SAMJ Vol 104, No 2 (2014) by HMPG

FEBRUARY 2014

VOL. 104 NO. 2 Palliative care in chronic disease

102, 114, 117, 119, 138

Medicine and the humanities

107, 109

Alcohol-related harms: The real costs

127

Strengthening pharmacovigilance

104

CME: Peripheral vascular disease

142-149

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2013/08/13 10:43 AM

Cape Town at night, nestled beneath Table Mountain. Cape Town has been voted the numberone tourist destination for 2014 by The New York Times and Table Mountain is a world heritage site. FEBRUARY 2014

VOL. 104 NO. 2

FROM THE EDITOR

Medicine and the humanities – doctors as artists Janet Seggie

EDITOR’S CHOICE

CORRESPONDENCE 94

A multidisciplinary approach to cardiac rehabilitation in SA L Sampson

95 The effects of obesity, smoking, and excessive alcohol intake on healthcare expenditure in a comprehensive medical scheme S A Craven 95

LCHF: Response to Drs Boyle and Wasserman T D Noakes

LCHF: Response to Dr Evenepoel T D Noakes

LCHF: Response to Dr Kapp T D Noakes

EDITOR Janet Seggie. BSc (Hons), MD (Birm), FRCP (Lond), FCP (SA) EDITOR EMERITUS Daniel J Ncayiyana, MD (Groningen), FACOG, MD (Hon), FCM (Hon) CONSULTING EDITOR JP de V van Niekerk, MD, FRCR DEPUTY EDITOR Bridget Farham, BSc (Hons), PhD, MB ChB EDITORIAL SYSTEMS MANAGER Melissa Raemaekers, BSc (Hons), PhD SCIENTIFIC EDITOR Kerry Gordon, MSc, PhD TECHNICAL EDITORS Taryn Skikne, BA (Hons), MA Paula van der Bijl, BA, HDipLib Emma Buchanan, BA

IZINDABA 97

Activists warn: Don’t fall victim to our HIV successes

100 100 101 101

OBITUARIES/HULDEBLYKE Louis Heyns Peter Jacobs Walter Hift Eleanor Nash

SAMJ FORUM

NEWS EDITOR Chris Bateman | E-mail: chrisb@hmpg.co.za HEAD OF PUBLISHING Robert Arendse PRODUCTION ASSISTANT Neesha Hassan PROFESSIONAL ADVERTISING Bronlyne Granger | Tel. 021-681-7000 E-mail: bronlyne.granger@hmpg.co.za

MEDICINE AND THE LAW  102 Withholding or withdrawal of treatment and palliative treatment hastening death: The real reason why doctors are not held legally liable for murder D J McQuoid-Mason 104

CLINICAL PRACTICE Strengthening pharmacovigilance in South Africa U Mehta, M Dheda, G Steel, M Blockman, A Ntilivamunda, G Maartens, Y Pillay, K Cohen

107

MEDICINE IN ART Surgery and anaesthesia in art: The contribution of Dorothy Kay P C Gordon, A R Reed

109

MEDICAL EDUCATION The ‘medical humanities’ in health sciences education in South Africa S Reid

111 The intercalated BSc (Med) Honours/MB ChB and integrated MB ChB/PhD tracks at the University of Cape Town: Models for a national medical student research training programme A A Katz, M Futter, B M Mayosi 114

EDITORIALS

115

A new mental health policy for South Africa D J Stein

117

Failing to numb the pain: The untreated epidemic R A Powell, L Radbruch, F N Mwangi-Powell, J Cleary, N Cherny

ART DIRECTOR Brent Meder DTP & DESIGN Anelia du Plessis | Carl Sampson ONLINE MANAGER Gertrude Fani DISTRIBUTION MANAGER Edward Macdonald | Tel. 012-681-7085 HEAD OF SALES AND MARKETING Diane Smith | Tel. 012-481-2069 E-mail: dianes@samedical.org HMPG BOARD OF DIRECTORS Prof. M G Veller (Chair), Prof. M Lukhele, Dr M Mbokota, Prof. A A Stulting, Dr M R Abbas, Prof. J Seggie, Dr G Wolvaardt ASSOCIATE EDITORS Q Abdool Karim, A Dhai, N Khumalo, R C Pattinson, A Rothberg, A A Stulting, J Surka, B Taylor ISSN 0256-9574 Publisher website: www.hmpg.co.za SAMA website: www.samedical.org Journal website: www.samj.org.za

