Healthcare Gazette - 2016 Jul/Aug

healthcare gazette

JULY/AUGUST 2016 • ISSN 2078-9750

BiPolar DisorDer - Dealing with the harsh ‘seasonal’ swings PG 30

Global trends in abortion

PG 17

08

17

news

Eliminating human papillomavirus – researcher positive

19

researCh

Late reactivation of Ebola virus

34

FeatUre

Teamwork eases pain relief challenges

H EALT H CARE G A ZETTE | J A NU A RY 2 0 1 6 www.hmpg.co.za

FoCUs

Chronic obstructive pulmonary disease

ETHICS FOR ALL 2016

Navigate your way through ethical risks and challenges ETHICS CPD

Ethics For All is back this October and is a must for all medical and dental healthcare practitioners. Our latest event brings together highly respected local and international speakers from your profession and beyond to provide support and guidance to help you practise safely and ethically.

This unique event is a great opportunity for you to network with likeminded professionals, meet the Medical Protection and Dental Protection team and earn your five required ethics, human rights and medical law units.

01

PRETORIA

02

DURBAN

06

CAPE TOWN

SATURDAY

OCT 2016

SUNDAY

OCT 2016

THURSDAY

OCT 2016

CSIR International Convention Centre 0830 – 1300, followed by lunch

Durban ICC 0830 – 1300, followed by lunch

Cape Town International Convention Centre (CTICC) 1730 – 2130, refreshments available on arrival

Ethics For All is FREE to Medical Protection and Dental Protection members. Don’t miss out on your opportunity to attend this popular event – find out more and reserve your place today.

VISIT medicalprotection.org/ethicsforall dentalprotection.org/ethicsforall The Medical Protection Society Limited (“MPS”) is a company limited by guarantee registered in England with company number 36142 at 33 Cavendish Square, London, W1G 0PS. MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association. MPS® and Dental Protection® are registered trademarks and ‘Medical Protection’ is a trading name of MPS.

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Contents | 03

Co n t ent s 07

neWs

16 Vaccination and childhood pneumonia

07 Soaring maternal deaths 08 MCC “not to blame” for SA’s lack of cheaper biosimilar drugs 08 Eliminating human papillomavirus – researcher positive 09 Skilled hospital “gatekeepers” save money and lives 11 Alarming rate of chronic obstructive pulmonary disease in South Africa 11 Drug stock-outs: “We’re being ignored,” say NGOs 13 KZN mobile clinic unit overpriced 13 Basson court appeal thrown out with costs

16 Rosuvastatin around heart surgery 17 More against the diet-heart hypothesis 17 Global trends in abortion 17 Late reactivation of Ebola virus 17 Potato intake and incidence of hypertension

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FeatUres 19 Teamwork eases pain relief challenges 25 SA cardiologists brace themselves for change

FoCUs

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30 Beef up on bipolar I and II

14 Child support grant fails to alleviate poverty 14 New-generation drugs, not exercise, work best for multiple sclerosis 15 A national TB prevalence survey – a first for South Africa 15 Occupational injuries – radiologists sue government

34 Chronic obstructive pulmonary disease – when to take that cough seriously

ProFile 39 Professor Ernette du Toit – transformer of lives

CliniCian’s VieW

researCH 16 Fruit intake in teenagers lowers breast cancer risk

42 Human papillomavirus

H EALT H CARE G A ZETTE | J U LY /A U G U S T 2 0 1 6

Plasmoquine Capsules contain chloroquine sulphate enclosed in a capsule, making them easy to swallow, with no bitter taste. This makes Plasmoquine Capsules the anti-malarial of choice for doctors prescribing in the treatment of rheumatoid arthritis as well as discoid lupus erythematosis (lupus syndrome)

Reg. No. Z/20.2.6/127 Each capsule contains 200mg Chloroquine Sulphate Monohydrate equivalent to 146.7mg Chloroquine base

Medchem Pharmaceuticals CC Tel no: 012 348 0752 • Fax: 012 348 0873 • Email: medchem3@gmail.com

Ed’s Letter | 05

ed’s letter C h r i s B at e m a n

Saving our mumS and babieS – national department of HealtH StepS up

F

or several years now, the survey data on avoidable deaths among pregnant mothers, infants and children <5 years have been begging for effective interventions after the National Department of Health (NDoH) shared the alarming statistics with provinces, hoping they’d act.

Now the NDoH has changed from asking “please do something, preferably this and this,” to “we’re coming to make sure you’re doing exactly this – and we’ll be watching!” The responsible NDoH programme chief has displayed admirable transparency in sharing this with Healthcare Gazette. We report on the NDoH’s bid to ensure the various committees’ key recommendations are implemented, province by province, in what is basically a human resources and

scarce obstetrics skills crisis.

Staying with the multiple challenges to women’s health, there’s now tangible hope that combined responses to the ubiquitous cancer-causing human papillomavirus (HPV) that kills 3 000 (mostly black) women annually will lead to an HPV-free generation of adult women within a decade.

That’s from the leading HPV researcher who is preparing for a national 1-hour “test and treat” rollout to supplement the current national HPV vaccination programme for 9-year-old schoolgirls.

Any healthcare worker who deals with cardiac patients at any level will find our feature on the latest changes in cardiac assessment fascinating.

Angiography, step aside – here comes “fractional flow assessment”, the latest buzzword in cutting-edge diagnostic efficiency.

Taking another breath, Cape Town and South Africa have the greatest prevalence of chronic obstructive pulmonary disease (COPD) in the world according to a recent survey – we report on the implications while focusing on the condition at length, followed by a second article about that Jeckyl and Hyde condition so disruptive to families, colleagues and friends: bipolar disorder. Chronic pain and the need for a team approach in handling something that affects onefifth of all South Africans is the subject of another feature. We also report on claims by a handful of highly respected NGOs that government is shutting them out of dealing with drug stock-outs, a new national TB prevalence baseline survey and just why well-placed emergency care specialists are so vital.

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EDITOR Chris Bateman CONTRIBUTORS Bridget Farham Patricia McCracken Leverne Gething Published by the Health and Medical Publishing Group (HMPG) CEO AND PUBLISHER Hannah Kikaya EXECUTIVE EDITOR Bridget Farham MANAGING EDITOR Ingrid Nye PRODUCTION AND ADMINISTRATION MANAGER Emma Jane Couzens CHIEF OPERATING OFFICER Diane Smith | +27 (0)12 481 2069 sales@hmpg.co.za SALES REPRESENTATIVES Charles Duke Renée Hinze Azad Yusuf Benru de Jager Ladine van Heerden CUSTOMER SERVICE AND ONLINE SUPPORT Gertrude Fani | +27 (0)21 532 1281 publishing@hmpg.co.za FINANCE AND ADMINISTRATION Tshepiso Mokoena | +27 (0)12 481 2140 tshepisom@hmpg.co.za LAYOUT AND DESIGN Tenfour Media Printed by Paarl Print HG online issues: https://issuu.com/ hmpg/stacks The Health and Medical Publishing Group is a wholly owned subsidiary of the South African Medical Association (www.samedical.org).

For information on subscribing to Healthcare Gazette, please contact sales@hmpg.co.za.

News | 07

soarinG maternal deatHs THE NATIONAL DEPARTMENT of Health (NDoH) said late last month that it is moving across provinces to centralise obstetric skills to a handful of district hospitals, urgently briefing district healthcare chiefs and ensuring they have sufficient blood supplies. This mainly occurring at district and post-theatre recovery and poor is in a bid to further lower the regional hospitals, where most monitoring in postnatal wards.

63% rise in c-section deaths due of the CDs were performed.

Public sector c-sections rose by to bleeding between 2008 and Of most concern, 85% were 30% from 2008 (181 405) to 2012 2014, uncovered by the National “clearly avoidable”. Multiple (236 149), raising suspicions that Committee of Confidential instances of health system failure many were medically unnecessary.

Enquiries into Maternal Deaths and substandard care were Pillay said safe c-section care (NCCEMD). Dr Yogan Pillay, identified as contributing to had been centralised in the NDoH Deputy Director General these preventable deaths. The Free State – with dramatically of Strategic Health Programmes, latest NCCEMD report follows improved results over 12 months. added that provinces were being the reports of the national “We’re insisting interventions told to buy and/or dedicate get to every health district,” he ambulances for quicker interfacility committee on perinatal mortality and the committee on mortality added. The NDoH team, led by transport of pregnant mothers and morbidity in children under national health minister, Dr Aaron and sick infants. He was speaking 5 years, completed last year – Motsoaledi, began intervening to Healthcare Gazette just days in the struggling Sekhukhune after the figures, described as also highlighting high numbers District of Limpopo and was due “scandalous and a disgrace” of avoidable deaths. It blames to move to the North West and were published in the South a low skillset among junior and the Eastern Cape provinces.

African Medical Journal (SAMJ) inexperienced doctors, especially Pillay said the recommendations this June. As early as 2011, the in rural under-resourced areas of all three reports were being NCCEMD highlighted the concern where they perform emergency implemented. “We’ve been far of haemorrhage associated with or unnecessary c-sections, too more interventionist over the last caesarean delivery (CD) in an often without supervision or 3 years than previously when we article published in the SAMJ proper obstetric/anaesthetic care. merely provided the information entitled “Haemorrhage associated Findings include delays in calling and hoped provinces would do with caesarean section in South for help with ongoing bleeding, the right thing,” he admitted.

Africa – be aware”. inappropriate discharges from The article drew What How attention to the findings Recommended by of the fourth triennial Focal areas for interviews HH to reduce deaths by health Pillars to improve Comittee worker training and health quality of care Saving Mothers report systems strengthening for 2005 - 2007. The 1 1 Care: Commitment to quality and outreach Knowledgeable Mother report showed that and skilled HIV and TB NCCEMD health care Hypertension bleeding associated 2 Coverage: providers n Essential Steps in Management of Obstetric Haemorrhage Emergencies (ESMOE) with CD was the n Helping Babies Breathe (HBB) and Management of Small and Sick Newborns (MSSN) most common causal n Essential Package of Care (EPOC) 2 Rapid Newborn subcategory of Asphixia inter-facility NaPeMMCo 3 Clinical Care: Prematurity emergency n Caesarean section safety haemorrhage-related transport system n Continous Positive Airway Infeciton Pressure (CPAC) maternal death – unlike n Early Child Development (ECD) 3 the pattern in other Appropriately Child 4 Contraception / resourced health Diarrhoea Road to Health Card CoMMic countries. It showed facilities (inculding Pneumonia equipment and that these deaths were Malnutrition 5 Community involvement human resources) and accountability increasing and were

3

I

5Cs

I

I

Source: National Department of Health healthcare worker guideline sheet.

H EALT H CARE G A ZETTE | J U LY /A U G U S T 2 0 1 6

mCC “not to blame” For sa’s laCk oF CHeaPer biosimilar drUGs

WIDESPREAD IGNORANCE ON how to register a biosimilar medicine and the lack of strict requirements could be behind the absence of highly costeffective biosimilar drugs in South Africa (SA). This is the view of a top Medicines Control Council (MCC) reviewer, Prof.

Henry Leng. A member of the MCC’s Biological Medicines Committee, Leng told

Healthcare Gazette that the lack of overall knowledge and insight into the data required for regulatory compliance of biosimilar medicines is largely due to the absence of any university courses on the registration of biopharmaceutical medicines. He knew of just one private company in the country doing the appropriate training. Leng was responding to assertions

by Mr Vivian Frittelli, CEO of the National Association of Pharmaceutical Manufacturers, that “overly strict” MCC guidelines are to blame. Fritelli felt that these are out of step with biosimilar compliance innovation in Europe. While the two men agreed on the ignorance “blockage” factor, they diverged sharply on the MCC’s role in enabling faster

access. Frittelli claimed the new (2014) regulatory pathway followed the European Medicines Authority single disease rule, but failed to stay “on the development curve” of six of the 25 European nations.

These nations are allowing registration for use against more than one disease. Frittelli would welcome the registration of any biosimilar, so that the dramatic successes of their original counterparts in treating cancers, rheumatic conditions, arthritis, diabetes and asthma could be emulated and accessed less expensively. “While some biologicals go for tens of thousands of Rands per month, biosimilars are on average 30 40% cheaper”, Frittelli revealed.

Leng said Frittelli was mistaken.

