetic Medicine New Trends in Aesthetic Medicine More than Just a Cure for Wrinkles Dr Riekie Smit, Aesthetic and Sports Physician The field of aesthetic medicine, being that of improving the external appearance of the face and body nonsurgically, has made some interesting shifts over the years. It was, and has always been, a field not confined to any specialty and from its inception, GPs, dermatologists and plastic surgeons practised and experimented in this field. This specific field of medicine was largely driven by public and media demand. Most people want to improve their appearance for numerous reasons that may include work (for example, actors), relationships, self-esteem and personal growth. The majority of people would prefer to have this done in an effective, subtle (not noticeable) manner and without the extensive recovery period experienced with surgical procedures. Aesthetic medicine mostly evolved in Europe and South America, where doctors started experi menting with chemical peels for skin rejuvenation, dermal filler injections and laser devices. Then came the discovery of botulinum toxin in Canada, by ophthalmologists Jean and Alastair Caruthers, who injected the product for eye conditions and noticed the wrinkle-reduction effect. This discovery suddenly became a major aspect of the field of medicine and gained priority media attention. This milestone attracted the large US demand for ‘quick fixes’ by the public and suddenly the field of aesthetic medicine became firmly entrenched in the public arena. The discovery of wrinkle injections was a major milestone in achieving dramatic results in patients seeking improved appearance. Due to the high demand, this has also become the bread and butter of most practitioners in this field. Many struggling medical practitioners were also lured into this industry to survive the financial turmoil experienced in clinical practices. Despite the negative publicity that accompanied the sudden surge in numbers of doctors offering wrinkle-reduction injections and unnatural-looking results in Hollywood stars, demand for procedures continues to increase. As a result, pharmaceutical companies, cosmetic companies and laser device developments continue to invest in research and development. The past decade has seen dramatic growth in the field, and has been supported by a large number of peer-reviewed medical articles. and hormonal profiles to create a tailor-made plan for anti-ageing and optimal health, combined with aesthetic procedures. Major breakthrough discoveries including laser and light technologies have further contributed to the growing scientific reputation of this field of medicine. The congress The Aesthetic Medicine Congress of SA will take place this year from 1-2 June at CSIR International Convention Centre, Pretoria. The theme ‘Natural Beauty’ will stress the importance of performing aesthetic procedures to obtain natural results. Modern techniques are increasingly focused on this aim, and are being progressively complemented by the cosmetics industry, which is seeing a significant shift towards more natural agents, and fewer preser vatives and parabens. Trend towards integrative, holistic approach The current trend leans heavily towards a highly integrative and holistic manner of achieving improved appearance. This can be seen in the increasing focus on skin healing and restructuring, treating the cause of the external condition and integrating allopathic as well as natural medicine into the field of aesthetic medicine. Aesthetic consultations are increasingly combined with a holistic interpretation of the patient’s health status, lifestyle and habits, as well as pathological More than 45 exhibitors will be launching, showcasing and demonstrating new developments in the field. The congress programme will include three auditoriums running parallel presentations by expert speakers who will also conduct live demonstrations on the latest procedures and techniques. The international faculty includes key opinion leaders such as Dr Mauricio de Maio, plastic surgeon from Brazil, a renowned expert on teaching facial evaluation before commencing with botulinum toxin and filler techniques. Dr Alessio Redaelli from Italy, author of a number of well-known books in aesthetic medicine, is a leader in the growing emphasis on maintaining a patient’s natural features while enhancing their beauty. Dr Hassan Galadari from Dubai will be updating the audience on new techniques with microcannulas, very thin, small and flexible hollow tubes with smooth, round tips, which are less invasive and painful than traditional needles. Dr Philippe Petit, expert in mesotherapy for over 45 years, will run a full-day course on using mesotherapy for aesthetic purposes. Mesotherapy employs multiple injections of pharmaceutical and homeopathic medications, plant extracts, vitamins, and other ingredients into subcutaneous fat, and is used in various aesthetic procedures. Local experts include well respected Dr David Presbury, a dermatologist with vast experience in lasers, Dr Nerina Wilkinson, plastic surgeon, Dr Alastair Clarke, aesthetic doctor in Johannesburg and Dr Craige Golding, anti-ageing and integrative medicine physician, among numerous others. For more information, visit www.amcsa.org or email [email protected] The Future Look of Anti-ageing Treatments Many fillers for the ageing face are now designed to create a fuller, more youthful appearance, instead of targeting only wrinkles or fine lines. In addition, facial rejuvenation with lasers is now more targeted, resulting in quicker results and less downtime, said dermatologist Dr Jenny Kim, associate professor of medicine, division of dermatology, University of California. “Couple these treatments with the wide range of inexpensive skincare products with high-quality ingredients that are now available and patients can see dramatic results for many problem areas.” New fillers pump up volume While skin fillers and botulinum toxin are the most widely used procedures to rejuvenate the skin, Dr Kim explained that the latest fillers work as volumisers to replace the plumpness of the face that is lost with ageing. “As much as lines and wrinkles make people look older, we’re learning that volume loss is just as critical,” said Dr Kim. “Because of that, we’re looking at the ageing process a little differently now and understanding the importance of replacing volume loss in the face to restore the fullness of a more youthful appearance.” Most facial volume loss occurs after age 40, although some people start noticing this change in their late 30s. When this happens, areas of the face that were once full become depressed and are made more prominent by shadowing or darkening - making the face look older. The newest filler introduced and approved by the US Food and Drug Administration for facial rejuvenation is calcium hydroxylapatite. This filler restores facial volume and promotes collagen production, lasting for up to a year. Lasers focus on skin repair New laser technologies offer another alternative to rejuvenate the skin with fewer side effects than earlier lasers. For example, fractional photothermolysis is a newer technology that works by targeting a very small percentage of the skin during each treatment, improving the damaged area and resulting in less adverse effects and downtime for the patient. “Laser technology continues to evolve and provides dermatologists with more options to target not only specific signs of ageing, but specific cells responsible for age-related changes in our appearance,” said Dr Kim. “In the future, lasers could even produce significant skin tightening or effectively target oil glands to improve acne, decrease oily skin and reduce large pores.” Products offering vitamins and antioxidants Dr Kim recommends that patients look for ingredients such as retinoids (chemical compounds derived from vitamin A), peptides (smaller proteins that stimulate collagen production), and growth factors (compounds that act as chemical messengers between cells and play a role in collagen production). These have the ability to repair skin damage from sun exposure or other toxic chemicals and, in some cases, stimulate collagen production. Future technologies Another area of research for its potential anti-ageing properties is stem cell technology. If stem cells from fat can be signalled to turn into skin structure, they could potentially make a person look younger by adding volume to depressed facial areas. Dr Kim explained that while this is an exciting area of research, the efficacy and safety of this technology has not been tested in large clinical studies. •••Source: American Academy of Dermatology medical chronicle | May 2012 | page 29 Visit our webpage: www.medicalchronicle.co.za Dermatology Late-onset Acne among Women on the Increase The findings of a study presented at the 70th annual meeting of the American Academy of Dermatology held in the US recently, showed that late-onset acne is becoming increasingly common among women. Reporting on the findings, Prof Bethanee Schlosser, director of women’s skin health at Northwestern University in California (US), said a study examining the prevalence of acne in adults over age 20 found that acne affects more than 50% of women between the ages of 20-29 and more than 25% of women between the ages of 40-49. The study also found that late-onset acne was more prevalent among women than men of the same age. In another study it was found that 45% of women between the ages of 21-30, 26% of women aged 31-40 and 12% of women in the 41-50 age range had clinical acne. According to Dr Sarina Drusinsky, chairperson of the Dermatology Society of SA, the study does not really shed new light on adult-onset acne. In fact, she said, she has been treating women for adult-onset acne for more than 25 years as this has been caused by pregnancy, contraceptives and hormone replacement. Treatment of late-onset acne The gold standard in the prevention of acne, said Prof Schlosser, is a proper treatment regimen and good skin care habits, and while there is currently no single cure that works in all patients with acne, dermatologists can recommend patient-specific treatment regimens to control acne and minimise future breakouts. Hormonal therapies are commonly used to treat acne safely and effectively in women. There are various causes of acne. These include excess sebum, or oil gland production, skin cells that shed become abnormally sticky and accumulate in, or clog up, the hair follicle, an increased number of the acne-causing bacterium Propionbacterium acnes and skin inflammation. Prof Schlosser explained that androgens, the male hormones present in both men and women, can also contribute to the flare-up of acne. Oil glands are often over-stimulated by androgens and alter the development of skin cells that line hair follicles in the skin. She added that while the majority of women with acne have normal androgen levels, hormonal testing is recommended for females who have acne accompanied by excess facial or body hair, deepening voice, or irregular or infrequent menstrual periods. Therapies Before embarking on a treatment regimen, it is important to take the following factors into con sideration, warned Prof Schlosser: • Therapy must be tailored to the patient’s specific type and severity of acne. • When prescribing acne medication, it is extremely important to ask whether or not the patient is pregnant or planning on becoming pregnant. Several oral and topical medications should not be used when trying to conceive or during pregnancy. • The skin of some women becomes drier as they age and topical acne medications may cause skin irritation in these patients. • Some adult women with acne also may show signs of rosacea, which would make some topical acne medications harder to tolerate. Prof Schlosser recommended the use of topical retinoids as first-line therapy for mild-to-moderate inflammatory acne accompanied by blackheads and whiteheads. Topical retinoids can be prescribed for patients of any age and are extremely effective in the overall long-term prevention of new acne. Hormone therapies including oral contraceptives are also effective in the treatment of adult acne. They can be used alone or in conjunction with an anti-androgen medication, such as spironolactone. It should be noted, said Prof Schlosser, that in some instances, oral contraceptives used in combination with other medications can alter the levels and activities of hormones, which in turn can trigger an outbreak of acne. She cautioned that patients must be screened carefully before hormonal therapy is prescribed for the treatment of acne, as there are numerous contraindications. The prescribing physician should rule out conditions such as breast cancer, heart attack, stroke or blood clots, uncontrolled high blood pressure and abnormal vaginal bleeding before prescribing hormone therapy. Patients on hormone therapy should be monitored regularly. It is also important that the dermatologist discusses realistic expectations with patients, said Prof Schlosser. “With acne, it’s important for patients to understand that there are no quick fixes, and none of the therapies used to treat acne work overnight.” Patients need to be consistent when using their acne medications and realise that they may not see the full effects of their treatment regimen for eight to 10 weeks - and in many cases, some type of maintenance therapy is required for long-term treatment of acne. •••Source: American Academy of Dermatology page 30 | medical chronicle | May 2012 Follow us on Twitter: @MedChronicle Men’s Health The Role of Testosterone in the Treatment of Obesity, MetS in Hypogonadal Men Dr Bradley Wood, Urologist, Fourways Life Hospital The folowing review considers the role of testosterone in the development and treatment of obesity, a condition that is acknowledged to be reaching global epidemic proportions. The role of testosterone in glucose homeostasis, lipid metabolism and cardiovascular (CV) pathology is examined, and the implications of low testosterone levels on morbidity and mortality are discussed. The article outlines evidence for the effects of normalising testosterone levels on insulin sensitivity, visceral adiposity and lipid profiles, and addresses the safety of testosterone, particularly in elderly men. Key points Testosterone plays a significant role in obesity, glucose homeostasis and lipid metabolism: • Although androgens appear to be involved in the deposition of visceral fat in males, continued androgen stimulation is not required once fat is stored, and low testosterone adversely affects fat storage and metabolism. • There is a direct correlation between plasma testosterone and insulin sensitivity, and low • • • • testosterone levels increase the risk of type 2 diabetes mellitus. Lower total testosterone and sex hormonebinding globulin (SHBG) predicts a higher incidence of the metabolic syndrome (MetS). Testosterone replacement therapy (TRT) reverses part of the unfavourable risk profile for the development of diabetes and atherosclerosis in hypogonadal men. There is growing evidence and acceptance that testosterone is a pivotal hormone for many aspects of men’s health. Rigorous scientific study does not support an adverse effect of testosterone on CV morbidity and mortality. The administration of TRT to elderly men is a responsible strategy provided that accepted treatment guidelines are followed. Testosterone and fat distribution The regional localisation of body fat, predominantly in the abdominal regions in men and in peripheral areas, such as breasts, hips and thighs in premenopausal women, suggests a role for sex steroids in the deposition of fat, although obese adults of either sex also store fat in the fat depots associated with the opposite sex. However, although androgens induce visceral fat accumulation in men, men who acquire hypogonadism later in life do not have less, and may indeed have a greater amount of visceral fat than eugonadal men. Induction of androgen deficiency in men with prostate cancer increases fat mass, reduces insulin sensitivity, worsens lipid profiles and increases CV risk, as well as worsening metabolic control in men with diabetes mellitus. Furthermore, lower endogenous androgens predict central adiposity in older men, and low testosterone adversely affects blood pressure (BP), fasting plasma glucose, triglycerides and body mass index. The metabolic syndrome There is an established relationship between obesity and the MetS, the clustering of risk factors predisposing to type 2 diabetes mellitus, atherosclerosis and CV morbidity and mortality. Visceral obesity is a central component of the MetS, together with insulin resistance, glucose intolerance, hypertension and dyslipidaemia. There is evidence across all age levels for a powerf ul inverse relationship between the severity of features of the MetS, including visceral obesity and plasma testosterone levels. A similar relationship is present between type 2 diabetes and testosterone, and low testosterone is an independent risk factor for the development of both the MetS and diabetes, and their clinical sequelae. Adiposity and associated insulin resistance has been shown to lower circulating levels of testosterone, even in younger men, and there is evidence for subtle disturbances in sex hormones in MetS that may contribute to its pathogenesis. What this review adds The role of TRT in the restoration of libido and potency in men with hypogonadism has long been accepted. However, this review draws together evidence for the key role played by testosterone in glucose homeostasis, lipid metabolism and the etiology of the MetS and associated diseases in ageing men. It challenges traditional assumptions held about testosterone regarding CV disease, voiding issues and prostate cancer. Further, it supports the emerging perspective, which proposes a role for TRT in the treatment of the MetS and its sequelae, such as type 2 diabetes and CV disease. Epidemiological evidence that low testosterone is a predictor of mortality in elderly men is further indication that testosterone is a vital hormone for men’s health throughout the lifespan of men. Testosterone deficiency has serious health consequences, including the MetS and its sequelae, type 2 diabetes, atherosclerotic disease, osteoporosis and loss of skeletal muscle mass and strength. There is a growing consensus that the administration of testosterone replacement therapy to elderly men is a responsible strategy if accepted treatment guidelines are followed. Reference: Saad F, Gooren LJ. The role of testosterone in the etiology and treatment of obesity, the metabolic syndrome, and diabetes mellitus type 2. J Obes 2011:pii:471584. medical chronicle | May 2012 | page 31 Visit our webpage: www.medicalchronicle.co.za Nutrition Responsibilities of Food and Nutrition Professionals in Weight Management An individual’s body weight is determined by a combination of genetic, metabolic, behavioural, environmental, cultural, and socioeconomic influences. These diverse influences make treating overweight and obese individuals complex. Food and nutrition professionals must understand each of these aspects as they develop a shared decision-making relationship with clients. They should also be aware of their own biases regarding individuals with this condition. In one study of registered dieticians (RDs), 87% viewed individuals with obesity as self-indulgent and 32% indicated that individuals with obesity lacked willpower. These characterisations could affect the style of counselling for clients with obesity. Food and nutrition professionals should understand the importance of weight gain prevention and the challenge of weight loss maintenance to effectively help their clients maintain normal weight and sustain long-term weight loss. Weight-loss maintenance Increased physical activity also appears to be key in successful weight-loss maintenance. RDs, with their understanding of energy balance and energy expenditure, along with their skills in teaching behaviour change, are in key positions to: • Educate physicians and other healthcare professionals about the importance of weight-loss maintenance. • Help the public, as well as other healthcare professionals, to understand the difference between weight loss and weight-loss maintenance. • Assist clients in developing strategies necessary for achieving weight-loss maintenance. Professional responsibilities As RDs counsel patients, they should be aware of the regulatory guidelines that help them define what range of services they can provide within a practice setting. It is the professional responsibility of RDs to ensure that competency is maintained to provide safe and effective services to overweight and obese clients. RDs must remain current on topics related to the treatment and management of patients with obesity, including the knowledge and skills that are required to counsel patients about physical activity. This may involve an understanding of when patients with obesity should be referred to a certified exercise professional or other appropriate healthcare provider. Every opportunity to increase weight management skills should be taken. Attending workshops and symposiums is advised. Treatment strategies The partnership between RDs and their patients should focus on developing strategies that will enhance opportunities for clients to control their own behaviours related to overweight or obesity. Incorporating various behavioural techniques into weight-loss counselling is a recommended approach. RDs need to use their skills and knowledge to support and encourage clients with their weight-loss efforts. If RDs work only with physicians or a team that includes a coordinated group of health professionals with a variety of skills, they should work effectively with the team to achieve the best outcome for the patient. Communication with other healthcare providers on the team is essential to accommodate the different needs of each patient. Understanding when to refer patients to other healthcare providers is important in managing patients’ needs. Within the past several years, various committees, foundations, governmental agencies and professional associations have addressed the increasing prevalence of obesity and overweight in the US. The 2005 US Dietary Guidelines addressed the issue by stressing the necessity of energy balance for weight maintenance and, for the first time, the importance of physical activity. Population-based interventions For food and nutrition professionals to have a substantial influence in achieving these goals, they are challenged to develop new, innovative and bold approaches for the prevention and treatment of obesity. The future paradigm will involve population-based interventions that will require the full cooperation of the entire healthcare community. The coordinated integration of expertise from different healthcare disciplines, encompassing a diversity of skills, is necessary to develop innovative ways to tackle the obesity problem. Because RDs are the primary nutrition practitioners, they should share the leadership role with other health professionals in stemming the tide of this obesity epidemic. Much of the literature also stresses the importance of working cooperatively with relevant government agencies, appropriate medical and scientific organisations, employer organisations, unions, educational authorities, and the media. RDs are encouraged to participate in nutrition advocacy at the local, state, and national levels to encourage healthful eating and lifestyle behaviours. More importantly, they should become involved in action programmes that support healthy eating at the grass-roots level. RDs have the necessary skills and broad educational preparation to contribute effectively to partnerships that are focused on stemming the obesity epidemic. Reference Seagle HM, Strain GW, Makris A, et al. Position of the American Dietetic Association: weight management. J Am Diet Assoc 2009;109:330-346. page 32 | medical chronicle | May 2012 SA Spine Surgery Congress CSIR Conference Centre 7-9 June Spine International Experts to Share Insights at SA Spine Surgery Congress SA’s medical practitioners are rated among the best of the world and it comes as no surprise that a number of leading experts from Europe and the US have agreed to present papers at this year’s SA Spine Surgery Congress (SASS). According to SASS president, Prof Robert Dunn, more than 100 delegates have registered for the congress to date. The majority of delegates are orthopaedic surgeons and neurosurgeons practising spine surgery and topics relate to their various fields of interest. The main focus areas will be tumour management, cervical myelopathy and lumbar degenerative disc disease. The congress is divided into various sessions covering areas such as spine approaches and complications, cervical, lumbar generative, degenerative, infection, spinal stenosis and issues relating to practice management. The latter will focus on the rapidly escalating cost of indemnity insurance as well as tariff and coding negotiations. International speakers Internationally renowned spinal oncology expert and director of oncological and degenerative spine surgery at the Rizzoli Institute in Italy, Prof Stefano Boriani, will present a paper on bloc resections of primary tumours, especially chordoma. Prof Boriani is considered the world leader in this field, said Prof Dunn. Apart from his presentation on chordoma, Prof Boriani will also share valuable insights about the principles of spine tumour management. Dr Vincent Pontillart, a spine surgeon attached to the Hôpital Tripode in France, is a well-known face at SASS congresses. This year, he will discuss degenerative cervical pathology, a common cause of neck pain. Although frequently present, it is less frequently symptomatic than lumbar disc degeneration, because the neck generally is subjected to far less torque and force. Degeneration is due to underlying genetic and environmental factors such as smoking, injury and poor body habitus with the insidious wear and tear on the disc resulting, over time, in axial neck pain and occasionally arm pain due to disc compression of the traversing nerve roots. Prof Rudi Bertagnoli, rated by medical professionals as the world’s leading motion preservation spine surgeon, will share some of his personal experiences in the field of lumbar degenerative disc disease with delegates. The disease is fairly common and it is estimated that at least 30% of people between the ages of 30-50 years will experience some degree of disc space degeneration. Prof Bertagnoli has performed more than 5000 artificial disc replacements and more than 7500 spinal device implants during his career. He will also present a talk on anterior lumbar spinal approaches and managing the complications thereof. Lumbar degenerative disc disease increases with age and is universally present in adulthood. Only a few well-selected patients need or will benefit from surgical intervention, said Prof Dunn, who heads the division of orthopaedic surgery at the University of Cape Town. Dr John Stark, an orthopaedic surgeon from the US with more than 30 years’ experience, will present a talk on sacroiliac pathology and the management of the disease, which affects between 15%-25% of patients suffering from axial low back pain. It is caused by high-impact injuries, which are often life-threatening. Mortality is estimated at 20% if neighbouring structures are also damaged. Local speakers Apart from Prof Dunn, a number of local experts will also present talks on a wide variety of subjects at the congress. They include Dr David Welsh, a neurosurgeon, who will talk about incidental durotomy: avoidance and management, while fellow neurosurgeon, Dr Michael Schubert, will present a paper on endoscopic spine surgery. Dr Jacques du Plessis, also a neurosurgeon, will discuss surgery for axial neck pain and orthopaedic surgeon, Dr Ian Zondagh will present a paper on anterior cervical interbody cage. Orthopaedic surgeons, Drs Koos Louw and Johan Nel will both present a number of talks. Dr Louw’s topics include uncusectomy, while Dr Nel will focus on disc replacements and transpsoas fusion. Dr Antonie Botha and Prof Dunn will join forces to discuss paediatric cervical instrumented fusion. According to congress organiser, Hendrika van der Merwe, a record number of exhibitors have registered for this year’s congress with more than 28 companies expected to showcase their products. medical chronicle | May 2012 | page 33 Spine Forum Dr Pradeep Makan The Link Between Obesity and Chronic Low Back Pain Obesity is one of the lifestyle factors thought to be responsible for increasing the incidence of low back pain. One could postulate that individuals with excessive body weight cause mechanical ill effects to their spine. It has been suggested that there may be biochemical changes in obesity that predispose these individuals to low back pain. Obese individuals are generally associated with poor lifestyles and this in itself could predispose the individual to low back pain. Does the literature support this association? Leboeuf-Yde et al surveyed 29 424 twins aged between 12 and 41 from the population-based Danish twin register. They found low back pain to be less common in younger individuals compared to adults. Low back pain was more common in women than in men. There was a modest positive association between a raised body mass index (BMI) and low back pain. Obesity was found to be positively associated with recurrent and chronic low back pain. They did not demonstrate an increased incidence of low back pain in monozygotic twin pairs of dissimilar body weight. They concluded that excessive body weight aggravates minor low back pain of short duration predisposing these individuals to develop recurrent episodes of back pain or to develop chronic low back pain. There was a positive association between the chronicity of low back pain in men who had jobs that involved mainly sitting and in women whose work entailed mixed activities (sitting, standing and walking). They concluded that if people are relatively sedentary at work, this was an obstacle to c omplete recovery from an acute episode of low back pain leading to recurrent episodes or chronicity. They were of the opinion that it would be unfair to tell overweight individuals that their low back pain is caused by the excessive body weight, but they should be warned that the excessive body weight may affect their recovery from an episode of back pain. In a subsequent paper, Lebouef-Yde reviewed 56 original research articles reporting on 65 studies between 1965 and 1997 that specifically looked at the association between body weight and low back pain. Only 32% of these studies reported a statistically significant weak association between increased body weight and low back pain. It was concluded that due to lack of evidence, an increased body weight could not be regarded as a cause of low back pain. In a study from Finland, Shiri et al found that women with a high BMI and specifically those with an increased waist circumference had an increased risk of low back pain. They showed that if the odds of developing low back pain with a waist circumference of under 80cm is 1, the odds were increased to 1.2 if the waist circumference was between 80 and 88 and increased to 1.8 if the waist circumference was greater than 88cm. It appears that trunkal obesity in women may be a risk factor for developing low back pain. In a study from Norway, Heuch et al examined the association between BMI and chronic low back pain in a total of 92 936 subjects. Adjustments were made for level of education, smoking status, leisure time, physical activity, employment status and activity at work. This large population-based study found a high prevalence of chronic low back pain in obese individuals. The odds ratio was highest in women with BMIs above 35 (1.7 compared to 0.79 in men with BMIs under 20). From this literature review, it appears that trunkal obesity in women may trigger an episode of low back pain. This may be due to mechanical and/or biomechanical factors. The risk of an acute episode of back pain progressing to recurrent and chronic back pain is increased in individuals with higher BMIs. References 1. Lebouef-Yde C, Kyvik KO, Bruun NH. Low back pain and lifestyle. Part II -Obesity. Information from a population based sample of 29 424 twin subjects. Spine 1999;24:779-784. 2. Lefouef-Yde C. Body weight and low back pain. A systematic literature review of 56 journal articles reporting on 65 epidemiological studies. Spine 2000;25:226-237. 3. Shiri R, Solovieva S, Husgafvel-Pursiainen K, et al. The association between obesity and the prevalence of low back pain in young adults: the cardiovascular risk in young Finns study. American Journal of Epidemiology. 