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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
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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
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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.”
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There are no contraindications associated with the use of the unit, as all efforts are active
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The one-ball system makes it safe to use and the fact that the patient is always in control of
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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our webpage:
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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
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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
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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 [email protected]
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
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Medical Chronicle’s classifieds!
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classifieds accepted - but not free.
Call Peter on 011-322-0975 or
fax him on 086-732-7131 or
email: [email protected]
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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
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