In his view, biosimilars only had to demonstrate clinical comparability for one indication.

eliminatinG HUman PaPillomaVirUs - researcher positive

Prof. Tim Noakes meets a European author of a book on the evils of sugar safe

HPV: Mum still at risk, baby

THE DEADLY CERVICAL CANCER-causing human papillomavirus (HPV) could be eliminated in South Africa (SA) within 15 years if ground-breaking new “screen and test” technology for women can be successfully introduced to supplement the nation-wide vaccination of primary-school girls. This positive claim was made by Prof. Lynette Denny, Head of the Department of Obstetrics and Gynaecology at the University of Cape Town’s Faculty of Health Sciences and Principal Specialist at Groote Schuur Hospital. Denny is SA’s lead researcher in “test and treat” HPV-detecting technology using the Gene Xpert machine (currently diagnosing TB and rifampicin resistance). She was asked what impact this would have if added to the

H EALT H CARE G A ZE TTE | J U LY /A U G U S T 2 0 1 6

News | 09

skilled HosPital “GatekeePers” saVe money and liVes IF EMERGENCY MEDICINE specialists could be strategically placed where the patient injury loads are heaviest and if more were trained, millions of healthcare Rands would be saved. So says Dr Stevan Bruijns, a specialist emergency physician and senior lecturer in the Division of Emergency Medicine (EM) at the University of Cape Town (UCT), after delivering a talk at the prestigious EM conference held in the Cape Town International Convention Centre from 18 to 21 April this year. Bruijns said last month that EM could provide a “whole-system solution” in a hospital, driving up quality and improving efficiency because an EM practitioner’s unique training enables good early decisionmaking, preventing unnecessary and/or shorter-term patient admissions and freeing up vital resources and manpower.

A “skilled decision-maker at the front door makes all the

difference”, Bruijns said, “saving lives and improving overall appropriate treatment, enabling economically active people to return to work quicker”. Too many hospitals, especially in the private sector, use general practitioners or junior doctors in their emergency centres. This results in inappropriate admissions or treatment, with the public happily buying into a system that channels them towards specialities. He said it was ironic that so many funded patients would, without a second thought, book appointments with plastic surgeons or neurosurgeons for patently non-life-threatening conditions. These same patients would then happily use an emergency centre not staffed by emergency care specialists.

His comments were echoed by Dr Jonathan Broomberg, CEO of Discovery Health, who said inexperienced emergency room doctors and unnecessary private

HPV vaccination being offered at primary schools. Dr Yogan Pillay, Deputy Director General of Strategic Health Programmes in the National Department of Health, says 659 330 grade 4 girls 9 years and older completed the required two doses of HPV vaccination at schools nationally in 2014/2015. The goal is to cover all 18 000 primary schools.

Cervical cancer is the most common cancer among SA women, with 6 000 new cases diagnosed annually. Half of these women eventually die from the disease and most of them are black. The vaccine cannot help the thousands already infected, so a 1-hour “test and treat” intervention would significantly reduce suffering

through early detection and treatment.

There are currently 250 Gene Xpert machines in SA. Denny says “there’s a bit more scientific work to do to make it slightly more accurate – we don’t want to waste resources; we’re already overtreating a small proportion of women”. In 5 years, her team would be ready “to go with infrastructure for point-of-care screen and treat” to prevent cervical cancer. “I reckon we’ll pick up 90% of existing disease – combine this with the vaccine and we’ll reduce, if not eliminate, HPV within 10 15 years,” she adds. Denny cited the follow-up of four European randomised control trials on HPVbased screening for prevention of invasive cervical cancer, published

A typical emergency room scene, taken at the GF Jooste Hospital near Manenberg, Cape Town.

hospital stays were partly to blame for high medical aid premiums.

Prof. Lee Wallis, head of the EM divisions of UCT and Stellenbosch University and the Western Cape’s Head of Emergency Medicine, recently spent over a year reviewing emergency care nationally. He told Healthcare Gazette that it is impossible to calculate whether or not South Africa has a shortage of emergency care doctors until they are properly deployed to where the greatest needs are – and given ancillary support to ensure they don’t spend chunks of their time doing “other people’s jobs”. in The Lancet (2014;383:524), and the HPV FASTER trial published in the National Review of Clinical Oncology (Bosch, et al.) to back her assertions.

HPV vaccination kick-off this March at Simaza Primary in Langa, Cape Town.

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Novo Nordisk South Africa

How can we overcome barriers to effective glycaemic control in type 2 diabetes?

Diabetes is a global epidemic. Worldwide, it is a leading cause of cardiovascular disease, blindness, kidney failure and lower limb amputation.1. p8a; 11a; 28a In SubSaharan Africa, the majority of people with diabetes will die before the age of 60. Furthermore, diabetes accounts for almost one out of every three 1 out of every deaths among the economically active age 3 deaths in group of 30 to 40 years.1 p71a,73 30-40 year olds

Diabetes is a global epidemic

Physicians may be afraid of causing harm and be overly cautious when prescribing so as to avoid weight gain and hypoglycaemia, especially in patients who already have comorbidities.5,8 5.p39a; 8. p17a They may be concerned about patient non-compliance, or merely not know how to manage a patient who simply refuses to entertain the thought of escalating treatment.8 p17-18a Accordingly, oral therapies are continued for as long as possible, in the hope that patients will implement lifestyle changes.9 p370 Physicians overly cautious when prescribing so oral therapies are continued for as long as possible

Insulin is an effective diabetes treatment Careful control of blood glucose can help prevent or delay micro- and macrovascular complications of diabetes. Initially this may be adequately achieved with lifestyle changes and oral medication, but because of the progressive nature of diabetes, characterised by gradual decline in ß-cell function and density, most patients will eventually require insulin to achieve glycaemic goals.2 p72a Nevertheless, the benefits of control achieved early in the disease remain for many years, despite it becoming more difficult to maintain target glucose levels.3 p1577a Insulin is an effective treatment to control blood glucose. With appropriate doses it is possible to achieve any level of glycaemic control depending on the target set for an individual patient.4 p197a However, in practice, achieving and sustaining these targets is very difficult, because patients do not always adhere to their treatment regimen, and doctors may be overly cautious, so that treatment is not intensified when it needs to be.5 p38a, b

Patient considerations In fact, a substantial proportion of patients with type 2 diabetes do not achieve internationally recognised glycaemic targets.5 p38a Even in some South African Adequate glycaemic control specialist clinics, adequate glycaemic control is achieved in no more than is achieved in no more than about 1 in every about 1 in every 4 patients 4 patients with diabetes!6 p154a with diabetes Of course, nonadherence to therapy is an important problem associated with chronic diseases. Nevertheless, there are also specific reasons why diabetic patients may be reluctant to initiate or intensify antihyperglycaemic medication. Some of these include feelings of failure about suboptimal glycaemic control, anxiety about hypoglycaemia or weight gain, and fear of injections. Poor education about type 2 diabetes and the importance of treatment can exacerbate nonadherence.5 p38b Nonadherence through anxiety of weight gain fear of injections

In addition to consideration of their patients’ concerns, clinicians themselves may have reasons to delay initiation or intensification of insulin therapy in a patient who needs it. This is a worldwide phenomenon, sometimes referred to as ‘clinician inertia’.5,7 5.p38b; 7.p2675a Causes range from time and resource constraints to underestimation of the patient’s needs, and failure to identify and manage comorbidities.

Physician-related barriers to timely initiation of insulin8 • • • • • •

Concerns over patients with comorbidities Excess weight gain in already overweight patients Concerns about patient non-compliance Risk of severe hypoglycaemia/adverse effects on quality of life Lack of resources Patient refusal

Novo Nordisk seeks to dismantle barriers to insulin prescribing In response to these complex challenges, Novo Nordisk is leading the way in developing new molecules and delivery devices to change the way people with diabetes, and their healthcare providers, think about insulin. Novo Nordisk understands that if treatment regimens can be made simpler and more comfortable, and concerns over side effects no longer get in the way of efficient glycaemic management, then life with diabetes will be simpler, less scary and of a much better quality than it has ever been before.

References 1. International Diabetes Federation. IDF Diabetes Atlas, 7th edn. Brussels, Belgium: International Diabetes Federation, 2015. http://www.idf.org/diabetesatlas. Accessed 11 May 2016.

2. Henske JA, Griffith ML, Fowler MJ. Initiating and titrating insulin in patients with type 2 diabetes. Clin Diab 2009; 27(2): 72-76.

3. Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008; 359: 1577-1589.

4. Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycaemia in type 2 diabetes: A consensus algorithm for the initiation and adjustment of therapy.

A consensus statement of the American Diabetes Association and the European Association for the study of Diabetes. Diabetes Care 2009; 32(1): 1-11.

5. Ross SA. Breaking down patient and physician barriers to optimize glycemic control in type 2 diabetes. Am J Med 2013; 126(9 Suppl 1): S38-S48.

6. Pinchevsky Y, Butkow W, Raal FJ, et al. The implementation of guidelines in a South African population with type 2 diabetes. JEMDSA 2013; 18(3): 154-158.

7. Peyrot M, Rubin RR, Lauritzen T, et al. Resistance to insulin therapy among patients and providers. Results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study. Diabetes Care 2005; 28: 2673-2679.

8. Kumar A, Kalra S. Insulin initiation and intensification: insights from new studies. JAPI 2001; 50(Suppl): 17-22.

9. Wallace TM, Matthews DR. Poor glycaemic control in type 2 diabetes: A conspiracy of disease, suboptimal therapy and attitude. QJM 2000; 93: 369-374.

This message is brought to you by Novo Nordisk, the world’s leaders in diabetes management.

News | 11

alarminG rate oF CHroniC obstrUCtiVe PUlmonary disease in soUtH aFriCa URGENT RESEARCH IS NEEDED to understand the huge potential burden of non-tobacco-related chronic obstructive pulmonary disease (COPD) in South Africa (SA), and Cape Town in particular, both of which have among the world’s worst COPD burdens, says Prof. Richard van Zyl, Associate Professor and Head of the Lung Clinical Research Unit at the University of Cape Town. He was responding to the 2007 global Burden of Lung Disease (BOLD) findings that were debated at the May 2016 Cipla Respiratory Congress in Cape Town. These showed Ravensmead in Cape Town to have the highest incidence (19%) of COPD among 47 towns

and cities globally. SA was shown as having the highest incidence of COPD among 24 countries surveyed. Van Zyl cautioned against extrapolating the Ravensmead findings (the only suburb surveyed in Cape Town) to the entire metro, saying the prevalence in Cape Town and nationally was probably between 10 and 15% – still among the world’s worst.

He stressed that the global study only examined smokers. Greater Cape Town is home to some of the highest TB rates in the country, and SA has one of the most serious TB epidemics globally.

Cigarette smoking prevalence among coloured people (the majority) is the highest among all

ethnic groups at 40.1%. According to Statistics SA, 34.4% are women – five times the national prevalence for women. Van Zyl said there was a glaring absence of COPD data on dagga smoking, biomass fuel indoor pollution, post-TB obstructive lung disease, and HIV, early childhood and intra-uterine issues that impaired lung development. “We have a confluence of all these in SA, so healthcare workers must look out for other potential causes besides tobacco,” he warned.

drUG stoCk-oUts: “We’re beinG iGnored,” say nGos GOVERNMENT IS IGNORING the recommendations of a group of highly respected NGOs, who found public-sector drug stock-outs nationally. This claim has recently been made by the Stop Stock-Outs Coalition (SSC). The SSC extracted healthcare worker feedback on state drug stock-outs in a national survey, with the aim to improve the quality of life and longevity of patients. The SSC spoke to 88% of primary healthcare facilities between July and December 2015.

It found 25% experienced stockouts of ARVs or TB medicines, 64% experienced stock-outs within the past 3 months, 20% experienced stock-outs of these drugs on the day of the call, and 11% experienced stock-outs of vaccines/ essential medicines on the day of the call. Half of all orders were

unplaced, insufficient or late.

SSC co-ordinator, Sue Tafeni, said the SSC exclusion followed last month’s recommendations by a National Department of Health (NDoH) task team that reviewed reports on medicine availability nationally.

Consisting of local and international experts (excluding civil society coalition partners), the task team studied reports from the Public Service Commission, the NDoH pharmaceutical team and the SSC. Tafeni said the recommendations were “news to us”. The SSC had been excluded from a stakeholder meeting held to discuss

interventions. The SSC consists of Médecins Sans Frontières, the South African HIV Clinician’s Society, Section 27, the Rural Health Advocacy Project, the Rural Doctors Association of South Africa and the Treatment Action Campaign.