2008:167:1110-1119. 4. Heuch I, Hagen K, Heuch I, et al. The impact of body mass index on the prevalence of low back pain. The HUNT study. Spine 2010;35:764-768. page 34 | medical chronicle | May 2012 3rd National TB Conference Durban ICC 12-15 June 2012 Tuberculosis Striving to Stop TB in our Lifetime Prof Martie van der Walt, TB Congress Chairperson Tuberculosis (TB) control in SA requires collaboration by all partners/stakeholders/ disciplines to reach the targets of the 20-year vision. TB as a disease has been with humankind since the dawn of humanity. It has affected well-known persons as well as unquantifiable faceless others, rich and poor, those with access to healthcare and those without, in highly developed and underdeveloped countries. It spans across all disciplines, public health, human rights, social sciences, natural science, and competes with other (health) priorities for funding and effort. Decreasing the burden of disease and its elimination as a public health threat have been elusive goals. The advances in medical science, technology, disease control have all contributed to the improved understanding of the disease and its causative agent, Mycobacterium tuberculosis. The tuberculosis bacillus is uniquely adapted for survival in man, its chief host. Annually, on 24 March, World TB Day is cele brated, and designed to build public awareness that TB remains an epidemic in much of the world. This specific day is in commemoration of the day in 1882 Dr Robert Koch astounded the scientific community by announcing that he had discovered the cause of TB, the TB bacillus. Koch’s discovery led the way to much improved diagnostic and control efforts, the advances thereof to be found in present-day drugs for treatment and, accurate and sensitive diagnostic tests. These tools led to the belief in the latter part of the 20th century that TB elimination was attainable. A growing epidemic But since the 21st century, there has been a global increase in disease burden fuelled by the HIV epidemic. In 2009, 9.4 million TB cases were reported worldwide, including 3.3 million women with 1.7 million people dying of the disease. In SA, approximately 1% of the population develops TB each year and in 2009 it was the most common cause of death. Inaction to stop the epidemic will result in over 50 million people developing TB by 2015, and over 10 million lives will be lost. Diagnosis, treatment, prevention - the common tools of communicable disease control, still fail patients today, and range from unawareness of signs and symptoms, inadequate and delayed diagnostics, unequal access to services, challenging treatment regimens and insufficient prevention tools. Stigma prevents many from seeking treatment, and marginalises the most vulnerable such as women, children and the poor. The emergence of HIV/AIDS has had a devastating impact on TB. In SA today, between 50%-60% of TB cases have HIV, and 80% of HIV cases present with TB as well. Among the challenges of managing the two diseases in a single person, is that HIV/AIDS has changed the face of TB. The typical signs and symptoms of pulmonary TB, such as coughing, night sweats, fever and weight loss, may not be as well developed, leading to longer time to diagnosis. In addition, extra-pulmonary forms of the disease are more prevalent in those living with HIV/AIDS, which are more complicated to diagnose. Concurrent treatment of TB and with antiretroviral drugs is successful, although overlapping toxicities of drugs require increased vigilance by care givers. The TB vaccine, BCG, although not granting very effective protection against TB, has even lower utility in communities with high co-infection rates. Control of this dual epidemic therefore requires TB/HIV integration, whereby control of one disease will also control the other. Integration therefore starts right at the onset of either disease, with awareness of symptoms of both diseases, patients having a one-stop service at health facilities, control programmes employing a single reporting system, and development of new tools for treating both diseases. content and context need to appeal to a diverse target audience, be affordable for all while also educating, entertaining and gaining insights from leading fellow South Africans. The conference is taking place at a significant point in time of TB control in the country: the National Strategic Plan on HIV, STIs and TB 20122016 was launched by SANAC on World AIDS Day last year. Goals of the conference This is the first time that TB has been included in the country’s HIV/AIDS plans, and implementation of this plan commenced on 1 April this year. It will dictate and drive TB/HIV integration in line with the country’s 20-year vision with regards to HIV and TB. Thus, the conference will present the state of TB in SA at this important point in history, and send out the challenge to stakeholders to coordinate efforts for reaching the targets. For more information on the conference, go to: www.tbconference.co.za Against this background, SA’s 3rd National TB Conference, taking place from 12-15 June 2012 at the International Convention Centre in Durban, will continue to build on the momentum of the two previous conferences of 2008 and 2010. These conferences have a multidisciplinary and inclusive approach towards the various disciplines of TB through basic sciences, research, medicine, civil society, policy, advocacy and service delivery. A unique South African flavour is paramount, as the In SA today, 80% of HIV cases present with TB as well TB Diagnosis Still a Challenge for SA Doctors In preparation for World TB Day, a series of workshops was held in Durban, Cape Town and Johannesburg involving local and international experts, policy makers and clinicians on diagnosing tuberculosis (TB). The workshops were attended by some 300 health practitioners and laboratory workers, who are at the forefront of managing SA’s devastating TB epidemic. Workshop participants recognised that there are big challenges in diagnosing TB rapidly and initiating treatment quickly. Many patients are lost because they come for a TB test but cannot be traced back for results and treatment or they die between the time they visit a health facility and are put on treatment following diagnosis. In the meantime, they spread the disease and infect others. After many years of working with outdated micro scopy tools, which are often ineffective when TB and HIV coexist, health workers now have more advanced TB diagnosis options at their disposal. Lack of uniform and correct positioning of TB diagnostic tools in SA Dr Francesca has left health practi- Conradie, tioners uncertain on clinical advisor to how and when to use Sizwe TB Hospital various TB diagnos- and president of the Southern African HIV tics tools in varying Clinicians Society situations. speaking at a The workshops workshop examined the diffe rent tools and gave experts and practitioners an opportunity to discuss how to utilise them better in order to improve TB control. Among the practical recommendations were the following: • Active case finding, both in-facil- Dr Nazir Ismai, ity and within head of the Centre for the community, TB, NICD should be stepped up so that persons with TB symptoms can be identified more quickly. • Clinical diagnosis should consider a combination of symptoms, on the basis of which treatment can be initiated while waiting for positive confirmation. • The latest rapid tests using molecular technology are less sensitive, but it is considered beneficial to sacrifice optimal accuracy in order to get rapid results to retain patients and identify drug- resistant TB cases. • Gold-standard liquid culture testing should work in parallel with other clinical measures and be used for confirming cases and the type of drug resistance that the patient might have. • In the medium- to long term, infection control, research for more effective prevention technologies (e.g. vaccine) and development of point-ofcare diagnostic and treatment options should be encouraged. New Diagnostic Assay for TB Hain Lifescience SA is a leading supplier of a full range of state-of-the-art polymerase chain reaction-based diagnostic tests for tuberculosis (TB) infections on the market today. They provide the Southern African market with high-quality, accurate and cost-effective solutions for TB diagnosis and relevant information on patient treatment. The new MTBDRplus VER 2.0 assay with its improved sensitivity is now also recommended for screening smear-negative clinical samples to detect Mycobacterium tuberculosis and its resistance to both rifampicin (RIF) and isoniazid (INH), thus diagnosing real multidrug-resistant TB. Recent articles published in the US show the importance of testing for INH and RIF, specifically because effective patient treatment is dependent on the RIF and INH resistance profile. This assay provides both results. The company takes TB diagnostics one step further in diagnosing extensively drug-resistant TB with the MTBDRsl assay. *Content provided by Hain Lifescience. medical chronicle | May 2012 | page 35 Visit our webpage: www.medicalchronicle.co.za Tuberculosis Curbing the TB Scourge through Assays An estimated one in three people worldwide is infected with tuberculosis (TB). The majority of patients have latent infection, and the chance of the disease progressing to active TB is 10% during a person’s lifetime. However, the TB risk for people living with HIV looks vastly different, explained Dr Jennifer Coetzee, a clinical microbiologist at Ampath Laboratory in Centurion. The chance of a patient with HIV and latent TB infection of developing active TB is 10% per year. Diagnostic challenges Diagnosing TB is not easy, said Dr Coetzee. In addition to TB, patients with advanced HIV infection might be infected or co-infected with non-TB strains of mycobacteria, such as Mycobacterium avium. In addition, multidrugresistant (MDR) and extensively drug-resistant (XDR) TB have shown an alarming increase over the past few years. MDR-TB does not respond to first-line drugs such as isoniazide (INH) and rifampicin. An estimated 3%-4% of patients in SA have MDR-TB. XDR-TB develops as a result of the mismanagement of patients with MDR-TB and it is estimated that 5.7% of MDR incidents meet the case definition of XDR-TB. This means that the disease is resistant to quinolones and one other second-line injectable drug. Other second-line drugs include capreomycin, kanamycin, ethionamide and cycloserine. The cure rate for MDR-TB is approximately 50%, said Dr Coetzee. Patients with XDR-TB are 64% more likely to die compared to patients with MDR-TB. Available assays Sputum smear microscopy is relatively quick and cheap, but requires 10 000 organisms/ml of sputum, which limits its sensitivity in HIV-infected persons to as low as 30%. Blood tests such as the gamma interferon-based assays, similar to skin tests, are useful only for the detection of infection, but cannot distinguish between active and latent infection. It is relatively expensive, and regardless of the result requires further investigations. The urinary lipoarabinomannan (LAM) test has poor sensitivity and specificity, and is mostly used as a screening test for patients with advanced HIV infection. In its current form, it is simply too insensitive for the diagnosis of active TB infection. More than 150 years after its invention by Dr Robert Koch, mycobacterial culture remains the gold standard in the diagnosis of TB. It is still the most sensitive test for diagnosis of active TB infection, but a negative result is only sent out after four to six weeks. There are two types of automated culture systems that are used; namely the Mycobacteria Growth Indicator Tube or the BacT/Alert System. These automated monitoring systems have reduced time-to-positivity from weeks to days, and can detect as little as 10 colony forming units per ml of sputum. It is also the test of choice for diagnosing TB from extrapulmonary sites, such as cerebrospinal fluid, where the organism load might be low. The test is governed by the same principles as a blood culture. Sputum is collected from the patient and decontaminated. It is then placed in a special culture bottle and loaded in the machine. The machine continuously monitors the gradient curve of the TB, and time-to-positivity has been reduced significantly. Phenotypic sensitivity testing can be done directly from a positive culture, but results can take a long time especially if the mycobacteria are resistant. The biggest modern innovations in TB diagnostics have been the development of molecular tests, which include real-time polymerase chain reaction (PCR) and the GeneXpert. Real-time PCR can be done on almost any clinical sample, and can be used for the diagnosis as well as sensitivity testing of TB. There are commercial PCRs available that can distinguish between M tuberculosis and the nontuberculous mycobacteria, or diagnose co-infection. The limitations of molecular assays are the relatively high cost, and although they are almost 100% sensitive and specific in smear-positive cases, the sensitivity in smear-negative cases approaches 75%. This means that while a positive result can be regarded as diagnostic, a negative result does not exclude the diagnosis. A positive development over the past few years has been the use of combined culture and PCR tests. Samples are submitted for TB culture, and as soon as it flags positive sensitivity, testing is done by using PCR. This is possible because mutations in the genome of the TB bacterium, which encodes for resistance, can be detected with PCR and the time to diagnose an XDR-TB infection has been reduced from up to three months to a few weeks. Knowing what drugs the TB is resistant to is essential in the treatment of patients, added Dr Coetzee. The GeneXpert is regarded as a historic milestone in TB diagnosis and management. It is a hands-free sputum processing system that, unlike other PCR testing, requires very little expertise to perform. It can detect simultaneously if M tuberculosis is present or not, and rifampicin resistance if present. The main advantage of the test is that it takes less than two hours to get a result. But according to Dr Coetzee, this target is not always feasible, because if you have 1000 patients to test, your time-to-result increases exponentially. The disadvantage is that it detects susceptibility to rifampicin only, and once the sample is put in the cartridge, it can’t be used for additional tests. INH mono-resistance, which can also lead to treatment failure and MDR-TB, is also not detected. The sensitivity and specificity is similar to other molecular tests. Dr Coetzee’s advice to doctors if TB is suspected in a patient: Every effort should be made to confirm the diagnosis and obtain sensitivity results. Don’t waste money on blood tests, which do not distinguish between active and latent infection, and if unsure of the best diagnostic approach for your patient, contact your microbiologist. page 36 | medical chronicle | May 2012 Follow us on Twitter: @MedChronicle Tuberculosis Selecting the Optimal Diagnostic Pathway for TB In 1980, BD introduced the first automated system for mycobacteria testing, the BD Bactec™ 460TB System and has since been recognised as the leading technology globally to fight against multidrugresistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB). Since the bacterium that causes TB (Mycobacterium tuberculosis) was first discovered in 1882, the healthcare community’s understanding of the organism and how to treat the disease have evolved dramatically. However, methods of diagnosis went largely unchanged for many years. Each person with active TB will infect, on average, between 10 and 15 people every year. However, people infected with TB bacilli will not necessarily become sick with the disease. The immune system ‘walls off’ the TB bacilli which, protected by a thick waxy coat, can lie dormant for years. When someone’s immune system is weakened, the chances of becoming sick are greater. Each year about 1.6 million people die from this curable disease. The only way to halt TB’s resurgence and eradicate it once and for all is to first improve our ability to detect it. Before patients can be appropriately treated - or treated at all - they must be accurately diagnosed. Laboratory diagnosis of TB largely relies on the direct microscopic examination of sputum specimens. However, the technique has low and variable sensitivity and cannot identify drug-resistant strains. Mycobacterial culture is more sensitive but growth of TB bacilli on traditional solid media typically requires two to four weeks, and as many as eight weeks of incubation. This consequently delays appropriate treatment in the absence of a confirmed diagnosis. In the late 1990s, BD developed an improved TB culture method, the Mycobacteria Growth Indicator Tube (BD Bactec MGIT™) system, which can provide diagnostic results much sooner than traditional culture methods. Rapid culture and drug susceptibility testing is more important than ever in the face of increasing MDR-TB and even XDR-TB, which is virtually untreatable. With increased sensitivity and reduced delays, BD Bactec MGIT system contri butes significantly to improved patient management. In 2004, BD entered into an agreement with the Foundation for Innovative New Diagnostics to improve diagnosis of TB, especially in HIV-positive patients. This collaboration established demonstration sites in Africa, Eastern Europe, Brazil and Asia to introduce advanced culture technology at the district hospital level. In 2007, the World Health Organization (WHO) endorsed liquid culture technology as the standard of care for TB diagnosis and patient management. Expanding culture capacity is urgently needed to address challenges due to the epidemics of HIVassociated TB and drug-resistant TB, especially in resource-limited settings. Recently, the WHO has endorsed molecular diagnostics and together, as part of a comprehensive TB control plan, these two complementary technologies offer exciting new possibilities for diagnosing TB. All available TB diagnostic tools are necessary and can be implemented in various combinations in country screening and diagnostic algorithms at different levels of laboratory network. The prevalence of HIV and drug-resistant TB, to a large extent, dictates the diagnostic algorithms at country level. Steps to define the optimal diagnostic portfolio are: 1. Define TB prevalence and rifampin resistance prevalence in your region/country. 2. Segment your data by sub-region, patient type, other risk factors, etc. 3. Identify those regions/patient populations with a TB prevalence of at least 15%-20%. 4. Identify those regions/patient populations with a rifampin resistance prevalence of at least 20%. 5. Define those regions where results can be reported back fast to the treating physician and to the patient. 6. Define those regions where second-line drugs are readily available. The rapid and accurate diagnosis of symptomatic patients is the cornerstone of global strategies for TB control. The BD Bactec MGIT liquid culture systems dramatically shorten mycobacterial culture recovery time and improve patient management, especially in smear-negative patients. Molecular tests can be used as a first screening test in high-risk patients for MDR-TB, but needs confirmation by liquid culture which is the gold standard. The product line for TB diagnostic testing includes: • BD Bactec™ MGIT™ 960 and 320 system offers high and medium capacity, safe operation, fast results and high throughput - the first fully automated system for high-volume mycobacteria growth, detection and susceptibility testing. • BD BBL™ MGIT™ Mycobacteria Growth Indicator Tube is a rapid, manually read and easy-to-use system with high accuracy for the detection of mycobacteria from clinical samples. • BD BBL Prepared Tube Media are used with Lowenstein-Jensen and Middlebrook media for the isolation and cultivation of mycobacteria. • BD Falcon™ Sputum Collection System is for the collection, transport and processing of sputum specimens. • BD Bactec™ Myco/F Lytic Blood Culture Media detects mycobacteria from blood sample, which is especially useful in acid-fast bacilli (AFB) smear-negative and extrapulmonary TB cases among persons infected with HIV. • BD MGIT™ Myco/F Lytic Medium detects mycobacteria from blood samples, which is useful in HIV positive patients. • BD MGIT TBc Identification Test is a rapid chromatographic immunoassay for the qualitative detection of M tuberculosis complex antigen from AFB smear-positive BD MGIT tubes. • TB stain kits and reagents are used to stain specimen smears for early presumptive diagnosis of mycobacterial infection. • BD MycoPrep™ System is for mycobacterial specimen digestion/decontamination. • BD BBL Taxo™ Niacin and Nitrate Test Strips are used to identify M tuberculosis from solid media. *Content supplied by BD Diagnostic Systems. medical chronicle | May 2012 | page 37 Visit our webpage: www.medicalchronicle.co.za Asthma / Allergies Mothers’ Asthma Predictor of the Disease According to the World Health Organization, the prevalence of asthma in children around the globe is increasing at an alarming rate. It is estimated that between 6%-13% of children living in urban areas in SA have asthma. In addition, the country has the fifth highest asthma case fatality rate in the world estimated at 18.5 per 100 000 asthmatics. Dr Salome Abbott, a paediatrician at Steve Biko Academic Hospital in Pretoria, pointed out that it is extremely difficult to diagnose asthma in children, especially preschoolers, because conventional lung function tests are not suitable for chil- Dr Salome Abbott, dren under five. They paediatrician at Steve also often have viral Biko Academic Hospital infections, allergic rhinitis or other allergic diseases, which can easily be mistaken for asthma. This can create confusion and pose a diagnostic dilemma for the family practitioner. Her research, together with previous studies, will hopefully shed some light on the diagnosis of allergic asthma in children, specifically in the developing world. SA studies have found that about 40% of asthmatic children are allergic Dr Abbott recently completed a two-year study entitled ‘The role of maternal atopy in children with asthma’. Previous studies looked at what percentage of asthmatic children have allergies while her study was the first to focus on whether or not a mother’s allergies served as a predictor of asthma in her offspring. She explained that previous studies in SA have found that only about 40% of asthmatic children are allergic. This is a lot less than the 80% reported in developed countries and has led to questions about the importance of allergies in asthma pathophysiology and etiology in the developing world. One hypothesis is that it is not as important in developing countries as in developed countries and that other environmental factors play a role in thirdworld settings. These factors include urbanisation, pollution, micronutrient deficiencies and antimicrobial burden. Study model Her study included 100 asthmatic children under the age of 12. The group was divided into two separate arms; namely atopic asthmatics and nonatopic asthmatics. The latter served as the control group. Dr Abbott explained that atopic asthmatics are asthmatic patients who also have an allergy to environmental factors, e.g. pollen, grass or cat and dog hair. “It is important to differentiate between the two groups because the patient’s treatment regimen will be based on the correct diagnosis,” she said. Various allergy tests were performed on the mothers and they were also asked to complete a questionnaire. The aim of the questionnaire was to determine whether or not there were differences in the allergy status of the mothers in the control arm vs the allergy arm. The questionnaire focused on two aspects; namely if the mother experienced any symptoms that might indicate that she had an allergic disease, but was not aware of it, and secondly, whether or not she has, in fact, been diagnosed with asthma. “I included questions about symptoms as well as diagnosis because previous studies have shown that a high percentage of people experience allergy symptoms, but many have not been diagnosed with an allergic disease,” said Dr Abbott. Her findings indicate that the mother’s allergy status and history of symptoms suggesting an allergic disease were poor predictors of whether or not her offspring will develop allergic asthma. The only useful predictor of allergic asthma in childhood was if the mother had a confirmed diagnosis of asthma. This implies that a family history of allergy may not be an appropriate tool to predict allergic asthma in children in developing countries, because it is not as predominant a feature as it is in developed countries. A misconception that Dr Abbott aimed to dispel is that children under the age of two cannot have asthma. This misnomer is based on the traditional atopic path. According to this view of the disease, progression of asthma, the child first develops eczema or food allergies, the disease then progresses to allergic rhinitis and only when the child reaches the age of three or four, asthma is identified as a possible diagnosis. A huge problem is that GPs often prescribe antibiotics to children for recurrent viral upper respiratory tract infections, while the underlying problem is in fact allergies or asthma. This eventually leads to antibiotic resistance. When to suspect asthma in a child A GP should suspect asthma in a child under five if he/she constantly has ‘colds’ going to the chest or allergic rhinosinusitis and if he/she improves following treatment with oral steroids or a bronchodilator. In addition, a family history of asthma and a personal history of allergies are also indicators of asthma. Dr Abbott stressed the importance of diagnosing asthma in a child. If the disease is left untreated, it not only impacts negatively on the development of the child, but also on his/her quality of life and, in many instances, the disease is fatal. Her advice to GPs is to refer children under the age of five who are suspected of being asthmatic to a paediatric pulmonologist. “It is not just about making a diagnosis, it is about making the correct diagnosis and ensuring that the child takes the treatment correctly and improves,” Dr Abbott concluded. page 38 | medical chronicle | May 2012 Follow us on Twitter: @MedChronicle Gastroenterology Hypnotherapy to Alleviate Symptoms of IBS? Gut-directed hypnotherapy can alleviate the symptoms of refractory irritable bowel syndrome (IBS), but only if it is offered by psychologists trained in this type of hypnotherapy, reported a group of researchers from the department of internal medicine at the University of Gothenburg’s Sahlgrenska Academy in Sweden. The group recently published their study entitled Effects of Gut-Directed Hypnotherapy on IBS in Different Clinical Settings in the American Journal of Gastroenterology. One of their main findings is that gut-directed hypnotherapy alleviated the IBS symptoms in 40% of test subjects that took part in their studies and that improvements were long term. IBS affects between 15%-20% of the total population and is more common among women than men. Although there is no gold standard for the treatment of IBS, individual symptoms including diarrhoea, pain, constipation and bloating are treated with pharmacotherapy. Unfortunately, there is not one effective therapy available to treat all symptoms simultaneously. According to lead researcher, Prof Magnus Simrén, IBS patients seek healthcare more often than others, for both gastrointestinal and nongastrointestinal symptoms. In addition, they take more time off work and often have to undergo repetitive investigations, which are very costly and adversely affect their quality of life and psychological wellbeing. He explained that a number of studies have already investigated the effectiveness of gut-directed hypnotherapy in the treatment of IBS, but that the objective of their research was to study the effect of hypnotherapy in different clinical settings outside traditional research units. What is gut-directed hypnotherapy? Gut-directed hypnotherapy was first prescribed for patients with severe IBS in the mid-1980s, after a study found that up to 80% of patients reported improvement of symptoms after undergoing gut-directed hypnotherapy. It is based on muscular and mental relaxation methods as well as general hypnotic suggestions. The aim of these methods and suggestions is to either focus patients’ attention on their symptoms or to distract them. The new study comprised two legs and included 138 IBS patients. In study 1, 90 patients were randomised to receive gut-directed hypnotherapy in private practices, while the remaining 48 patients in study 2 underwent therapy in a small country hospital. Patients in the control groups were informed that they would only receive gutdirected hypnotherapy at a later stage. Patients in the hypnotherapy arm of the studies underwent 12 sessions, with each session lasting 60 minutes. Sessions were held once a week and patients were told to practice their hypnotic skills at home between sessions. Gastrointestinal symptom severity and quality of life were evaluated at baseline, at three months follow-up and after one year. After feedback was received, individually adapted suggestions were developed and used to ‘convince’ a patient that he/she was able to control his/her IBS symptoms. These included suggestions toward normalising gastrointestinal functions. “The main aim was to let the patient experience that he/she had the ability to control external stimuli such as sounds, lights and pressure from the surface of the chair and to gain control of inner physiological phenomena such as breathing and finally the IBS symptoms,” explained Prof Simrén. Findings The main finding of the study was a significant reduction in IBS symptoms in both studies, said Prof Simrén. The reduction was more pronounced for sensory symptoms such as pain and bloating than for bowel habit disturbances. No improvement in IBS symptoms was seen in the control groups. The researchers also found that the effects of IBS symptoms were sustained for up to one year follow-up in both studies. In addition, 87% of the patients who reported improvements after therapy said that they considered gut-directed hypnotherapy as worthwhile. A substantial number of patients indicated a reduction in the number of visits to healthcare practitioners and changes in their drug use to alleviate symptoms. In addition, their findings indicated that improvements reported by patients who underwent hypnotherapy by private practice psychologists who specialise in gut-directed hypnotherapy were greater than in patients who were treated at an outpatient clinic by a psychologist trained in general hypnotherapy. Prof Simrén concluded by saying that their study showed that the effectiveness of gut-directed hypnotherapy is superior to the available pharmacological treatment options for IBS. Findings difficult to interpret Director of the Endoscopy Unit at the Wits Donald Gordon Medical Centre, Dr Kay Karlsson, said it is difficult to interpret the results of the study, because a placebo arm was not included. In fact, she said, they could just as well have given their test subjects Smarties and achieved the same results. Previous studies have shown that giving IBS patients ‘any placebo’ improves the symptoms of 40% of test subjects. Despite the fact that gut-directed hypnotherapy has been around for more than 30 years, Dr Karlsson has never referred any of her patients for this type of therapy. Nor is she aware of any gastroenterologists who regularly refer patients for this type of therapy. She commented that hypnotherapy might have a positive impact on patients who do not respond to conventional therapies. In addition, IBS patients who have high stress levels might bene fit from the relaxation brought about by hypno therapy. However, she concluded, it may also be more effective if a patient believes in alternative medicine. •••Source: The American Journal of Gastroenterology medical chronicle | May 2012 | page 39 Prof Reid Ally Dr Keith Pettengell Dr John Wright Gastroenterology Forum Are SA Doctors Behind the Curve in Treating Crohn’s Disease? There was a fundamental change in the management of Crohn’s disease in 1990 when the value of immunosuppression with azathioprine was generally accepted. In 1998, the whirlwind of infliximab hit the profession after the US Food and Drug Administration approved its use in an unusual fast-track approval process. At last, we had disease-modifying drugs at our disposal. We should now be able to report that the rest is history. Unfortunately, this is not the case. Many patients continue to be treated by the old cortisone and more