Palliative care in chronic disease L Gwyther

February 2014, Vol. 104, No. 2

RESEARCH

CONTENTS LISTED IN Index Medicus (Medline) Excerpta Medica (EMBASE) Web of Knowledge Biological Abstracts (BIOSIS) Science Citation Index (SciSearch) Current Contents/Clinical Medicine

119

Maintaining wellbeing for South Africans receiving ART: The burden of pain and symptoms is greater with longer ART exposure L Farrant, L Gwyther, N Dinat, K Mmoledi, Ntombi Hatta, R Harding

124

A 5-year analysis of the helicopter air mercy service in Richards Bay, South Africa P A D’Andrea, D J van Hoving, D Wood, W P Smith

127

The cost of harmful alcohol use in South Africa R G Matzopoulos, S Truen, B Bowman, J Corrigall

SAMJ SUBSCRIPTION RATES Local subscriptions R1 044.00 p.a. Foreign subscriptions R2 352.00 p.a. Single copies R95.00

133

Attitudes to organ donation among some urban South African populations remain unchanged: A cross-sectional study (1993 - 2013) H R Etheredge, R E Turner, D Kahn

Members of SAMA receive the SAMJ only on request, as part of their membership beneﬁt.

138

A point-prevalence survey of public hospital inpatients with palliative care needs in Cape Town, South Africa L van Niekerk, P J Raubenheimer

CONTINUING MEDICAL EDUCATION 142

143

147

REVIEW Anticoagulation: Where have we come from and where are we going? The evidence for and against novel anticoagulants G Symons ARTICLES Chronic venous disorders N Cloete Screening for peripheral arterial disease B Natha

149

ABSTRACTS

The SAMJ is published monthly by the Health and Medical Publishing Group (Pty) Ltd, Co. registration 2004/0220 32/07, a subsidiary of SAMA. 28 Main Road (Cnr Devonshire Hill Road), Rondebosch, 7700 Tel. (021) 681-7200. E-mail: publishing@hmpg.co.za Website: www.hmpg.co.za

GUEST EDITORIAL Vascular disease – everyone’s problem G Symons

148

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Table Mountain under full moon light with stars in the sky, Cape Town, South Africa. Photo and text: Eric Nathan Email: eric@ericnathan.com