All these groups have historically been ahead of government in initiating lifesaving public sector drug access and appropriate treatment. While welcoming the initiative, as well as Finance Minister Pravin Gordhan’s R300m for a national electronic medicine stock management system, Tafeni said huge logistical challenges remain.

H EALT H CARE G A ZETTE | J U LY /A U G U S T 2 0 1 6

Proprietary Name: Ryzodeg® Scheduling Status: S3 Composition: Each ml contains insulin degludec/insulin aspart (70 % soluble insulin degludec and 30 % soluble insulin aspart) 100 units/ml. Indications: Treatment of adult diabetes mellitus patients, as basal add on to co-medication in patients who are inadequately controlled: - In type 1 diabetes mellitus, Ryzodeg® should be used with short-acting soluble insulin for use at the meal times when Ryzodeg® is not used. - In type 2 diabetes mellitus, Ryzodeg® should be used as an add on to oral antidiabetic medicines. Contra-Indications: Hypersensitivity to the active substances or to any of the excipients, pregnancy. Warnings & Special Precautions: Too high insulin dose, omission of a meal or unplanned strenuous physical exercise may lead to hypoglycaemia. Patients whose blood-glucose control is greatly improved may experience a change in their usual warning symptoms of hypoglycaemia and must be advised accordingly. Usual warning symptoms may disappear in patients with long-standing diabetes. Inadequate dosing and/or discontinuation of treatment in patients requiring insulin may lead to hyperglycaemia and potentially to diabetic ketoacidosis. Concomitant illness, especially infections, may lead to hyperglycaemia and thereby cause an increased insulin requirement. Transferring to a new type, brand, or manufacturer of insulin must be done under strict medical supervision.

When using Ryzodeg® in combination with pioglitazone, patients should be observed for signs and symptoms of heart failure, weight gain and oedema. Thiazolidinediones should be discontinued if any deterioration in cardiac function occurs. Hypoglycaemia may constitute a risk when driving or operating machinery. Pregnancy and lactation: Safety has not been established in pregnancy and lactation and Ryzodeg® should not be recommended for use during pregnancy. Dosage and Directions for Use: Ryzodeg® can be administered once- or twice-daily with the main meal(s). When needed, the patient can change the time of administration as long as Ryzodeg® is dosed with a main meal. The potency of insulin analogues, including Ryzodeg®, is expressed in units (U), 1 unit (U) Ryzodeg® corresponds to 1 international unit (IU) of human insulin and one unit of all other insulin analogues. In patients with type 2 diabetes mellitus, Ryzodeg® can be combined with oral anti-diabetic products approved for use with insulin, with or without bolus insulin In type 1 diabetes mellitus, Ryzodeg® is combined with short-/rapid-acting insulin at the remaining meals. Ryzodeg® is to be dosed in accordance with individual patients’ needs. Dose-adjustments are recommended to be primarily based on pre-breakfast glucose measurements. An adjustment of dose may be necessary if patients undertake increased physical activity, change their usual diet or during concomitant illness.Initiation: For patients with type 2 diabetes mellitus, the recommended total daily starting dose of Ryzodeg® is 10 units once daily with meal followed by individual dosage adjustments. For patients with type 1 diabetes mellitus, Ryzodeg® is to be used once-daily at mealtime and a short-/rapid-acting insulin should be used at the remaining meals with individual dosage adjustments.

The recommended starting dose of Ryzodeg® is 60 − 70 % of the total daily insulin requirements.

Transfer from other insulin medicinal products: Close glucose monitoring is recommended during transfer and in the following weeks. Patients with type 2 diabetes: Patients switching from once-daily basal or premix insulin therapy can be converted unit-to-unit to once-daily Ryzodeg® at the same total insulin dose as the patient’s previous total daily insulin dose. Patients switching from more than once-daily basal or premix insulin therapy can be converted unit-to-unit to twice-daily Ryzodeg® at the same total insulin dose as the patient’s previous total daily insulin dose. Patients switching from basal/bolus insulin therapy to Ryzodeg® will need to convert their dose based on individual needs. In general, patients are initiated on the same number of basal units. Doses and timing of concomitant antidiabetic treatment may need to be adjusted. Patients with type 1 diabetes: For patients with type 1 diabetes mellitus, the recommended starting dose of Ryzodeg® is 60 − 70 % of the total daily insulin requirements in combination with short-/ rapid-acting insulin at the remaining meals followed by individual dosage adjustments. Doses and timing of concurrent short-/rapid-acting insulin products may need to be adjusted. Flexibility: Ryzodeg® allows for flexibility in the timing of insulin administration as long as it is dosed with the main meal(s). If a dose of Ryzodeg® is missed, the patient can take the next dose with the next main meal of that day and thereafter resume the usual dosing schedule. Patients should not take an extra dose to make up for a missed dose. Ryzodeg® should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Side Effects: Very common (≥1/10); common (≥1/100 to < 1/10); uncommon (≥1/1.000 to < 1/100); rare (≥ 1/10.000 to < 1/1.000); very rare (< 1/10.000); not known (cannot be estimated from the available data). Very common: Hypoglycaemia. Common: Injection site reactions. Uncommon: Peripheral oedema and rare: Hypersensitivity and urticaria. Pharmacological classification: A 21.1 Insulin Preparations Reg. No.: 47/21.1/0165 References: 1. Ryzodeg® [summary of product characteristics]. Bagsværd, Denmark: Novo Nordisk A/S; 2013. 2. Fulcher G, Christiansen JS, Bantwal G, Polaszewska-Muszynska M, Mersebach H, Andersen TH, Niskanen LK; on behalf of the BOOST: Intensify Premix I Investigators. Comparison of insulin degludec/insulin aspart and biphasic insulin aspart 30 in uncontrolled, insulin-treated type 2 diabetes: a phase 3a, randomized, treat-to-target trial. Diabetes Care. In press. 3. De Rycke A, Mathieu C. Degludec – first of a new generation of insulins. European Endocrinology. 2011;7(2):84–87.

Novo Nordisk (Pty) Ltd. Reg. No.: 1959/000833/07. 150 Rivonia Road, 10 Marion Street Office Park, Building C1, Sandton, Johannesburg, 2196. Tel: (011) 202 0500 Fax: (011) 807 7989 www.novonordisk.co.za RYZ11/05/2016

NEW At Novo Nordisk, we are changing diabetes.

In our approach to developing treatments, in our commitment to operate profitably and ethically and in our search for a cure.

News | 13

kZn mobile CliniC Unit oVerPriCed CORRUPTION AND DYSFUNCTION continue to sabotage healthcare delivery in KwaZulu-Natal (KZN).

Earlier this year, public protector advocate Thuli Madonsela began probing a tender that saw the provincial Health Department lease a mobile clinic unit for R52.5m over 3 years. This is four times the cost of buying a similarly equipped vehicle.

The announcement was made

by Madonsela’s spokeswoman, Kgalalelo Masisibi, on 5 May 2016. Masisibi said the decision to probe followed a preliminary investigation by the public protector in October last year.

In January 2015, the KZN Health Department awarded a R61m tender to two companies – Mzansi Lifecare and Mobile Satellite Technologies. Mzansi Lifecare was created just 17 days before the

tender (ZNB 9281/1012-H) was advertised in the Government Gazette in June 2012. The accepted tender agreed to lease the department a truck and trailer equipped with a standard X-ray machine and ultrasound for R52.5m over 3 years. KZN Health Department chief Dr Sibongile Zungu signed off the lease in August 2013, agreeing to pay Mzansi Lifecare R1.5m every month until August 2016 to lease the vehicle, without staff. Initial investigations showed that four similar units with comparable floor plans could have been purchased from a US company, including the ultrasound and X-ray machines, a tent, training and warranty costs for a similar price. In October 2015, police spokesman Hangwani Malaudzi confirmed that the Hawks were investigating the

A mobile clinic and entirely foreign-qualified Nkandla District Hospital, KZN, staff. tender. Dr Zungu’s 5-year contract as health chief in KZN expired on 31 March 2015 amid allegations of mismanagement and corruption by the National Education, Health and Allied Workers Union (NEHAWU). In a futile bid, Dr Zungu took the provincial government to court, demanding that her subsequent month-tomonth contract be extended.

basson CoUrt aPPeal tHroWn oUt WitH Costs LAST MONTH, THE GAUTENG High Court in Pretoria dismissed apartheid-era “dirty tricks” mastermind Dr Wouter Basson’s review application challenging a decision by the Health Professions Council of South Africa (HPCSA) to refuse his recusal application. Basson was found guilty of unethical conduct in December 2013 for his role as the head of the apartheid government’s chemical and biological warfare programme, Project Coast, in the 1980s and 90s. He claims the Medical and Dental Professions board professional conduct hearing committee members were “biased” in having failed to disassociate themselves from a

South African Medical Association (SAMA) statement supporting a petition calling for the “strongest possible censure” of him. Basson’s lawyers walked out of what would have been the start of his sentencing, claiming that because tribunal members Dr Jannie Hugo and Dr Eddie Mhlanga were members of SAMA, they were inherently biased. Basson’s team returned in April last year, bearing a High Court-approved order that the tribunal hear their application for their recusal. The tribunal complied, but turned it down flat.

Chairperson Dr Hugo claimed that he and his colleague were inactive in SAMA management, with their association confined to academic and professional work.

Basson then took it back to the High Court. The court has, however, now ruled that he has to go through the HPCSA’s appeals procedure to challenge its decisions. A spokesperson for the HPCSA, Priscilla Sekhonyana, said the respective legal teams would be considering the judgment before “coming up with a date” for either an HPCSA appeal or sentencing.

Speaking on 26 April, Dr Hugo said he had not been informed of any hearing date.

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Wouter Basson

CHild sUPPort Grant Fails to alleViate PoVerty ONE OF THE MANY reasons primary healthcare workers in South Africa (SA) continue to see stunted and malnourished children is that Among the luckier ones, these crèche children get the country’s Child an extra daily meal Support Grant (CSG) fails to meet their patients’ basic nutritional needs. These are the findings of an SA Medical Research Council study carried out earlier this year. In his article entitled “The experience of cash transfers in alleviating childhood poverty in South Africa: Mothers’

experiences of the Child Support Grant Research”, Dr Wanga Zembe concludes that the grant is inadequate to meet the basic needs of children in the context of extreme poverty, rising food prices and food insecurity. The CSG is SA’s largest cash transfer programme, targeting children from poor households. Zembe found the administration of the CSG to be the greatest barrier to receipt, with long queues and waiting times, and a lack of coordination between departments processing applications. His team interviewed 746 mothers of children (on average 22 months old) in Paarl (peri-urban), Rietvlei (rural) and Umlazi (urban). A staggering 28%

of the children seen in Umlazi were stunted, 20% in Rietvlei and 17% in Paarl. The survey found that the duration of a CSG had no effect on stunting. HIV exposure and low birth weight were associated with stunting while maternal education was protective. The respondents were part of a larger multicountry cluster randomised intervention trial between 2005 and 2008 across the three sites. After this trial, former participants were traced (children ranging between 9 months and 3 years in age) and invited to participate in the CSG cross-sectional study that aimed to measure uptake and duration of the CSG and its nutritional outcomes.

neW-Generation drUGs, not exerCise, Work best For mUltiPle sClerosis HEAD OF NEUROLOGY AT THE University of the Witwatersrand, Prof. Girish Modi, believes that new-generation drugs are more effective than exercise in treating multiple sclerosis (MS). He claims

Multiple ScleroSiS Multiple sclerosis is a chronic, typically progressive disease causing disruption of the myelin that insulates and protects spinal and brain nerve cells. The low risk in the second-line drugs referred to is for a condition known as progressive multifocus leuco-encephalopathy (PML) due to the activation of the John Cunningham (JC) virus in the brain, which can be fatal.

that these drugs are responsible for fewer South Africans being in wheelchairs than ever before.

Modi claims this has mainly been due to the advent of interferon drugs over the last decade, with better second-line drugs over the past 3 years. He was responding to claims last month by the Biokinetics Association of South Africa (BASA) that physical activity helps manage symptoms, prevent complications and may even slow the progression of MS. May was International MS Awareness Month and Healthcare Gazette was testing assertions by BASA that movement and exercise were therapeutic. This was contrary to decades-old “wisdom” that exercise worsens MS. Modi, who is also Head of Neurology at Charlotte Maxeke Johannesburg

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Academic Hospital, said a sense of wellbeing had been shown to have “some relevance” in auto-immune diseases, “so a healthy lifestyle is a good thing, but there’s no scientific evidence that exercise will reduce attacks or control the disease.” Modi said the most profound therapeutic change was in pharmaceuticals, with interferon or the similar Copaxone far more widely available in the private sector over the last decade. Second-line drugs such as Tysabri and Gilenya modified the immune response and avoided relapse, although they carried some risk. Evidence following the use of interferon clearly showed fewer people in wheelchairs. Medical aids were now paying for interferon, the private-sector drug of choice.