cortisone regimen then cut and resect regimen. Some patients, in particular children, continue to suffer with this approach. The reasons for this sorry state of affairs are related to the cost of modern medication and the perceived dangers of therapy. Secondly, there is often a belief, harking back to the early days of cancer surgery, that you can cure the disease by removing it surgically. The only way to change this paradigm is to convince the primary physician that Crohn’s disease is a medical condition that needs to be treated with disease-modifying drugs. The term ‘primary’ includes the family practitioner, medical physician and, surprisingly, gastroenterologist. Let us now look at their difficulties. Cost of therapy The cost of therapy cannot be denied. Azathioprine and blood tests will cost about R12 000 a year. At the end of the year, only 40% of patients will be in remission. However, virtually all patients given cortisone will relapse and have had significant side effects in the process. Recently, it has been shown that the efficacy of azathioprine can be improved and toxic effects reduced by manipulating the dose on the basis of its metabolites. The private laboratories should have these tests available soon. When it comes to the new drugs, such as inflixima (Revellex) and adalimumab (Humira) (both antitumour necrosis factor [TNF] anti bodies) commonly called biologics, the costs escalate to about R120 000 a year. This seems exorbitant until you compare the cost of hospitalisation, surgery and sick leave. When this is calculated, it has been shown that the total costs are more for similar patients not being treated with biologics. Although the major medical schemes have accepted the cost benefit of the biologics, others, particularly the smaller medical schemes, do not. Private patients need to be given this advice to change their medical scheme, if necessary, at the time of diagnosis. Unfortunately, the public sector is showing no sign of accepting the biologics as standard therapy. This is very worrying if the current standards of care are forced on all citizens in the proposed new nationalised system. Perceived side effects of drugs The next problem with moving treatment regimens forward is the perceived dangers of the anti-TNF drugs. The most serious problem is that TNF, which these drugs neutralise, is an important part of the bodies’ defence against tuberculosis. In weighing up the risks one needs to consider the benefits of the medication vs the tuberculosis rate in the patient group that you are treating. Whereas anyone can be infected with tuberculosis or re-activate old disease, not all patients have the same risk of this. Likewise, Crohn’s disease can occur in anyone but generally it is the middle- and upper-income strata that are affected more commonly. It is nevertheless critical to test annually for tuberculosis exposure with history, chest x-ray and initially blood or skin tests. An initial test for hepatitis B infection is also recommended. The risk of malignancy developing in Crohn’s disease patients on anti-TNFs is thought to be very low, especially compared to the risks of not treating. Surgery option Finally, there is surgery where the primary role is to remove fibrotic strictures in the small bowel. Active disease is best treated medically and that includes swollen ileal loops and fistula. Biologics are the primary treatment for penetrating/fistulating disease. Abscess formation in severe disease is common. Fortunately, perforation and generalised peritonitis as one sees in appendicitis does not often occur in Crohn’s disease. This means that with a biologic to control the Crohn’s disease, antibiotics to treat the infection and intravenous feeding to maintain the patient, even traditionally severe ileocolonic disease can be managed medically. Conclusion In summary, the standard of medical management of Crohn’s disease has leaped forward over the last few years. Our primary physicians need to hear the message. page 40 | medical chronicle | May 2012 Follow us on Twitter: @MedChronicle Gastroenterology Risk Factors for NSAID-associated Upper GI Clinical Events Upper gastrointestinal (GI) clinical events such as bleeding and ulcers, as well as upper GI symptoms such as dyspepsia, are significantly increased with the use of traditional nonsteroidal antiinflammatory drugs (NSAIDs). These side effects have important clinical implications in terms of quality of life, morbidity and mortality, and they increase healthcare resource utilisation such as diagnostic testing, doctor visits, hospitalisations and medications. The cost of NSAID-associated upper GI side effects is substantial. North American studies have indicated that for every dollar spent on NSAIDs, $0.66 (R5) to $1.25 (R9.50) may be spent on GI side effects, and that nearly one-third of total medical costs in arthritis patients may be related to GI adverse events. Strategies recommended to decrease the risk of NSAID-associated upper GI clinical events include medical cotherapy with misoprostol or proton pump inhibitors (PPIs), and ⁄or the use of cyclooxygenase (COX)-2 selective inhibitors. arthritis were randomised to etoricoxib or diclofenac in a prespecified intent-to-treat analysis of three double-blind randomised trials. Potential risk factors for upper GI clinical events (bleeding, perforation, obstruction, or ulcer), complicated events (perforation, obstruction, bleeding) and discontinuations due to dyspepsia were assessed with Cox proportional hazard models. Materials and methods Potential upper GI clinical events (bleeding, perforation, obstruction, ulcer diagnosed on clinical work-up) Patients ≥50 years with osteoarthritis or rheumatoid Endpoints were identified through active surveillance of reported adverse events, and were adjudicated by an independent blinded committee using predefined criteria. The subset of complicated events included those with perforation, obstruction and complicated bleeding. Uncomplicated events included uncomplicated bleeding and uncomplicated ulcer. Uncomplicated bleeding was defined as occult blood-positive stool associated with a documented upper GI lesion judged to be the source of the bleeding and stigmata of recent bleeding (visible vessel, pigmented spot or clot) at endoscopy, but no clinically significant bleeding (hypotension, orthostatic changes in heart rate or blood pressure, haemoglobin drop ≥2g ⁄dℓ, or transfusion), or patient-reported haematemesis, melaena, or haematochezia associated with a documented upper GI lesion judged to be the source of the bleeding and stigmata of recent bleeding at endoscopy, but no clinically significant bleeding. Uncomplicated ulcers were defined as gastric or duodenal ulcers documented on clinical evaluation by endoscopy, surgery, upper GI contrast radiography, or autopsy. Discontinuations due to upper GI symptoms consistent with dyspepsia were also assessed. The definition of dyspepsia required pain or discomfort in the upper abdomen (including ‘epigastric’, or ‘stomach’) or nausea. Patients were not queried regarding specific symptoms of dyspepsia; these symptoms represent spontaneous reports by patients. As reports of mild GI adverse events are extremely common and may be variably reported by different sites and investigators, we assessed discontinuations as a marker of clinically meaningful upper GI symptoms to study patients whose symptoms more clearly had an adverse effect on their quality of life. Statistical analysis A list of 13 baseline clinical variables, which were considered potential risk factors for NSAID-associated clinical events, were specified for assessment along with treatment group in a multivariable analysis. Rates of upper GI clinical events and complications per 100 patient-years as well as rates of patient discontinuations for dyspepsia were calculated and a Cox proportional hazard model was applied with inclusion of the specified covariates in the model for all upper GI clinical events, the subset of complicated upper GI events, and discontinuations for dyspepsia. All analyses were performed in the intention-to-treat population of all patients randomised followed up until 14 days after discontinuation of study medication. The treatment effects within subgroups based on the individual risk factors were assessed and performed by adding terms for the subgroup factor and interaction with treatment to the Cox model. Results Significant predictors of clinical events and complicated events included age ≥65 years [hazard ratios (HRs) = 2.25 (1.84-2.76), 4.09 (2.82-5.92)], prior event [HRs = 2.57 (1.94-3.39), 3.23 (2.095.00)], low-dose aspirin [HRs = 2.34 (1.87-2.92), 3.41 (2.33-5.00)] and corticosteroid [HRs = 1.85 (1.41-2.43), 2.09 (1.29-3.38)]. Predictors of discontinuation due to dyspepsia included prior dyspepsia [HR = 1.78 (1.44-2.00)], prior event [HR = 1.78 (1.40-2.27)] and age ≥65 years [HR = 1.35 (1.16-1.57)]. Conclusion Assessment for age ≥65 years, prior upper GI clinical events and low-dose aspirin use are key in identifying patients who should either avoid NSAIDs or employ management strategies to reduce NSAID-associated upper GI events. Findings show that prior dyspepsia or upper GI clinical events and age ≥65 years also predict an increased risk of developing dyspepsia that is severe enough to necessitate discontinuation of NSAIDs. References available on request. medical chronicle | May 2012 | page 41 Visit our webpage: www.medicalchronicle.co.za Fertility Forum Assisted Reproductive Technologies Can’t Help Women ‘Rewind’ the Biological Clock Many women do not fully appreciate the consequences of delaying motherhood, and expect that assisted reproductive technologies can reverse their aged ovarian function, researchers from Yale University reported in a study published in a recent issue of Fertility and Sterility, an international journal for obstetricians, gynaecologists and reproductive endocrinologists. “There is an alarming misconception about fertility among women,” said Dr Pasquale Patrizio, professor in the department of obstetrics and gynaecology at Yale School of Medicine and director of the Yale Fertility Center. “We also found a lack of knowledge about steps women can take early in their reproductive years to preserve the possibility of conception later in life.” The growing popularity of ART has given women the impression that female fertility may be manipulated at any stage in life The report stemmed from the observations Dr Patrizio and colleagues made that more women are coming to the fertility clinic at age 43 or older expecting that pregnancy can be instantly achieved, and they’re disappointed to learn that it can’t be done easily. “We are really seeing more and more patients ‘upset’ after failing in having their own biological child after age 43, so we had to report on this,” said Dr Patrizio. “Their typical reaction is, ‘what do you mean you cannot help me? I am healthy, I exercise, and I cannot have my own baby?’” These women delay pregnancies in their most fertile years for a variety of reasons, such as focusing on careers, lack of financial stability, or not having a partner. They are vaguely aware that fertility decreases with age, but it is only when they experience age-related infertility first hand that they begin to understand the reality of their situation, noted the researchers. Misconceptions The growing popularity of assisted reproductive technologies (ART) has given women the impression that female fertility may be manipulated at any stage in life, noted Dr Patrizio. He said the problem is exacerbated due to images of celebrities who seem to effortlessly give birth at advanced ages. According to the Society for Assisted Reproductive Technologies, the number of in vitro fertilisation (IVF) cycles performed for women under age 35 increased by about 9% between 2003 and 2009. During this same time period, the number of IVF cycles performed for women aged 41 and older increased by 41%. But this procedure doesn’t always result in success. “Even though the number of women turning to ART has increased, the number of IVF cycles resulting in pregnancy in women above age 42 mostly remained static at 9% in 2009,” said Dr Patrizio. “If pregnancy is achieved at an older age, women then face higher risk of pregnancy loss, birth defects and other complications.” Dr Patrizio hopes to prevent age-related infertility by combating these misconceptions with education. “Women should be given the appropriate information about postponing fertility, obstetric risks, and the limited success of ART in advanced age to allow them to make informed decisions about when, if at all, they hope to become pregnant.” Weighing other options Dr Patrizio said that one of the techniques women should take advantage of is oocyte (egg) freezing, which appears to be the best strategy for women who want to postpone motherhood but really care about having a child with their own genetic material. Alternative options such as egg donation, which leads to the highest pregnancy rates reported for any ART method, are also available. “There is an urgent need to educate women that reproductive ageing is irreversible and, more importantly, that there are options to safeguard against the risk of future infertility,” said Dr Patrizio. “These techniques are valid options for women and should not be viewed as experimental,” he added. “Doctors and health professionals must begin the discussion about fertility preservation in their patients and make certain that young women truly understand all their options.” •••Sources: ScienceDaily, Yale University medical chronicle | May 2012 | page 43 Dr Xolile Dlamini HIV Forum Medical Male Circumcision and HIV Circumcision is the removal of the foreskin of a penis. The foreskin’s main function is to cover the glans penis. It also lubricates it and makes it ultra sensitive to enhance sexual experience. The frenulum is a highly vascularised fold of the prepuce whose function is to ensure that the covering of the glans by the foreskin is continuous. Benefits of medical male circumcision (MMC): • Penile hygiene: it is easier to keep the penis clean. • It reduces the risk of urinary tract infections, especially in children. • It prevents phimosis and paraphimosis. • It prevents balanitis and posthitis. • It reduces the risk of acquiring HIV. • It reduces the risk of some sexually transmitted infections, especially the ulcerative ones such as chancroid and syphilis. However, it offers no risk reduction in the nonulcerative sexually transmitted infections such as gonorrhoea. • It reduces the risk of human papillomavirus infection. • It also reduces the risk of developing invasive penile cancers. The highly vascularised foreskin mucosa, which is prone to tearing and/or bleeding during intercourse, facilitates HIV infection in uncircumcised men Risks associated with the procedure: • Pain: especially after the procedure. • Bleeding (usually at the frenulum) during and after the procedure. • Injury to the penis such as amputation of the glans. • Infection at the circumcision site. • Increased sensitivity and irritation of the glans. • Meatitis. • Reaction to one (or more) of the local anaesthetic agents. It has been shown that countries with low prevalence of male circumcision have a high prevalence of HIV. Less than 20% of the male population in African countries south of the Sahara is circumcised and the prevalence of HIV ranges from 14.1% to 33.4%. In Central, East and West African countries, the male circumcision rate is more than 80% and HIV prevalence ranges from 1.5% to 6.1%.1 Independent studies, all randomly controlled trials done in Orange Farm in SA, in India, Kisumu in Kenya, and in Rakai district in Uganda all came up with the same conclusion that male circumcision performed by well-trained medical professionals was safe and reduced the risk of acquiring HIV infection by 60%.2,3,4 Based on the above evidence, the World Health Organization then recognised male circumcision as an efficacious intervention for HIV prevention. The organisation has added it to its list of recommendations: Promoting male circumcision should be recognised as an additional, important strategy for prevention of heterosexually acquired HIV infection in men. Reasons for male circumcision’s protective effect against HIV: • The inner foreskin is much less keratinised when compared with other genital mucosa. Its numerous Langerhans cells and other immune cell targets are usually susceptible to HIV infection. An in vitro study showed that viral uptake in this tissue was seven times more efficient than in cervical tissue in women. • The highly vascularised foreskin mucosa, which is prone to tearing and/or bleeding during intercourse, facilitates HIV infection in uncircumcised men. This is more so with the ‘dry sex’ practice (vaginal lubrication is removed using herbal aphrodisiacs, household detergents, antiseptics, or by placing leaves in the vagina), which is quite common in Southern Africa. • Ulcerative sexually transmitted infections such as herpes simplex virus type 2, syphilis and chancroid are more prevalent in uncircumcised men. These provide a port of entry for HIV. Conclusion Medical male circumcision has been shown to be strongly protective against HIV-1 infection. It reduces the risk that men will contract HIV through sexual intercourse with infected women by about 60%. Patients that are not yet circumcised must be encouraged to do so. References 1. Halperin DT, Bailey RC. Male circumcision and HIV infection: 10 years and counting. Lancet 1999;354:1813-1815. 2. Reynolds SJ et al. MC and risk of HIV-1 and other STI’s in India, Lancet 2004;363:1239-40. 3. Bailey RC et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised trial. Lancet 2007;369:643-656. 4. Gray R et al. Lancet 2007;369:457-466. 5. Medical Male circumcision training, CHAPS, ANOVA Health Institute, FPD, USAID. page 44 | medical chronicle | May 2012 Follow us on Twitter: @MedChronicle Oncology The Changing Face of Cancer Cancer is often perceived as a disease that only affects older people. However, over the past few years, oncologists are increasingly treating younger patients with various forms of the disease. Age should therefore no longer be a deterrent if cancer is suspected in a patient. This is the advice of Dr Owen Nosworthy, a medical oncologist at the Wits Donald Gordon Medical Centre (DGMC) in Johannesburg. He joined DGMC, the country’s first publicprivate academic hospital, full-time at the end of last year, further strengthening the multidisciplinary medical oncology team based at the centre. The clinic offers comprehensive services to patients with all types of cancers - including blood cancers - that require chemotherapy. Dr Nosworthy’s special interest is colon and lung cancer, and he is passionate about creating greater awareness about early diagnosis. suspected that there is a link between early onset of this form of cancer and fast food. Prevalence of colon and lung cancer One of the greatest stumbling blocks that many oncologists face is that patients are often only referred for specialised treatment when they are in the end stages of the disease. This is particularly true for patients with colon cancer, as there is not as much awareness surrounding it as e.g. breast and lung cancer, explained Dr Nosworthy. He added that many GPs and patients are not aware that colon cancer is more treatable than any other form of cancer if diagnosed in the early stages. Similarly to colon cancer, patients with lung Although lung cancer is still more prevalent among men, the number of women with the disease is on the increase. Colon cancer is the secondleading cause of death in men and the third-leading cause in women. A worrying factor, said Dr Nosworthy, is that they are seeing more and more young people with colon cancer - sometimes as young as 18. Diet is the leading cause of colon cancer and research has proven that a diet rich in fibre can play a huge role in preventing the disease. It is also Patients often referred too late cancer are often only referred to oncologists when it is almost too late to treat the disease. More than 90% of patients with lung cancer are diagnosed too late, often because small tumours are overlooked on x-rays or scans and only picked up when they are more visible and thus in an advanced stage, explained Dr Nosworthy. Red flags He advised GPs to suspect colon cancer when patients present with symptoms including low iron levels, anaemia or changes in bowel habits (constipation alternated with bouts of diarrhoea). A family history of colon cancer and smoking also play a role in the development of the disease, while recurrent chest infections and persistent coughing in smokers should act as red flags for lung cancer. Dr Owen Nosworthy, an oncologist with a special interest in colon and lung cancer People should go for a colonoscopy at least once between the ages of 20-30 and thereafter, at least once every five years. Those with a genetic disposition should undergo a colonoscopy at least once or twice per year, while smokers should go for chest x-rays at least once a year. Dr Nosworthy reiterated that age should not be a factor when cancer is suspected. Medical and technological advances The key to the success of the team at the DGMC is the fact that they follow a multidisciplinary approach, said Dr Nosworthy. The team, comprising oncologists, surgeons, radiologist and pathologists, meet once a week to discuss the most appropriate mechanisms to use in order to achieve the best outcomes for patients. This approach is supported by state-of-the-art medical equipment. The gold standard in the treatment of both lung and colon cancer is surgery and chemotherapy. Over the past five years, great advances have been made in medical, technological and treatment techniques, making it possible to not only improve quality of life, but, in many instances, extend the life expectancy of patients. New medical advances include surgical techniques that allow surgeons to remove tumours from areas that were previously inaccessible, while technological advances include the refinement of chemotherapies that have fewer side effects. Another major breakthrough has been the development of treatments that use the body’s own immune system to fight the disease, used in conjunction with chemotherapy. A new technique used worldwide and also at DGMC is called maintenance chemotherapy, in which the medication is administered in tablet form and used on an ongoing basis to keep the disease under control. Cancer is thus treated as a chronic disease. medical chronicle | May 2012 | page 45 Oncology Forum Dr Louis Kathan Treatment and Prognosis of Osteosarcoma Primary bone tumours are rare, accounting for <0,2% of malignant tumours registered. Osteosarcoma is the most common malignant bone tumour in adolescence and childhood (it accounts for over 50% of primary bone tumours in patients <20 years of age), and is the sixth leading cancer in children >15 years. The age distribution is bimodal, with a first peak during the second decade of life (during the adolescent growth spurt: 16 years in girls, 18 years in boys) and a second peak in older adults. The male:female ratio is 1.6:1. It is a highly aggressive tumour typically composed of osteoid-producing spindle cells, with an affinity for the metaphyseal portions of long bones as these sites have growth plates and a high cell turnover. Although any bones may be affected, the most common sites include distal femur, proximal tibia and proximal humerus, with 50% occurring around the knee area. Pelvic osteosarcomas account for approximately 7%-9%, spinal osteosarcomas 0.85%-3%. Osteosarcomas can occasionally occur in the craniofacial bones, and in the soft tissue, heart, uterus, lung, kidney and thyroid gland. 63% Cancer cells in the bone marrow/ peripheral blood that are identified by highly sensitive immunologic techniques Etiology It is unclear at present as to what the exact cell of origin of osteosarcoma is, but it is likely that they arise from osteoprogenitor cells, given their ability to form bone. Mesenchymal stem cells have been implicated as possible progenitor cells. Many studies have shown a correlation between the faster rate of bone growth in puberty and the occurrence of osteosarcoma. Young osteosarcoma patients tend to be taller than the general population of the same age group. Additional risk factors include ionising radiation and metabolic bone diseases (e.g. Paget’s). Trauma has been proposed as a risk factor but no evidence-based etiological relationship has been established. Osteosarcoma is also associated with a number of rare inherited syndromes (Li-Fraumeni, Bloom, RothmundThomson), suggesting that gene mutations play a role in pathogenesis. Clinical symptoms and signs Pain related to activity is the presenting sign in 85% of patients, with nearly 50% attributing their symptoms to minor trauma. Anorexia, weight loss, fever and fatigue are rarely associated with osteosarcoma. Patients generally have symptoms for, on average, three to four months before a diagnosis is made. Approximately 92% of patients have tenderness to palpation at the tumour, 39% present with a palpable mass, 39% have pain with passive range of motion of the adjacent joint, and 31% walk with a limp. Presentation by pathologic fracture (5%-10%) worsens prognosis via an increase in local recurrence rate. Approximately 15%-20% of patients present with radiographically detectable metastases. However, as 80% of patients develop metastases after surgical resection, all patients are presumed to have subclinical, microscopic metastases. The most frequent site of metastases in osteosarcoma is to the lungs, followed by bone. Tumour nodules growing outside the reactive zone but within the same bone or neighbouring joint are termed ‘skip-lesions’, often confused with multiple bone metastases. If osteosarcoma is widely metastatic, spread to the central nervous system and other sites can occur. Diagnosis and staging Laboratory findings may show an increase in alkaline phosphatase (ALP). In addition, a raised erythrocyte sedimentation rate (ESR), serum lactate dehydrogenase (LDH) (30%) and a mild anaemia may be seen. Imaging modalities include plain radiographs of the affected area in two planes. The combination of radiographic features, clinical presentation and location allows for accurate diagnosis in 66% of cases. Obtaining radiographs at initial presentation decreases the delay to diagnosis by 11 weeks. Additional workup should include MRI to assess tumour extension and involvement of surrounding structures, as well as tumour size, which affects prognosis. CT for pulmonary metastases is 75% sensitive and 100% specific and is superior to PET scanning. A technetium-99m bone scan/ PET scan should be used to evaluate for nonpulmonary metastases. Highly sensitive immunologic techniques can identify cancer cells in the bone marrow/peripheral blood of 63% of patients. The definitive diagnosis is made by biopsy (either open biopsy or core needle aspiration). This should be a carefully planned multidisciplinary approach to ensure, above all, adequacy of the specimen and to maintain the viability of definitive surgery and possible limb salvage. It should be carried out by the surgeon who will carry out the tumour resection, the radiologist, or a member of the team. Histologically osteosarcoma is characterised by proliferating malignant spindle cells with several histological subtypes described including: osteoblastic (most common), chondroblastic, fibroblastic, telangiectatic, small cell, parosteal, periosteal, high-grade surface and secondary osteosarcoma. A staging system described by Enneking divides osteosarcomas into three stages according to tumour grade (low grade - stage I or high grade - stage II), and by local anatomic extent (intra or extra compartmental). The American Joint Committee on Cancer stages osteosarcomas according to grade, tumour size, and the presence and location of metastases. Differential diagnosis This includes Ewing’s sarcoma, chondrosarcoma, malignant fibrous histiocytoma, lymphoma, fibrous dysplasia, giant cell tumours, and metastases from other primary tumours. Treatment Before the use of effective chemotherapy, the twoyear overall survival rate following surgery and/or radiotherapy was 15%-20%. Approximately 80%90% of patients will develop metastatic recurrence if treated with surgery and/or radiotherapy alone. Successful treatment thus involves multiagent neoadjuvant and adjuvant chemotherapy, together with aggressive and, if possible, limbsparing surgery. The most commonly used chemotherapy drug regimen is a combination of: cisplatin, doxorubicin, high-dose methotrexate and ifosfamide. Doxorubicin and cisplatin are commonly used as the basis of treatment with the addition of methotrexate and/or ifosfamide possibly providing additional benefit. Localised disease: Neoadjuvant chemotherapy has become the standard approach to treatment, giving the advantages of early treatment of micrometastases and facilitating limb-salvage procedures. (An added survival benefit with preoperative chemotherapy vs postoperative chemotherapy alone has not been proven). This is followed by surgery to gain local control with adequate margins, since this tumour is relatively radioresistant. Whether limb-salvage techniques/amputation are required depends on a number of factors including location of tumour, ability to get clear margins, age and desires of the patient/families. In addition, the use of adjuvant chemotherapy regimens provides a relapse-free survival rate of 66% at six years, compared with 11% in those patients receiving surgery alone. Treatment is commonly given over 6-12month periods. Osteosarcomas are relatively radiotherapyresistant tumours A Scandinavian series of 64 patients who received interferon-alpha as single adjuvant therapy to surgery showed a 69% rate of complete remission. Further clinical trials with interferon-alpha are however required. Muramyl tripeptide has been approved in Europe for patients <30 years with completely resected localised disease, but has not been included in ongoing prospective clinical trials. Osteosarcomas are relatively radiotherapy-resistant tumours. The indications for radiotherapy mainly include unresectable disease, or tumours where gaining adequate margins at surgery is not possible. Low-grade central and parosteal osteosarcoma have lower malignant potential, and are treated by surgery alone. The role of chemotherapy for jaw and periosteal osteosarcoma has not been defined. The treatment of patients with metastatic vs nonmetastatic disease follows the same principles. In metastatic disease, there is additional mandatory removal of all known metastatic deposits. Although the disease-free survival of the metastatic group of patients is poorer, approximately 30% of all patients with primary metastatic disease become long-term survivors. The treatment of patients who develop recurrent osteosarcoma depends on the initial therapy, time to recurrence, and the site and number of recurrent tumours. Treatment is primarily surgical. Longterm postrelapse survival is <20%, but complete surgical removal of metastases must be attempted as the survival of those who achieve a second surgical remission is >5 years. As long as recurrences are resectable, even patients with multiple recurrences can be cured. There is no accepted standard regimen of second-line chemotherapy for recurrent osteosarcoma. Choices may include ifosfamide and/or etoposide and/or carboplatin. Prognosis The presence of clinically detectable metastatic disease at presentation is a poor prognostic factor, with the number and site of pulmonary lesions and their resectability being of prognostic significance. The volume and site of the primary tumour are also prognostic factors, with axial lesions having a less favourable outcome. Serum LDH and ALP levels reflect tumour burden and thus also correlate with outcome. The histologic response to induction chemotherapy is also commonly used to determine prognosis. The treatment of osteosarcoma requires a multi disciplinary approach. Early tumour detection by maintaining a high index of suspicion when patients present with any of the sometimes subtle symptoms and signs mentioned, will decrease the delay to diagnosis and improve treatment outcomes. While surgery is the mainstay of treatment in terms of gaining local control of the tumour, advances in chemotherapy over the last 30 years have led to greatly improved disease-free survival, reduction in metastases or at least delay in their occurrence, as well as increased survival after recurrence of disease. References available on request. Minimally Invasive Procedure for Oesophageal Cancer Shows Better Results Removing the oesophagus via minimally invasive surgery is considerably more beneficial for individuals with oesophageal