February 2014, Vol. 104, No. 2

FIRST PUBLISHED IN 1884

Medicine and the humanities – doctors as artists The clinical gaze [has] much in common with the artist’s eye.[1] – M Faith McLellan While only some can claim to be physician/artists, like neurosurgeon Roger Melvill whose paintings featured frequently on the covers of CME,[2] we can surely all claim to be physician/connoisseurs of the arts. This piece is sparked by the art of Dorothy Kay, an acclaimed portrait painter, whose paintings of surgeons and anaesthetists at work in Port Elizabeth in the late 1930s we feature in this edition.[3] There is a growing trend towards integrating the arts into medical education with the aim of promoting creative and scholarly work at the intersections between the arts, humanities and medicine. There exist journals of the creative arts such as The International Journal of the Creative Arts in Interdisciplinary Practice whose mission is to publish research and articles featuring the arts and medicine.[4] Against this background and the establishment of formal programmes that seek to integrate the arts and humanities in medical education, especially in the US, Canada and the UK, the University of Cape Town recently launched a ‘Medicine and the Arts’ masters-level course in the medical humanities.[5] Doctors are also painters, authors, poets and musicians. According to Martha Fleming, ‘Artists and doctors share highly developed observational skills and a fundamental love for humankind’.[6] Luke the Greek physician, patron saint of artists, physicians, students and surgeons (and, interestingly, also of butchers), was an early physician/painter and the first painter of icons (including those of the Virgin Mary and child and Saints Peter and Paul). In the first century AD, Luke wrote the Gospel of St Luke and the Book of the Acts of the Apostles,[7] which has been followed by a long list of physicians writing creatively outside their field of medicine.[1,8] There were several whose novels I enjoyed while contemplating medical school. Frank G Slaughter was an American novelist and surgeon, whose novels sold millions of copies. Slaughter ignored the advice to ‘stick to operating’ from his Pulitzer Prize winning patient and published his first novel, That None Should Die, in 1941. He went on to write a further 55 novels, his last being Transplant in 1987. That None Should Die dealt with socialised medicine and The Road to Bithynia (1951) captured the medical training that Luke would have undergone in Jesus’ time. Scottish novelist AJ Cronin’s The Citadel may have influenced the creators of the UK’s National Health Service. Richard Gordon’s hilarious Doctor in the House novels spawned movies and TV series and featured that most pompous of surgeons, Sir Lancelot Spratt, and his retinue of sycophantic junior staff, nurses and students. Arthur Conan Doyle began writing as a student at Edinburgh University. He specialised as an ophthalmologist, but began to develop the exploits of the legendary sleuth Sherlock Holmes when his practice proved slow. Doyle had Holmes employ the scientific thinking in the course of reasoning out a diagnosis used by Joseph Bell, his former teacher and chief, to solve crimes … ‘It is most certainly to you that I owe Sherlock Holmes ... around the deduction and inference and observation which I have heard you inculcate’.[9] Interestingly, there is an South African-Doyle connection[10] – Doyle served during the second Boer war. Arriving in Cape Town in March 1900, he was assigned to the Langman Enteric Hospital in Bloemfontein. He wrote of the experience, ‘the general condition of the town was very bad. Coffins were out of the question, and the men were lowered in their brown

blankets into shallow graves at the average rate of sixty a day. A sickening smell came from the stricken town. Once when I had ridden out to get an hour or two of change, and the wind changed … You could smell Bloemfontein long before you could see it. Even now if I felt that lowly death smell compounded of disease and disinfectants my heart would sink within me.’ Britain’s conduct in the war – her scorched earth policy and establishment of concentration camps – was widely criticised. In a mitigating response, Doyle wrote ‘The War in South Africa: Its Cause and Conduct’ to emphasise that 14 000 British soldiers died of disease during the conflict, in addition to 8 000 killed in combat.[10] Like Doyle, Kopano Matlwa, a contemporary South African doctor/ novelist, began writing as a medical student. She won the European Union Literary Award and the Wole Soyinka Prize for African Literature in 2010 for her debut novel Coconut that dealt with young blacks negotiating life in the ‘new’ South Africa[11] and was listed for the 2011 Sunday Times Fiction Prize for her subsequent novel, Spilt Milk.[12] Doctors’ success as writers is a reflection of their dealing with patients’ narratives, repeating these in the course of case presentations and documenting consultations, histories and physical examinations, to which all apply analysis and interpretation. According to McLellen,[1] it is ‘through their privileged and intimate contact with those moments of greatest human drama (birth, illness, injury, suffering, disease, death) that physicians are in a unique position to observe, record and create the stories that make us human’. The connection between medicine and poetry was honoured by the ancient Greeks under the dominion of Apollo and there are many well-known modern doctor/poets – John Keats comes to mind. In 2011, the School of Medicine at Yale University and the Medical School at the University College London jointly sponsored a students’ poetry contest that attracted more than 160 entries. The winning poems are worth reading.[13] Many physicians are musicians: the world’s great cities sport symphony and chamber orchestras comprising members of the profession, which are also worth a listen.[14] Janet Seggie