News | 15

a national tb PreValenCe sUrVey – a first for south africa FOR THE FIRST TIME, SOUTH Africa (SA) is to conduct a nationwide TB prevalence survey starting this July, with results expected in 2018. If the survey is repeated five-yearly as recommended internationally, it will enable epidemiologists to scientifically track valid trends in their own lifetime.

Deputy president Cyril Ramaphosa made this announcement last month from Lephalale, Limpopo Province, to mark World TB Day. Ramaphosa said the World Health Organization (WHO) estimates were “informative” but open to contestation. Accurate data would enable a better response to the epidemic. The survey’s co-principal investigator and director of the TB Platform of the SA Medical Research Council (SAMRC), Prof. Martie van der

Walt, says the country has relied on reported and treated TB cases and vital registration data (death notices) to estimate treatment numbers at 380 000 per annum. This is with incidence at 834 per 100 000 population. These were numbers that “seemed to have stabilised” over the past decade. These numbers and impending survey results exclude multiple drugresistant/extreme drug-resistant TB. SA has the highest (HIV-driven) TB burden in Africa and ranks among the top five TB-burdened countries globally. Van der Walt said SA was doing badly in terms of numbers treated. Hundreds of National Department of Health nurse surveyors would, for the first time, go into people’s homes to capture data on undiagnosed TB sufferers, assess knowledge levels and ask why they had not sought care. This

would enable a more appropriate health system response.

Her team members will screen people and learn on the job, using mobile HIV/TB clinics in Durban X-rays that are more (above) and Greytown (KZN), respectively. sensitive and accurate than bacteriological investigations, picking up lung pathology long before a person begins coughing. Their findings will benefit other patients in the long term.

oCCUPational injUries – radiologists sue government RADIOLOGISTS WERE EARLY LAST month (6 June) still awaiting a court date for their R121.5m claim against the Compensation Fund (CF). Despite the R52b CF has in its coffers, it keeps many doctors waiting for payments – sometimes for up to a year.

In what could be a landmark case, the Radiological Society of South Africa (RADSA) and 19 individual radiology practices are suing the labour minister over the CF’s failure to process and pay out this amount in claims for services they have provided to injured workers. The litigant grouping represents just under one-quarter of existing private radiology practices, with most using thirdparty agencies to collect money.

This is at a cost of 20% of debt recovered. RADSA’s Executive Director‚ Richard Tuft‚ says it is deeply unjust for doctors to have to forfeit a fifth of their income just to increase their chances of getting paid. Last June, CompSol – the biggest company handling claims on behalf of doctors – chose to temporarily suspend its services because its job had become so difficult. The South African Medical Association (SAMA) said many doctors were refusing to attend to “injured-on-duty” cases due to non-payment. CF commissioner Vuyo Mafata conceded that the fund has a history of unpaid claims‚ but said it had improved its turnaround time to an average of 60 days by automating processes

with a new electronic claims system called Umehluko. The fund had R52b in reserve and had paid claims totalling R6b this year. Tuft said the average debtors’ days for claims from the CF was 350‚ compared with an average 12 20 days for claims from medical schemes. Contacted on 6 June, Tuft said that although the state had responded, no date had yet been set down for argument.

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bite-siZed sUmmaries oF tHe latest sCientiFiC adVanCes Vaccination and childhood pneumonia

Fruit intake in teenagers lowers breast cancer risk The consumption of fruit and vegetables affects the pathogenesis of breast cancer through several biological mechanisms, but epidemiological studies on the relationship between risk of breast cancer and fruit and vegetable consumption have been ambiguous to date. Information on diet in early life was used from the Nursesâ&#x20AC;&#x2122; Health Study II â&#x20AC;&#x201C; an ongoing prospective cohort study that began in 1989, analysing female participants aged 25 42 years. A total of 90 476

premenopausal women participated in the study, having completed a questionnaire on their diet in 1991. In 1998, about half of these women completed another questionnaire about their diet during adolescence. The research showed that fruit intake during adolescence is beneficial and helps prevent breast cancer. Fruit and vegetables that are rich in Îą-carotene at this early stage were particularly associated with lower risk.

From May 2012 to December 2014, 314 of 967 fully immunised children from Drakenstein, South Africa, developed pneumonia, 60 of them severe. The immunisation included pertussis vaccine and PCV13. Respiratory syncytial virus was the pathogen most frequently associated with the disease.

Bordetella pertussis and influenza virus were also strongly associated with pneumonia. The continued high incidence of pneumonia in such a highly vaccinated population suggests that new vaccines and strategies are needed to address this burden of disease.

Zar HJ, Barnett W, Stadler A, et al.

Rosuvastatin around heart surgery Perioperative rosuvastatin does not prevent postoperative atrial fibrillation or perioperative myocardial damage in patients undergoing elective cardiac surgery, and is associated with an increased risk of acute kidney injury. The drug was given to 1 922 randomly assigned patients in sinus rhythm scheduled for either coronary artery bypass grafting, surgical aortic valve replacement or both. Those already on a statin stopped it and took rosuvastatin for 8 days before surgery and 5 days after. There was no difference in either the rate of postoperative atrial fibrillation or perioperative cardiac damage assessed by measuring levels of cardiac troponin 1.

Farvid MS, Chen WY, Michels KB,

Aetiology of childhood pneumonia

et al. Fruit and vegetable

in a well vaccinated South African

consumption in adolescence

birth cohort: A nested case-control

Zheng Z, Jayaram R, Jiang L, et

and early adulthood and risk of

study of the Drakenstein Child Health

al. Perioperative rosuvastatin in

breast cancer: Population based

Study. Lancet Respiratory Medicine

cardiac surgery. N Eng J Med

cohort study. BMJ 2016;353:i2343.

2016;4(6):463-472. DOI:10.1016/

2016;published online 6 May.

DOI:10.1136/bmj.i2343

S2213-2600(16)00096-5

DOI:10.1056/NEJMoa1507750

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Research | 17

late reactivation of ebola virus

More against the diet-heart hypothesis Global trends in abortion

Potato intake and incidence of hypertension

The traditional diet-heart hypothesis predicts that replacing saturated fats with vegetable oils rich in linoleic acid will reduce coronary heart events and improve survival. A re-analysis of previously unpublished data from the Minnesota Coronary Experiment shows that replacing saturated fats with linoleic acid lowers cholesterol, but there is no reduction in death from coronary heart disease, or from any other cause. This analysis adds to the growing body of evidence that incomplete publication has contributed to overestimates of the benefits of replacing saturated fats with vegetable oils rich in linoleic acid.

Abortion is legal in many countries worldwide, and information on global trends on the incidence of induced abortion can inform policy around avoiding unintended pregnancy. Data from government agencies and from international and national sources show that about 35 abortions occurred annually per 1 000 women worldwide from 2010 to 2014, with an increase of 5.9 million from 50.4 million between 1990 and 1994 to 56.3 million in 2010 - 2014 due to population growth.

Abortion rates have not decreased significantly since 1990 in the developing world, suggesting that more can be done around access to sexual and reproductive healthcare.

In Sierra Leone, at least, it appears that late reactivation of severe Ebola virus is rare, with no evidence for an effect of infecting dose on disease severity. The frequency of fatal reactivation was assessed after discharge from treatment centres, as was the influence of the infecting dose. Follow-up information was obtained for 151 survivors for 10 months after discharge.

There were 4 deaths, all within 6 weeks – 2 due to late complications, 1 to prior tuberculosis and 1 after apparent full recovery. Maximum estimate of reactivation leading to death was 0.7%.

Ramsden CE, Zamaora D,

Sedgh G, Bearak J, Singh S, et

Bower H, Smout E, Bangura MS,

Majchrzak-Hong S, et al. Re-eval-

al. Abortion incidence between

et al. Deaths, late deaths, and

Borgi L, Rimm EB, Willett WC, et

uation of the traditional diet-heart

1990 and 2014: Global, regional,

role of infecting dose in Ebola

al. Potato intake and incidence of

hypothesis: Analysis of recovered

and subregional levels and trends.

virus disease in Sierra Leone:

hypertension: Results from three

data from Minnesota Coronary

Lancet 2016;published online 11

Retrospective cohort study. BMJ

prospective US cohort studies. BMJ

Experiment (1968-73). BMJ

May 2016. DOI:10.1016/S0140-

2016;353:i2403. DOI:10.1136/bmj.

2016;353:i2351. DOI:10.1136/bmj.

2016;3(52):i1246.

6736(16)30380-4

i2403

i2351

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Potatoes – boiled, baked, mashed or fried – are independently associated with an increased risk of hypertension. This is the result of prospective longitudinal studies of three large cohorts of adult men and women in the USA, who were all normotensive at baseline. Four or more servings of any type of potato per week were found to increase the risk of developing hypertension.

In contrast, replacing one serving of potatoes a day with a serving of non-starchy vegetables reduced the risk of hypertension.

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teamWork eases Pain relieF CHallenGes

By Patricia McCracken

Pain treatment is routinely overlooked in South Africa (SA), and at least one in five people suffer from chronic pain. Soon more people may benefit from improved pain management through increasing focus on practitioner teams treating chronic pain.

P

AIN IS THE NUMBER ONE symptom prompting patients to visit doctors and clinics, says Prof. Peter Kamerman of the University of the Witwatersrand (Wits) Pain Lab and president of Pain SA. Despite this, it remains poorly managed worldwide. Chronic pain affects at least one in five in SA, yet it is still a condition with more questions than answers. “No single factor has yet been identified as causing uncontrolled acute pain to develop into chronic pain,” says Kamerman.

“It’s difficult to take away pain and retain function as patients don’t want to be so medicated that they are unconscious,” says Bev Bolton, a Port Elizabeth physiotherapist, director of the non-profit Train Pain Academy and a member of the teachers’ group of the European Association for Communication in Healthcare. “By removing pain

sufficiently for patients to live their lives as fully as possible – driving a car or going out to a braai – they regain a sense of control they often lose when pain becomes chronic,” she says. Even in palliative care, people wanted their suffering decreased sufficiently to be able to live a life they valued, even if it was just to talk to their children, their family and friends.

Previous experiences of pain and anticipation of pain feed into the threat messages interpreted by the brain as pain.

This is variously categorised, such as by duration or expectation as acute, chronic or palliative, or by cause as nociceptive (from tissue injury), neuropathic (from nerve injury) or neuroplastic (from central sensitisation). The fact that pain is poorly managed is poor medical practice, explains Kamerman, often with selfdefeating, long-term consequences for the healthcare system.

catcH-up witH profeSSor tracy JackSon

Nashville

A specialist in anaesthesiology and pain management from the USA’s Vanderbilt University in Nashville, Prof. Jackson visits the Groote Schuur Chronic Pain Management Unit in Cape Town annually and was a keynote speaker at the 2016 Pain SA Congress. Find her TEDx Talk on pain management at: http://tedxtalks.ted.com/video/The-Hardest-Pill-to-Swallow-Tra

H HEALT EALTH HCARE CARE G GA AZETTE ZETTE || JJU ULY LY/A /AU UG GU USSTT 22001166

Better pain relief

“When healthcare practitioners ask patients if they want pain relief and they answer no, it’s often assumed pain might be mild,” says Prof. Peter Kamerman of Wits Pain Lab. But a patient perhaps doesn’t want to be seen as troublesome, especially if there is a wide social gap between the patient and a more privileged doctor. They may believe that pain must simply be borne – as an inevitable part of childbirth, for example.

“In acute pain situations especially, rather make a more

Prof. Kamerman

“

It is 10 years since the American Pain Society formalised the concept of pain as ‘the fifth vital sign’, but medical professionals globally still lack pain education

positive offer such as, ‘Would you like more pain relief?,’” he says.

“Inadequate or poorly managed acute pain relief can contribute to patients developing chronic pain, so assess pain as accurately as possible,” says Kamerman. Rating pain on a scale of 1 to 10 can be managed by patients from late teens to the elderly, depending on the patient’s sophistication or ability to communicate. A scale using facial expressions often works better for adults who are functionally illiterate, innumerate, battling to communicate or for children.