cancer than traditional open surgery, according to a new study published Online First in The Lancet. Results from the study indicate that oesophageal cancer patients who undergo the minimally invasive procedure have better short-term quality of life, considerably shorter hospitalisations and are nearly three times less likely to develop pulmonary infections. According to the researchers, over the last two decades, the incidence of oesophageal cancer has increased by 50%. At present, the mainstay of treatment is a procedure called open oesophagectomy, which involves removing part of or the entire oesophagus by cutting through a patient’s chest. However, over half of patients develop pulmonary complications after undergoing this invasive procedure. These complications result in poorer quality of life, as well as longer hospital stays. The researchers note that minimally invasive oesophagectomy could have potential benefits over traditional open surgery. Even though the first minimally invasive oesophagectomy was performed 20 years ago, this is the first randomised trial comparing the two procedures. Researchers from the VU University Medical Center, Amsterdam, enrolled 115 individuals with resectable oesophageal cancer from five centers in the Netherlands, Italy and Spain to participate in the study. They randomly assigned 56 participants to receive open oesophagectomy and 59 patients to receive minimally invasive oesophagectomy. The researchers found that significantly more patients (16 [29%]) in the open surgery group developed pulmonary infections two weeks after surgery than in the minimally invasive oesophagectomy group (5 [9%]). Overall, 19 (34%) of participants in the open surgery group developed a pulmonary infection in hospital vs 7 (12%) of participants who underwent minimally invasive surgery. In addition, the team found that at six weeks after the procedure, participants assigned to the minimally invasive group had better quality of life (significantly less pain and vocal-cord paralysis), shorter hospitalisations, and had significantly reduced blood loss. •••Source: The Lancet Online First page 46 | medical chronicle | May 2012 Follow us on Twitter: @MedChronicle Pain Management Tolerability of Osmotic-controlled Release Oral Delivery System Hydromorphone The tolerability profile of osmotic-controlled release oral delivery system (OROS) hydromorphone appeared to be similar to that of hydromorphone immediate release (IR) in patients with predominantly noncancer pain as shown by preliminary information from one trial that indicated a similar proportion of patients reported adverse events in the OROS hydromorphone and hydromorphone IR groups. In addition, the nature and incidence of adverse events associated with OROS hydromorphone in clinical studies were similar to those reported in a pooled analysis of tolerability data from clinical trials in which patients received OROS hydromorphone or another formulation of hydromorphone. All opioid medications carry with them the risk of developing tolerance and physical dependence, especially with longer-term use. Although uncommon or rare, opioid tolerance or dependence has been reported in hydromorphone recipients in a pooled analysis of tolerability data from clinical trials. However, it appears that these adverse events may all have occurred in patients receiving formulations of hydromorphone other than OROS hydromorphone. Despite this, with continued use of OROS hydromorphone, the development of tolerance or physical dependence may be expected. Comparisons with other opioids The tolerability profile of OROS hydromorphone appeared to be similar to that of oxycodone extended release (ER) in patients with chronic, moderate to severe pain associated with osteoarthritis of the hip or knee and in those with chronic, moderate to severe nonmalignant pain of various underlying causes. In the osteoarthritis pain study, adverse events were reported in 78.9% of OROS hydromorphone recipients and 79.1% of oxycodone ER recipients. The incidence of treatment-related adverse events in OROS hydromorphone and oxycodone ER reci pients in the nonmalignant pain study was 67.3% and 69.6%. In both trials, including the 28-week extension phase of the nonmalignant pain trial, the nature and incidence of specific adverse events was similar in the OROS hydromorphone and oxycodone ER groups. In the osteoarthritis pain study, nausea, vomiting, somnolence and dizziness tended to occur with the lowest dosage of OROS hydromorphone (8mg once daily) and the 20mg twice-daily dose of oxycodone ER. In this study, approximately twice the number of adverse events was reported during the titration phase than during the maintenance phase in both the OROS hydromorphone and oxycodone ER groups. Vital signs were not affected to a clinically relevant extent by either OROS hydromorphone or oxycodone ER in the osteoarthritis pain study. Adverse events leading to study discontinuation occurred in similar proportions of patients who received OROS hydromorphone or oxycodone ER (35.2% vs 32.8%) in the osteoarthritis pain study. Of the 25 OROS hydromorphone recipients who discontinued because of an adverse event, 23 reported adverse events that were thought possibly, probably or definitely related to the study drug. In addition, numerically more of these discontinuations occurred during the titration phase than during the maintenance phase in both the OROS hydromorphone (29.6% and 5.6%) and oxycodone ER (19.4% and 13.4%) groups; statistical analyses were not performed for these comparisons. Serious adverse events were reported in three OROS hydromorphone recipients and one oxycodone ER recipient in the osteoarthritis pain trial, but only one serious adverse event (diarrhoea in a patient receiving OROS hydromorphone) was thought to be possibly related to the study medication. In the nonmalignant pain trial, four of 254 (1.6%) hydromorphone recipients and six of 250 (2.4%) oxycodone ER recipients reported a total of 16 serious, treatment-related adverse events (eight in each treatment arm), including vertigo and somnolence. A total of five patients withdrew from the trial because of a serious adverse event. The tolerability profile of OROS hydromorphone also appeared to be similar to that of morphine controlled release (CR) in patients with chronic, moderate to severe cancer pain. In this study, at least one adverse event was reported during the titration and/or maintenance phase by 81.8% of OROS hydromorphone recipients and 89.1% of morphine CR recipients. Of all reported adverse events, approximately 30% were not thought to be related to the study medication. The nature and incidence of adverse events was similar in the OROS hydromorphone and morphine CR groups. Study discontinuations because of adverse events occurred in six of 77 (7.8%) and four of 86 (4.7%) OROS hydromorphone and morphine CR reci pients in the maintenance phase of the trial. There was no significant difference between the groups in the time to study discontinuation. Serious adverse events occurred in seven of 77 (9.1%) OROS hydromorphone recipients and nine of 86 (10.5%) morphine CR recipients during the maintenance phase; approximately one-third of all serious adverse events reported in the study were thought to be probably or definitely related to study medication. Deaths occurred in three morphine CR reci pients, but none were thought to be related to the study medication; no deaths occurred in the OROS hydromorphone group. References available on request. *Content provided by Janssen Pharmaceuticals. medical chronicle | May 2012 | page 47 Dr Luc Evenepoel Pain Forum Avoiding Complications in Oral Analgesics To enhance their analgesic effect, or to perk up or relax the aching patient, many painkillers contain more than just molecules that counteract pain. They often contain stimulants (caffeine, pemoline), sedatives such as meprobamate or antihistamines (e.g. doxylamine, diphenhydramine), or centrally acting muscle relaxants (mephenesin). Analgesic cocktails Although these additional molecules are only present in subtherapeutic doses, they can create a psychological dependence. The popular press reports people keeping these analgesics readily at hand (handbag, car) for their relaxing or energising effect - two ordinary pain tablets can give you as good a caffeine fix as a small cup of coffee, or relax you enough to be able to cope with the rest of the day. Epidemiological studies point out that through chronic overuse of these analgesic cocktails, the ‘patient’ (in this case actually not a sick or a painsuffering person) runs the risk for hepatic and renal failure from the actual analgesic component. In the past, phenacetin abuse was a major cause of renal failure, but after having been taken off the market in 1983, abuse of preparations containing paracetamol, aspirine and nonsteroidal anti-inflammarory drugs (NSAIDs) have been associated with the same problem. Although a few days of an analgesic cocktail against flu or minor aches and pains won’t do harm, it is better practice to prescribe ‘pure’ painkillers, containing only a single molecule per tablet. New Anaesthesia Workstation The Perseus A500 anaesthesia workstation is one of the largest development projects ever from Dräger. It includes flexible product design, links with the Infinity Acute Care System (IACS) and with patients in intensive care, and provides a level of automation that supports the workflow in the operating room. “The development of the Perseus A500 took into account the option for customers to arrange their anaesthesia workstation as they like and as it fits their specific situation,” said Oliver Rosenthal, director of Dräger’s strategic anaesthesia business unit. Within the scope of the so-called customer process monitoring system, Dräger specialists have observed anaesthesiologists and nurses around the world in their work environment and subsequently interviewed them. “Only during daily use do technology problems reveal themselves,” explained Rosenthal. “Our objective was, therefore, to empathise with the user even more intensely than before and to integrate and implement our observations into a concept for new anaesthesiology workstations.” The observations have been incorporated into the product design of the Perseus A500. More than 100 different versions of the anaesthesia workstation can be created to match the needs of hospitals by combining the different hardware options, shelf arrangements and storage areas. In addition, freely selectable software options such as ventilator or monitoring modes increase the number of possible configurations. 110 years of Dräger anaesthesia equipment In 1902, the ‘Roth-Dräger’ anaesthesia machine was already a revolutionary device for achieving a reliably controlled mixture of oxygen and anaesthetic agents. The Cicero anaesthesia machine, built in the 80s, was the first machine of its kind to feature an integrated patient monitor, device monitor, and ventilator with respiratory system, as well as a dosing unit for anaesthetic gases in a single apparatus. Today’s devices have become comprehensive anaesthesia workstations and ensure not only the exact dosage of anaesthetic agents but also provide detailed monitoring of patients and feature intelligent alarm systems. With the Perseus A500 anaesthesia workstation, Dräger continues the success story of the company. For example: prescribe paracetamol tablets, as well as an NSAID tablet, taken in combination if necessary. Painkillers in seperate tablets As I pointed out in a previous article, through genetic polymorphism, patients experience different degrees of relief from different drugs. If they receive their painkillers in separate tablets, they can choose to either take the combination, or only the one that they feel helps them the most. Combinations to avoid Tramadol, an atypical synthetic opioid, has found widespread success because of its decreased risk for respiratory depression. Its mechanism of action is through modulation of the GABAergic system, and through inhibition of noradrenaline and serotonine reuptake. Combining this drug with other drugs that work on the serotonin pathways puts the patient at risk for serotoninergic syndrome. Therefore, strictly avoid prescribing tramadol together with selective serotonin reuptake inhibitors or mono-amino oxidase inhibitors. Also, avoid the combination with HT3-antagonists: ondansetron (Zofran), granisetron (Kytril) and dolasetron (Zamanon). Pethidine, because of its stimulation of serotonin receptors, should also not be prescribed together with tramadol. changes can be seen as agitation, disorientation, hallucinations, confusion and insomnia. Autonomic changes are hypertension, tachycardia, sweating, diaphoresis and a rise in temperature. Musculoskeletal changes can be hypertonia, hyperreflexia, tremor, shivering, stuttering and mydriasis. The syndrome develops over hours or days, and its severity can range from barely perceptible to lethal. Treatment is withdrawal of all potential precipitating drugs, and in severe cases, administration of nonspecific serotonin antagonists (e.g. chlorpromazine, propranolol, methysergide and cyproheptadin). Serotonergic syndrome Conclusion Serotonergic syndrome is characterised by mental, autonomic and muscoloskeletal changes. Mental It is probably best to stick to prescribing ‘pure’ painkillers, without additions. page 48 | medical chronicle | May 2012 Sexual Health Forum Dr Prithy Ramlachan Sexual Function in Hypertensive Men Erectile dysfunction (ED) is a common disorder of the male population, affecting both patients and their partners, creating distress, reduced relationship satisfaction, quality of life and wellbeing. In the landmark Massachussets Male Aging Study, 30% of men who responded as having ED also reported a history of hypertension. Some published data have even suggested that over half of the men with hypertension also may have ED. Medication side effects are a common cause of ED with antihypertensive drugs being the most implicated. The extent of ED varies depending on the particular class of antihypertensive medications. Sexually related side effects of antihypertensive treatment may lead to withdrawal or poor compliance with therapy resulting in poor blood pressure control. A recent review by Marcos Karavitakis et al, evaluated whether hypertension clinical practice guidelines (CPGs) address ED or other sexual issues as either an adverse outcome or as a factor to consider in treatment decision making. A total of 12 hypertension CPGs were identified and analysed and guidelines were assessed using four survey questions: problems’; the guideline of the Japanese Society of Hypertension recommends that ‘sexual life should be evaluated as objectively and comprehensively as possible;’ and the guideline of the Heart Foundation mentions that evaluation in patients with confirmed hypertension should include a full history with particular attention to ED. Question 1: Do CPGs emphasise the importance to assess sexual function prior to initiating or during any antihypertensive drug treatment? The assessment of sexual function prior to initiation of or during antihypertensive therapy is recommended by three out of 12 identified CPGs. Namely, the American Heart Association states that ‘clinicians should be willing to discuss sexual dysfunction Question 2: Do CPGs warn of any anti hypertensive drug-induced sexual side effects? Only five of the 12 CPGs described potential sexual side effects. Drugs potentially responsible for sexual sequelae include thiazide diuretics, clorthalidone, centrally acting alpha agonists and beta blockers. The guideline of the Japanese Society of Hypertension states that sexual dysfunction (SD) is a possible side effect of antihypertensive drugs but no drug-specific details are provided. Question 3: Do CPGs provide recommendations on antihypertensive drug choice when commencing anithypertensive therapy in sexually active men or in men with pre-existing ED? Recommendations on drug choice when commencing antihypertensive therapy are provided by two out of the 12 recognised CPGs. The American Heart Association guideline states that SD has not been associated with the use of angiotensin converting enzyme inhibitors, angiotensin receptor blockersand calcium channel blockers; and the Saudi Hypertension Management Group guideline contraindicates the use of thiazide diuretics on sexually active men. Question 4: Do CPGs provide special management recommendations in cases of antihypertensive drug-induced impairment of sexual function? Only the American Heart Association and the Japanese Society of Hypertension provide special management recommendations. The American Heart Association guideline recommends that if ED appears after institution of antihypertensive therapy, the offending agent should be substituted with another drug and/or a phosphodiesterase type 5 enzyme inhibitor should be added so long as nitrates are avoided. Only the American Heart Association covers all sexual life issues related to the treatment of hypertension. Evidence from the scientific literature and clinical experience suggests that patients and clinicians are hesitant to discuss SD as it is an extremely private and sensitive topic. If the topic of SD is more frequently assessed by physicians, identifying and treating SD may not only be beneficial to a patient’s sexual life and devotion to treatment, but it might also be a lifesaving practice, as ED symptoms occur prior to coronary artery disease symptoms and may be the forerunner of future major cardiovascular events. Potential sexual side effects associated with certain antihypertensive drugs are often neglected by many CPGs. It should be emphasised that the interrelationship between hypertension, antihypertensive drug therapy, and SD is complex and involves the interaction of many factors, not all of which are completely understood. Practitioners should choose antihypertensive therapy for both efficacy on the pathology and impact on quality of life. ED is considered drug-induced if it develops within four weeks of initiating antihypertensive drug therapy or if there is a strong temporal relationship between the start of therapy and the development of a sexual side effect. On the other hand, when there is no strong temporal relationship, ED may be the consequence of the underlying generalised arteriopathy and should be managed accordingly without alteration of initial antihypertensive drug therapy. The proposed algorithm attempts to integrate sexual health into the management of hypertension. Conclusion CPGs have the potential to standardise management and improve patient quality of care. The results of the review indicated that there is an information gap pertaining to sexual health in the current hypertension CPGs, which could negatively affect the long-term treatment outcome and the quality of life of hypertensive patients. Because both ED and hypertension are chronic conditions requiring skilled care service. Suitable counselling and management should be offered. All patients with hypertension should be encouraged to lead a healthy lifestyle, improve nutrition and become physically active. Sexual function should be assessed in all men prior to initiation and follow-up of antihypertensive treatment. References available on request. medical chronicle | May 2012 | page 49 Psychiatry Forum Dr Rykie Liebenberg Social Anxiety Disorder: Sick or Just Shy? Many people go through life in an agony of tension and anxiety because of social anxiety disorder, because they never knew it existed or realised they could be helped. They consider themselves to be awkward and shy, and somehow never achieve their potential on a social or occupational level. Social anxiety disorder is classified as an anxiety disorder, and new research and awareness in the past two decades has shown it to be relatively common, although underdiagnosed and undertreated. The lifetime prevalence in community surveys varies between 0.6%-13.3%. Clinical features The core clinical features are marked persistent fear of one or more social or performance situations, where the person fears scrutiny and negative evaluation by others, being the focus of attention, behaving in an embarrassing way, or humiliating him-/herself in front of others. This can lead to severe anxiety, and very often to the typical avoidance behaviour seen in most anxiety states. Although the fear is recognised as being excessive or unreasonable, the behaviour is very resistant to change. The social and occupational functioning is significantly impaired by the anticipatory fear and avoidance behaviour. In practical terms, these patients do not date, they often remain single, they do not get jobs, they are not promoted and don’t ask for salary increases. Some of the commonest fears tie in with symptoms of anxiety; blushing, sweating, shaking, stammering, stuttering, fear of vomiting, urinating or defecating in public. They can also fear writing in public, eating in public, using public toilets, speaking on the phone and speaking in public or in meetings. Initiating or maintaining conversations is difficult or impossible, and they commonly complain of not knowing what to say. Their perception is that people are looking at them and assessing them negatively, for instance when walking in a shopping mall or entering a restaurant, lecture or a meeting. Although the anxiety is more related to meeting strangers, it can extend to family and friends. These patients often remain single, they do not get jobs or are not promoted Anticipatory anxiety is high, and social events are dreaded, feared and often avoided. If alcohol is taken before an event, just to get there, that is often a diagnostic clue. Alcohol abuse and dependence, and comorbid major depression, are the commonest presenting complaints. People suffer for years and never ask for help until they become depressed or the substance abuse becomes a problem. high morbidity in the form of social and occupational dysfunction. Sufferers are often lonely, economically disadvantaged and at risk of depression and alcohol abuse. Treatment The social anxiety starts in childhood and creates so many rigid cognitive distortions and avoidance behaviours that treatment is difficult and quite prolonged by the time that patients receive medical attention. The treatment involves psychopharmacology and cognitive behaviour therapy, with both individual and group intervention. Patients also need to practise self-exposure in real-life social situations. Medication can traditionally be selective serotonin reuptake inhibitors or a reversible monoamine oxidase inhibitor. The dosages need to be higher than usage for depression, and combined with cognitive behaviour therapy to achieve optimal results. Benzodiazepines should probably be avoided, although this is often already part of the dependence problem when they present for treatment. Beta blockers might be useful for symptom management in performance anxiety. Gabapentin might be helpful as adjunctive medication, as it is not addictive and has few drug interactions. In summary, social anxiety disorder is common and may be undetected for many years. There is Clinicians should be aware and ask the right questions. Think about social anxiety when treating depression and alcohol abuse. Study Links Genes to PTSD Susceptibility For many years, South Africans have been exposed to traumatic events on an almost daily basis. Posttraumatic stress disorder (PTSD) is a significant public health problem that places a huge burden on healthcare in the country. It can be a disabling condition and many of those affected are never treated at all, said Prof David Edwards from Rhodes University and an expert in PTSD and anxiety disorders. Several studies have shown that patients with PTSD are twice as likely to die from heart disease, while it has also been linked to dementia and atherosclerosis among elderly people. Studies have also found that women are twice as likely to develop the disorder as men. A question that has intrigued researchers for some time is why some people are affected by PTSD, while others, who have suffered the same ordeal, aren’t. A team of scientists from the University of California in the US believe that they might have found the answer. In an article published in the online edition of the Journal of Affective Disorders last month, the team, led by Prof Armen Goenjian from the Semel Institute for Neuroscience and Human Behaviour, reported that they have ‘discovered’ two specific genetic variations that contribute to PTSD - suggesting that susceptibility to the disorder is inherited. Some people develop PTSD after surviving a life-threatening ordeal such as war, rape or a natural disaster. PTSD can also arise as a result of child abuse, terrorist attacks, sexual or physical assault, major accidents, natural disasters or exposure to war or combat. Symptoms include flashbacks, feeling emotionally numb or hyper-alert to danger, and avoiding situations that remind one of the original trauma. Objective of research The objective of their research was to examine the potential link between the serotonin hydroxylase (TPH1 and TPH2) genes and the serotonin transponder (5-HTTLPR) and susceptibility to PTSD. Their study is the first to show that variants in TPH1 and TPH2 genes constitute risk factors for PTSD and depressive symptoms, said Prof Goenjian. According to him, their study differed from others in that previous investigations have used case or case-control design, while their subjects were members of multigenerational families. Study model Prof Goenjian and his colleagues extracted the DNA of 200 adults from several generations of 12 families who survived the 1988 Spitak earthquake in Armenia who developed PTSD symptoms thereafter. More than 25 000 people died in the earthquake, which measured 7.1 on the Richter scale. According to Prof Goenjian, all the subjects included in their study experienced the earthquake and witnessed the resulting destruction. Approximately 90% of the people who took part in the study saw bodies lying in the street and severely injured people. Findings Their main finding was the association between PTSD symptoms and TPH1 (p<0.004) and TPH2 (p=0.03). According to Prof Goenjian, their study design allowed determination of the proportion of variance of PTSD symptoms due to the TPH1 gene (3%) and the TPH 2 gene (4%). “A possible mechanism underlying the present findings is that these alleles reduce the transcriptional activity of the two TPH enzymes, thereby reducing the production of intracellular serotonin resulting in vulnerability to PTSD symptoms,” explained Prof Goenjian. Previous studies have shown that the TPH genes play a role in the production of serotonin and that the serotonergic system, in turn, is responsible for controlling arousal, sleep, anxiety and depression. PTSD disrupts the production of serotonin, thus causing patients to experience symptoms including anxiety, sleeplessness and depression. Another interesting finding of the study, explained Prof Goenjian, was the association between depressive symptoms and the ‘s’ allele of the 5-HTTLPR gene - confirming the findings of previous studies. A study published in 2010 revealed that both the short allele of 5-HTTLPR and activity in the amygdala are associated with depression. If their findings are confirmed, it may spearhead new ways of screening people at risk for PTSD, prescribing specific medicines to prevent and treat the disorder and developing alternative treatments such as gene therapy or new drugs that regulate the chemicals responsible for PTSD symptoms. Findings don’t always result in workable treatments These results may provide details of the mechanism for something that has been known for decades. “We know that children are born with different temperaments and this has a genetic basis. Decades ago, selective breeding research showed that you can breed a race of very anxious rats and another race of very ‘cool’, relaxed rats. We also know that people who are temperamentally more anxious are more prone to develop anxiety disorders. However, very often these kinds of scientific insights do not rapidly spell out into workable treatments,” commented Prof Edwards. Nevertheless, according to him, current psychological treatments, including cognitive therapy, are very effective when delivered by well-trained professionals and may take only a few sessions. However, when multiple traumas have been experienced, particularly childhood trauma, individuals develop what is called ‘complex PTSD’, and treatment with psychotherapy will usually need to be much longer, Prof Edwards concluded. •••Source: Journal of Affective Disorders page 50 | medical chronicle | May 2012 Follow us on Twitter: @MedChronicle Psychiatry Diet and ADHD: Fact or Fallacy? Is there a genuine, scientific treatment for adult attention deficit hyperactivity disorder (ADHD), based on dietary manipulation? Enter ‘adult ADHD and diet’ into Google, and over eight million references appear! Why does diet always dominate the list of natural remedies, even if conclusive research is lacking? Dr Dora Wynchank, Psychiatrist in Private Practice, Parkview One of the most challenging aspects of a mental disorder is losing control over that precious aspect of self: the mind. How and what one thinks about, feels, perceives, believes, focuses, remembers or concentrates on are stripped from one’s control. The extent to which this occurs depends on the diagnosis, but all mental disorders involve a dislocation between the familiar self and the illness. In an attempt to ‘fix’ this terrifying situation, psychiatry offers treatments that are at the forefront of scientific knowledge. But scientific explanations and interventions often feel alien for the mentally ill. They complain that medical specialists ‘take over’ and deny any autonomy to the patient. In any treatment regimen, it is critical for the patient to have a sense of control. Psychological disorders and inflammation A treatment that returns the power to the mentally ill has a huge psychological benefit. This is perhaps why diet plays such a crucial role. In addition, there are many respected theories about the causation of psychiatric conditions that implicate an inflammatory or ‘allergic’ process. These new theories of mental disorders imply that food sensitivities and allergies could be etiological in psychiatric illness. For example, in patients with depression, there in an increased risk for coronary artery disease. The mechanism(s) causing this link are as yet unclear. An underlying inflammatory process could explain the linked vulnerabilities. Unfortunately, the results of such studies have proved contradictory. Theories about psychiatric conditions implicate an inflammatory process One study of remitted, unmedicated women with depression showed that there was an elevated serum level of the acute phase proteins, C-reactive protein and serum amyloid A. The increased levels of these inflammatory markers may indicate a pro-inflammatory state in the depressed patients; and this state may be unrelated to current depressive symptoms or pharmacotherapy. These findings suggest that inflammatory mechanisms may, in part, underlie findings of increased coronary artery disease in depressed patients.1 Another more recent study refuted this connection. This study assessed current major depression with five inflammatory biomarkers (white blood cell count, CD40 ligand, C-reactive protein, fibrinogen, and interleukin-6). In fact, depression was associated with lower levels of C-reactive protein, fibrinogen and interleukin-6. The authors concluded there was no evidence that current depression is associated with greater inflammation in outpatients with coronary artery disease and that inflammation is unlikely to explain the adverse cardiovascular outcomes associated with depression in patients with established coronary artery disease.2 ADHD and genes/allergies When it comes to ADHD in children and adults, there have been some theories around allergies causing the disorder. Once again, the research data are conflicting. Allergic disorders are believed to be influenced by both underlying genetics and environmental triggers (pets, pollen and foods). Some researchers have proposed that ADHD may, in fact, be a disorder of hypersensitivity, allergy and atopy.3 This hypothesis will only be proven once it has been thoroughly tested by randomised, controlled trials. These would need to examine environmental triggers and study the underlying immunologic factors. Perhaps the genes involved in ADHD are also ... to page 51 medical chronicle | May 2012 | page 51 Visit our webpage: www.medicalchronicle.co.za Diet and ADHD: Fact or Fallacy? ... from page 50 related to the immune system? Hence, further genetic research would be mandatory. The authors concluded that if this approach proved to be true, immunotherapeutic approaches, using immunotherapy and probiotics, might subsequently be implicated in the treatment of ADHD. If hyper sensitivity to environmental stimuli such as certain foods contributes to the development of ADHD, the assessment and treatment of ADHD will have to be reconsidered, thereby improving the quality of care for these patients. ADHD and fatty acid metabolism So far, it has been proposed that at least some features of ADHD may reflect an underlying abnormality of fatty acid metabolism. A functional deficiency of certain long-chain polyunsaturated fatty acids could contribute to many of the features associated with this condition.4 My understanding of fatty acid metabolism was significantly aided by the following website: www. fatsoflife.com/ADHD.php. It appears that several decades ago, researchers observed signs of fatty acid deficiency in hyperactive children. It is also known that severe deficiencies in essential fatty acids, including long-chain omega-3s, can cause profound mental retardation. There are two ‘families’ of essential fatty acids; omega-3 and omega-6. Omega-3s, being required for both structure and function, are needed for the developing brain’s maturity in children. These fatty acids can only be obtained from the diet. Polyunsaturated fatty acids (PUFAs) make up about 20% of the brain. In the entire nervous system, one third of every fatty acid is polyunsaturated. PUFAs are critical structural components of cell membranes and nerve tissue, and omega-3s, particularly docosahexaenoic acid, are essential for the formation of new tissue, thus they are important for development and growth. The potential biological mechanisms that explain the impact of omega-3s on neurological disorders are complex and are still being investigated for verification. Deficiency of certain long-chain polyunsaturated fatty acids could contribute to the condition Deficiencies in long-chain omega-3 fatty acids are known to affect behaviour and cognition both directly and indirectly. Evidence to suggest a link with ADHD derives, in part, from human studies that reported reduced plasma omega-3 fatty acids in ADHD subjects. Studies have shown that abnormally low intakes or tissue levels of various types of polyunsaturated fatty acids (PUFAs), including omega-6s and omega-3s, are associated with ADHD. Reductions in these fatty acids (FAs) may persist into adulthood. Once again, the research has been contradictory. Although earlier research suggested that low levels of omega-3 were associated with more severe Psychiatry behavioural and possibly cognitive symptoms of ADHD, recent research revealed few associations between PUFAs and cognition in adults with ADHD. Other studies in children with ADHD showed that their plasma fatty acids did not reflect an omega-3 PUFA deficiency. The studies examining PUFA supplementation as a treatment for ADHD have been limited and contradictory. (Among these limitations are mixed diagnosis of participants; differences in doses, productsand duration; small numbers of participants; combined treatment with special diets and medications; concurrence or other health conditions; different treatment durations and variable statistical methods.) In spite of these inadequacies, there may be some evidence that ADHD responds to long-chain PUFA supplementation, including omega-3 PUFAs. Preliminary evidence from treatment trials suggests that long-chain omega-3s may be a useful adjunctive treatment for ADHD in children, because symptoms did not improve in all studies. This may be because the studies themselves are flawed. Omega-3s are not yet recommended as primary treatment of any mental or behavioural disorder. Flax oil, high in the omega-3 alpha-linolenic acid, decreased ADHD symptoms in children and improved attention in healthy adults. All in all, the research on PUFA supplementation is far from clear. The optimal dosage of omega-3s and omega6s is also still not known. It is also unclear whether they should be given separately or together, to be most effective in different types of ADHD. More research is needed. Ensuring that the diet provides a regular source of long-chain omega-3s through eating fish twice a week as recommended by the American Heart Association, or consuming fish oil supplements or omega-3-enriched eggs is a reasonable approach for someone with ADHD. References 1. Kling MA et al. Sustained low-grade proinf lammatory state in unmedicated, remitted women with major depressive disorder as evidenced by elevated serum levels of the acute phase proteins C-reactive protein and serum amyloid A. Biological Psychiatry 2007;62:4:309-313. 