Editor janet.seggie@hmpg.co.za 1. McLellan MF. Literature and Medicine: Physician-writers. Lancet 1997;349(9051):564-567. [http:// dx.doi.org/10.1016/S0140-6736(97)80120-1] 2. Roger Melvill: Representational art. http://www.melvillart.com/ (accessed 10 January 2014). 3. Gordon PC, Reed AR. Surgery and anaesthesia in art: The contribution of Dorothy Kay. S Afr Med J 2014;104(2):107-109. [http://dx.doi.org/10.7196/SAMJ.7247] 4. The International Journal of The Creative Arts in Interdisciplinary Practice. http://www.ijcaip.com/ (accessed 14 November 2013). 5. Reid S. The ‘medical humanities’ in health sciences education in South Africa. S Afr Med J 2014;104(2):109-110. [http://dx.doi.org/10.7196/SAMJ.7928] 6. Fleming M. Looking and Healing: Artists and their Doctors. Lecture Seminar, Centre for Humanities and Health, King’s College London, UK, 2012. http://www.marthafleming.net/looking-and-healingartists-and-their-doctors (accessed 12 July 2013). 7. Luke the Evangelist. http://en.wikipedia.org/wiki/St._Luke (accessed 12 July 2013). 8. Physician writer. http://en.wikipedia.org/wiki/Physician_writer (accessed 12 July 2013). 9. Chalmers J. Conan Doyle and Joseph Bell: The Real Sherlock Holmes, Surgeons’ Hall Museums, Edinburgh. The Independent, UK, 2006. http://www.independent.co.uk/arts-entertainment/theatredance/reviews/conan-doyle-and-joseph-bell-the-real-sherlock-holmes-surgeons-hall-museumsedinburgh-410821.html (accessed 18 November 2013). 10. Roden C. Arthur Conan Doyle: A brief biographical study. The Arthur Conan Doyle Society, 2003 http://www.ash-tree.bc.ca/acdsbio.htm (accessed 18 November 2013). 11. Nthebolan E. Coconut (by Kopano Matlwa). Africa Book Club. 29 January 2012. http://www. africabookclub.com/?p=7688 (accessed 18 November 2013). 12. Makatile D. 2011 Spilt Milk (by Kopano Matlwa). Africa Book Club. 19 May 2011. http://www. africabookclub.com/?p=3742 (accessed 18 November 2013). 13. Chen PW. The Doctor as Poet. Well, NY Times Blog. 1 December 2011. http://well.blogs.nytimes. com/2011/12/01/the-doctor-as-poet/?_r=0 (accessed 18 November 2013). 14. OrchestraDocs. http://www.doctorshobbies.com/OrchestraDocs.htm (accessed 19 November 2013).

S Afr Med J 2014;104(2):92. DOI:10.7196/SAMJ.7936

February 2014, Vol. 104, No. 2

EDITOR’S CHOICE

CME: Peripheral vascular disease

This month’s education component deals with peripheral vascular disease. A review article presents the evidence for and against novel anticoagulants,[1] the use of which was detailed in ‘Venous thromboembolism: Prophylactic and therapeutic practice guideline’. [2] We include summaries of full articles (available online), which consider: • the clinical screening for peripheral arterial disease,[3] important because its presence signals future cerebrovascular complications and premature mortality • the spectrum of chronic venous disorders – which, with a prevalence of 5 - 30% in adults, impact significantly on health and wellbeing – and its clinical and radiological diagnosis.[4]

Palliative care needs in South Africa

Two articles[5,6] and two editorials[7,8] address the palliative care needs in South Africa (SA), and Africa more widely. Van Niekerk and Raubenheimer[5] address the particular needs of patients with severe chronic medical illness … ‘the greatest burden of disease was found in the general medical wards’. Their survey found that the inpatient mortality of medical patients admitted to the general medical service was 11%, with a 12-month post-discharge mortality of 35%. In many cases this was predictable on discharge, reflecting the burden of patients requiring palliative care in the acute medical service. Farrant et al.[6] describe palliative care needs in HIV-positive patients receiving highly active antiretroviral therapy (HAART). The authors found a high symptom burden despite patients receiving treatment, and recommend that detailed symptom assessment and control should be part of HIV care to address palliative care in HIV alongside HAART, as is well established in the UK. A notable finding regarding medical patients was their much younger average age compared with international samples reflecting the burden of disease in patients with non-communicable diseases, cancer and HIV/AIDS.[5] In addition, resource constraints result in patients requiring palliative care for conditions (e.g. end-stage renal failure) that would be treatable in better-resourced settings. The need for palliative care is increasing globally, but is especially critical in developing countries. Of the 58 million annual deaths in 2008, 45 million occurred in developing countries, with the World Health Organization (WHO) estimating that approximately 10 million people are in need of palliative care across Africa. Providing palliative care to patients not only relieves symptoms and improves patient satisfaction, but may also reduce admission rates and length of hospital stay and decrease the overall cost of care.