Whether because of surgery experiences or underlying chronic physical or psychological conditions, some people are more likely to develop chronic pain than others. So says Dr Kerry-Ann Louw, a psychiatrist at the University of Cape Town and at the Groote Schuur Chronic Pain Management Unit. The proportion of comorbidity with depression, posttraumatic stress, personality and anxiety disorders is significantly higher among people with chronic pain.

“Depression is 60% pain related but pain masks depression diagnosis in primary care,” she says. “Treating the mental-health comorbidity improves outcomes of both the pain and depression or other disorder.”

“It is 10 years since the American Pain Society formalised the concept of pain as ‘the fifth vital sign’, but medical professionals globally still lack pain education,” says Prof. Kamerman.

SA medical undergraduates receive about 6 hours of lectures or tutorials on pain, so junior doctors, for example, are uncomfortable with assessing and managing pain.

“They often don’t ask patients whether they have pain because they don’t want to cope with the answer ‘yes’,” says Prof.

Kamerman. “Focus has thus been on the pathology and treating the disease or condition. Long term, we need to treat both causes and the patient’s experience of the pain it triggers.”

There is some light on the horizon with the introduction of team management of pain. This involves a range of skills from neurology and physiotherapy to psychiatry in assisting patients with pain

management, helping them regain a sense of control and resuming their lives.

“This was a particular focus at the Pain SA Congress in May,” says Kamerman.

ACUTE PAIN: THE FIRST FRONTIER

Starting points of chronic pain can include a condition such as a migraine, where muscular spasms can contribute to pain intensity. Chronic pain can be related to a disease affecting the skeletal system, such as osteo-, rheumatoid or gouty arthritis, or ankylosing spondylitis, or HIV, which contributes to pain in about three-quarters of patients.

Acute pain can develop into chronic pain “by rewiring the way pain signals are sent and received in the nervous system,” says Kamerman. “This is a risk no matter how good pain management is.”

“As a result, patients’ fundamental human rights are being seriously shortchanged,” believes Dr Milton Raff, a member of the International Association for the Study of Pain (IASP) Developing Countries Working Group and former president of Pain SA. In his strongly worded preface to the 2009 South African Acute Pain Guidelines, Dr Raff wrote: “Acute pain management is not a luxury, it is a human right!” Last year he told the the SAMJ (August issue) that vets in North America, for example, focus 20 times more on pain during training than doctors, “meaning animals get treated better there than human beings.”

Dr Raff’s foreword to the 2015 updated guidelines (now available for free download at http://www.sasaweb.com/ Publication/Guidelines) re-emphasises the

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Feature | 21

lasting relevance of his concerns: “The World Federation of Anaesthesiologists and the IASP have both identified the fact that pain is badly managed in all parts of the world, but that attention needs to be given to pain management in developing countries. Reports from the European PAIN OUT Symposium 2014 were also not encouraging as it was evident they had received better pain therapy.” Raff believes “the effective treatment of acute pain must become a fundamental component of quality patient care,” both in itself and to reduce chronic pain incidence.

FACING UP TO PAIN

Healthcare practitioners often choose not to give opioids or offer patient-controlled analgesia because of concerns about respiratory depression, staffing levels and skills allowing for adequate patient monitoring, observes Kamerman. “Opioids should be an option for patients who aren’t responding to other therapies. The evidence of high prescription levels and addiction is mainly from the USA but this needs to be separated from dose-related tolerance, which doesn’t prompt drugseeking behaviour. SA has the highest opioid consumption in Africa but is still far below levels in western Europe and especially the USA and Germany.”

The South African Society of Anaesthesiologists (SASA)’s 2015 guidelines again emphasise the importance of using tools such as numeric rating scales and breathing or facial expressions to assess pain. They also recommend that pain, “the fifth vital sign”, should be included in routine nursing charts.

cHronic pain in operation Chronic pain can develop from an acute pain episode, note SASA’s Acute Pain Guidelines 2015, such as postoperative, post-herpes zoster or lower back pain. Four risk factors for developing chronic pain are: n intense and prolonged preoperative and/or postoperative pain n repeated surgery n postoperative complications (infections) n chemotherapy and/or radiotherapy perioperatively.

Kamerman notes: “Particularly in the public sector, healthcare practitioners don’t feel comfortable talking about pain because they haven’t been adequately trained and there isn’t enough time on a busy ward. The point at which pain treatment starts can be a big determinant in developing chronic pain. These days we particularly recommend more proficient analgesia during and after surgery. This should be applied timeously by everyone, from the surgeon and the anaesthetist to the nursing staff.”

However, with pain often poorly managed in palliative care and among HIV patients, it will require effort and upskilling to achieve this. A study by UCT’s Prof.

Romy Parker, published this year in the Journal of Pain Symptom Management, showed HIV among Xhosa women in Khayelitsha was well managed but that healthcare practitioners were not asking about, let alone managing, HIV-related pain, which affects about three out of four patients. Another study in KwaZulu-Natal Province revealed patients with HIV-related pain were often sent home by clinics with inadequate quantities of paracetamol.

HIV has a high burden of multiple types of pain, not only in the end-stage of the disease. Peripheral neuropathy remains difficult to treat.

“More broadly, neuropathic pain, which causes between 7% and 10% of all chronic pain, has a greater impact on psychosocial wellbeing than other chronic pain,” says Kamerman. “Although some patients get relief from pharmaceutical treatments, sometimes they’re not much better than a placebo, particularly in the public sector.

Most patients have residual pain.”

THE TREATMENT jOURNEY

Until there is a new panacea, managing chronic pain remains about shifting expectations to enable patients to get on with life. “Pain is so subjective and private that it is challenging to understand other cultures’ words for their pain experience,” says Bolton. “Communication skills are as important as diagnostics because patients may be reluctant to discuss their pain. But

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“

Although some patients get relief from pharmaceutical treatments, sometimes they’re not much better than a placebo, particularly in the public sector.

Most patients have residual pain

HEALTHY LIVING LIFESTYLE Wellness centre: Your Spiritual Awakening •

• • • • • •

Was formed in 2005 as a means of finding a niche to bring something different to the beauty therapy,nails and Physiotherapy and wellness name which means you are taking care of your healthy lifestyle Its focuses both on inward and outward beauty as means of spiritual awakening Its services are rare experience of true African indulgence Wellness centre is 100 % black owned Our Therapist offer guests decadent pampering from head to toe and indulgence all the senses Our services includes, Facial, Massage, Waxing, Manicure, Pedicure, Body wrap , Acrylic-New Set , Slimming Treatment, Lashes and make- overs Wellness centre was formed with the primary purpose of promoting Broad Based Black Economic Empowerment (BBCSI) thereby assisting private sector to implement their wellness centre so as to benefit the people who matter most, employees.

Objectives •

• • • • • • • • •

To be a reputable organisation in implementing CSI and wellness programmes. Enabling it to be an organisation of choice to companies wishing to invest their Enterprise Development and CSI funds effectively.

To support and fund long-term development projects within the communities.

To address the conditions and challenges faced by employees, which may be causing a void in personal development plan To empower small businesses; in return creating more jobs and reducing poverty.

To enable disadvantaged communities to actively participate in the South African economy.

To allow the communities to participate and benefit from CSI and providing the private sector with a vehicle to comply with the Government’s CSI legislation.

To be an advocate and a major role player within the wellness empowerment sphere.

To provide skills and present employment opportunities to the impoverished, more especially the youth.

To promote Government’s Broad-Based CSI strategy aimed at providing a better life for all.

To acknowledge and celebrate the success of CSI implementation through Broad Based Black Economic.

Vision •

To identify, develop and implement exceptional standard in wellness, Beauty therapist and Physiotherapist that benefit both beneficiaries and funders, which would in turn bring measurable change in the lives of the our clients

under which practice number is registered? Which health professional is registered to acquire this, is it a physiotherapist, if so, it would legally mean each spa must be seen by a physiotherapist to comply with the Health Professionals Council and Board of Health Funders regulation. However, beauty and leisure massages are not within the practise scope of a registered physiotherapist thus I would need to be privy to information regarding the discussion with the Board of Health Funders and what were the terms of getting accreditation and the practise number.

Health and sports • • • • • • •

Ibholalethu sports development Virgin spas turn into wellness Training ex-offenders to beauty therapist Launch of SA Football supporters initiatives Training professional sex workers into beauty therapy and massages Doing wellness days/weeks bringing international events to SA

Wellness Week/day programme • • • • • • • • • •

Macufe fun walk Soweto Marathon Forever living holiday resorts Protea hotel Planet fitness Virgin Active Ibholalethu tournaments PSL and 1st division games Rhema Bible church 16 days against women abuse

Ibholalethu Sports programme joining fee: •

Bronze is R250.00 for 16 soccer, rugby & cricket matches P.A - transport, food & ticket.

•

Silver - R500.00 for 16 soccer, rugby & cricket matches P.A - transport, food, accomodation & ticket.

•

Gold - R750.00 for 16 soccer, rugby & cricket matches P.A - flight , 3 star hotel & ticket.

•

Platinum - R1000.00 - for 16 soccer, rugby & cricket matches P.A - flight, 5 star hotel & suite ticket

Questions to be answered •

Physiotherapy is a science which is relevant to either sports medicine of treatment of musculo-skeletal disorders, you indicated that medical aid would pay,

Dr Tshego Gapane, Chairperson, Wellness Centre

Please call us to visit us soon Zama: 082 977 1370, Nozipho: 072 446 8903 Offi ce: 011 055 6406 All medical aid accepted Website: www.wellnesscentre.com

“

Physiotherapy helps patients improve their mobility and function.

Mindfulness, meditation or relaxation all help them accept the need to pace their activity around severe pain.

they will talk about the impact it has on their lives, such as not being able to pick up a child, have an intimate relationship with a partner or walk round the shops. Many people lose everything they hold dear in the search for a magic bullet for chronic pain.”

“It’s essential to appreciate the patient’s path to reach you,” says Kamerman. “Often they’ll have seen several other doctors, tried complementary medicine, pain-control devices and even hoped quick-fixes would work. A treatment team offers better physical, pharmaceutical, psychological and occupational therapy solutions that might reduce severe pain to moderate, allowing patients to function better and do what’s important to them in life. Anyone who claims they can treat pain from a single therapeutic perspective is not telling the truth.”

pinpointinG cHronic pain riSk Healthcare practitioners need to monitor pain, particularly in patients who have undergone certain procedures with increased chronic-pain risk, warn the SASA Acute Pain Guidelines 2015: Procedure Chronic-pain incidence (%) Dental surgery 5 - 13 Vasectomy 0 - 37 Cholecystectomy 3 - 56 Mastectomy 11 - 57 Inguinal hernia repair 0 - 63 Thoracotomy 5 - 67 Amputation 30 - 85

“The therapeutic relationship has been shown to affect up to 30% of health outcomes,” says Bolton. “Practitioners from different practices can come together to treat patients as a multidisciplinary team,” she says, “helping patients live the fuller, more valued and meaningful life they want. With patients’ permission, the practitioners should exchange updates on their treatments, recommendations, observations and outcomes.”

“Physiotherapy helps patients improve their mobility and function. Mindfulness, meditation or relaxation all help them accept the need to pace their activity around severe pain. There is evidence that as the body strengthens and the nervous system perceives threats decreasing, it becomes calmer and pain is triggered less frequently,” explains Bolton.

This team approach is even more powerful within a single institution, she believes, with the Groote Schuur model allowing practitioners to meet and discuss case management.

“Each patient is presented to the full team – anaesthetists, physiotherapists, psychiatrists and psychologists, plus nursing staff – and together we construct an individual management plan,” says Dr Louw. “This cuts down on individual hours and is a form of continual peer education.

Working together, we have all upskilled each other and become better pain clinicians. However, this strategy doesn’t yet work so well in private practice, where patients tend to be passed from one practitioner to the next.”

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sa CardioloGists braCe tHemselVes For CHanGe

By Patricia McCracken

As the non-communicable diseases (NCDs) wave begins to break over South Africa (SA), state healthcare providers, private healthcare funders and patients are all looking for better, cheaper care.

Washington DC’s Professor Gus Pichard proposed two paradigm shifts during his SA tour.

G

ROOTE SCHUUR CARDIOLOGIST Dr Ntobeko Ntusi has had a glimpse into the future of his profession. He and his SA cardiology colleagues will soon see the back of unconsidered and routine coronary angiography and publicly embrace available tracking of their work.