2. Whooley MA et al. Depression and inf lammation in patients with coronary heart disease: Findings from the Heart and Soul Study. Biological Psychiatry 2007;62:4:314-320. 3. Pessler LMJ et al. ADHD as a (non) allergic hypersensitivity disorder: A hypothesis. Pediatric Allergy and Immunology 2009;20:2:107-112. 4. Richardson AJ, Puri BK. The potential role of fatty acids in attention-deficit/hyperactivity disorder. Prostaglandins, Leukotrienes and Essential Fatty Acids 2000;63:1:79-87. page 52 | medical chronicle | May 2012 Follow us on Twitter: @MedChronicle Psychiatry Omega-3 Fatty Acid Supplementation Can Improve Symptoms of ADHD in Children A meta-analysis undertaken by researchers from the Child Study Centre based at the Yale School of Medicine (US), has found that using omega-3 fatty acids containing eicosapentaenoic acid can significantly improve the symptoms of children with attention deficit hyperactivity disorder (ADHD) if it is used in combination with pharmacotherapy. A number of double-blind, placebo-controlled trials have been conducted in the past to test this theory, but the results have been mixed and have only caused confusion and controversy. According to one of the lead researchers, Prof Michael Bloch, the aim of their study, the mega-analysis of its kind, was to provide some clarity as to the efficacy of omega-3 supplementation in children with ADHD. Research shows that more than 70% of children with ADHD respond to psychostimulant medications including methylphenidate, dextroampheta mine derivatives, atomoxetrine and desipramine. But there are parents who prefer not to use pharmacotherapies to treat their childrens’ ADHD because of concerns about the short- and long-term effects of these medications, said Prof Bloch. These parents prefer to use alternative, complementary medicine or supplements and despite the fact that clinical trials have shown mixed results in the efficacy of omega-3 used in conjunction with pharmacotherapy, it is the most popular supplement used, he added. The reason for this is that omega-3 exhibits anti-inflammatory properties, which can alter the central nervous system cell membrane fluidity and phospho-lipid composition. In turn, cell membrane fluidity can alter serotonin and dopamine neurotransmission, believed to play a huge role in ADHD. Methodology In this meta-analysis - the first of its kind - the researchers analysed the findings of 10 randomised placebo-controlled trials examining the efficacy of omega-3 fatty acid supplementation in children with ADHD or targeting ADHD symptoms in other children (undiagnosed or with comorbid conditions) and used a validated rating scale to measure ADHD severity during the trial. These trials involved 699 children. Data was extracted and the outcome measurements used was the difference in mean improvement between a group with omega-3 fatty acid supplementation and a placebo group in a clinical rating scale measuring ADHD severity over the course of the trial. A fixed-effects model was chosen for meta-analysis because this method is favoured when testing for subgroup differences in stratified meta-analysis. For secondary analysis, the researchers used the same methodology to examine the effect of omega-3 supplementation on symptoms of inattention and hyperactivity/impulsivity separately. In addition, they used meta-regression techniques to examine the association between omega-3 and naturally continuous variables including trial duration (trials included in the study lasted from four weeks to four months), proportion of dropouts in trials using completers analysis and doses of omega-3 fatty acids in supplementation preparations. Findings The researchers found that: • Higher doses of EPA within omega-3 fatty acid supplements were significantly associated with increased efficacy in treating ADHD symptoms. • There was no significant difference in the efficacy of omega-3 fatty acid supplementation based on whether it was given as a monotherapy vs augmentation to other traditional ADHD medications. • The efficacy of omega-3 fatty acid supplementation did not significantly differ whether ADHD was the subjects’ primary diagnosis or whether ADHD symptoms were being targeted in other psychiatric conditions. • The type of placebo had no significant effect on the measured effect of omega-3 supplementation. • There was no significant effect of study quality found on the measured efficacy of omega-3 fatty acid supplementation in the treatment of ADHD. Lower-quality studies did not show a significant greater efficacy of omega-3 fatty acid supplementation than higher-quality studies. Recommendations The researchers cautioned that although there was a significant effect of omega-3 fatty acid supplementation in treating ADHD symptoms, their study had several weaknesses and limitations. One of these is the fact that the clinical trials conducted and used in the study were of poor quality. In addition, said Prof Bloch, many trials did not account for dropouts in their analysis methods, which could have introduced bias in the results. They also warned that, based on the current available evidence, it is not advisable that omega-3 fatty acids replace the use of traditional pharmacologic treatments in children with significant ADHD symptoms. “However, given the evidence of modest efficacy omega-3 fatty acid supplementation and its relatively benign side-effect profile, omega-3 fatty acid supplementation, particularly with higher doses of EPA, is a reasonable treatment strategy as augmentation to traditional pharmacotherapy or for those families reticent to use psychopharmological agents,” said Prof Bloch. •••Source: Journal of the American Academy of Child and Adolescent Psychiatry medical chronicle | May 2012 | page 53 Visit our webpage: www.medicalchronicle.co.za Winter Ailments Accuracy of Rapid Diagnostic Flu Tests Worldwide, 3 to 5 million individuals develop severe influenza each year and 250 000 to 500 000 die of influenza-related causes. Even in developed countries, influenza is responsible for more than 200 000 hospitalisations annually and up to 49 000 deaths. Moreover, as illustrated by the 2009 H1N1 pandemic that affected 214 countries, influenza has the potential to rapidly spread globally. Early identification of influenza is important for optimal patient management and infection control. However, the case definition of influenza-like illness, defined by the Centers for Disease Control and Prevention and the World Health Organization (WHO) as fever (temperature 37.8 °C) and cough or sore throat, has modest sensitivity (64%-65%) and specificity (67%). For this reason, physicians sometimes use tests to diagnose influenza. Viral culture was the time-honoured gold standard for influenza diagnosis. However, 3- to 10-day turnaround times for results reduce its utility for patient management, although shell vial culture can produce results in 48 hours with similar accuracy. More recently, reverse transcriptase polymerase chain reaction (RT-PCR) has replaced viral culture as the gold standard. It is considered the most sensitive and specific test for influenza, with a 2%-13% higher detection rate than culture and results that can be obtained within hours. It is also the most expensive and least widely available test because of the specialised equipment and expertise required, and results may be delayed because samples are usually run in batches. Rapid influenza diagnostic tests (RIDTs) attempt to overcome some of these problems. They are simple to use, give results in 15 to 30 minutes; and, in some cases, can be used at the point of care in a routine clinical setting, such as a physician’s office or an emergency department. These tests are usually immunochromatographic assays that detect specific influenza viral antigens in respiratory specimens. Their costs (approximately $15 to $20 (R116-R155) per test for kit and reagents) are similar to those of laboratory-based influenza tests, such as RT-PCR. Unfortunately, RIDTs may have inconsistent accuracy, with reported sensitivity ranging from 10%-80%, whereas specificity usually exceeds 90%. Even so, the Infectious Diseases Society of America, the Centers for Disease Control and Prevention, and the WHO still consider them part of their guidelines, recognising their usefulness in patient and outbreak management - especially when other tests, such as RT-PCR or immunofluorescence, are not readily available - while cautioning against potential misdiagnosis associated with their use. In light of these recommendations and the availability of many RIDTs approved for point-of-care use, it is important for healthcare providers to better understand the accuracy of these tests. Previous systematic reviews have been limited to paediatric studies or have addressed only one commercial RIDT and were conducted before the emergence of the influenza A(H1N1) 2009 strain. Discussion Overall, RIDTs have high specificity, with modest and highly variable sensitivity. For the clinician, this means that a positive test result is unlikely to be false-positive. In the presence of a positive RIDT result in a patient with influenza-like illness, a doctor can confidently diagnose influenza and begin appropriate infection-control measures and antiviral therapy, if indicated, while forgoing unnecessary additional diagnostic testing and antibiotic prescription. However, a negative RIDT result has a reasonable likelihood of being false negative and should be confirmed by other laboratory diagnostic tests if the result is likely to affect patient management. An important finding is that RIDTs perform better in children than in adults, with approximately 13% higher sensitivity in children. This is plausible because young children have higher viral loads and longer viral shedding than adults. After adjustment for other factors, such as reference standard used, brand of RIDT, and type of specimen, RIDTs still show increased accuracy in children compared with adults. RIDTs have a higher sensitivity for detecting influenza A than influenza B. Studies have shown that infection with influenza A(H3N2) leads to more severe disease and higher annual rates of influenzaassociated hospitalisation and death than infection with influenza B. Conversely, influenza A(H1N1) has been shown to have the lowest severity index and the lowest morbidity and mortality. More severe disease usually means higher viral load and, thus, better sensitivity. During the H1N1 2009 pandemic, there were reports of even lower sensitivity of RIDTs for this new strain, compared with published accuracy estimates. However, researchers found no important difference in the accuracy of the RIDTs between studies conducted during the influenza A(H1N1) 2009 pandemic and those conducted before, with any small difference disappearing after adjustment for the reference standard used. Point-of-care testing also showed no effect on the accuracy of RIDTs. Thus, in this analysis, administration of the RIDTs by personnel other than a trained laboratory technician does not seem to adversely influence the performance of these tests. This could be good news, because it is likely that they find their most useful application and have the most effect in the diagnostic work-up for influenza when they are used as first-line tests, outside of the laboratory setting. However, no study directly compared accuracy between RIDTs performed at the point of care vs in a laboratory setting or made a distinction between who collected and who processed the specimen. The most important advantage of RIDTs is their rapid turnaround time, providing clinicians with an answer within minutes. Although they undoubtedly have higher accuracy, RT-PCR and viral culture take hours or even days to give results, even discounting transportation time to the nearest laboratory. As long as clinicians understand the limitations of RIDTs, namely that a negative result is unreliable and should be confirmed by using culture or RT-PCR, RIDTs could enable clinicians to institute prompt infection-control measures, begin antiviral treatment in high-risk populations, and make informed decisions about further diagnostic investigations. Studies that evaluate clinical effect of RIDTs on patient management are needed to confirm whether and when RIDTs may decrease use of ancillary tests and empirical antibiotic treatment and increase appropriate use of antiviral treatment. Finally, costeffectiveness studies are essential to see whether potential benefits offset the added costs of routine use of RIDTs. Reference Chartrand C, Leeflang M, Minion J et al. Accuracy of rapid influenza diagnostic tests: A meta-analysis. Ann Intern Med. 2012:3;156(7):500-11. Flu Hospital Admissions on the Rise in SA Data from the two influenza surveillance programmes, the Viral Watch (monitoring influenzalike illnesses) and the Severe Acute Respiratory Illness (SARI) programme (monitoring severe disease in hospitalised patients) show that, although the influenza season has not started officially in SA, the frequency of patient admissions for respiratory illness and specimen submissions has been steadily increasing. Ninety-eight specimens were received from Viral Watch sites in the first three months of 2012; 13 in January, 20 in February and 65 in March. Influenza A (H1N1)pdm09 virus has been detected in one, influenza A(H3N3) in three, and influenza B virus in five patients. Six of the nine patients were known to have travelled in the northern hemisphere shortly before the onset of symptoms. Other respiratory viruses have been detected in the specimens of 33 patients, including adenovirus, enterovirus, human metapneumovirus, parainfluenza, respiratory syncytial virus (RSV) and rhinovirus. For the same period (January to March 2012), 1191 patients with SARI were enrolled at the five sentinel sites, and three patients from Gauteng were positive for influenza - one positive for influenza A(H1N1)pdm09 and two positive for influenza B. The number of patients admitted with severe respiratory tract infection testing positive for RSV continues to increase, with the highest detection rate to date of 29% at week 11 (the week starting 12 March 2012). Of the 191 patients who tested positive for RSV, 54% (105/196) were children less than one year old. The start of the annual influenza season in SA is defined as the week where the influenza detection rate rises above 10% and remains ≥10% for at least two consecutive weeks. To date, the influenza detection rate has only sporadically risen above 10% and high detection rates have not been sustained. Doctors are urged to vaccinate risk groups targeted for influenza vaccination prior to the start of the influenza season. Flu vaccination is indicated for the following priority groups: • Persons (adults or children) who are at high risk for influenza and its complications because of underlying medical conditions for which they are receiving regular medical care, including: chronic pulmonary or cardiac disease, chronic renal disease, diabetes mellitus and similar metabolic disorders, individuals who are immunosuppressed (including HIV-infected persons with CD4 counts >100 cells/μl), and individuals who are morbidly obese (BMI≥40). • Pregnant women - irrespective of stage of pregnancy. • Residents of old-age homes, chronic care and rehabilitation institutions. • Children on long-term aspirin therapy. • Medical and nursing staff in contact with highrisk persons. • Adults and children who are family contacts of high-risk persons. • All persons over the age of 65 years. • Any person wishing to protect him/herself from the risk of contracting influenza, especially in industrial settings, where large-scale absenteeism could cause significant economic losses. Healthcare workers should encourage people to be vaccinated as soon as possible, since it takes about two weeks for protective antibodies to develop. Persons who were vaccinated in 2011 should be vaccinated again in 2012, as influenza vaccines do not offer long-lasting protection. •••Source: Centre for Respiratory Diseases and Meningitis, NICD-NHLS page 54 | medical chronicle | May 2012 Follow us on Twitter: @MedChronicle Winter Ailments What Is a Cough and What Causes It? A cough, also known as tissus, is a sudden reflex that humans and many animals have to clear the throat and breathing passage of foreign particles, microbes, irritants, fluids and mucus - it is a rapid expulsion of air from the lungs. Coughing can be done deliberately or involuntarily. If somebody coughs a lot it can be a sign of a disease. Germs often spread to new hosts through coughs. In the majority of cases, a cough is caused by an infection in the respiratory tract, but it can also be due to pollution, gastro-oesophageal reflux disease (GORD), chocking, chronic bronchitis, a tumour in the lung, heart failure, some drugs (e.g. angiotensin converting enzyme inhibitors [ACE] inhibitors), postnasal drip and smoking. There are three phases to a cough reflex: • An inhalation • A forced exhalation with the glottis closed. • An explosive release of air when the glottis opens. A cough typically has a characteristic sound. Doctors should focus on treating the cause of the cough, for example, if it is due to an ACE inhibitor it may be discontinued. Codeine, dextromethorphan and other cough suppressants are often used to treat coughs. However, a cough is a natural reflex, so suppressing it might have a negative effect. What are the causes of a cough? The majority of coughs are caused by viruses and clear up without treatment. In most cases of acute cough, the infection is in the upper respiratory tract and affects the throat, known as an upper respiratory tract infection (URTI). Examples include flu, the common cold and laryngitis. If it is a lower respiratory tract infection, the lungs are infected and/or the airways lower down from the throat (windpipe). Examples include bronchitis and pneumonia. An acute cough can also be caused by hay fever. According to the National Health Service, UK, an acute cough might be the initial sign of a chronic disease. Classification of coughs • Acute cough this is a cough of sudden onset that lasts up to three weeks. • Subacute cough - this type of cough persists for between three and eight weeks. • Chronic cough this type persists for over eight weeks. • Productive cough - a cough that brings up sputum. • Dry cough - a cough that brings nothing up. • Nocturnal cough - only occurs at night. Causes of chronic cough As mentioned at the beginning of this article, a chronic cough may be caused by smoking, mucus dripping down the throat from the back of the nose (nasal drip), GORD, asthma and some medications. Chronic coughs in children may be also be caused by whooping cough and respiratory tract infections. Less common causes of chronic cough include tuberculosis or a clot in the lung (pulmonary embolism). Diagnosing a cough The majority of coughs caused by the common cold or flu will clear up after a week or two. Patients are advised to rest, drink plenty of fluids and let it run its course. A cough caused by a viral infection that persists for more than a couple of weeks will probably require medical attention. Diagnostic tests include a chest x-ray and a sample of phlegm to be sent to a laboratory for analysis to determine the cause of the infection. A spirometry test might also be performed. If asthma is diagnosed, the patient may be prescribed asthma medication. GPs might refer patients to a respiratory specialist. What are the treatment options for a cough? The best way to treat a cough caused by a viral infection is to let the immune system deal with it - generally, such coughs clear up on their own. According to the National Health Service, UK, a homemade remedy with honey and lemon is as good, if not better than many over the counter (OTC) products sold in pharmacies. Honey coats the throat, resulting in less irritation and possibly less coughing. It is a demulcent and is known for its antibacterial properties. Cough medications Some may help associated symptoms, such as fever or a blocked nose. Public health authorities in many countries today advise practitioners not to give OTC cough and cold medications to children less than six years of age. Cough suppressants: These suppress the cough reflex and are generally only prescribed for dry cough. Examples include pholcodine, dextromethorphan and antihistamines. Expectorants: These help bring up mucus and other material from the trachea, bronchi and lungs. An example is guaifenesin (guaiphenesin), which thins the mucus and also lubricates the irritated respiratory tract, thus promoting drainage from the lungs. •••Source: Medical News Today Sensitive Airway Receptors Blamed for Prolonged Coughing and Wheezing People suffering from chronic lung diseases often experience prolonged bouts of coughing and wheezing with a cold. Researchers from Queen’s University in Ireland, at the recent Society for General Microbiology’s Spring Conference, have found that this is because the cough receptors in the airways become more sensitive when an asthmatic person has a cold. Unfortunately, there is currently no medicine available on the market to effectively treat increased bouts of coughing, wheezing and breathlessness. The findings of this new study could lead to the development of new medicines that can reduce virus-induced coughing, said one of the lead researchers, Dr Hani’ah Abdullah. Cough receptors, called transient receptor potential (TRP), respond to chemical and physical stimuli in the environment, including air pollutants, changes in temperature and toxic chemicals found in cigarette smoke. Once these receptors are activated, they cause individuals to cough and wheeze. Prof Louise Cosby and Dr Lorcan McGarvey are jointly leading the research team of scientists and clinicians. Their group took airway cells from mild asthmatics and healthy individuals and infected them in the laboratory with rhinovirus, which is the most common virus to exacerbate symptoms of asthma. The results showed that rhinovirus infection caused an increase in the number of TRP receptors in the airway cells and that this effect was most pronounced in the mild asthmatics. “The increase in receptor numbers makes individuals more sensitive to environmental stimuli, making them more likely to suffer from prolonged bouts of coughing,” explained Dr Abdullah. She added that the findings of their study could lead to the development of new medicine that reduces virus-induced coughing and wheezing in patients with chronic lung diseases. The objective of the medication will be to block either the sensitivity of cough receptors or their increase in number. This will control symptoms and ultimately improve the lives of asthmatics. •••Source: ScienceDaily medical chronicle | May 2012 | page 55 Visit our webpage: www.medicalchronicle.co.za Winter Ailments New Research: The First Flu can Affect the Immune System for Life During the 2009 swine flu (H1N1) outbreak, it became clear that certain age groups were more vulnerable than others. Swedish epidemiologist, Toomas Timpka, is now planning to study immunity against influenza in children. There is a connection between age and susceptibility to the influenza virus. It can’t be explained by frailty in general, because it is not obvious that very small children and the very old are the biggest risk groups. In a study of the connection between age and the risk of suffering from the flu, Timpka and his colleagues showed that the 2009 swine flu affected age groups 10-19 and 20-29 the worst. They studied how five different influenza epidemics struck in East Sweden between 2005 and 2010. Except for the H1N1 strain, they were all what is known as seasonal flu. The difference in those taken sick among age groups varies up to 10 times in certain cases, they stated. For example, with swine flu, 2.3 cases per 1000 inhabitants were diagnosed in the 10-19 age group, compared with 0.2 cases per 1000 in the 70 and older age group. This was before they were able to start up the vaccinations. For all five outbreaks, the risk of falling ill was greatest in the 30-39 age group, and least for those aged 70 and over. The researchers, however, point out that this data should be interpreted carefully, since many of the elderly are regularly vaccinated against seasonal influenza. On the other hand, their study does not support the hypothesis that school children are a bigger risk group in general. “One hypothesis is that the first influenza infection you get in your life affects your immune system. This means that your immune system learns to react to one category of influenza, but has poorer defenses against other types. This is one of the theories we want to study,” Timpka said. Which type of flu you suffer from as a child should thus be able to affect your immune system for the rest of your life. The body has two types of defenses against infections, Timpka explained. On the one hand, antibodies, which are formed as a response to an infection and then remain, make us less susceptible to an infection of that type. Antibodies thus cannot help us the first time we suffer from an infection. However, the second defense type, T-cells, can; they’re released immediately once the body is infected and they kill off the virus. “Very small children have their mother’s antibodies. The most vulnerable group is children between the ages of one and three; they still lack their own antibodies. As a rule, they develop them in some form later. Timpka and his colleagues want to study which antibodies against various types of influenza are found in children by using a register in Sweden of blood tests from 17 000 children born between October 1997 and October 1999. The researchers want to follow a selection of these children up to the age of 16, that is, through 2015 at the latest. They hope to see the first results next year. “Today, we know very little about immunity in children against influenza and flu-like illnesses. This is knowledge that’s necessary, especially to better plan future vaccination programmes,” Timpka said. •••Source: Linköping University, Sweden page 56 | medical chronicle | May 2012 Follow us on Twitter: @MedChronicle Winter Ailments Antibiotics Overprescribed in Sinusitis The overprescription of antibiotics is a major concern in the management of rhinosinusitis. A study done in the US showed that antibiotics were prescribed for 81% of adults with acute rhino sinusitis, despite the fact that approximately 70% of patients improve spontaneously in placebocontrolled, randomised clinical trials. The reason for this is that many practitioners have difficulty in differentiating between rhinosinusitis caused by a bacterial infection or by an upper viral respiratory infection (URI). The prevalence of a bacterial infection during acute rhinosinusitis is estimated to be between 2%-10%, whereas viral causes account for 90%-98%. To address some of these misconceptions, a panel of experts including internal medicine clinicians and investigators, paediatricians, emergency medicine personnel, otolaryngologists, public health officials, epidemiologist and infectious disease specialists, developed evidence-based guidelines for the diagnosis and initial management of suspected acute bacterial rhinosinusitis (ABRS) in adults and children. The guidelines were published by the Infectious Diseases Society of America and are suitable for use by primary care physicians involved in direct patient care. The aim of the guidelines is to address issues that create confusion in the management of ABRS. These include the following: • The inability of existing clinical criteria to accurately differentiate bacterial from viral acute rhinosinusitis, leading to excessive and inappropriate antimicrobial therapy. • Gaps in knowledge and quality evidence regarding empiric antimicrobial therapy for ABRS due to imprecise patient selection criteria. • The changing prevalence and antimicrobial susceptibility profiles of bacterial isolates associated with ABRS. • Impact of the use of conjugated vaccines for Streptococcus pneumonia on the emergence of nonvaccine serotypes associated with ABRS. Gold standard in diagnosing ABRS The panel agreed that the gold standard for