Failing to numb the pain: The untreated epidemic

An editorial by Powell et al.[7] highlights the consensus statement arising out of the first session of the African Ministers of Health on palliative care, held in September 2013 at the joint conference

of the African Palliative Care Association/Hospice and Palliative Care Association of South Africa in Johannesburg, that proposed ‘... the use of the already established global and regional frameworks provided by the African Union and WHO, to ensure availability of, and access to, essential medicines and technologies for the treatment of pain and other symptoms being experienced by so many in Africa, including children. This includes the procurement and distribution of morphine, to ensure greater availability and access of this main opioid for the management of moderate to severe pain’. This was in response to the reality that no one African country has all seven of the formulations considered essential for the relief of cancer pain (i.e. codeine, immediate and slow-release oral morphine, injectable morphine, oral oxycodone, oral methadone and transdermal fentanyl).

Hidden costs of alcohol-related harms

Matzopoulos et al.[9] unpack, in impressive detail, the economic, social and health costs associated with alcohol-related harms to inform alcohol management policies and laws. The combined total tangible and intangible costs of alcohol harm to the economy were estimated at 10 - 12% of (the 2009) gross domestic product. The impact on health is huge: alcohol is the third-largest contributor to death and disability after unsafe sex/sexually-transmitted infections and interpersonal violence, both of which are themselves influenced by alcohol consumption. The pros and cons of alcohol advertising have been much in the news. Given the prevalence and magnitude of drinking in SA, companies on the supply side of the alcohol market are powerful and their economic influence means that the existing frameworks that guide the regulation and distribution of alcohol are founded on claims of their contributions to the local economy. The authors assert that these industry claims must be assessed against the economic, social and health costs associated with the end use of their products. Furthermore, consideration should be given to who is benefiting from the industry and who is paying its costs. JS 1. Symons G. Anticoagulation: Where have we come from and where are we going? The evidence for and against anticoagulants. S Afr Med J 2014;104(2):143-146. [http://dx.doi.org/10.7196/SAMJ.7873] 2. Jacobson BF, Louw S, Büller H, et al. Venous thromboembolism: Prophylactic and therapeutic practice guideline. S Afr Med J 2013;103(4):260-267. [http://dx.doi.org/10.7196/SAMJ.6706] 3. Natha B. Screening for peripheral arterial disease. S Afr Med J 2014;104(2):148. [http://dx.doi. org/10.7196/SAMJ.7919] 4. Cloete N. Chronic venous disorders. S Afr Med J 2014;104(2):147. [http://dx.doi.org/10.7196/ SAMJ.7918] 5. Van Niekerk L, Raubenheimer PJ. A point-prevalence survey of public hospital inpatients with palliative care needs in Cape Town, South Africa. S Afr Med J 2014;104(2):138-141. [http://dx.doi. org/10.7196/SAMJ.7262] 6. Farrant L, Gwyther L, Dinat N, et al. Maintaining wellbeing for South Africans receiving ART: The burden of pain and symptoms is greater with longer ART exposure. S Afr Med J 2014;104(2):119123. [http://dx.doi.org/10.7196/SAMJ.7461] 7. Powell RA, Radbruch L, Mwangi-Powell FN, et al. Failing to numb the pain: The untreated epidemic. S Afr Med J 2014;104(2):117-118. [http://dx.doi.org/10.7196/SAMJ.7803] 8. Gwyther L. Palliative care in chronic disease. S Afr Med J 2014;104(2):114-115. [http://dx.doi. org/10.7196/SAMJ.7683] 9. Matzopoulos RG, Truen S, Bowman B, Corrigall J. The cost of harmful alcohol use in South Africa. S Afr Med J 2014;104(2):127-132. [http://dx.doi.org/10.7196/SAMJ.7644]