This paradigm shift was underlined by interventional cardiology opinion leader Prof.

Gus Pichard when he toured SA. Pichard is a senior consultant at the Innovation and Structural Heart Disease, Medstar Heart & Vascular Institute, Washington DC. He is the latest of the international cardiology “legends” brought out every year as the guest of the SA Society of Cardiology Intervention (SASCI). He gave presentations to SASCI members in Cape Town, Durban, Bloemfontein, Johannesburg and Pretoria,

and visited catheterisation laboratories in major academic hospitals.

“Prof. Pichard outlined his vision of appropriate, evidence-based care which was particularly useful to the profession,” says SASCI president Dr Dave Kettles. Pichard predicts that scrutiny of cardiologists’ practice will intensify in SA, with outcomes of diagnostic and interventional procedures publicly reported and compared with national benchmarks. He also pinpointed replacing the “gold standard” of routine coronary angiography with fractional flow reserve (FFR) assessment, supplemented with intravascular

tHere’S an app for tHat …

“

Pichard predicts that scrutiny of cardiologists’ practice will intensify in SA, with outcomes of diagnostic and interventional procedures publicly reported and compared with national benchmarks

Free apps are available to input patient criteria and calculate the appropriateness of PCI, announced Prof. Pichard. Created by the Society for Cardiac Angiography and Interventions, these are available from the Apple App Store and Google Play Store. Search for SCAI AUC Tools.

SEARCHING FOR ACCURACY

Atherosclerotic build-up

“

Pichard believes quantifying ischaemia and the severity of symptoms noninvasively should determine the need for angiography in stable coronary artery disease (CAD)

ultrasound (IVUS). This, he claims, has cut routine, invasive percutaneous coronary interventions (PCIs) by half.

Pichard’s revelations created a big splash in SA cardiology’s relatively small pool. There are about 170 cardiologists in the country, with 40 of these in public hospitals, estimates Ntusi.

The adjustments will ripple outwards to all SA’s health practitioners and healthcare workers involved with cardiology patients. Nurses will also need to familiarise themselves with new procedures, and patient advice sheets and handouts will need to be rewritten.

This will be intensified by the twin pushes of cost rationalisation and the wave of NCDs in SA. A burden of disease analysis published in the October 2014 edition of SAMJ by Day et al. showed “NCDs have become the largest broad cause of Years of Life Lost (YLLs) in SA (32% of YLLs in 2009)”. This was highest in metros (especially Mangaung) and least-deprived districts. One conclusion was that: “Reducing NCDs and their risk factors is one of the neglected [healthcare] priorities.”

In a 2009 article for the Expert Review of Cardiovascular Therapy, Dr Ntusi and Prof.

Bongani Mayosi of the University of Cape Town had observed that the sub-Saharan African burden of heart failure contributes to cardiovascular disease mortality being much higher than in most developed countries, affecting younger people and women disproportionately.

“Angiography’s shortcomings were Pichard’s first ‘big shock’ for many SA cardiologists,” observes Ntusi. “He presented compelling evidence that part of our interventional cardiology practice may be woefully inadequate, probably outdated and not always supported by evidence.” Pichard believes quantifying ischaemia and the severity of symptoms non-invasively should determine the need for angiography in stable coronary artery disease (CAD). He highlighted a study published in the Journal of the American Medical Association in 2011 by Chan et al. on PCI appropriateness. Of more than 500 000 PCIs, nearly threequarters (71%) were patients with heart attacks or who were high-risk due to unstable chest pain. For them, PCIs were appropriate 98.6% of the time. But nearly a third (29%) of patients had non-acute heart disease and only about half (50.4%) of the procedures were appropriate.

More than one in 10 was inappropriate (11.6%) and for 38%, procedure benefits were uncertain.

According to results presented by Pichard, angiography may be adequate for mild lesions (20 - 40% stenosis) and for severe lesions (more than 90% stenosis). But most coronary lesions are intermediate (40 - 85% stenosis). Here FFR is superseding angiography as the optimal method to decide whether intervention is needed in intermediate lesions.

“Pichard explained FFR has been proved to be physiologically accurate and reproducible, making it clinically useful as the best means of measuring when to perform revascularisation of coronary lesions,” says Dr Ntusi.

Pichard believes that angiography is least accurate for left mainstream lesions and complex CAD. As these carry “the most dire prognostic significance,” he favours a heart team approach. Better assessment of CAD prognosis can be achieved by including IVUS, he adds.

As this can assist in measuring lesion severity, it should be used in complex, high-risk PCI.

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jOINING THE FFR REVOLUTION

A PERVERSE INCENTIVE?

A key take-home point for Ntusi was that intervening routinely with a stent or balloon or even surgical revascularisation “may be inadequate” for most patients with intermediate lesions. “The angiographic image is as good as flipping a coin for intermediate lesions,” he notes. “Shooting dye down coronary arteries doesn’t give you the most accurate assessment possible, either. For really confident medicine, we need FFR,” he states.

“FFR can reveal the true significance of a lesion showing, for example, that though a normal-looking artery may have only a small amount of plaque, this is haemodynamically significant”, says Ntusi.

Some senior cardiologists in private practice, such as Dr Mark Abelson of the Vergelegen Heart Unit in Somerset West and Dr Dave Kettles of St Dominic’s Hospital in East London, already use FFR. SA cardiology is moving towards FFR and IVUS, although it is difficult to estimate take-up, says Dr Kettles.

“Using more modalities rather than pure angiography to determine whether a lesion is physiologically or functionally significant definitely helps ensure the right person gets revascularisation,” explains Kettles.

The shift could require re-equipping and reskilling in some cardiology units.

The potential disincentive, with the current focus on containing costs, should not be a major obstacle as the equipment is “not particularly expensive and is usually subsidised for teaching hospitals,” says Kettles. In the public sector, Ntusi adds, the equipment will quickly pay for itself through the lower spending on inappropriate and unnecessary procedures.

“Stents have been lucrative for cardiologists,” says Ntusi. “So ultimately, this shift will also make CAD treatment more affordable for patients and for medical aids.”

“Angiograms might possibly be seen as a perverse incentive,” says Dr Abelson, explaining that they cost about R30 000 and that moving away from their routine use will mean medical aids – and ultimately private patients – save this cost and on hospital admission. He favours a new cost model with a flat fee for any chest pain diagnosis, whether the treatment is prescribed medication or an angiogram, with a higher consultation rate compensating somewhat for lost income due to fewer angiograms.

Cost-effective shifts are particularly timely, feeding into the SA medical costs debate and the current Competition Commission Health Market Inquiry (HMI). The impassioned pitch by Kettle on SASCI’s behalf was widely reported in the media. So too was the discussion of power imbalances resulting from funders’ empowerment and patient disenfranchisement and the future availability of cardiologists to patients.

“Routine angiograms have never been as extreme in SA as in the USA though,” says Abelson. “Angiogram and intervention rates dropped considerably there but the procedure had been very abused. In fact, some American doctors went to jail or paid massive fines for overtreating.”

“I’d like to think there hasn’t been that level of abuse in SA interventional cardiology.

SA cardiology is a very small community and most know of someone doing things they shouldn’t – but there’s no official sanction.

Patients can sue or go to the HPCSA [Health Professsions Council of South Africa] but we

6 key take-HoMeS froM prof. picHard

n Avoid overtreating: Angiography can overestimate severity of intermediate lesions – these have better outcomes with optimal medical therapy than with stents. n The reduced gold standard: Angiography is now the gold standard to indicate revascularisation only for lesions greater than 90%. n When to revascularise intermediate lesions: Revascularise in stable CAD when lesions remain greater than 50% and symptoms persist despite optimal medical therapy.

“

“Angiograms might possibly be seen as a perverse incentive,” says Dr Abelson, explaining that they cost about R30 000 and that moving away from their routine use will mean medical aids – and ultimately private patients – save this cost and on hospital admission

n Least accurate: The use of angiography in left main coronary artery disease is the least accurate method. n Use plaque morphology: High-risk plaque morphology is associated with worse outcomes, so use plaque imaging to help predict prognosis. n Drug-eluting stent (DES) vs. bare metal stent (BMS): Current data prove lower stent thrombosis, myocardial infarction and death with DES. Prof. Pichard’s presentation available at: http://www.sasci.co.za/uploads/files/ SASCI_VPP_2016_Evening_Lecture_Prof_Gus_Pichard_Revascularization.pdf

H EALT H CARE G A ZE TTE | J U LY /A U G U S T 2 0 1 6

“

IVUS technology

I use IVUS to make sure what I leave alone is truly an intermediate lesion and not something severe I just don’t see on angiography.

Results have been outstanding. There is no increase in restenosis or thrombosis

really should have a standards watchdog for cardiology.”

Hospital groups and medical aids already play a policing role, notes Abelson: “A cardiologist can find a medical aid has deducted R200 000 from his account when his performance doesn’t fall within their bell curves, suggesting overtreating or overbilling.

Hospital groups also log and monitor many statistics including cardiologists’ catheterisation rates, patients admitted, intervention type and fatality rates.”

AN OPEN AND CLOSED CASE

Pichard’s second paradigm shift for SA cardiologists – closer scrutiny and public reporting of interventions and outcomes – could make cardiologists part of SA’s move towards greater public accountability backed by publicly accessible “open data” in this country. This is despite some inconsistencies such as restricting access to cause of death data to Statistics SA only. Currently lead chair of the global Open Government Partnership, SA aims to make substantial swathes of government data available online by 2020.

There has been some resistance to the US National Cardiovascular Data Register, which

in tHe catH. laB witH prof. picHard

“I use IVUS on all my angioplasties! I always image, before and after.”

“I always say I save the hospital money because by knowing exactly what I’m doing, I have fewer complications.”

“We use a lot of FFR. If the lesion is a difficult interpretation on the angio., and the IVUS give me a borderline

monitors and reports on PCI activity, Pichard notes. In February 2016, the American College of Cardiology and the American Heart Association proposed excluding from public reporting patients with out-of-hospital cardiac arrest and patients in cardiogenic shock.

When working in England in 2010, Ntusi saw monitoring being introduced, with national benchmarks and open reporting of outcomes of diagnostic and interventional procedures becoming “established and acceptable”. There may be some initial resistance in SA as well because doctors still work with a great degree of impunity. Patients hardly ever complain and doctors are hardly ever sued.

Fears that introducing monitoring would make doctors more risk averse and selective about patients they choose to take on have not translated into reality elsewhere, says Ntusi. As well as protecting patients by ensuring they get maximum benefit from procedures, monitoring allows physicians to justify expenses incurred to funders.

“Several publications have shown unequivocally that monitoring leads to greater resource utilisation and cost-effectiveness, which is very important for SA’s public-sector healthcare. Patient outcomes improve rather than being adversely affected,” he says.

“Change works well when doctors participate through their own medical bodies as it’s much less disruptive and more palatable when your peers come up with a system that works in your profession, rather than change being forced on you by government or other external agencies.”

Both monitoring and the superseding of stents as the gold standard of treatment are about smarter use of resources, Ntusi concludes. He expects ways in which the profession will take forward these paradigm shifts to be discussed at professional gatherings this year – and will put them on the agenda himself if they’re not already there.

measurement, I do FFR.” “Two or three years ago, I started using spot stenting for really tight lesions and left the rest alone. I use IVUS to make sure what I leave alone is truly an intermediate lesion and not something severe I just don’t see on angiography. Results have been outstanding. There is no increase in restenosis or thrombosis.”

Source: http://www.ptca.org/ivus/pichard.html

H EALT H CARE G A ZE TTE | J U LY /A U G U S T 2 0 1 6

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beeF UP on biPolar i and ii

By Leverne Gething

BIPOLAR DISORDER IS MORE THAN extreme “mood swings”. Bipolar patients experience a sudden, dramatic shift in emotions that hardly seems to relate to the external situation. In the manic or “high” phase of the illness they aren’t just happy, they are ecstatic. Great bursts of energy normally precede severe bouts of depression in the “low” phase of the disease. Periods of fairly normal moods can be experienced between cycles, and cycles can last for days, weeks, or even months. Since many other diseases can masquerade as bipolar disorder, a thorough medical evaluation is crucial to initiating effective treatment.

HOW TO MAkE AN ACCURATE DIAGNOSIS

Typically a number of tests and examinations are done. Apart from enquiring about mood swings and asking specific questions about the nature of these, the following are red flags: n History of recurrent depression with melancholic features n History of depression with psychotic features n Positive family history of a mood disorder

n Onset of melancholic or psychotic depression before the age of 40 n For women, first onset of depression in postnatal period.