the diagnosis of ABRS is the recovery of bacteria in high density from the cavity of a paranasal sinus. Failure to adequately decontaminate the paranasal mucosa during sinus aspiration or to quantify any bacterial isolates in the aspirate, are the most common pitfalls that may lead to misinterpretation of results. The following clinical presentations (any of the three) are recommended for identifying patients with acute bacterial vs viral rhinosinusitis: • Onset with persistent symptoms or signs compatible with acute rhinosinusitis, lasting for more than 10 days without any evidence of clinical improvement. • Onset with severe symptoms or signs of high fever (>39˚C) and purulent nasal discharge or facial pain lasting for at least three to four consecutive days at the beginning of illness. • Onset with worsening symptoms or signs characterised by the new onset of fever, headache, or increase in nasal discharge following a typical viral URI that lasted five to six days and were initially improving (double-sickening). Recommendations The panel strongly recommended that: • Empiric antimicrobial therapy is initiated as soon as the clinical diagnosis of ABRS is established. • Amoxicillin-clavulanate rather than amoxicillin alone is used in empiric antimicrobial therapy for ABRS in children. • Macrolides (clarithromycin and azithromycin) are not used for empiric therapy because of the high rates of resistance among Streptococcus pneumonia. In addition, trimethoprim-sulfamethoxazole should not be used for empiric therapy due to high resistance rates among both Streptococcus pneumoniae and Haemophilus influenza. • Either doxycycline (not suitable for children) or a respiratory fluoroquinolone (levofloxacin or moxifloxacin) should be used as an alternative agent for empiric antimicrobial therapy in adults who are allergic to penicillin. • Although Staphylococcus aureus (including methicillin-resistant Staphylococcus aureus [MRSA]) is a potential pathogen in ABRS, on the basis of current data, routine antimicrobial coverage for Staphylococcus aureus or MRSA during initial empiric therapy of ABRS, is not recommended. • Neither topical nor oral decongestants and/ or antihistamines are used as adjunctive treatment in patients with ABRS. • An alternative management strategy is followed for nonresponsive patients if symptoms worsen after 48-72 hours of initial empiric antimicrobial therapy or fail to improve despite three to five days of initial empiric antimicrobial therapy. • Patients who clinically worsen despite 72 hours or fail to improve after three to five days of empiric antimicrobial therapy with a firstline agent should be evaluated for the possibility of resistant pathogens, a no-infectious etiology, structural abnormality, or other causes for treatment failure. • Cultures are obtained by direct sinus aspiration rather than by nasopharyngeal swab in patients with suspected sinus infection who have failed to respond to empiric antimicrobial therapy. • Nasopharyngeal cultures are unreliable and should not be used for the microbiologic diagnosis of ABRS. The panel also recommended that the following patients are referred to a specialist: • Patients who are seriously ill and immunocompromised. • Patients who continue to deteriorate despite extended courses of antimicrobial therapy. • Patients who have recurrent bouts of acute rhinosinusitis with clearing between episodes. •••Source: Clinical Infectious Diseases medical chronicle | May 2012 | page 57 Visit our webpage: www.medicalchronicle.co.za Winter Ailments The Psychology and Genetics of Flu In two separate studies, a group of researchers from the Carnegie Mellon University (US) has shown how psychological stress can make some individuals more susceptible to flu than others, while a team from the Wellcome Trust Sanger Institute (UK) has found a genetic link that explains why some people become lifethreateningly ill as a result of influenza, while others only experience mild symptoms. The link between high levels of stress and vulnerability to illnesses has long been established. However, the new study from the Carnegie Mellon University shows how psychological stress impacts on an individual’s health. It turns out that cortisol is to blame. Lead researcher, Prof Sheldon Cohen, explained that cortisol temporarily suppresses the immune system, thus reducing the body’s natural inflammatory response to viruses and bacteria. Stressed people are therefore unable to regulate the inflammatory response, and therefore, when they’re exposed to a virus, they’re more likely to develop a cold, he added. Cortisol suppresses the immune system, reducing inflammatory response Two experiments were conducted. In the first, the researchers interviewed 276 healthy adults on what had stressed them out during the previous year. The participants were then given nasal drops, which contained a common cold virus to make them sick. They were quarantined for five days and approximately 39% of the participants deve loped a cold. Those who reported being stressed were found to be twice as likely as the others to become ill. In the second experiment, the researchers ana lysed the ability of 79 participants to regulate their inflammatory response. They were then exposed to a cold virus and their production of proinflammatorycytokines was tracked. Participants who started out with poor inflammatory response regulation were found to produce more cytokines when they ‘caught’ the virus. The immune system’s ability to regulate inflammation predicts who will develop a cold, but more importantly it provides an explanation of how stress can promote disease, said Prof Cohen. “When under stress, cells of the immune system are unable to respond to hormonal control, and consequently, produce levels of inflammation that promote disease.” The researchers hope their findings can help lead to better ways to protect health in the chronically stressed. Genetics and flu The other study, led by Prof Aaron Everitt from the Wellcome Trust Sanger Institute is the first to identify a human gene that influences how individuals respond to influenza. The findings were published in the journal Nature. Prof Everitt explained that people who carry a particular variant of a gene called Interferoninduced transmembrane protein 3 (IFITM3), are more likely to be hospitalised when they contract influenza than those who carry other variants. IFITM3 plays a critical role in protecting the body against infection with influenza. A rare version of the gene seems to make individuals more susceptible to severe forms of the disease than others. IFITM3 protects cells against virus infection and plays an extremely important role in the body’s immune system against viruses such as the H1N1 pandemic influenza or swine flu. The researchers found that when the protein is present in large quantities, the spread of the virus in the lungs is obstructed. However, if IFITM3 is either defective or absent, the virus spreads more easily, causing an increase in the severity of the disease. Prof Abraham Brass, a researcher at the Ragon Institute and the Gastrointestinal Unit based at the Massachusetts General Hospital, explained that since IFITM3 appears to be a first-line defender against infection, their findings suggest that individuals and populations with less IFITM3 activity may be at increased risk during a pandemic. He added that IFITM3 could be vital for defending human populations against other viruses such as the avian influenza and dengue viruses. The findings are extremely important for people who have the rare version of the gene, because researchers can now predict whose immune systems are more susceptible to certain virus infections. This can help people take precautions such as vaccination to prevent infection. •••Source: Time Healthland and EurekAlert page 58 | medical chronicle | May 2012 Follow us on Twitter: @MedChronicle Women’s Health More than Just Morning Sickness: Managing Hyperemesis Gravidarum Dr Jonathan de Souza, Gynaecologist in private practice, Netcare Park Lane Hospital At least 65% of women experience some form of nausea and vomiting in the early weeks of pregnancy. However, this state of affairs is not always mild or short-lived - many women are obliged to endure a protracted period of utter wretchedness and helplessness, which, in many cases, persists for the remaining duration of pregnancy. In the average case, vomiting reaches its peak at 9-10 weeks. A limited number progress to hyperemesis gravidarum (HG). Estimates on the percentages of women thus afflicted range from 0.3%-2%. As compared with morning sickness, HG tends to present somewhat earlier in pregnancy and lasts for significantly longer. Because the nausea and vomiting in pregnancy exist on a continuum, it is difficult to establish a clear boundary between common morning sickness and established, full-blown hyperemesis. Adequate hydration, fluid and electrolyte status, and nutritional status are all jeopardised. It is the second leading cause of hospitalisation in pregnancy in the US. Aggravating factors Symptoms of vomiting in pregnancy and HG may be aggravated by the following factors: hunger, fatigue, prenatal vitamins (especially those containing iron) odours and diet. They have a direct correlation with the level of beta human chorionic gonadotropin, which explains their association with multiple pregnancies, and with trophoblastic disease. Hormonal, mechanical and psychological factors have been implicated, but except for thyroid abnormalities, other hormonal factors have not been proven. Serious morbidity and mortality may result if the full-blown malady is inadequately or inappropriately treated. Inadequate therapy may lead to serious muscle wasting, malnutrition, thrombo-embolism and fetal intrauterine growth restriction. Inappropriate therapy can lead to permanent maternal neurological deficiency and fetal and maternal death. The latter appears to be related to the injudicious administration of dextrose-containing fluids, inability to recognise the need for replacement of key nutrients such as thiamine, and the inability to appreciate critical aspects of electrolyte disturbances that may intercede. Diagnosis In essence, vomiting in pregnancy is a diagnosis of exclusion. There is no single confirmatory test. Vomiting beginning after the 12th week of amenorrhoea should not be attributed to hyperemesis. Causes such as urinary tract infection (UTI), Addison’s disease, peptic ulcer, pancreatitis and appendicitis should always be considered. Previous history makes the diagnosis more likely. Its onset is usually at around six to eight weeks. Weight loss and ketosis, dehydration, postural hypotension, tachycardia and ptyalism are the key features, and in some cases can continue to be problematic and last even until term. Manifestation that should be guarded against and proactively managed include low sodium (Na), low potassium, low urea, hypochloraemic alkalosis, ketonuria, raised packed cell volume and a raised specific gravity urine. Other important features to be evaluated in the mandatory clinical assessment include abnormal liver function, abnormal thyroid function, Wernicke’s Encephalopathy, a complex electrolyte disturbance, a degree of subnutrition, psychological effects and a possible effect on the fetus. Abnormal liver function: This will be found in up to 50% of cases. Abnormal thyroid function: This will be found in up to 66% of cases - raised T3 and/or a suppressed thyroid stimulating hormone (TSH), despite the patient being clinically euthyroid without thyroid antibodies. Abnormal thyroid function tests do not require treatment with antithyroid drugs and resolve as the hyperemesis improves. Genuine hyperthyroidism encountered for the first time usually presents late in the first trimester or early in the second trimester and is most likely to have the accompanying features of tremor, persistent tachycardia, lid lag and exophthalmos. There is a direct relationship between the severity of hyperemesis and degree of biochemical hyperthyroidism. Wernicke’s encephalopathy This dire complication is bought about by deficiency of vitamin B1 (thiamine). What became evident in the UK in the early 1990s was that hyperemesis leading to Wernicke’s encephalopathy was by no means a rarity. Its appearance is characterised by ophthalmoplegia, diplopia, ataxia and confusion. The typical eye signs are sixth nerve palsy, gaze palsy and nystagmus. Very perturbing was that the malady seemed to be precipitated by the initiation of IV fluids containing dextrose. In this regard, it used to be mistakenly believed that it was desirable to provide the patient with at least some calories as the first measure to be taken, but this assumption is erroneous and dangerous. Firstly, Wernicke’s encephalopathy may be precipitated by carbohydrate-rich fluids or dextrose administered intravenously. Secondly, the hyponatraemia apt to develop in hyperemesis demands the judicious infusion of sodium-containing fluids, and ... to page 59 medical chronicle | May 2012 | page 59 Visit our webpage: www.medicalchronicle.co.za More than Just Morning Sickness: Managing Hyperemesis Gravidarum ... from page 58 this should be provided by normal saline (sodium chloride 0.9%; 150mmol/ℓ Na+). Double-strength saline is explicitly contraindicated. These measures are necessary to combat neurological manifestations that may become permanent. Magnetic resonance imaging scanning in acute Wernicke’s encephalopathy reveals symmetrical lesions around the aque duct and fourth ventricle, which can resolve after treatment with thiamine. If the above signs of the malady are also accompanied by retrograde amnesia, impaired ability to learn and confabulation (Korsakoff psychosis) the recovery rate is only 50%. The Confidential Enquiry into Maternal Deaths reported three such deaths between 1991 and 1993. In addition, severe hyponatraemia and particularly its rapid reversal can lead to central pontine myelinolysis (Osmotic demyelinisation syndrome) causing central pyramidal tract signs, spastic quadroparesis, pseudobulbar palsy and impaired consciousness. Other vitamin deficiencies: These can manifest concurrently and include deficiencies in vitamins B12 and B6, which can cause anaemia and peri pheral neuropathy. Mallory-Weiss tears: These can lead to hematemesis. Malnutrition Protein and calorie malnutrition result in weight loss, which can be as much as 20% accompanied by muscle wasting and consequent weakness. Psychological problems These may predate the pregnancy but more likely result from the stress and loss of morale, especially if the condition is unrelenting. Requests for termination of pregnancy do not mean the pregnancy is not wanted but rather reflects the degree of desperation reached. Certain psychological factors do play a role in a proportion of cases and this may be exemplified by the rapid improvement on admission to hospital and consequent removal from a stressful home environment. Psychological counselling can go a long way into the patient coming to terms with separation from family, inability to work, anger at being unwell and guilt when this anger is turned inwards towards the fetus, where resentment of the pregnancy results. Fetal complications Wernicke’s encephalopathy is associated with a 40% incidence of fetal demise. Where the mother has lost >5% of body mass, there are significantly lower birth weights and birth weight percentiles, especially where these are accompanied by electrolyte disturbances. Women admitted repeatedly for treatment have more nutritional disturbance and significantly reduced weight gain and their babies have even more significantly lower birth weights. Management Always consider pancreatitis, Addison’s disease and peptic ulcer disease. Ultrasound, UTI exclusion and accurate dating is mandatory. The potential maternal and fetal complications argue for early and aggressive treatment. Any woman who is ketotic and unable to maintain hydration should be admitted to hospital. The most important components of management include: • Adequate and appropriate fluid and electrolyte replacement. In a severely affected individual, use of dextrose solutions in the first 12-24 hours are erroneous and dangerous and should be scrupulously avoided in favour of, in the interim, introducing thiamine in the form of thiamine 100mg diluted in 100mg of saline and run in over 30-60 minutes. • Ideal is 0.9% normal saline, +/- 40mMol potassium chloride. • In patients not requiring admission, there are likely benefits of introducing thiamine supplementation with thiamine tablets at a dose of Women’s Health 25-50mg three times a day. • After IV rehydration is completed, patients generally progress to frequent, small, liquid or bland meals. After rehydration, treatment should focus on managing symptoms to allow normal intake of food. However, cycles of hydration and dehydration recur, making continuing care necessary. • Adapt regimen at least daily according to state of hydration, and urea and electrolytes test results. • Weigh frequently to objectively determine improvement or deterioration. • Antiemetics should be offered to women failing to respond to IV fluids and electrolytes alone. In some cases, rather than administering as needed, a continuous dosing scheme needs be worked out: - Antihistamines (H1-receptor agonists e.g. promethazine, cyclizine) - Phenothiazines (chlorpromazine, prochlorpromazine) - Dopamine agonists (metochlopramide, domperidol) - In the US and UK, a highly selective 5-HT3 (serotonin) antagonist ondansetron (Zofran) has gained support for treating intractable cases based on evidence that it is the most effective and successful single agent. Its safety has not yet been established. • Other pharmacological management includes the prescription of thromboprophylaxis in the form of low-molecular-weight heparin to avert deep vein thrombosis. The use of H2-receptor blockers and proton pump inhibitors afford dramatic relief in cases where dyspeptic symptoms trigger the vomiting. • The only definite cure is termination of pregnancy. Corticosteroids Corticosteroids have resulted in dramatic and rapid improvement in case series of women with severe refractory hyperemesis. Randomised trials appear to support this benefit. They should not be used until conventional therapy with IV fluid replacement and regular anti-emetics has failed. Suggested dose is prednisolone 40mg orally daily or hydrocortizone 100mg intravenously twice daily. In cases that do respond, reduce the dose slowly, but only once the period of gestation is reached at which hyperemesis would have resolved completely. Patients who have undergone the desperate step of terminating a pregnancy and then seek advice regarding planning a new pregnancy can be consoled to hear that dramatic success with corticosteroids has been achieved in situations of severe refractory hyperemesis. If no response, discontinue completely. References available on request. page 60 | medical chronicle | May 2012 Follow us on Twitter: @MedChronicle Women’s Health New Screening Guidelines for Cervical Cancer New, age-appropriate, screening guidelines for cervical cancer that include the use of cytology and high-risk human papillomavirus (HPV) testing, follow-up of women after screening, the age at which to exit screening, future considerations regarding HPV testing and strategies for women vaccinated against HPV16 and 18 infections, were published in the April issue of the American Journal of Clinical Pathology. The US guidelines are very similar to those drafted by the SA Society of Obstetricians and Gynaecologists’ (SASOG) HPV Advisory Board in 2008 and revised in 2010, said Prof Greta Dreyer, a gynaecologist oncologist at the University of Pretoria (UP) and the Steve Biko Academic Hospital. Prof Dreyer was one of the authors of the South African guidelines. Prof Gerhard Lindeque, former president of SASOG and chairperson of the SA HPV Advisory Board and the School of Medicine at UP, added that SASOG’s guidelines were more appropriate for South African conditions. US guidelines The new US guidelines are based on a review conducted by an international team of multidisciplinary researchers at the request of the American Cancer Association. A key finding was that one-time HPV testing was more sensitive than cytology (Pap smear) in detecting cervical intraepithelial neoplasia (CIN3+/CIN2+), but was less specific. For CIN3+ outcomes, point estimates sensitivity ranged from 86%-97% for HPV testing, compared to 46%-50% for cytology. CIN is the potentially premalignant transformation and abnormal growth of squamous cells on the surface of the cervix. The new guidelines recommend that: • Cervical cancer screening should begin at age 21. • Women aged 21-29 years should be screened with a Pap smear every three years. • Women aged 30-65 years should be screened with Pap smear and HPV test (co-testing) every five years (preferred) or with Pap smear every three years (acceptable). • Women who co-test HPV positive but cytology negative should be followed with either repeat co-testing within 12 months or immediate HPV genotype-specific testing for HPV 16 alone or for HPV 16 and HPV 18. If cotesting is repeated at 12 months, women testing positive on either test should be referred for colposcopy; women testing negative on both tests should return to routine screening. • In most clinical settings, women aged 30-65 years should not be screened with HPV testing alone as an alternative to co-testing at fiveyear intervals or Pap test alone at three-year intervals. • Women at age 65 with adequate negative screening in the last 10 years and no history of cancer may stop screening. • Women at any age following a hysterectomy with removal of the cervix who have no history of CIN 2+ should not be screened for vaginal cancer using any modality. • Recommended screening practices should not change on the basis of HPV vaccination status. Risk factors and symptoms The primary cause of cervical cancer is the HPV virus, which is sexually transmitted and accounts for 70% of cervical cancer cases. Other risk factors include a weakened immune system, sexual promiscuity and smoking. Women between the ages of 18-40 and those who have been pregnant five times or more are also at higher risk. Progression of the disease is slow and it can take as long as 10-20 years before it becomes invasive. Symptoms include bleeding between periods, unusually heavy periods, pain during intercourse or after a pelvic examination and bleeding after menopause. Mortality rates Squamous cell cervical cancer, which comprises 80%-90% of cervical cancers, is one of the most common cancers in SA. Survival rates depend on the stage of the disease. The first stage (1A) is known as microinvasive or very early onset cervical cancer. The five-year survival rate is between 96%-99%. At this stage, the preferred treatment option is surgery. In the next stage (1B), the cancer becomes more visible and the five-year survival rate drops to between 80%-90%. Treatment options include surgery, chemotherapy and radiation. During the next stage (II), the cancer starts spreading to adjacent tissue, but has not yet reached the lower third of the vagina or all the way to the lateral wall of the pelvis. The five-year survival rate drops drastically to between 65%69%. Treatment options are similar to the second stage of the disease. The five-year survival rate in stage III drops to between 40%-43%. The cancer has now advanced further and has caused changes in the kidneys. In the final stage (IV), the cancer has spread beyond the pelvis and affects organs further away. The five-year survival rate is now 15%-20%. Treatment options in stage III and IV include chemotherapy and radiation. Early detection is key According to Prof Lindeque, cytology still remains the gold standard in screening for cervical cancer in SA. Although Pap smears have a lower than expected sensitivity (54%), it has led to a significant reduction in mortality since its introduction in the 1950s. HPV screening was introduced in clinical settings some 20 years ago. Studies have shown that HPV tests are more sensitive than cytology or Pap smears for precancer and may also be better at forecasting which women will develop CIN 3+ over the next five to 15 years. medical chronicle | May 2012 | page 61 Visit our webpage: www.medicalchronicle.co.za Wound Care Stamping Out Diabetic Foot Ulcers Andy Zoepke, Managing the diabetic foot ulcer Clinical Manager: Smith & Nephew and Problems associated with diabetes as (e.g. PVD) must be identified and managed. Should the ulcer be reoccurring and a new ulcer develops in the same location, there may be a more sinister reason for this occurrence (e.g. underlying osteomyelitis, presence of a foreign body). An ulcer that has opened up spontaneously or the presence of black or discoloured toes or feet may indicate a blood-flow problem. In all the above cases, it would be advisable that the patient is referred to an interdisciplinary team including a physician, a surgeon, a wound care specialist, and podiatrist/orthotist for further treatment. If the wound is relatively superficial and does not involve any major underlying structures, good Bronwyn Green, Wound Care Consultant One of the debilitating complications faced by people with diabetes is diabetic foot ulcer. More than 15% of people with diabetes will develop a diabetic foot ulcer in their lifetime. These open wounds may occur when an injury to the foot (for example, a blister or small cut) goes unnoticed. The diabetic condition is often associated with peripheral neuropathy, a disorder that is common among people with diabetes. Infected diabetic foot ulcers are a major cause of hospitalisation in diabetic patients and most nontraumatic amputations are associated with diabetic foot infections. What is a diabetic foot ulcer? The term ‘diabetic foot ulcer’ is used to define a clinical condition, but simply put, it is merely a wound on the foot of a patient who is diabetic. Healthcare workers should remember that when they are dealing with a diabetic patient with a foot ulcer, they should focus on a holistic approach to dealing with the diabetic patient. This requires the involvement of an interdisciplinary team of practitioners, including a diabetic physician, surgeon (general or vascular), wound care practitioner, podiatrist, nutritionist and orthotist. It is important to remember that the ulcer has developed as a result of the underlying diabetes and to manage the wound effectively, the diabetic condition and associated complications with the disease need to be managed as well. Sites and causes of diabetic foot ulcers Diabetic foot ulcers usually develop in areas of the foot that are exposed to either friction and sustained pressure, and/or areas of the foot that are exposed to repetitive trauma e.g. rubbing of toes on the stitching of a shoe. There are many factors that contribute to the development of diabetic foot ulcers, but it is widely accepted that the loss of sensation and poor blood supply (arterial disease) are the main contributing factors. The loss of sensation in the foot is directly related to nerve damage. Diabetics, due to progressive nerve damage and the loss of protective sensation, are unable to feel pain when they hurt themselves and are often unaware of foot problems and injuries go unnoticed and untreated for long periods of time. Nerve damage also affects foot control and movement, since the small muscles of the foot are no longer able to receive the nerve signals that control foot function and movement. Therefore abnormal pressures are applied to areas of the foot that would not normally be exposed to these pressures. This can lead to callus and ulcer formation. Poor blood flow to the diabetic foot leads to the bones in the foot losing their integrity, increasing the risk of dislocation and the collapse of the foot bone structure, either spontaneously or as a result of slight trauma. Often multiple fractures to the foot go unnoticed, which may lead to foot deformities. This in turn leads to increases in pressure to areas of the foot that were previously not exposed to pressure, and this in turn leads to callus formation and ulcer development. All diabetics have varying degrees of arterial disease. The risk of peripheral vascular disease (PVD) is four times higher in diabetic patients than in nondiabetic patients. The severity of the disease in the diabetic patient will greatly influence whether or not an ulcer develops, or the ability of the ulcer to heal. Decreased blood flow leads to delayed healing in the diabetic, due to a decrease in the delivery of oxygen and nutrients, and white blood cells to the wound. This directly affects the ability of the wound to heal, to respond to and manage bacterial bio-burden, as well as the delivery of antibiotic agents. Poor blood supply also increases the risk for the development of gangrene and ultimately amputation. local wound bed preparation principles should be followed when managing the local wound environment. Standard treatment for diabetic foot ulcers involves regular ‘moist’ dressing changes. The diabetic foot can be seen to be TIME dependant and includes the following areas of wound bed preparation: • T - Tissue: debridement of necrotic tissue and calloused wound edges • I - Inflammation/infection: reducing the bacterial wound burden and achieving bacterial balance • M - Moisture: ensuring that the moisture in the wound bed achieves a moisture balance • E - Epidermal margin: If all the above factors are in balance, then the epidermal margins will progress and the wound closure will be achieved over time. Conclusion Managing the diabetic foot is a complex process and it is important to identify when the patient requires referral for more specialised care. One of the most important aspects to take into consideration when managing the diabetic patient with a foot ulcer is patient education. Diabetic patients must understand the rationale behind the treatment and they also need to be aware of the role they play in preventing further ulceration and limb deterioration. References available on request. page 62 | medical chronicle | May 2012 // Periscope Updates and New Products A First-line Treatment Option for Protect cells, Smoking Cessation Nourish the Pfizer Laboratories is pleased to announce the launch of a new pack size for Champix®, a nicotine partial receptor agonist indicated as an aid to smoking cessation in patients committed to stop smoking. The two original two-week packs that made up the first four weeks of treatment, have now been consolidated into a single four-week starter pack. New presentation Starter (initial dosing) pack contains one blister of 11 x Champix 0.5mg film-coated tablets and three blisters of 14 x Champix 1mg film-coated tablets in a carton (providing first four weeks of initial treatment). Follow-on (maintenance) pack contains four blisters of 14 × 1mg film-coated tablets in a carton (providing weeks five through to 12). The recommended course of therapy is 12 weeks. It is important to take the medication for the full 12 weeks to increase the chances of stopping smoking. With its unique mechanism of action, through partial agonist activity at α4β2 nicotinic acetylcholine receptors, the product blocks nicotine-induced dopamine increase in a dosedependent manner, thereby decreasing the reinforcing effects of smoking satisfaction and physiological reward associated with smoking.1 With a predominantly mild and transient adverse event profile in healthy adult smokers, Champix has been found to be effective and generally well tolerated for up to 52 weeks of therapy in clinical trials.1 Reference: Garrison GD, Dugan SE. Varenicline: A First-Line Treatment Option for Smoking Cessation. Clinical Therapeutics 2009;31(3):463-491. Please refer to detailed package insert for full prescribing information. 