February 2014, Vol. 104, No. 2

ADVERTORIAL

A BIONIC REHABILITATION WONDER and a chance to ‘walk tall’ again A South African first, an exoskeletal bionic walking suit designed to help wheelchair-bound people stand or walk again, perhaps even enabling some to regain independent full mobility, is changing the lives of patients at a rehabilitation centre in Rivonia, Gauteng. Just Walk Bionics is the first rehabilitation centre in South Africa to offer people with lower-extremity paralysis or weakness the chance to stand and walk again using the Ekso suit. The only United States and European officially-approved exoskeleton available, this technological marvel consists of a ready-to-wear portable, battery-operated bionic walking suit. It’s basically a clinical rehabilitation tool for patients with neurological disorders such as MS, ALS, and Guillain Barre, Parkinson’s disease, and generalised weakness caused by other conditions. In future it may also be used for patients who have suffered a stroke. The user needs arm function and adequate upper extremity strength to manage crutches or a walker, depending on the evaluation. The most likely candidates are patients who can transfer themselves independently from a wheelchair to a chair, are between 5’2” – 6’2” (150-190 cm) tall, and weigh 220lbs (100kg) or less.

HOW IT WORKS

Developed and manufactured by Ekso Bionics, the world leader in exoskeleton technology, the Ekso augments mobility, strength and endurance and allows wheelchair users to begin standing and walking again with the help of either a front-rolling walker or crutches. Strapped over the patients clothing, the Ekso uses the patients forward lateral weight shift to initiate a step. Battery-powered motors drive the legs and replace neuromuscular function. Motors power the hip and knee joints. All motion is initiated via an external controller. To use the device effectively, a patient must learn how to balance and shift their weight to achieve an efficient reciprocal gait pattern. The physical therapist uses an electronic pad to control the Ekso and programme desired walking parameters, such as step length and speed. This allows the therapist to teach the patient when to take a step, how to position their body for proper balance, and how to shift their weight for the next step. Ekso walk modes include; FirstStepTM: a physical therapist activates steps with a button push. The user progresses from sitting and standing, to using a walker, to walking with crutches, often in their first session. ActiveStepTM: the user takes control of their steps via buttons on the crutches or walker. ProStepTM: the user achieves the next step by moving their hips forward and shifting them laterally. (Ekso ‘recognises’ that the user is in the correction position, and steps). • All candidates must be medically screened and cleared prior to walking in the suit. They are then evaluated by a biokineticist or physical therapist with extensive training in rehabilitating patients using the Ekso. Most patients are able to master the suit in two to three, one-hour sessions, though this varies from patient to patient. An experienced user can fit or remove the suit in less than five minutes and walk for up to 50 minutes in an hour-long session. The current model can only be used on flat surfaces but future generation suits may be able to navigate steps.

THE JUST WALK BIONICS CENTRE IS REDEFINING MOBILITY AND HOPE FOR LOCAL WHEELCHAIR BOUND PATIENTS.

THE BENEFITS

Over 3 500 people around the world have walked in Ekso (as of August last year). Beyond the psychological benefits of standing and being mobile again, anecdotal evidence suggests significant rehabilitative benefits. These include: • Decreases in spasticity • Decreases in urinary tract infections and better overall bladder and bowel function • Decrease in chronic systemic pain experienced • Metabolic and cardio benefits (according to research results from the Kessler Institute)