As well as interviewing the patient, it can also be helpful to talk (with the patient’s permission, of course) to their partner, a close family member or friend about what they notice when the person is “high” or “low”. These informants can often give useful information that the patient may not recall or may lack insight into.

MECHANISM OF THE DISEASE

Bipolar disorder has two categories: bipolar I and bipolar II. Bipolar I is what most people are referring to when they use the term “bipolar”, and includes mania that is severe enough to cause serious problems in the life of the sufferer. When someone is manic they may do things that end up being harmful, such as risky sexual behaviour, and repeatedly spending too much money on unneeded or unaffordable items.

The disorder disrupts daily rhythms and patterns tremendously. Bipolar II consists

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Feature Focus | 31

of hypomania and depression. Hypomania is when a person’s mood fluctuates greatly, but not to the degree where their life is seriously disrupted.

The exact cause of bipolar disorder is yet to be established, but the following are said to play a role: n Biological differences. People with bipolar disorder appear to have physical changes in their brains. The significance of these is still uncertain. n Neurotransmitters. An imbalance in naturally occurring brain chemicals called neurotransmitters seems to play a major role in bipolar and other mood disorders. n Inherited traits. Bipolar disorder is more common in people with a close relative with the condition.

HOW CLINICAL MANAGEMENT HAS EVOLVED OVER THE LAST DECADE

The last decade has seen a major rise in medicines for treatment of mania and depression. Until relatively recently the mainstays of bipolar disorder treatment included lithium, divalproex and, to a lesser extent, carbamazepine. However, with the approval of atypical antipsychotics as well as of the novel anti-epileptic agent lamotrigine as maintenance therapy, the armamentarium for managing bipolar disorder has increased significantly.[1] The prevalence of the disease, treatment outcomes and key side-effects of lamotrigine and the atypical antipsychotics olanzapine and quetiapine were featured topics at this year’s American Psychiatric Association meeting. In addition, two novel approaches to treatment for bipolar depression – repetitive transcranial magnetic stimulation and vagus nerve stimulation – were discussed, as well as the importance of psycho-education as part of a comprehensive treatment plan.

RECOMMENDATIONS FOR TREATMENT The South African National Department of Health (2006)[2] lists the following in their treatment guidelines: Non-drug treatment n Hospitalisation may be required during acute mania.

n Psychotherapy, usually after the manic episode has been controlled with medication. n Family therapy and psychoeducation of patient and family to increase compliance and knowledge of the condition. n In severe cases, psychiatristdirected electroconvulsive therapy may be required.

Drug treatment (manic or mixed episodes: acute management) n For agitated and acutely disturbed patients: haloperidol, IM, 2 - 5 mg. This can be repeated in 60 minutes if required. n Monitor vital signs and beware of acute dystonia. and/or n Benzodiazepine, repeat as necessary, to achieve containment, e.g. clonazepam, IM, 2 mg or lorazepam, IM, 2 mg or diazepam, IV, 10 mg. n Switch to oral once containment is achieved.

DIFFICULT CASES

Some of the most tricky cases are when patients come to the clinic with depression and deny all of the typical symptoms that would definitively meet the diagnostic criteria for either bipolar I or bipolar II, but something in the personal or family history suggests that bipolar disorder is possible, or even likely.

It is vitally important to make a proper diagnosis because the treatments used in major depressive disorder (unipolar depression), bipolar I and bipolar II are very different. For example, patients with bipolar disorder should not take a traditional antidepressant alone, because it can make their mood swings more frequent and more intense.

NEW RESEARCH DIRECTIONS

According to a new study undertaken by Osmani et al.[3] at the Center for Research and Telecommunication Experimentation for Networked Communities (CREATE – NET) in Trento, Italy, smartphone sensors can accurately sense mood changes that

H HEALT EALTH HCARE CARE G GA AZE ZETTE TTE || JJU ULY LY/A /AU UG GU USSTT 22001166

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The last decade has seen a major rise in medicines for treatment of mania and depression

â&#x20AC;&#x153;

Lance Katz, managing director of the South African (SA) College of Applied Psychology, says that the intervention of skilled, experienced and professional counsellors and coaches is key to the solution

are indicative of bipolar disorder, which could lead to faster treatment and better outcomes.

Smartphones could be used to track well-known behaviour patterns that are a signature of the condition. For example, the manic phase is often characterised by: hyperactivity, which can be measured by an accelerometer and a GPS; rapid speech, which can be monitored by speech analysis; and frequent conversations, which can be monitored through phone records. In contrast, patients in the depressive stage of this condition demonstrate much-changed levels of all of these behaviours.

WHAT CAN HEALTHCARE WORkERS DO TO HELP PATIENTS?

Lance Katz, managing director of the South African (SA) College of Applied Psychology, says that the intervention of skilled, experienced and professional counsellors and coaches is key to the solution.[4] Key to achieving the above is to be aware of the red

flags and features described in this focus, so that patients can be steered to a diagnosis.

Operations director at the SA Depression and Anxiety Group, Cassey Chambers, says that fewer than 16% of sufferers receive treatment for mental illnesses in SA. Awareness and vigilance can help to change this picture.

1. South African Depression and Anxiety Group (SADAG). New Therapies for Bipolar Disorder. http://www.sadag.org/index.php?option=com_ content&view=article&id=898:new-therapies-forbipolar-disorder&catid=15&Itemid=150 (accessed 27 May 2016).

2. National Department of Health, South Africa. 2006.

Standard Treatment Guidelines and Essential Drug List.

Pretoria: National Department of Health, 2006.

3. Osmani V, Gruenerbl A, Bahle G, et al. Smartphones in mental health: Detecting depressive and manic episodes.

IEEE Pervasive Comput 2015;14(3):10-13.

4. South African College of Applied Psychology. Mental health in South Africa: Whose problem is it? 2013. http:// www.sacap.edu.za/blog/counselling/mental-healthsouth-africa-whose-problem-counselling/ (accessed 27 May 2016).

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CHroniC obstrUCtiVe PUlmonary disease – WHen to take tHat CoUGH serioUsly

By Leverne Gething

WHAT IS OFTEN TERMED “SMOKER’S cough” may in fact be chronic obstructive pulmonary disease (COPD), an underdiagnosed life-threatening lung disease that interferes with normal breathing.

COPD claimed the lives of 3 million people in 2012, accounting for 6% of all deaths globally.[1] The primary cause of COPD is tobacco smoke (including second-hand or passive exposure). An increase in the number of smokers in developing countries and the widespread use of biomass fuels sees COPD increasing. It is projected to become the third leading cause of death globally by 2030.[2] In South Africa (SA) the “colliding epidemics” of TB and HIV infection and the effects of burning biomass fuels and mining exposure threaten to increase the burden.[3]

WHAT DOES IT LOOk LIkE?

COPD encompasses a number of conditions, including emphysema and chronic bronchitis. The partially reversible airflow limitation is caused by an inflammatory response to inhaled toxins, most notably tobacco smoke. Antitrypsin deficiency and various occupational exposures are less common causes in nonsmokers.[4] The airways become inflamed and air sacs in the lungs are damaged, causing the airways to become narrower, making it harder to breathe in and out. Most common symptoms are breathlessness (or a “need for air”), abnormal sputum (a mix of saliva and mucus in the airway) and a chronic cough.

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Feature Focus | 35

MECHANISM OF THE DISEASE

The immune inflammatory changes associated with COPD are linked to tissue repair and remodelling that increases the production of mucus and causes abnormal enlargement of air spaces in the lungs, accompanied by destruction of tissue lining the walls of the air sacs.

HOW TO MAkE AN ACCURATE DIAGNOSIS

To confirm the presence of COPD, patients need to take a spirometry test to measure the size of their lungs and the amount of air flowing in and out. Diagnosis is supported by patient history and physical examination. By looking at how narrow the patient’s airways are, how often symptoms flare up and how breathless they are during everyday activities, the severity of the condition can be assessed. key indicatorS for conSiderinG a diaGnoSiS of copd Consider COPD and perform spirometry if any of the following indicators are present in an individual over 40 years. These indicators are not diagnostic themselves, but the presence of multiple key indicators increases the probability of a diagnosis of COPD. Dyspnoea that is: n progressive (worsens over time) n characteristically worse with exercise n persistent.

Chronic cough: n may be intermittent and may be unproductive.

Chronic sputum production: n any pattern of chronic sputum production may indicate COPD. History of exposure to risk factors: n tobacco smoke (including popular local preparations) n smoke from home cooking and heating fuels n occupational dusts and chemicals n family history of COPD. Source: Global Initiative for Chronic Obstructive Lung Disease (GOLD). 2015. A Pocket Guide to COPD Diagnosis, Management and Prevention: A Guide for Heallth Care Professionals. http://www.goldcopd.it/ materiale/2015/GOLD_Pocket_2015.pdf

HOW CLINICAL MANAGEMENT HAS EVOLVED OVER THE LAST DECADE

Guidelines formulated by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) for management of COPD[5] include assessment and monitoring of the disease, reduction of risk factors and treatment of patients with stable COPD. Smoking cessation improves the early course of the disease. Long-term oxygen improves the length and quality of life in selected patients with hypoxaemia. Surgery benefits a select few only.

GOLD tables the following for the management of stable COPD: reduce symptoms, relieve symptoms by improving exercise tolerance, prevent disease progression, and prevent and treat exacerbations. The main methods of symptom control are improving airflow limitation and reducing dynamic hyperinflation. Airflow limitation is mainly treated with bronchodilators, a vast array of which are currently being developed or are in phase 3 clinical trials. They fall into two categories: the ß2 agonists and muscarinic receptor antagonists. Latest in the ß2 category are very long-acting ß2 agonists, with a duration of action >24 hours, suitable for once-daily dosing. There are also newer, long-acting antimuscarinic agents.[6] The landmark UPLIFT and INSPIRE trials demonstrated the benefits of tiotropium therapy. Patients receiving tiotropium had significant improvement in lung function and reduced risk of exacerbations, episodes of respiratory failure and hospitalisation. Treatment with tiotropium over 4 years was associated with decreased mortality.[6] A new phase 3 clinical study

by GlaxoSmithKline and Innoviva showed that the drug Anoro Ellipta significantly improves lung function in people with COPD who remain symptomatic on tiotropium.[7]

ACUTE EXACERBATIONS The most frequent cause of exacerbations is tracheobronchial infection. Management of exacerbation-prone COPD patients requires the administration of influenza

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Smoking cessation improves the early course of the disease. Long-term oxygen improves the length and quality of life in selected patients with hypoxaemia.

Surgery benefits a select few only

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and pneumococcal vaccinations.

Specific therapy for reduced flareups includes the addition of a phosphodiesterase-4 inhibitor, roflumilast, recently registered in SA for the treatment of severe COPD.

NEW RESEARCH DIRECTIONS

“

Patients should be identified before the end-stage of the illness, when disability is substantial.

Physicians and patients should therefore be educated to recognise that cough, sputum production and especially breathlessness are not trivial

A new study at Manchester Metropolitan University published in Chest demonstrates a link between the exacerbation of COPD and depression.[8] This has implications for healthcare practitioners, who could potentially screen for mental health problems in patients with a history of difficulty coping at home, poor adherence to therapy or experience of a recent bereavement, in a bid to reduce COPD-related hospital readmission.

Other research presented at the European Respiratory Society’s Lung Science Conference this year[9] highlighted new findings around use of ß-blockers to reduce risk of COPD exacerbation.

The findings revealed that use of cardioselective ß-blockers, primarily for the treatment of heart disease, reduced relative risk of COPD exacerbations by 21%. The benefits were increased for patients with heart failure, who saw a reduced risk of 55%.

WHAT CAN HEALTHCARE WORkERS DO TO HELP PATIENTS?

Goals of COPD management in primary care are to improve functional capacity, treat or prevent secondary complications, and improve the quality of life by managing symptoms. With smoking being the primary COPD risk factor, smoking cessation is essential. These goals should ideally be reached with a minimum of sideeffects – a particular challenge in patients with COPD, in whom comorbidities are common. Patients should be identified before the end-stage of the illness, when disability is substantial. Physicians and patients should therefore be educated to recognise that cough, sputum production and especially breathlessness are not trivial.