11/CHX/03/12/ JA KMMSA Exhibits at Internationally Renowned Lung Course Konica Minolta Medical South Africa (KMMSA) was invited to exhibit its innovative digital radiography solution, the AeroDR, at the first of the Radiology Society of SA (RSSA)/ Leuven high resolution computed tomography (HRCT) lung imaging courses held back-to-back in Johannesburg and Stellenbosch. RSSA chair, Prof Leon Janse van Rensburg, said this hands-on, interactive teaching course on HRCT of the lung is internationally acclaimed and recognised as ‘the lung course to do’. Both the Gauteng and Western Cape events were attended by a select group of approximately 100 delegates, and the course was conducted by leading Belgian radiologists, Profs Dr Johny Verschakelen and Walter De Wever, of the department of radiology, University Hospitals, Catholic University of Leuven. “We are pleased to have been able to interact and share KMMSA’s technology and expertise with delegates of the RSSA as well as the esteemed lecturers,” said Wendy Biggins, product manager for medical at KMMSA. “According to the professors, a cost-effective, pragmatic and comprehensive imaging approach to patients with lung disease is of particular importance to all radiologists providing a service to these patients and the clinicians and therapists caring for them. The human and social impact, as well as the financial implications of lung disease, is far-reaching, especially in developing countries.” The aim of the course was to train and update radiologists and teach those in training about HRCT imaging of the lung. On completion of the course, the participant should be able to recognise the different basic disease patterns that can be seen on an HRCT of the lungs and to suggest a differential diagnosis. Body and Win Spirulina is a tiny spiral-shaped algae that absorbs sun energy and converts it into over 60 nutrients including vitamins, minerals, all of the essential amino acids, chlorophyll, enzymes and antioxidants, like no other plant. Marcus Rohrer Spirulina® is nature’s most power-packed multinutritional product that not only nourishes the body but also promotes natural cleansing processes, leaving one feeling stronger and more energetic. It’s been proven to contain higher concentrations of nutrients than all competing brands. Health and wellness company, OTC Pharma SA, is giving away a super health hamper, featuring the product, valued at R1500. See the back page of Medical Chronicle for details. Marcus Rohrer Spirulina and other OTC products are available at health stores, pharmacies, Dis-Chem, Clicks, Pick n Pay, Medi-Rite, Wellness Warehouse and Springbok Pharmacy. Go to www.otcpharma.co.za or call 086‑199‑8880 for more details. GP - Medicross Medical Centre Hayfields Full time GP required to join large family practice of eight Doctors. Situated in Pietermaritzburg at the Medicross Medical Centre Hayfields. For enquiries: e-mail Amanda.vanvuuren@ medicross.co.za Spine Congress 2012 Date: 7-9 June 2012 Venue: CSIR ICC, Meiring Naude Road, Pretoria Invited International Speakers Stefano Boriani – Italy Vincent Pontillart – France Rudi Bertagnoli – Germany Shankar Acharya – India Congress Theme Tumour Management, Cervical Myelopathy, Lumbar Degenerative Disease Registration Details Online registration is NOW open: www.saspine.org Early bird closing date: 30 April 2012 Social Events Wednesday 6 June: 18h00-19h30 – Welcome Cocktail Friday 8 June: 19h30 for 20h00 – Gala Dinner Congress Secretariat Hendrika van der Merwe – Tel 021-910-3322 Email: [email protected] For further details please visit the website: www.saspine.org medical chronicle | May 2012 | page 63 Updates and New Products New Addition to Anti-infective Range Pharma Dynamics have launched the latest edition to their anti-infective range: DYNA Cefpodoxime suspension. It is mostly prescribed to children for the treatment of upper respiratory tract infections, hence the child-friendly and colourful packaging. Together with its tasty banana flavour, DYNA Cefpodoxime will improve compliance when children are taking the medicine, to put the adventure back in their day in no time. The 50ml and 100ml suspension are available at R52.63 and R105.26 SEP (excl VAT) respectively, which is 36% more cost effective than the originator.¹ ●●● For more information, contact Marc Wilensky, group product manager (F02 Grapevine House, Steenberg Office Park, Westlake, 7945) on 021‑707‑7000, fax 021‑701‑5898, or go to www.pharmadynamics.co.za Dyna Cefpodoxime Suspension. Each 5ml of suspension contains cefpodoxime proxetil equivalent to 40mg cefpodoxime. Reg. No.: RSA S4 43/20.1.1/1084. For full prescribing information, refer to the package insert approved by the Medicines Regulatory Authority. Reference: Prices as per Department of Health website: www.doh.org.za accessed 28/03/2012. Botulinum Toxin(BoNT-A) and Dermal Filler Training Dates Training provided in a real working clinic Each course approved for 8 clinical CPD points • Basic Botulinum Course - 30 May 2012 • Basic Dermal Filler Course - 27 June 2012 • Advanced Botulinum Course - 25 July 2012 • Basic Botulinum Course - 29 August 2012 Visit www.medisculpt.co.za or contact 011‑958‑2261 / [email protected] for more information. Periscope // A Strong Team: Anaesthesia Monitor, Monitoring System The new Dräger centralised Perseus A500 15.3” widescreen monitor can be successfully combined with the Infinity Acute Care System (IACS) monitoring system. The IACS consists of the stationary Infinity Medical Cockpit and portable M540 monitoring component. The Infinity Medical Cockpit imports the anaesthesia data from the Perseus A500 and depicts these on a monitor in real time, together with the vital signs of the patient. It can be mounted to the side rails as required, either on the left or the right of the device. As soon as the M540 is connected to the Perseus A500, it automatically adjusts its alert behaviour to the surgical situation. The anaesthesiologist can retrieve from the system a case summary consisting of patient data, surgery time, consumption of anaesthetic gases, and equipment data, and save or print this data for further documentation. Automation relieves hospital staff The automated features of the Perseus A500 provide benefits to personnel throughout the hospital. It features an automatic and self-starting device test and is therefore ready as soon as the operating room doors open. The automatic drying of the breathing system frees the care staff to do other tasks and optimises hygiene. Radio frequency identification technology reminds users of the timely replacement of disposable materials such as the water trap, breathing tubes and lime scale absorber. As an ergonomic anaesthesia workstation, the Perseus A500 user interface, nomenclature and touch screen are in accordance with the operating philosophy of existing Dräger equipment. Moving Forward with Medical Informatics Technology Technology emerging from the medical informatics sector is providing healthcare workers and managers with new and novel tools to assist in their everyday tasks. These tools give access to centralised information; allow collaboration and communication between team members, and improve efficiency, economy and patient outcomes expected by modern medicine. Companies not able to harness and use this new technology to their advantage Dr John Biggs, COO, are at risk of becoming outdated CTO, Kokstad Private Hospital, Kokstad and inefficient, as innovative Medical Centre companies leave them behind. Kokstad Private Hospital and practice have benefitted from this technology since 2009 when the Professional Medical Office DEPARTMENT OF SURGERY UNIVERSITY OF THE WITWATERSRAND 25 - 27 June 2012 23rd Biennial Symposium “Mastery of Surgery - 2012” A Surgeon’s Roots FNB Auditorium West Campus, University of the Witwatersrand The 23rd Biennial Symposium will cover many sessions of interest including Hepato-biliary-pancreatic and Transplantation; GastroIntestinal; Colorectal; Paediatric surgery; Vascular surgery; Breast & Endocrine Surgery; Upper GIT and General surgery; plus an Ethics session. Our international guest is Professor John Windsor who currently is the Head of the Department of Surgery at the Faculty of Medical and Health Science, University of Auckland, New Zealand. He is an internationally recognised HPB and upper GIT surgeon with a current research focus mostly in the field of acute pancreatitis. In addition, he has an interest in teaching and training and has also been active in issues related to patient safety. A unique social evening will be held at the Origins Centre on Tuesday 26th June. Faculty will include many eminent local speakers. Full details will be available on our website: www.witsbiennial.co.za Contact details: RSVP Events Management Amanda Pyne-James Tel: (011) 463-4064 Fax: (011) 463-1041 Email: [email protected] Department of Surgery Susan Parkes Tel: (011) 717-2080 Fax: (011) 484-2717 Email: [email protected] (PMO) was installed. By deploying software solutions such as PMO, teams of healthcare workers and administrators can now be seamlessly brought together digitally. The hospital case management department easily communicates with doctors, receptionists and other team members. This has lead to improved efficiency, better communication between team members, less duplication of work, improved healthcare of patients and ultimately reduced administration costs. Doctors have adopted the new technology with enthusiasm as they have seen the improvement in patient and case management. The solution to the fragmentation of information experienced by many healthcare institutions is to have a centralised patient database on a stable and userfriendly platform such as PMO. By giving team members appropriate access-level rights and letting them communicate electronically in context with each other, the power of these new tools can be realised. The potential to bring institutions together in networks that span geographic locations and share information with a centralised database is apparent and will lead to even greater cohesion and economy. page 64 | medical chronicle | May 2012 Product & Service Listing // Directory Refer to Company Listing for contact details Ambulances and Accessories • 3M • Afrivent • Afrox Medical Gases • B Braun • Dräger Medical SA • East Coast Medical • Electro Spyres Medical • Flurovizion • Gabler Medical • Live Wire Learning • Miracle Medical • Myriad Medical • SSEM Mthembu Medical Ambulance Equipment • 3M • Afrivent • Afrox Medical Gases • B Braun • East Coast Medical • Gabler Medical • Miracle Medical • Myriad Medical • Respiratory Care Africa • Sere-med • SSEM Mthembu Medical • Stat Tiakeni Medical • Viking Medical • Welch Allyn Anaesthetic Equipment • Afrivent • Afrox Medical Gases • CareFusion • Clinical & Medical Services • Covidien • Dinaledi Medical • Dräger Medical SA • Edwards Lifesciences • Gabler Medical • Hutz Medical • Marland Medical • Med Loyd • Myriad Medical • Respiratory Care Africa • R. Moloney & Company • Scientific Group • Stat Tiakeni Medical • Surgimed Hospital Supplies • Viking Medical Anaesthetic Masks, Breathing Bags, etc. • Afrivent • Afrox Medical Gases • Clinical & Medical Services • Dräger Medical SA • East Coast Medical • Intersurgical RSA • Laurike Marketing • Marland Medical • Myriad Medical • SSEM Mthembu Medical • Stat Tiakeni Medical • Surgimed Hospital Supplies • Viking Medical Anaesthetic Trolleys • East Coast Medical • Kendon Medical • Surgimed Hospital Supplies Aneurysm Clips Bandages • 3M • Hartmann - Vitamed • Health In Form • Johnson & Johnson Medical • Kendon Medical • Laurike Marketing • Med Loyd • Miracle Medical • Sere-med • Surgical & Ophthalmic Supplies • Surgimed Hospital Supplies Bath Tubs and Showers • Franke Kitchen Systems Bed Pan Flushing Equipment • Franke Kitchen Systems • SAFMED • Scientific Group Bed Pans • Health In Form • Kendon Medical • Miracle Medical • Surgimed Hospital Supplies Bedding • Miracle Medical • Restonic Bedside Tables and Cupboards • BioClin Solutions • Cook Chill • East Coast Medical • Medical Excellence • Miracle Medical • Respiratory Care Africa • Scientific Group • Surgimed Hospital Supplies Biopsy Forceps • Johnson & Johnson Medical • Medequip • Surgimed Hospital Supplies Biopsy Needles - Bone Marrow • Adcock Ingram Critical Care • Philisa Biomedical • Surgimed Hospital Supplies • Vertec Scientific Biopsy Needles - Soft Tissue • Adcock Ingram Critical Care • Philisa Biomedical Biopsy Units - Vacuum Assisted • Vertec Scientific Blood Bank Equipment • Clinical Sciences Diagnostics • Hemocue South Africa • Scientific Group • Viking Medical Blood Bank Refrigerators • Surgimed Hospital Supplies Blood Conservation Equipment • Earth Medical • Medtronic • Viking Medical Architectural Systems • Dräger Medical SA Archiving and Documentation Equipment • Tidy Files Arthroscopy • Earth Medical • Flurovizion • R. Moloney & Company Assistive Listening Devices • Hearing Innovations • Live Wire Learning Audiology Diagnostic Equipment • 3M • Amtronix • HASS Industrial • Hearing Innovations • Medical Excellence • R. Moloney & Company • Surgimed Hospital Supplies • Viking Medical • Welch Allyn Automated External Defibrillators • East Coast Medical • Kendon Medical • Live Wire Learning • Medical Excellence • Medtronic • Miracle Medical • Sere-med • SSEM Mthembu Medical • Stat Tiakeni Medical • Welch Allyn Autopsy Tables • Dinaledi Medical • Franke Kitchen Systems • Hutz Medical Baby Warmers • BioClin Solutions • Dinaledi Medical • East Coast Medical • Gabler Medical • Medical Excellence • Miracle Medical • Stat Tiakeni Medical • Surgimed Hospital Supplies Balance Assessment Equipment Blood Gas Analysis • Hartmann - Vitamed • Ilex • Myriad Medical Blood Grouping Equipment • Ilex Blood Grouping Kits • Ilex Blood Pressure Monitoring Equipment • Alcomed Medical Supplies • BioClin Solutions • Clinical & Medical Services • Dinaledi Medical • East Coast Medical • Edwards Lifesciences • Hartmann - Vitamed • Kendon Medical • Manta Medical • Medical Excellence • Miracle Medical • Sere-med • SSEM Mthembu Medical • Stat Tiakeni Medical • Surgimed Hospital Supplies • Welch Allyn Blood Transfusion Equipment • B Braun • CareFusion • Clinical Sciences Diagnostics • Earth Medical • Viking Medical Blood-warming Equipment • Augustine Medical SA • BioClin Solutions • Clinical & Medical Services • Covidien • Dinaledi Medical • East Coast Medical • Gabler Medical • Medical Excellence • Surgimed Hospital Supplies Body Contouring • Intamarket • Radiant Healthcare • Technolase Bone Density Tests • Mammography Centre • Vertec Scientific • Amtronix Bandage Trolleys • Cook Chill • East Coast Medical • Health In Form • Surgimed Hospital Supplies Bone Grafting • Bone SA Bone Mineral Analysers and Densitometers • Vertec Scientific Bone Regeneration Substances • Flurovizion Bottle Warmers • Vertec Scientific Brachytherapy • CR Bard • Earth Medical Breast Implants • Conquest Surgical Supplies • Genop Healthcare Breast Self-Examination Gel • Vertec Scientific Building Administration and Supplies Management • Radiant Healthcare Building Technical Management • Radiant Healthcare Cannulae, Rigid and Flexible • Afrox Medical Gases • Conquest Surgical Supplies • Covidien • Edwards Lifesciences • Flurovizion • Manta Medical • Medtronic • Med Loyd • Ophthalmic Precision Instruments • Radiant Healthcare • Respiratory Care Africa • Surgical & Ophthalmic Supplies • Viking Medical Cardiac Pacemakers • Amayeza Abantu • Medtronic Cardiology - Balloon Catheters • B Braun • Johnson & Johnson Medical • Manta Medical • Medtronic • Paragmed • Viking Medical Cardiology Catheter Sheath Introducers • Amayeza Abantu • B Braun • Johnson & Johnson Medical • Manta Medical • Medtronic • Paragmed • Viking Medical Cardiology - Diagnostic Catheters • Amayeza Abantu • B Braun • Johnson & Johnson Medical • Manta Medical • Medtronic • Paragmed • Viking Medical Cardiology - Guidewires • Amayeza Abantu • B Braun • Johnson & Johnson Medical • Medtronic • Paragmed Cardiology - High Pressure Syringe • Covidien • Medtronic Cardiology - Stents • B Braun • Flurovizion • Johnson & Johnson Medical • Medtronic • Paragmed • Viking Medical Catering Equipment and Contractors • Cook Chill • Franke Kitchen Systems Catheters • Alcomed Medical Supplies • B Braun Medical • Covidien • CR Bard • Earth Medical • Edwards Lifesciences • Manta Medical • Medequip • Med Loyd • Miracle Medical • Nu Angle Medical • Philisa Biomedical • Surgimed Hospital Supplies • Viking Medical Certification and Testing of Medical Devices • Myriad Medical Chest Drains • Covidien • Dinaledi Medical • Johnson & Johnson Medical • Viking Medical Children’s Cots and Basinettes • East Coast Medical • Health In Form • Surgimed Hospital Supplies Cleaning of Buildings • Manta Medical • Prestige Cleaning Services Cleaning of Health Care Facilities • Evolution Medical • Mediguard Healthcare Services • Prestige Cleaning Services Clinical Education and Support • 3M • Afrivent • B Braun Medical • CareFusion • Live Wire Learning • Manta Medical • Myriad Medical • Viking Medical Clinical Management • BHG (SA) • CareFusion • SleepNet / BreatheNet Clinical Pathology • Abbot Laboratories • Hemocue South Africa Colorectal Solutions • B Braun Medical • Covidien • Earth Medical • Johnson & Johnson Medical Colposcopes • R. Moloney & Company Complete Equipping of Hospitals • Afrox Medical Gases • CareFusion • Clinical & Medical Services • Live Wire Learning • Miracle Medical • Radiant Healthcare Computer Hardware • Delta 9 Hospital Software Solutions • Pro Med Computer Services • Vertec Scientific Computerised Tomography (CT) Equipment • Philips Healthcare • Pro Med Computer Services Conference Venues • CSIR Conference Centre • Eskom Conference Centre Conforming Gel Pads for Ultrasound • Alcomed Medical Supplies • Vertec Scientific • Viking Medical Convention Centres • Cape Town International Convention Centre • Durban International Convention Centre • Sandton Convention Centre Cosmetics • G A Active • Lesmed Procucts • Radiant Healthcare Critical Care • East Coast Medical • Hutz Medical • Ilex • Stat Tiakeni Medical • Viking Medical Cryotherapy and Cryosurgery Equipment • Macromed • Medtronic • Nitran Surgical Systems • Radiant Healthcare • R. Moloney & Company • Sere-med • Surgimed Hospital Supplies Darkroom Equipment • Imagex • Lomaen Medical Defibrillators • Alcomed Medical Supplies • Amayeza Abantu • Dinaledi Medical • Medical Excellence • Medtronic • Miracle Medical • Philips Healthcare • Sere-med • SSEM Mthembu Medical • Stat Tiakeni Medical Diagnostic Sets • R. Moloney & Company Dialysis Consumables • Adcock Ingram Critical Care • B Braun Medical • Covidien • SSEM Mthembu Medical • Viking Medical Dialysis Equipment • Adcock Ingram Critical Care • B Braun • CR Bard • SSEM Mthembu Medical Dialysis Fluids • Adcock Ingram Critical Care • B Braun Medical Diathermy Equipment • B Braun Medical • Clinical & Medical Services • Covidien • East Coast Medical • Electro Spyres Medical • Laurike Marketing • Medequip • Medical Excellence • Miracle Medical • Nitran Surgical Systems • Onemed • R. Moloney & Company • Scientific Group • Sere-med Digital Radiography/Computed Radiography Equipment • AGFA Healthcare • Carestream Health • Imagex • Konica Minolta Medical SA • Lomaen Medical • Philips Healthcare • Pro Med Computer Services • Scientific Group Disabled Access • Evolution Medical • JessenDakile Disinfectant Cleaner for Ultrasound Probes • Alcomed Medical Supplies • Evolution Medical • Vertec Scientific Disinfectants • Alcomed Medical Supplies • Earth Medical • Evolution Medical • Health In Form • Johnson & Johnson Medical • Kendon Medical • Miracle Medical • SAFMED • Scientific Group • Sere-med Disinfecting Washers • Evolution Medical • Franke Kitchen Systems • Johnson & Johnson Medical • Miele • SAFMED • Scientific Group Disinfection Preparations • Laurike Marketing Disposable Articles for Hospitals • 3M • AGFA Healthcare • B Braun • Coloplast • Dinaledi Medical • Dräger Medical SA • Earth Medical • Electro Spyres Medical • Kendon Medical • Laurike Marketing • Miracle Medical • Myriad Medical • Ophthalmic Precision Instruments • Respiratory Care Africa • Viking Medical Doctors’ Bags, Emergency Cases • Macromed • Miracle Medical • Sere-med Drug Tests • Clinical Sciences Diagnostics • Health In Form • Kendon Medical • Miracle Medical • Philisa Biomedical ECG Equipment • BioClin Solutions • Clinical & Medical Services • Covidien • Dinaledi Medical • East Coast Medical • Electro Spyres Medical • Imagex • Kendon Medical • Medical Excellence • Miracle Medical • Philips Healthcare • Respiratory Care Africa • Stat Tiakeni Medical • Surgimed Hospital Supplies • Welch Allyn Educational Appliances • Live Wire Learning • Miracle Medical EEG Equipment • Kendon Medical • Respiratory Care Africa • R. Moloney & Company • SSEM Mthembu Medical EEG Monitoring Equipment • Philips Healthcare • Respiratory Care Africa • SSEM Mthembu Medical Electronic HealthCare Records • BHG (SA) • CareFusion • Delta 9 Hospital Software Solutions • Pro Med Computer Services Electronic Patient Record Software • BHG (SA) • CareFusion • Delta 9 Hospital Software Solutions • Pro Med Computer Services Electrophysiology • Amayeza Abantu • CR Bard • Medtronic Electrosurgical Instruments • B Braun • Covidien • CR Bard • Earth Medical • Electro Spyres Medical • Flurovizion • Johnson & Johnson Medical • Laurike Marketing • Medtronic • Nitran Surgical Systems • Ophthalmic Precision Instruments • R. Moloney & Company • Scientific Group • Surgimed Hospital Supplies Electrotherapy Equipment • Alcomed Medical Supplies • CR Bard • Macromed • Medtronic • Nitran Surgical Systems • Radiant Healthcare • Scientific Group • Viking Medical EM Wave Equipment / Biofeedback Systems • Earth Medical Emergency and Transport Ventilators • Afrox Medical Gases • Clinical & Medical Services • Dräger Medical SA • Miracle Medical • Myriad Medical • Respiratory Care Africa • Scientific Group • SSEM Mthembu Medical • Stat Tiakeni Medical • Viking Medical Emergency Call Systems • Hutz Medical Emergency Room Equipment • 3M • B Braun • East Coast Medical • Miracle Medical • Myriad Medical • Respiratory Care Africa • R. Moloney & Company • SSEM Mthembu Medical • Surgimed Hospital Supplies • Viking Medical • Welch Allyn Endoscopy Equipment - Capsule • Flurovizion Endoscopy Equipment - Flexible • B Braun • Covidien • Imagex • Medequip • R. Moloney & Company Endoscopy Equipment - Rigid • B Braun • Covidien • Flurovizion • Imagex • Medequip • Nitran Surgical Systems • Onemed • R. Moloney & Company • Smith & Nephew • Welch Allyn Endotracheal Tubes • Covidien • Dinaledi Medical • Laurike Marketing • Med Loyd • Miracle Medical • SSEM Mthembu Medical • Viking Medical ENT Diagnostic Equipment • Amtronix • BioClin Solutions • Clinical & Medical Services • Dinaledi Medical • East Coast Medical • Flurovizion • Kendon Medical • Medical Excellence • Medtronic • Miracle Medical • R. Moloney & Company • Sere-med • Surgimed Hospital Supplies • Viking Medical • Welch Allyn Equipment for Reception, Consulting and Waiting Rooms • East Coast Medical Equipment Accessories • B Braun • Earth Medical • East Coast Medical • Electro Spyres Medical • Franke Kitchen Systems • Hutz Medical • Kendon Medical • Myriad Medical Equipment for Day Wards • Afrox Medical Gases • BioClin Solutions • B Braun • Clinical & Medical Services • Cook Chill • Dinaledi Medical • East Coast Medical • Hutz Medical • Medical Excellence • Respiratory Care Africa • R. Moloney & Company • SSEM Mthembu Medical • Welch Allyn Equipment for Neonatal Units • 3M • Afrivent • BioClin Solutions • B Braun • CareFusion • Clinical & Medical Services • Dräger Medical SA • East Coast Medical • Gabler Medical • Hutz Medical • Medical Excellence • Myriad Medical • Philips Healthcare • Respiratory Care Africa • Scientific Group • SSEM Mthembu Medical • Stat Tiakeni Medical • Viking Medical medical chronicle | May 2012 | page 65 Product & Service Listing Directory // Refer to Company Listing for contact details Ergometers • Hutz Medical • Welch Allyn Exam, Treatment, ICU and Recovery Rooms equipment • Afrivent • Afrox Medical Gases • BioClin Solutions • B Braun • Clinical & Medical Services • Dräger Medical SA • East Coast Medical • Gabler Medical • Health In Form • Hutz Medical • Medical Excellence • Miracle Medical • Philips Healthcare • Respiratory Care Africa • R. Moloney & Company • SSEM Mthembu Medical • Viking Medical Examination and Medical Lamps • BioClin Solutions • Clinical & Medical Services • Dinaledi Medical • Dräger Medical SA • East Coast Medical • Hutz Medical • Kendon Medical • Medical Excellence • Miracle Medical • R. Moloney & Company • Scientific Group • Sere-med • SSEM Mthembu Medical • Stat Tiakeni Medical • Welch Allyn Exhibition Organisers • Fair Consultants Feeding Tubes • Covidien • Med Loyd • Miracle Medical • Respiratory Care Africa • Viking Medical Fibre-optic Equipment • East Coast Medical • Flurovizion • Kendon Medical • Miracle Medical • R. Moloney & Company • Welch Allyn First-aid Equipment • B Braun • Electro Spyres Medical • Kendon Medical • Miracle Medical • Sere-med Floor Coverings, Wall Cladding and Ceilings • Floorworx • Polyflor Fluid Management Pumps • B Braun • Earth Medical • Flurovizion Fetal Monitoring Equipment • Bioclin Solutions • Clinical & Medical Services • Medical Excellence • Miracle Medical • Nitran Surgical Systems • Philips Healthcare • Respiratory Care Africa • SSEM Mthembu Medical • Stat Tiakeni Medical • Surgimed Hospital Supplies Fontanelle Scanning Pads for Ultrasound • Vertec Scientific Food Supplements • Meri Brands Forced Air Warming • Augustine Medical SA • Clinical & Medical Services • Covidien • East Coast Medical Gas and Compressed Air Systems • Air Liquide • Hutz Medical Gas Therapy Equipment (oxygen, ozone, etc) • Afrox Medical Gases • Air Liquide • Gabler Medical Gaseous Exchange Monitoring Equipment and Breathalysers • Air Liquide • Myriad Medical Gases for Cold Sterilisation • Air Liquide Genetic Counselling • Gknowmix Genetic Care Centre Genetic Testing • Gknowmix Genetic Care Centre Gloves - Examination and Protective • Alcomed Medical Supplies • Auckland Orthopaedics • B Braun • Covidien • Hartmann - Vitamed • Kendon Medical • Laurike Marketing • Manta Medical • Med Loyd • Miracle Medical • Sere-med Gloves - Surgeon Infant Incubators • Alcomed Medical Supplies • B Braun • Covidien • Hartmann - Vitamed • Kendon Medical • Laurike Marketing • Manta Medical • Med Loyd • Sere-med • BioClin Solutions • Clinical & Medical Services • Dräger Medical SA • East Coast Medical • Medical Excellence • Respiratory Care Africa • Scientific Group • Stat Tiakeni Medical Gynaecology Diagnostic Equipment • Adcock Ingram Critical Care • B Braun • CareFusion • Clinical & Medical Services • Fresenius Kabi • Gabler Medical • Myriad Medical • Scientific Group • Stat Tiakeni Medical • Afrox Medical Gases • Alcomed Medical Supplies • BioClin Solutions • Dinaledi Medical • Kendon Medical • Medical Excellence • Miracle Medical • Nitran Surgical Systems • Onemed • Philips Healthcare • R. Moloney & Company • SSEM Mthembu Medical • Viking Medical • Welch Allyn Haemodynamic Monitoring • Edwards Lifesciences • SSEM Mthembu Medical • Viking Medical Hammers, Percussion and Reflex • Alcomed Medical Supplies • Miracle Medical Headlights • R. Moloney & Company Health Information Exchange • MediSwitch Hearing Aids • Hearing Innovations Hearing Instruments • Oticon SA Heart Valves (Aortic and Mitral) • Edwards Lifesciences • Medtronic • Viking Medical Heart-Lung Machines • Scientific Group • Viking Medical Hernia Meshes • Flurovizion Hip Endoprotheses, Knee & Shoulder Prostheses • Auckland Orthopaedics • B Braun • Flurovizion • Laurike Marketing HIV Diagnosis & Management • Dr Keyser & Marshall HIV Testing • Dr Keyser & Marshall Hospital Beds • BioClin Solutions • Cook Chill • Health In Form • JessenDakile • Medical Excellence • Scientific Group • Stat Tiakeni Medical Hot-air Sterilisers • Miracle Medical Image Documentation Systems • Flurovizion • Nobel Biocare SA • Pro Med Computer Services Implantable Catheters and Long-term Access • CR Bard • Manta Medical Implants and Protheses • Auckland Orthopaedics • B Braun • Bone SA • Conquest Surgical Supplies • CR Bard • Dinaledi Medical • Earth Medical • Flurovizion • Genop Healthcare • Johnson & Johnson Medical • Macromed • Medtronic • Nobel Biocare SA • R. Moloney & Company • Surgical & Ophthalmic Supplies • Synthes Implant Surgery Instruments • Flurovizion • Macromed • Medtronic Incontinence and Stoma Aids • Coloplast • CR Bard • Earth Medical • Hollister SA • Manta Medical • Nu Angle Medical Incontinence Products • B Braun • Earth Medical • Flurovizion • Hartmann - Vitamed • Johnson & Johnson Medical • Nu Angle Medical Infusion Pumps Infusions Sets • Adcock Ingram Critical Care • B Braun • CareFusion • Fresenius Kabi • Gabler Medical • Kendon Medical • Myriad Medical • Scientific Group • Sere-med • Stat Tiakeni Medical Infusor Bags • East Coast Medical Inhaler and Aerosol Equipment • Myriad Medical Insect Repellent • Acorn • BioClin Solutions Instrument and Syringe Sterilisers • BioClin Solutions • Sere-med Insulin Syringes and Injectors • B Braun • Health In Form • Kendon Medical • Manta Medical • Med Loyd • Sere-med Intra-aortic Balloon Pumps • Medtronic Intraoperative Drains • Dinaledi Medical • Johnson & Johnson Medical Invasive Pressure Monitoring Products • Amayeza Abantu • Manta Medical • SSEM Mthembu Medical Laparoscopic Equipment • B Braun • Covidien • Earth Medical • Flurovizion • Gabler Medical • Hutz Medical • Johnson & Johnson Medical • Medequip • Nitran Surgical Systems • Onemed • R. Moloney & Company Laryngoscopes • BioClin Solutions • Clinical & Medical Services • Dinaledi Medical • East Coast Medical • Kendon Medical • Live Wire Learning • Medequip • Medical Excellence • Miracle Medical • R. Moloney & Company • Sere-med • Welch Allyn Laser Equipment - Aesthetic • Intamarket • Radiant Healthcare • Scientific Group • Technolase Laser Imaging Equipment • Carestream Health • Scientific Group Laser Surgery Equipment • Radiant Healthcare • Spectra-Medic Laser Therapy Equipment • Alcomed Medical Supplies • Genop Holdings • Radiant Healthcare Laundry Equipment & Facilities • Evolution Medical • Floorworx Lifting Platforms • JessenDakile Lighting Equipment • Dinaledi Medical • Flurovizion • Hutz Medical • Medical Excellence • SSEM Mthembu Medical • Welch Allyn Linen • Health In Form Liposuction • Macromed • Radiant Healthcare • Sound Aesthetics Liposuction - Radio Frequency • Radiant Healthcare • Technolase Lithotripsy Equipment • Spectra-Medic Lubricants - Sterile • Johnson & Johnson Medical Male Sling - Advance • Flurovizion • Marcus Medical Mammo Pads • Vertec Scientific Mammography • AGFA Healthcare • Konica Minolta Medical SA • Mammography Centre • Philips Healthcare • Vertec Scientific Mattresses • BioClin Solutions • East Coast Medical • Health In Form • Medical Excellence • Respiratory Care Africa • Restonic Medication Safety Software • CareFusion Microdermabrasion • Radiant Healthcare • Technolase Microscopes • Carl Zeiss • Clinical Sciences Diagnostics • Medequip • Nitran Surgical Systems Minimally Invasive Surgery • Earth Medical • Flurovizion • Medequip • Radiant Healthcare Mobile X-Ray Equipment • AGFA Healthcare • Carestream Health • Hutz Medical • Imagex • Lomaen Medical • Philips Healthcare • Vertec Scientific Modular Systems • Hutz Medical Molecular Diagnostics • Carestream Health • Ilex • Molecular Diagnostic Services Monitoring Equipment Pulse, Respiration & ECG • Afrivent • BioClin Solutions • Clinical & Medical Services • Dräger Medical SA • East Coast Medical • Medical Excellence • Miracle Medical • Myriad Medical • Philips Healthcare • Respiratory Care Africa • Scientific Group • SSEM Mthembu Medical • Stat Tiakeni Medical • Welch Allyn MRI Equipment • Afrivent • Dräger Medical SA • East Coast Medical • Philips Healthcare • Vertec Scientific Nebulisers • Sere-med Needle-free Disposable Devices • Alcomed Medical Supplies • B Braun • CareFusion • Gabler Medical • Manta Medical • Radiant Healthcare • Viking Medical Neonatal Care Equipment • B Braun • Clinical & Medical Services • Dräger Medical SA • East Coast Medical • Gabler Medical • Medical Excellence • Myriad Medical • Scientific Group • SSEM Mthembu Medical • Stat Tiakeni Medical • Viking Medical Nephrostomy Sets, Stone Baskets • Philisa Biomedical Neurology Diagnostic Equipment • Earth Medical • Philips Healthcare • SSEM Mthembu Medical Neurosurgery Equipment • Amayeza Abantu • Flurovizion • Medequip • Medtronic • Nitran Surgical Systems • Viking Medical Nuclear Medicine • Covidien Nuclear Medicine Equipment • Philips Healthcare Nurse Call Systems • Hutz Medical Occupational Therapy Equipment • Alcomed Medical Supplies • Live Wire Learning Ocular Diagnostic Equipment • Genop Healthcare • Ophthalmic Precision Instruments Office Furniture • CN Business Furniture OMF Implants • Marcus Medical Operating Room Textiles • Manta Medical Operating Tables • Clinical & Medical Services • Dräger Medical SA • Miracle Medical • Respiratory Care Africa • SAFMED • Stat Tiakeni Medical Ophthalmic Implants, Artificial Eyes, Lenses • Carl Zeiss • Genop Healthcare • Surgical & Ophthalmic Supplies • Viking Medical Ophthalmic Instrumentation and Fluids • Carl Zeiss • Flurovizion • Marcus Medical • Ophthalmic Precision Instruments • Viking Medical Ophthalmic Monitoring Equipment • Amtronix • Ophthalmic Precision Instruments Ophthalmic Units • Carl Zeiss • Genop Healthcare • Gerry van Winsen Optics • Surgical & Ophthalmic Supplies Ophthalmoscopes • Dinaledi Medical • East Coast Medical • Genop Healthcare • Gerry van Winsen Optics • Medical Excellence • Sere-med • Welch Allyn Optometry Instruments • Gerry van Winsen Optics OR Lights • Clinical & Medical Services • Dräger Medical SA • Hutz Medical • Medical Excellence • Miracle Medical • SAFMED • Scientific Group • SSEM Mthembu Medical • Stat Tiakeni Medical OR Technology and Equipment • Dräger Medical SA • Hutz Medical • Myriad Medical • Respiratory Care Africa • SSEM Mthembu Medical Orthopaedic Prostheses - Hip • Auckland Orthopaedics • Flurovizion • Laurike Marketing Orthopaedic Prostheses - Knee Oximeters • Alcomed Medical Supplies • BioClin Solutions • Clinical & Medical Services • Covidien • Dinaledi Medical • East Coast Medical • Health In Form • Laurike Marketing • Medical Excellence • Miracle Medical • Respiratory Care Africa • Scientific Group • Sere-med • SleepNet / BreatheNet • Stat Tiakeni Medical Oxygen Flowmeters and Regulators • East Coast Medical Oxygen Generating Systems • Air Liquide • Intaka Tech • Medical Excellence • Miracle Medical Oxygen Therapy Equipment • Afrivent • Afrox Medical Gases • Clinical & Medical Services • East Coast Medical • Gabler Medical • Hutz Medical • Intersurgical RSA • Radiant Healthcare • Respiratory Care Africa • Sere-med • SSEM Mthembu Medical • Viking Medical P.A. Catheters • Edwards Lifesciences • SSEM Mthembu Medical Patient Care Trolleys • BioClin Solutions • Medical Excellence Patient Lifting Equipment • East Coast Medical • Kendon Medical • Scientific Group Patient Monitors • BioClin Solutions • Clinical & Medical Services • Dinaledi Medical • Dräger Medical SA • East Coast Medical • Kendon Medical • Medical Excellence • Miracle Medical • Nitran Surgical Systems • Philips Healthcare • Respiratory Care Africa • Scientific Group • SSEM Mthembu Medical • Stat Tiakeni Medical • Surgimed Hospital Supplies • Vertec Scientific • Viking Medical • Welch Allyn Patient Transfer Equipment • Respiratory Care Africa • Scientific Group • Stat Tiakeni Medical PCA Devices • CareFusion • Gabler Medical • Viking Medical Penile Prostheses • Marcus Medical • R. Moloney & Company Pharyngeal Tubes, Laryngeal Masks • Dinaledi Medical • Med Loyd • Myriad Medical • Scientific Group • SSEM Mthembu Medical Physiotherapy Equipment • Alcomed Medical Supplies • Electro Spyres Medical • Nitran Surgical Systems Plaster of Paris Bandages • Auckland Orthopaedics • Flurovizion • Laurike Marketing • Kendon Medical • Sere-med Orthopaedic Prostheses - Shoulder • B Braun • Flurovizion • Macromed • Medtronic • Flurovizion • Laurike Marketing Orthopaedic Prostheses Small joint • Flurovizion • Laurike Marketing Orthopaedic Powertools • Earth Medical • Flurovizion • Macromed • Medtronic Orthopaedic Per systems • Flurovizion • Macromed Orthopaedic Trauma Products • Auckland Orthopaedics • Laurike Marketing • Macromed • Marcus Medical • Philips Healthcare • Smith & Nephew • Surgimed Hospital Supplies Power Tools Pregnancy Tests • Clinical Sciences Diagnostics • Kendon Medical • Philisa Biomedical • Sere-med Premature Baby Products & Services • East Coast Medical • Little Miracle Products & Services • Stat Tiakeni Medical • Viking Medical Prolapse Surgery Products • Earth Medical • Flurovizion • Johnson & Johnson Medical • Marcus Medical • Onemed • R. Moloney & Company Prostate Thermotherapy Equipment • CR Bard • R. Moloney & Company page 66 | medical chronicle | May 2012 Product & Service Listing // Directory Prostheses - Eyes • Custom Eyes Refer to Company Listing for contact details Services - BLS Training Centre • Sere-med Prostheses - Hip • Auckland Orthopaedics • Flurovizion • Laurike Marketing • Smith & Nephew Prostheses - Knee • Auckland Orthopaedics • B Braun • Flurovizion • Laurike Marketing • Smith & Nephew Prostheses - Shoulder • Flurovizion • Laurike Marketing • Smith & Nephew Protective Clothing • AGFA Healthcare • Alcomed Medical Supplies • Miracle Medical Pulmonary Function Equipment and Spirometers • Covidien • East Coast Medical • Medical Excellence • Respiratory Care Africa • R. Moloney & Company • SSEM Mthembu Medical • Welch Allyn Radiotherapy Equipment • CR Bard • Nitran Surgical Systems • Vertec Scientific Rebreathing Bags • Clinical & Medical Services • Covidien • East Coast Medical • Intersurgical RSA • Laurike Marketing • Miracle Medical • Myriad Medical • Scientific Group • SSEM Mthembu Medical • Stat Tiakeni Medical • Surgimed Hospital Supplies Reconstruction Instruments and Implants • Flurovizion • Synthes Services - Information Technology • MediSwitch Services - Insurance Underwriters • Alexander Forbes Compensation Technologies Services - Financial Advisors • First Health Finance • Imperial Bank Services - Financial Services • PPS Insurance Services - Lawyers • Webber Wentzel Services - Managed HealthCare • Agility Global Health Solutions Services - Medical Administrators • Health-Worx • Status Medical Administrators Services - Medical Aid Care • Eternity Private Health • Fedhealth Services - Medical Scheme • GEMS • Genesis Medical Scheme • Resolution Health Medical Scheme Services - Medical Scheme Managed Care Services • Agility Global Health Solutions Services - Ocularist • Custom Eyes Services - Pathology Services • Ampath • Lancet • Toga Services Practice Revenue Management • Quantum Revenue Management Services - Recruitment • Thymic Connections Rehabilitation Devices and Equipment • Alcomed Medical Supplies Rescue Helicopters and Aircraft • B Braun • CareFusion • Miracle Medical • Myriad Medical Respiration Masks • Afrox Medical Gases • Covidien • Dräger Medical SA • Intersurgical RSA • Laurike Marketing • Myriad Medical • Respiratory Care Africa • SleepNet / BreatheNet • SSEM Mthembu Medical • Stat Tiakeni Medical • Surgimed Hospital Supplies Respiratory Monitoring Equipment • Afrox Medical Gases • Amtronix • Myriad Medical • Nitran Surgical Systems • Respiratory Care Africa • SSEM Mthembu Medical • Stat Tiakeni Medical • Surgimed Hospital Supplies Rib and Sternal Fixation • Flurovizion • Synthes Services - Smoking Cessation • Dr Gavin Zipp & Associates Services - Staff Outsourcing • Prestige Cleaning Services • Quintiles Commerical Solutions Services - Travel Agency • Edenvale Travel • Rosebank Travel Service • Thompson’s Leisure Travel • XL Travel Sigmoidscopes, Protoscopes and Anoscopes • R. Moloney & Company Sleep Disorders Diagnostic Equipment • Respiratory Care Africa • SleepNet / BreatheNet • SSEM Mthembu Medical Slit Lamps • Gerry van Winsen Optics Software • AGFA Healthcare • Amtronix • Delta 9 Hospital Software Solutions • Pro Med Computer Services • Vertec Scientific Specialised Skin Care RIS/PACS Systems • AGFA Healthcare • Carestream Health • Imagex • Lomaen Medical • Philips Healthcare • Pro Med Computer Services Scales • BioClin Solutions • East Coast Medical • Live Wire Learning • Medical Excellence • Miracle Medical • R. Moloney & Company • Scientific Group • Sere-med Scalpel and Surgical Blades • B Braun • Medequip • Sere-med Self-Retaining Retractors • Marcus Medical • Medequip Self-Monitoring Equipment • Dräger Medical SA • Health In Form • Sere-med Sentinel Node Detection Equipment • Johnson & Johnson Medical • Environ Skin Care • Radiant Healthcare Sphygmomanometers • Alcomed Medical Supplies • BioClin Solutions • Dinaledi Medical • Medical Excellence • Miracle Medical • R. Moloney & Company • Scientific Group • Sere-med • Welch Allyn Spinal Anaesthesia Products • B Braun • Manta Medical Spinal Implants • Astech • Bone SA • Laurike Marketing • Medtronic Splints • Kendon Medical • Miracle Medical • Sere-med Stapling Devices Open and Laproscopic • Covidien • Gabler Medical • Johnson & Johnson Medical Stents • B Braun • CR Bard • Earth Medical • Johnson & Johnson Medical • Medtronic • Philisa Biomedical • Viking Medical Sterilisation Containers • Marcus Medical Sterilisation Indicators Biological • 3M • SAFMED Sterilisation Indicators - Chemical • 3M • SAFMED Sterilisation Packaging • SAFMED Sterilisers - Low Temperature • 3M • SAFMED Sterilisers - Steam (Autoclaves) • 3M • BioClin Solutions • Kendon Medical Steriliser Ultra violet • Sere-med Stereotactic Biopsy Equipment • CR Bard • Johnson & Johnson Medical Stethoscopes • 3M • Alcomed Medical Supplies • BioClin Solutions • Dinaledi Medical • East Coast Medical • Kendon Medical • Medequip • Medical Excellence • Miracle Medical • R. Moloney & Company • Sere-med • Stat Tiakeni Medical • Welch Allyn Suction Equipment • Alcomed Medical Supplies • BioClin Solutions • Clinical & Medical Services • Dräger Medical SA • East Coast Medical • Gabler Medical • Hutz Medical • Kendon Medical • Medequip • Medical Excellence • Miracle Medical • Myriad Medical • Nitran Surgical Systems • Radiant Healthcare • Scientific Group • Sere-med • Stat Tiakeni Medical Surgical Dilatators • Onemed Swimming Goggles and Dive Masks • Danker Lenses Syringe Drivers • B Braun • CareFusion • Clinical & Medical Services • Gabler Medical • Miracle Medical • Myriad Medical • Stat Tiakeni Medical Syringes • Alcomed Medical Supplies • B Braun • CareFusion • Conquest Surgical Supplies • Kendon Medical • Laurike Marketing • Manta Medical • Med Loyd • Miracle Medical • Sere-med Technical Service, Training and Support • AGFA Healthcare • B Braun • CareFusion • Flurovizion • Medical Excellence • Myriad Medical • Pro Med Computer Services • Radiant Healthcare • Vertec Scientific Telemedicine Equipment • AGFA Healthcare • Welch Allyn Telemetry Systems • Dräger Medical SA • Medtronic • Stat Tiakeni Medical Testicular Implants • Conquest Surgical Supplies • Marcus Medical • Nu Angle Medical • R. Moloney & Company Thermal Ablation Equipment Women’s Health • Earth Medical • Johnson & Johnson Medical • Radiant Healthcare • R. Moloney & Company Thermography Equipment • Electro Spyres Medical Thermometers • Alcomed Medical Supplies • East Coast Medical • Hartmann - Vitamed • Kendon Medical • Medical Excellence • Miracle Medical • Sere-med • Stat Tiakeni Medical • Welch Allyn Thermotherapy Equipment • Covidien Topical Skin Adhesives Surgical Drapes • 3M • AGFA Healthcare • Earth Medical • Hartmann - Vitamed • SAFMED • SSEM Mthembu Medical Surgical Haemostat • B Braun • Dinaledi Medical • Flurovizion Surgical Instruments and Devices • BioClin Solutions • B Braun • Conquest Surgical Supplies • CR Bard • Dinaledi Medical • Earth Medical • Electro Spyres Medical • Environ Skin Care • Flurovizion • Intamarket • Johnson & Johnson Medical • Marcus Medical • Marketspace Medical • Medequip • Medical Excellence • Nitran Surgical Systems • Onemed • Ophthalmic Precision Instruments • R. Moloney & Company • SAFMED • Scientific Group • Sere-med • Surgical & Ophthalmic Supplies • Surgimed Hospital Supplies • Synthes Surgical Operating Loupes and Lights • Danker Lenses • R. Moloney & Company Sutures • Alcomed Medical Supplies • B Braun • Covidien • Dinaledi Medical • Flurovizion • Gabler Medical • Johnson & Johnson Medical • Kendon Medical • Laurike Marketing • Sere-med • Surgical & Ophthalmic Supplies • Dinaledi Medical • Johnson & Johnson Medical Torniquet Machines • Earth Medical • East Coast Medical • Surgimed Hospital Supplies Tracheostomy Tubes • Covidien Ultrasonic Surgical Instruments and Devices • Johnson & Johnson Medical • Nitran Surgical Systems Ultrasonic Therapy Equipment • Nitran Surgical Systems • Ophthalmic Precision Instruments Ultrasound Equipment Anaesthesia • R. Moloney & Company Ultrasound Equipment - Diagnostic • Earth Medical • Imagex • Kendon Medical • Lomaen Medical • Medical Excellence • Miracle Medical • Ophthalmic Precision Instruments • Philips Healthcare • Respiratory Care Africa • Scientific Group • Sound Aesthetics • SSEM Mthembu Medical • Live Wire Learning • Miracle Medical • R. Moloney & Company • Scientific Group Transcutaneous Nerve Stimulators • Alcomed Medical Supplies • Nitran Surgical Systems Trial Lenses • Gerry van Winsen Optics Trolleys • Hutz Medical Tubes for Anaesthesia • Clinical & Medical Services • Covidien • Intersurgical RSA • Myriad Medical • Respiratory Care Africa • Scientific Group • SSEM Mthembu Medical Tympanometers • Hearing Innovations • Medical Excellence • Welch Allyn Ultrasonic Cleaning Equipment • Alcomed Medical Supplies • BioClin Solutions • Gerry van Winsen Optics • Medical Excellence • SAFMED • Vertec Scientific Ultrasonic Nebulisers • Alcomed Medical Supplies • Miracle Medical • Myriad Medical • Nitran Surgical Systems • Stat Tiakeni Medical Ward Equipment • B Braun • Cook Chill • Dräger Medical SA • Franke Kitchen Systems • Health In Form • Hutz Medical • Medical Excellence • Miracle Medical • Respiratory Care Africa • Scientific Group • SSEM Mthembu Medical • Stat Tiakeni Medical • Welch Allyn Warming Blankets • Covidien • East Coast Medical Waste Processing/Treatment • Solid Waste Technologies • Wasteman Healthcare Wheelchairs Ultrasound Gel - High Viscosity • Alcomed Medical Supplies • Electro Spyres Medical • Kendon Medical • SSEM Mthembu Medical • Vertec Scientific Ultrasound - HIFU • Intamarket Ultraviolet and Infrared Radiation Equipment • Alcomed Medical Supplies • East Coast Medical Ultraviolet Germicidal Irradiation • R. Moloney & Company Ureteric Catheters • Earth Medical Urine Bags • Adcock Ingram Critical Care • B Braun • Covidien • CR Bard • Earth Medical • Holister SA • Kendon Medical • Laurike Marketing • Med Loyd • Nu Angle Medical • Sere-med Urology Bulking Agents • Earth Medical • Manta Medical • R. Moloney & Company Urology Diagnostic Equipment • CR Bard • Earth Medical • Philips Healthcare • R. Moloney & Company • SSEM Mthembu Medical Urology Products • AGFA Healthcare • B Braun • Covidien • Earth Medical • Medequip • Med Loyd • Nu Angle Medical • Philisa Biomedical • R. Moloney & Company • SSEM Mthembu Medical Vaginal Specula Training Equipment Vision Therapy • Danker Lenses • BioClin Solutions • Dinaledi Medical • Kendon Medical • Medequip • Med Loyd • Onemed • Sere-med • SSEM Mthembu Medical • Welch Allyn Vein Strippers • Marcus Medical • Scientific Group Ventilation and Respiration Equipment • Afrivent • Clinical & Medical Services • Covidien • Dinaledi Medical • Dräger Medical SA • Med Loyd • Myriad Medical • Respiratory Care Africa • Scientific Group • Sere-med • SleepNet / BreatheNet • SSEM Mthembu Medical • Stat Tiakeni Medical Video Endoscopes and CCD Cameras • Medequip • Nitran Surgical Systems • R. Moloney & Company • Smith & Nephew Video Imaging - HD/SD • Hutz Medical Virtual Colonoscopy - Viatronix • Vertec Scientific Vision Aids • Danker Lenses • Alcomed Medical Supplies • Miracle Medical Working Clothes and Protective Clothing • Health In Form • Manta Medical Wound Care • 3M • AGFA Healthcare • Silvocure • Coloplast • Covidien • Dinaledi Medical • Electro Spyres Medical • Johnson & Johnson Medical • KCI Medical SA • Laurike Marketing • Manta Medical • Sere-med • Smith & Nephew Wound Drainage Equipment • Silvocure • Coloplast • Dinaledi Medical • Filterworks • Gabler Medical • Johnson & Johnson Medical • KCI Medical SA • Manta Medical Wound Dressings • Silvocure Wound Management - Advanced • 3M • Coloplast • Covidien • Dinaledi Medical • Electro Spyres Medical • KCI Medical SA • Macromed • Manta Medical • Sere-med • Smith & Nephew X-ray Chemicals • Afrox Medical Gases • AGFA Healthcare • Carestream Health • Dinaledi Medical • Radshield X-ray Contrast Media • AGFA Healthcare • Radshield X-ray Equipment • AGFA Healthcare • Carestream Health • Imagex • Konica Minolta Medical SA • Lomaen Medical • Philips Healthcare • Scientific Group • Vertec Scientific X-ray Film Processors • AGFA Healthcare • Carestream Health • Imagex • Konica Minolta Medical SA • Lomaen Medical • Radshield X-ray Films and Screens • AGFA Healthcare • Carestream Health • Imagex • Konica Minolta Medical SA X-ray Protection Items • AGFA Healthcare • Imagex • Lomaen Medical • Vertec Scientific X-ray Quality Assurance Software, Phantoms • AGFA Healthcare • Carestream Health • Radshield • Vertec Scientific X-ray Viewing Panels • Hutz Medical medical chronicle | May 2012 | page 67 Company Listing Directory // ADCOCK INGRAM CRITICAL CARE www.adcock.com Bard Medical South Africa (Pty) Ltd www.crbard.com Carestream Health www.carestream.com EDWARDS LIFESCIENCES (Pty) Ltd www.edwards.com Adcock Ingram Critical Care is a company which has committed itself over the last 60 years to the development of the healthcare community. Products include intravenous solutions, minibags, SVPs, pour bottles, IV antibiotics, infusion pumps and administration sets, dialysis equipment, theatre disposables and blood collection systems. CR Bard Inc is a leading multinational developer, manufacturer, and marketer of innovative, life-enhancing medical technologies in the product fields of vascular, urology, oncology and surgical specialities. BARD’s core values of quality, integrity, service, and innovation represent our reality and our aspirations and prepare us for the challenges ahead, guiding our everyday activities and aligning us to our mission. CARESTREAM HEALTH is a leading provider of medical and dental imaging systems including information technology solutions, molecular imaging systems and x-ray products for non-destructive testing. Carestream Health’s medical digital imaging portfolio includes RIS, PACS, CR, DR, Laser Printers, as well as Mammography & Oncology Solutions. Global leader in the science of heart valves and haemodynamic monitoring, with more than five decades of experience in developing life-saving innovations. Edwards treats advanced cardiovascular disease with its market-leading heart valve therapies, critical care and vascular technologies. Global brands include Carpentier-Edwards, Cosgrove-Edwards, Edwards SAPIEN, FloTrac, Fogarty, PERIMOUNT Magna and Swan-Ganz. PO Box 6888 Johannesburg 2000 PO Box 1977 Kelvin 2054 PO Box 1901 Cramerview 2060 20 Regency Drive Route 21 Corprate Park Irene, Centurion 0062 Tel: 086-102-2273 Fax: (011) 444-6047 Email: [email protected] Tel: (011) 794-8322 Fax: (011) 794-6979 Email: [email protected] Tel: (012) 345-2482 Fax: (012) 345-5848 Email: [email protected] ELECTROSPYRES HEALTHCARE www.electrospyres.com floorworx www.floorworx.co.za Fluorovizion Medical Equipment Suppliers www.fluorovizion.co.za Hutz Medical www.hutz.co.za Product range includes: • ECG Electrodes • ECG, EEG and Sonar/Ultrasound Gels • Electrosurgical Accessories • Wound Care Dressings • Re-usable Hot/ Cold Therapy Packs • Sterile Personal Lubricating Jelly Benefits: • Locally manufactured • Hospital proven • Competitively priced • Internationally acceptable quality standard. With over 55 years of business experience, FloorworX is the only manufacturer in South Africa who produces semi-flexible tiles, fully flexible vinyl sheeting and tiles. Our factory is ISO 9001 and ISO 14001 certified. Additionally, FloorworX also distributes a comprehensive range of International resilient floor coverings, wood laminates and engineered wood floors. A wide range of flooring adhesives, accessories and floorcare can also be acquired through FloorworX. Fluorovizion is proud to be associated with internationally recognised brand names such as Conmed, DJO, Linvatec, Dynamesh, Sharpoint and Hemcon, whom we represent in Southern Africa. We specialise in Orthopaedics, Imaging, ENT, Ophthalmics, General Surgery, Cardiac, Gynaecology and Arthroplasty. Fluorovizion places strong emphasis on adding value to our customers by focusing on and supporting niche markets within each of these disciplines. Hutz Medical specialises in the manufacturing of high-tech hospital equipment. With over 38 years of experience, Hutz offers specialised solutions to suit customer requirements. The Hutz range of products includes various Medical Services Supply Units, Operating Theatre Ceiling Pendants and Technical Panels, Highcare and Intensive Care Ceiling Pendants, Medical Lighting as well as X-Ray Viewing Screens and Attachments. PO Box 87020 Houghton ZA-2041- SouthAfrica 404 Accentuate Business Park, Southern Klipriviersberg Road Steeledale, 2197 PO Box 1754 Alberton 1450 PO Box 1042 Port Elizabeth 6000 Tel: : 0860 346 679 Email: [email protected] Fax: 0861 346 679 808 Hammets Crossing Office Park, Fourways, Jhb North Tel: (011) 462-9553 Fax: (011) 462-9298 Toll Free Line: 0860 2666 33 Email: [email protected] Tel: (011) 494-8000 Tel: (011) 402-7208 Email: [email protected] Fax: (011) 494-8757 Fax: (011) 402-7132 KCI Medical South Africa (PTY) LTD www.kci-medical.co.za Medtronic Africa (Pty) Ltd www.medtronic.com R. MOLONEY & COMPANY www.moloney-medtech.com Kinetic Concepts Inc. is a leading global medical technology company devoted to the discovery, development, manufacture and marketing of innovative, high-technology therapies and products for the woundcare, tissue regeneration and therapeutic support system markets. Innovating For Life At Medtronic we’re changing what it means to live with chronic disease. We’re creating innovative therapies that help patients do things they never thought possible. Seeing our work improve lives is a powerful motivator. The more we do, the more we’re driven to push the boundaries of medical technology. To learn more about Medtronic, visit Medtronic.com 21 Years of service to the South African Medical Profession. Products include: Heine Diagnostic Instruments, Loupes and Lights; eZono Ultrasound for Anaesthesia; Wallach instruments for women’s health; Endoglobe Endoscopy; SANI MedTech UV Germicidal Irradiation lights; Promedon Gynaecology and Urology solutions; Medispec Shockwave Therapy; Clarus Intubation Stylettes. Building 24 Thornhill Office Park 94 Bekker Road Midrand, 1685 PO Box 75172 Gardenview 2047 Tel: (011) 315-0445 Tel:(011) 677-4800 Fax:(011) 616-1104 Email: [email protected] PO Box 84375 Greenside 2034 Tel: (011) 327-1201, (021) 939-3070, (031) 266-9871 Fax: (011) 442-5863 Email: [email protected] The Scientific Group www.scientificgroup.com Sere-med www.seremed.com Expanding on the association’s maxim - ‘Advancing Innovation Responsibly’ - SAMED’s mission is to achieve ‘the responsible and ethical advancement of the interests of the medical devices industry within the South African healthcare environment, while promoting better patient outcomes’. The Scientific Group is a distributor of niche products for the electro medical, laboratory and surgical fields. Our reputation is based on supplying and supporting quality products into South Africa and sub-Saharan countries. A BEE empowered healthcare company with core values and a reputation to deliver innovative technology for an improved patient outcome. Sere-med is an established and trusted supplier to the medical industry. Situated in Sandton, Sere-med provides the professional healthcare market namely GP’s, specialists, pharmacies, clinics, mine hospitals and the public sector with over 600 products. Our range includes medical consumables, surgical dressings, medical equipment, instruments, first aid and emergency care products. Sere-med provides products that are innovative, affordable and at the forefront of medical technology. PO Box 651761 Benmore 2010 PO Box 13119 Scientific Group House, Vorna Valley Cosmo Business Park, Malibongwe Drive, Randburg 1686 Unit 1, Eastborough Business Park Cnr Olympia & Spartan Crescent Eastgate Ext. 11, Sandton Tel: 087-353-5600 Fax: 086-500-6436 Email: [email protected] Tel: (011) 262-2220 Fax: (011) 262-2226 Email: [email protected] Smith & Nephew (Pty) Ltd www.smith-nephew.com/za SSEM MTHEMBU MEDICAL (PTY) LTD www.ssemmthembu.co.za Vertec Scientific SA www.vertecsa.co.za Smith & Nephew is a specialist supplier of Orthopaedic Trauma, Arthroplasty, Endoscopy and Advanced Wound Management products that help healthcare professionals treat patients more effectively. The company has been committed to helping people regain their lives for over 150 years globally, and 75 years in Africa. SSEM Mthembu Medical (Pty) Ltd is a distributor of electro-medical devices and medical consumables throughout Southern Africa. We provide an extensive range of medical equipment for the ICU, high care, emergency and operating room as well as to the specialist physician and home care market. Vertec Scientific SA has built up an enviable reputation for delivering and supporting quality products over a wide range of modalities, including analogue and digital mammography, bone densitometry, mini c-arms, digital radiography, dedicated head CT and radiotherapy immobilisation products. We build and nurture long-term relationships with our customers and offer outstanding after sales service, including technical and clinical applications. 30 The Boulevard Westend Office Park Westville 3629 PO Box 2530 Johannesburg 2000 8 Charmaine Avenue President Ridge Randburg 2194 Fax: (011) 444-8171 Email: [email protected] Tel: (011) 789-7177 Fax: (011) 789-7391 Email: [email protected] Fax: (011) 315-1757 SOUTH AFRICAN MEDICAL DEVICE INDUSTRY ASSOCIATION www.samed.org.za Tel: (011) 467-0855 Email: [email protected] Tel: (031) 242-8111 Fax: (011) 467-1697 Fax: (031) 242-8251 Tel: (041) 451-0964 Fax: (041) 451-0977 Email: [email protected] Call Lynn on 084-400-1235 Classifieds Place a free ad in Medical Chronicle’s classifieds! Doctors only. Commercial classifieds accepted - but not free. Call Peter on 011-322-0975 or fax him on 086-732-7131 or email: [email protected] Get the free mobile app at http://gettag.mobi Taking the Gap Dr Ron Kemper SA Doctors - Dejected and Demoralised I have a small upmarket practice that is supported by a core of loyal families that I have grown to love over the years. I minister to their needs as best I can and I endeavour to maintain the highest possible standards. In return, they pay me what I think I deserve, and it enables me to pursue the simple but adventurous lifestyle that I desire. Nevertheless, I am a thoroughly demoralised doctor. I have lost all interest in building or developing my practice, or in helping to develop a healthcare system that will look after all our citizens, or in getting involved in fighting any of the profession’s battles. Our professional contract with society (see Prof Lukhele’s excellent article in SAMA Insider April 2012) has essentially been declared null and void. Medical schemes are telling our patients that we are overcharging if we don’t abide by their hopelessly inadequate tariffs. The HPCSA is encouraging patients to complain about our services, but stands by approvingly while we are being ground into the dirt by administrators and politicians. Society is demanding impossible guarantees of us and insisting on us complying with oversight requirements that serve only to waste our time. Ill-informed and sensationseeking journalists are harrying us on the periphery. Government is wailing at us to keep our fees down while doing absolutely everything in their power to escalate our costs and reduce our available working time. The profession is fully into defensive mode. This certainly isn’t what I signed up for. It’s quite simply not worth my while to fight all these battles, nor does it in any way help my patients, particularly since this is a war that cannot be won. I’d rather just wait it out like a defeated POW, and start a new life when it’s over. What I would be interested to know, though, is just how many of my colleagues feel the same way or even worse? The question now is whether any amount of legislation, quality control, enforced further learning, periodic recertification or public humiliation can ever induce a group of demoralised doctors to give of their best and produce a healthcare system that will make the nation proud. When I started up, I did all I could to ensure that my practice met medical and ethical standards of the day, which, in many ways, exceed current standards. And I did it quite simply because it was the right thing to do, and it made me feel proud that I did it well. Now, my practice is all about meeting diluted medical standards and prohibitive administrative/legal standards in case some arbitrary official comes round with a one-size-fits-all checklist and legalised threats of closing me down if I don’t show a suitable level of humility. But you know, I’m not really a POW. I’m actually a highly trained and experienced professional person who is performing a valuable service to society, and I am entitled to respectful treatment. Personally, I can’t see myself making any effort anymore to get my practice legally compliant. Why waste my valuable time playing silly buggers just to appease some dubious petty government functionary who has no understanding of why he is doing what he does? I have patients who need me and they come first. Fortunately, like so many of the remaining GPs in my area, I am approaching retirement, and when the Nazi jackboot comes down, I will quite simply make my escape. Put that in your peace pipe and smoke it. ●●● Announcement Dr David Marshall (cardiologist) wishes to inform his colleagues that he will be practising exclusively from the Melomed Gatesville Private Hospital in Cape Town. His contact information is as follows: Suite 313, 3rd Floor, Block B, Melomed Gatesville, call 021‑637‑8100 or 076‑862‑6682, or email: [email protected] Dr Yunus Khan, rheumatologist, wishes to inform his colleagues that he is now practising at Netcare Garden City Hospital. Dr Khan can be contacted on: 011‑495‑5235. ●●● Practices for sale GP practice in Graaff‑Reinet for sale. Fully equipped, well established, busy practice. Cash and medical scheme patients. One big waiting room/reception area. Three consulting rooms, one procedure room, administration office, kitchen area. Well‑trained staff, safe location, parking area, potential to expand. Owner relocating. Contact: 072‑117‑7215 or [email protected] Obstetric part of a busy obstetrics and gynaecology practice in The Bay Hospital in Richards Bay for sale. Goodwill includes all equipment in rooms in hospital. Work in association. Theatre time in hospital granted. Contact Dr George on 083‑653‑3669. ●●● Practices to rent Office space to rent in an established medical centre in Fourways. GP, physiotherapist and dentist currently practising out of these rooms. Chiropractic clinic next door. Various room sizes available, ranging from 20m2 to 60m2. Shared reception area and receptionist. Contact Fiona Lamberti for more information: [email protected], 083‑235‑2858. ●●● Equipment for sale Colposcope with video attachment for sale. Price: R40 000. Contact Dr George 083‑653‑3669. Or visit us at: http://www. medicalchronicle.co.za/ classifieds/ Surgical instruments for sale: Complete rhinoplasty set, Welch Allyn headlamps (three), electric derma brader, small dermatome, bone nibblers etc. Also various types of forceps, scissors, retractors, instrument dishes, etc. All as good as new. Call 083‑776‑6181. MRI Scan Machine for sale ‑ Toshiba Excelart model. Price negotiable. Contact: Dr A Manning (hospital manager, Lenmed Private Hospital) on 011‑213‑2000. Can be viewed at Lenmed Private Hospital. Resmed S8 Spirit 2, Mirage activa nasal mask, H4i humidifier for sale. This is a demo model in brand new condition, boxed. Please make me an offer if you are interested. Call Dr E van Niekerk on 082‑448‑4864 or email [email protected] ●●● Positions available An opportunity exists for a specialist physician to join a successful, busy physicians practice in East London as a partner or an assistant. Contact the practice manager on 083‑780‑1257 or [email protected] Full‑time and part‑time locum required for busy medical practice on south coast of KwaZulu‑Natal, Port Edward region. Email [email protected] or call 082‑336‑6777 for further details. Established GP practice for sale in Fourways, Johannesburg. Cash‑based practice. Sold as going concern, all equipment included. Shared overheads and reception staff with other medical practitioners. Contact 078‑456‑0129 or email [email protected] for further information. Long‑term GP locum required at GP practice in Fourways, Johannesburg. Would suit female doctor. Send detailed CV to [email protected] Locum available in SA: Dr K Buyse, gynaecologist and obstetrician, with special interest in infertility, senology and breast cancer surgery. Contact details: MP 0237159 SA, Pottelberg 174, 8510 Marke, Belgium. Call (32)475‑660138 or email [email protected] MEDICAL C H RONIC L E © Copyright Medical Chronicle 2012 EDITORIAL EDITOR-IN-CHIEF Marietjie van den Berg email: [email protected] DEPUTY EDITOR Maggie Monsieur email: [email protected] Senior journalist René Bosman email: [email protected] PRODUCTION EDITOR Claire Smith email: [email protected] CONTRIBUTORS Prof Morgan Chetty, Dr Jonathan de Souza, Dr Xolile Dlamini, Dr Luc Evenepoel, Bronwyn Green, Dr Ron Kemper, Dr Louis Kathan, Prof James Ker, Elsabé Klinck, Dr Karen Koch, Dr AM Levin, Dr Rykie Liebenberg, Dr D Lipinska, Dr Pradeep Makan, Dr Prithy Ramlacan, Mike Scott, Dr Riekie Smit, Prof Martie van der Walt, Dr Louis van Zyl, Sarah Whitehouse, Dr Bradley Wood, Dr John Wright, Dr Dora Wynchank, Andy Zoepke FEATURE WRITERS René Bosman, Maggie Monsieur, Marietjie van den Berg PHOTOGRAPHS Unless previously agreed in writing, Medical Chronicle owns all rights to all contributions, whether image or text. 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