EKSO’S OFFICIAL REFERENCE CENTRE IN SOUTH AFRICA

Just Walk Bionics, EKSO’s official reference centre in South Africa, is an advanced rehabilitation centre, opened in June 2013 by Justin Smith and co-founders, biokineticists, Justin Jeffery and Charl Kaschula. It’s the only centre of its kind in Southern Africa. Justin Smith was classified as an incomplete quadriplegic after being shot in his C6 cervical vertebrae in a near-fatal car hijacking. He began his recovery in 2004 and first walked again in 2007. Believing in the benefits of walking normally again after years in a wheelchair, opening the Just Walk Bionics Centre is part of his long-term vision. Smith is now sharing the benefits of his journey with South Africans in a similar position. In addition to the Ekso rehabilitation, the centre provides non-traditional exercise-based therapy to individuals suffering from spinal cord injuries. Just Walk Bionics Biokineticist, Justin Jeffery, says: ‘The Ekso is without a doubt the future for spinal rehabilitation. With a few more engineering advancements and other refinements, I believe within 10 years spinal cord injury patients will walk out of the hospital in an exoskeleton, instead of rolling out in a chair.’ Jeffrey says in his experience, the most amazing benefits for a patient are psychological. ‘One cannot underestimate the effect of standing again after being confined to a wheelchair. Being tall again – seeing eyeball to eyeball – that’s the inherent magic.’ An hour-long supported session in the suit costs R900.

NOTE: Support by Ekso Bionics in the USA is mandatory for all biokineticists or physical therapists. The company has a 100% safety record using the bionic walking suit. For further information, visit www.justwalkbionics.co.za, or join us on Facebook: JustWalkBionics.

CORRESPONDENCE

A multidisciplinary approach to cardiac rehabilitation in SA

To the Editor: As is known, a significant amount of South Africa’s (SA’s) burden of disease is attributed to non-communicable diseases (NCDs) such as ischaemic heart disease (IHD). The South African National Burden of Disease Study 2000[1] showed that 58% of the Western Cape’s burden of disease alone can be attributed to NCDs, with 12% due to IHD. The Global Register of Acute Coronary Events (GRACE) study[2] showed that within 6 months after discharge, 15.8% of patients who have had a myocardial infarction (MI) will suffer a possibly fatal repeat event. The benefits of cardiac rehabilitation (CR) as a preventive measure have been well documented, prompting the development of guidelines for international programmes. In SA, CR is mainly offered in the private sector, with little or none offered in the public sector. Such a programme has, however, existed at Victoria Hospital Wynberg (VHW) since the 1990s, directed at changing the health behaviours and lifestyles of patients who have recently had an MI. VHW serves patients from the Southern Suburbs drainage area of Cape Town. In this population, NCDs accounted for a total of 30.7% of years-of-life-lost, with IHD contributing 7.6%.[3] Between 15 July 2013 and 11 August 2013, an audit was undertaken that compared the CR programme at VHW with the 1995 guidelines of the British Association for Cardiovascular Prevention and Rehabilitation (BACPR). The BACPR guidelines state that a ‘patient pathway of care’ (Fig. 1)[4] should be followed and that seven ‘core components’ (Table 1)[5] should be implemented by a multidisciplinary team.

The CR programme at VHW is facilitated by the occupational therapy department, with involvement of members of the departments of medicine, physiotherapy and dietetics. An audit of the VHW programme was carried out using an auditing sheet that was developed for the South African context, adapted from the auditing sheet of the BACPR. During the four-week audit, four patient sessions were observed (one cycle of CR). The audit confirmed that the programme followed a patient pathway of care similar to that described by the BACPR, and that six of the seven core components were met. The only outstanding component was ‘audit and evaluation’, as this was the first formal audit of the programme itself (Table 1). We concluded that the VHW CRP programme is functional and suitable in the South African context. With further auditing and research, along with partnership with other industries, the programme can be improved and used as a model for the development of national guidelines for CR in SA.

5. The British Association of Cardiovascular Prevention and Rehabilitation. The BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation 2012. 2nd ed. London: BACPR, 2012.