ACTIONS TO BE TAkEN

n Consider non-pharmacological and pharmacological management in the treatment plan. n Prescribe appropriate inhaled medicines based on symptoms and severity. n Ensure patients have their inhaler device technique and usage checked regularly. n Reassess patients yearly and 3 weeks after each episode of the symptoms worsening. n Detect, monitor and manage comorbidities in conjunction with COPD. n Refer patients to support groups and educational resources.

FURTHER READING Abdool-Gaffar MS, Ambaram A, Ainslie GM, et al.

Guideline for the management of chronic obstructive pulmonary disease – 2011 update. S Afr Med J 2011;101(1):63-73.

1. World Health Organization. March 2015. Chronic obstructive pulmonary disease fact sheet. http://www.who.int/ mediacentre/factsheets/fs315/en/ (accessed 25 May 2016).

2. World Health Organization. Chronic obstructive pulmonary disease. http://www.who.int/respiratory/copd/ en/ (accessed 25 May 2016).

3. Allwood B, Calligaro G. Pathogenesis of chronic obstructive pulmonary disease: An African perspective.

S Afr Med J 2015;105(9):789. DOI:10.7196/SAMJnew.8424 4. Merck Manual. Chronic Obstructive Pulmonary Disease. http://www.merckmanuals.com/professional/pulmonarydisorders/chronic-obstructive-pulmonary-disease-andrelated-disorders/chronic-obstructive-pulmonary-diseasecopd (accessed 25 May 2016).

5. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of COPD. 2016. http://www.who.int/respiratory/ copd/GOLD_WR_06.pdf (accessed 22 June 2016).

6. Kalla IS. Management of COPD and asthma in the 21st century. CME 2013;31(9):331-334.

7. Ozkaya O. Phase 3 drug improves lung function for COPD patients with symptoms after tiotropium. Lung Disease News, 19 May 2016. http://www.lungdiseasenews. com/2016/05/19/anoro-ellipta-improves-lung-functionin-people-with-copd-who-remained-symptomatic-ontiotropium/ (accessed 25 May 2016).

8. Science Daily, 14 March 2016. Beta-blockers could reduce the risk of COPD exacerbations. https://www.sciencedaily. com/releases/2016/03/160314091003.htm (accessed 25 May 2016).

9. Abebaw MY, Iracema L. Treat the brain to improve the lungs? Mental illness as a risk factor for readmission in COPD. Chest 2016;149(4):887-888.

H EALT H CARE G A ZETTE | J U LY /A U G U S T 2 0 1 6

Profile | 39

ProFessor ernette dU toit – transFormer oF liVes

WERE IT NOT FOR 80-YEAR-OLD PROFESSOR Ernette du Toit’s lifetime of achievements in immunology, tissue typing and stemcell registry, thousands of South African (SA) fathers would probably not be paying alimony today and well over 100 other people would be dead.

A pioneer in tissue typing for establishing paternity, Du Toit also set up the SA stem-cell registry and connected it to its global counterparts. She was the medical director of the SA Bone Marrow Registery (SABMR) for 25 years. Prof. Du Toit’s life bears testimony to the power of happenstance, especially when backed by her fierce determination and an ability to make sacrifices and seize opportunities.

Her mother was a no-nonsense Montagu farmer’s widow whose diabetic husband passed away when Du Toit was a mere 6 weeks old. Du Toit showed an early talent for singing and won the Western District Eisteddfod in Swellendam at the tender age of 9. This musical achievement set the tone for a secondary life-long passion, and in her twenties Du Toit took lessons at the University of Cape Town (UCT)’s College of Music. After her medical graduation, she sang the alto solo in Handel’s Messiah at the Cape Town City Hall – a lifetime highlight that she remembers with fondness. When a senior lecturer at the College once asked why she chose medicine over singing, the young Du Toit simply cited her mother’s “no way” attitude. It was a life-changing decision – both for her and the countless beneficiaries of her work in medicine.

The first opportunity came when she was a house surgeon in Cape Town and her surgical mentor George Sachs and his wife Betty told her to “get out of this place and see the world”, leveraging her into an anaesthetics scholarship at the University of Rome. Footloose and fancy-free at 24, she met Aldo, a dashing Italian ship’s

“

Prof. Du Toit’s life bears testimony to the power of happenstance, especially when backed by her fierce determination and an ability to make sacrifices and seize opportunities.

ernette Du toit

engineer on a Mediterranean cruise. For Du Toit, this was the “romance of a lifetime”, yet her mother’s strong will prevailed yet again. She was told: “if you marry an Italian Catholic, you needn’t come back”. That led her to the UK, where she met and married now ex-husband, fellow South African GP, Garron Kaine. The couple worked locums across the UK, including a long stint on the Isle of Harris in the Outer Hebrides.

Du Toit did house visits while her husband poached trout and salmon with the local police chief in his spare time. They returned to Cape Town in 1962, and she became a locum at the Brooklyn Chest Hospital.

While based there, she bumped into Prof.

MC Botha, who remembered her from her student days. At this stage, Botha was heading up the UCT/Groote Schuur blood grouping laboratory and he offered her

a job immediately, which she accepted.

Shortly after Du Toit gave birth to her daughter Nicola, she was offered a chance to spend 3 months in Amsterdam working on her thesis in immune genetics.

This meant leaving her small baby in someone else’s care at home. It was a painful sacrifice Du Toit remembers to this day. Her daughter One of the youngest-ever South Africans to underis now a top medical go a successful bone marrow transplant, Christian Zwanepoel, then 10-months, with his gynaecologist defence lawyer in mother Albie, at the Groote Schuur Private Cape Town.

Academic Hospital in February 2013.

Du Toit changed the face of paternity disputes in this Du Toit country. Thanks to her, many thousands of changed the SA fathers have to confront the scientific face of paternity veracity of her tissue-matching prowess in disputes in this court when paternity is being questioned country. Thanks in alimony claims. She has worked on to her, many over 20 000 paternity cases within the first thousands of decade of the technology being available.

SA fathers have One of the most unique cases involved to confront the twins in a Port Elizabeth paternity dispute scientific veracity – each fathered by a different man. The of her tissuemother was only able to trace one of them matching prowess for alimony. in court when Perhaps most importantly, Du Toit paternity is being translated her early work in what became questioned in Groote Schuur Hospital’s Laboratory alimony claims for Tissue Immunology (LTI) into a bone marrow registry. Today this has international life-saving reach for patients suffering terminal haematological disorders, including leukaemia, lymph-node cancers, certain anaemias and severe combined immune deficiency – a rare genetic disorder in which affected children have no resistance to disease and must be kept isolated from infection after birth.

Prof. Du Toit also had a role in the first-ever heart transplant, by Prof. Chris Barnard, in 1967, in that the LTI tissuematched the heart donor for Louis Washkansky, who survived for 16 days.

Over the ensuing months and years, the LTI moved from matching tissue for hearts

“

to kidneys and then to livers. The LTI staff toured the world with Prof. Barnard, which gave them direct access to the world’s top haematologists and immunologists.

In the meantime, the late Prof. Peter Jacobs had broken new immunological ground in SA with stem-cell transplants.

While the chance of a genetic match in family members was as high as 25%, the net needed to be thrown far wider. This would greatly reduce the chance of immunological transplant rejection. The next obvious step was to set up a tissue-typing registry – stimulated by a Dutch haematologist who coordinated the registration of unrelated potential stem-cell donors worldwide.

“Peter Jacobs said he’d do the transplant side and I was told that you cannot get donors from a global source unless you have a competent donor registry yourself – a kind of a quid-pro-quo and quality assurance set-up”, Du Toit explains. She set to work to comply.

There are 76 bone marrow donor registries worldwide with 28 million registered donors, of whom just 71 000 are South Africans. There are tragically few black donors both locally and globally.

There is also a vast gap between SA’s private transplant funding and unfunded state sector transplants. Add SA’s genetic diversity to the melting pot and it becomes very clear just how miraculous the survival of South African recipients is. For over 70% of patients, their only hope is to find a donor via the SABMR, with the chances of finding a compatible unrelated donor standing at about 1 in 100 000. The therapy itself has a 60 - 70% success rate. A total of 380 unrelated (non-family) bone marrow transplants have been conducted in SA since 1991 after the SABMR was set up.

In 2006 Du Toit coordinated the hosting of the World Marrow Donor Association conference in Cape Town. She also helped discover a unique low-frequency HLA antigen called A43 (a rare genetic marker found mainly in Khoisan people). She tried to take early retirement 16 years ago but nobody could be found to replace her. She finally succeeded this year, and now lives in an oasis-like retirement complex at Century City with her current husband, well-known pathologist Len Anstey.

H EALT H CARE G A ZE TTE | J U LY /A U G U S T 2 0 1 6

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42 | Clinician’s View

HUman PaPillomaVirUs LYNETTE DENNY

Lynette Denny is Chair and Professor of Obstetrics and Gynaecology, registered sub-specialist in Gynaecological Oncology at Groote Schuur Hospital and the University of Cape Town (UCT), and a member of the Institute of Infectious Diseases and Molecular Medicine at UCT. She was named Distinguished Scientist for Improving the Quality of Life of Women by the South African Department of Science and Technology in 2006, and is rated a B2 scientist by the National Research Foundation of South Africa. She received the South African Medical Association award for Extraordinary Service to Medicine in 2012.

She was presented with the British Society for Colposcopy and Cervical Pathology’s Founders’ Medal at the 15th World Congress for Cervical Pathology and Colposcopy in London in 2014, in recognition of her outstanding contribution to women’s health and the prevention of cervical cancer in Africa. In 2015 she won the International Federation of Gynaecology and Obstetrics Award in Vancouver. She runs UCT’s Gynaecological Cancer Research Centre, probing cancers of the cervix, uterus and ovaries.

T

HE HUMAN PAPILLOMAVIRUS (HPV) is so common in general society that many people consider it a benign virus without too much impact on public health. Unfortunately, this is not the case, and the fact that the recent Nobel Prize was awarded to the man who first detected the virus, Prof. Harald Zur Hausen, bears testimony to its importance.

More than 100 types of HPV have been described, many of which infect animals (bovine PV) and skin in various parts of the human body. About 40 types infect the human anogenital tract, causing a range of benign, premalignant and malignant diseases. The most common consequence of infection with certain cancer-associated HPVs is an abnormal Pap smear, and the infection, if not treated, may progress to cervical cancer in some women. Noncancer-associated HPVs are the cause of genital warts, with HPV types 6 and 11 the most common types responsible. The most common types associated with cancer of the cervix are types 16 and 18, along with 13 other less common types. For most individuals, infection caused by HPV, which is transmitted by skin-to-skin contact, including sexual and orogenital contact, will be cleared spontaneously by a healthy immune system within 8 - 18 months. For a small number of individuals, persistent infection will result in disease of the anogenital tract. This can include cervical cancer (the fourth most common cancer

found in women globally after breast, lung and colorectal cancer), anal, vulval and penile cancer as well as cancer of the oropharyngeal tract (including the tonsils).

The advent of the HPV vaccines may have made the long-term outcome of HPV infection much less of a daunting public health problem. There are two types of HPV vaccine: one protects from infection by HPV types 16 and 18 and is known as the bivalent vaccine, and the other protects against types 6, 11, 16 and 18, and is known as the quadrivalent vaccine. There is now a new vaccine that acts against 9 types, known as the 9-valent vaccine. The bivalent and quadrivalent vaccines have been tested in large numbers of human subjects, and with 9 years of follow-up have been shown to be safe, acceptable and, most importantly, effective at preventing disease associated with these types of HPV. It is, however, important to vaccinate girls (and boys) before the onset of sexual activity as the vaccines work to prevent infection, not to treat infection. Another important aspect to current research into HPV is that there are multiple studies that show that the new test can replace the Pap smear as the primary screening test. HPV DNA testing is robust, reproducible and more accurate in detecting cervical cancer and its precursors.

There are many different types of HPV DNA tests, but only a few that have been properly validated. Our research group has for the past 15 years been evaluating the impact of HPV DNA testing followed by immediate treatment on site. This is instead of waiting for a Pap smear result and sending women for a second test known as colposcopy, which illuminates and magnifies the cervix to help make a diagnosis. We have found HPV DNA testing followed by immediate treatment to be a very effective intervention, and we call this “screen and treat”. A new test has come on the market that tests for 15 cancerassociated types of HPV and gives a result within an hour. This is as close to a “pointof-care” test as one can get and we are busy working on its potential impact for coverage of a large segment of the population.

H EALT H CARE G A ZE TTE | J U LY /A U G U S T 2 0 1 6

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