S Afr Med J 2014:104(2):94. DOI.10.7196/SAMJ.7834

Patient presents

Identify + refer

Manage patient and recruit

Assess patient Develop care plan with patient

Deliver care plan

Luke Sampson

Fifth-year MB ChB student, University of Cape Town, South Africa smpluk001@myuct.ac.za

Conduct final assessment 1. Bradshaw D, Nannan N, Laubscher R, et al. South African National Burden of Disease Study: Estimates of Provincial Mortality Western Cape 2000. Cape Town: South African Medical Research Council, 2004. 2. Fox KAA, Dabbous OH, Goldberg RJ, et al. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: Prospective multinational observational study (GRACE). BMJ 2006;333(7578):1091. [http:// dx.doi.org/10.1136/bmj.38985.646481.55] 3. Groenewald P, Bradshaw D, Daniels J, et al. Cause of Death and Premature Mortality in Cape Town, 2001-2006. Cape Town: South African Medical Research Council, 2008. 4. Coates AJS, McGee HM, Stokes HC, Thompson DR. BACR Guidelines for Cardiac Rehabilitation. Oxford: Blackwell Science Ltd, 1995.

Transition to long-term management

Discharge from programme

Fig. 1. ‘Patient Pathway of Care’ proposed by the BACPR guidelines 2012.[5]

Table 1. BACPR requirements fulfilled in the VHW CR programme BACPR core component

Fulfilled

Method used by VHW programme

Health behaviour change and education

Yes

Angina v. MI, what action to take in the event of an MI

Lifestyle and risk-factor management

Yes

Exercise, cessation of smoking, better diet

Psychological health

Yes

Stress and time management, dealing with harsh emotions

Medical risk factor management

Yes

Graded exercise, monitoring of BMI, monitoring of blood glucose in diabetic patients; the venue is located near the emergency unit

Cardioprotective therapies

Yes

Record of surgery and/or pacemaker, use of warfarin is also noted

Long-term management

Yes

The physician addresses treatment concerns and alterations to medical treatments

Audit and evaluation

This was the first comparative audit done, auditing is otherwise sporadic

BACPR = British Association for Cardiovascular Prevention and Rehabilitation; VHW = Victoria Hospital Wynberg; CR = cardiac rehabilitation; MI = myocardial infarction; BMI = body mass index.

February 2014, Vol. 104, No. 2

CORRESPONDENCE

The effects of obesity, smoking, and excessive alcohol intake on healthcare expenditure in a comprehensive medical scheme

To the Editor: In your November 2013 edition, Sturm et al.[1] confirm quantitatively that which we clinicians have known qualitatively for many years, viz. that ‘obesity and tobacco use are associated with significantly increased healthcare expenditure’. This, and other research papers on the same issue, prompt me to ask when the Commissioner of Medical Schemes will permit the various medical aids to charge non-smokers, and those of an appropriate body mass index, a lower monthly premium? And when will the Provincial Health Departments charge appropriately higher fees for management of the preventable salvage work? Why should those who look after themselves subsidise the feckless? S A Craven

Hon. Lecturer in Family Medicine, University of Cape Town, South Africa sacraven@mweb.co.za 1. Sturm R, An R, Maroba J, Patel D. The effects of obesity, smoking, and excessive alcohol intake on healthcare expenditure in a comprehensive medical scheme. S Afr Med J 2013;103(11):840-844. [http://dx.doi.org/10.7196/SAMJ.7260]

S Afr Med J 2014;104(2):95. DOI:10.7196/SAMJ.7791

LCHF: Response to Drs Boyles and Wasserman

Third, the authors are unhappy that I apparently made ‘quite stunning outcomes claims for an undefined intervention, even suggesting that “LCHF has the potential to ‘cure’ some individuals with morbid obesity, [type-2 diabetes mellitus] T2DM, hypertension or metabolic syndrome.”’ Again, the question: Why should we not believe the reports of those who have the most intimate knowledge of their personal medical histories? I was trained to listen very carefully to each patient’s story. If the patients’ memories are correct and they were indeed cured of conditions for which our profession currently provides no cure/s, then perhaps we might learn something by listening more carefully to their stories (‘claims’).[3] Fourth, the authors argue that the burden of proof lies with the proponents of change. Perhaps they are unaware that the revolutionary change in nutritional advice introduced by the US Department of Agriculture in 1977 was based on speculation, not on any definitive scientific proof.[4-6] Many reputable scientists expressed their grave concerns at the time, as stated in my article. The conclusion to my article does in fact provide a review of the evidence for the benefits of LCHF diets, with numerous references to support this. It is heartening to see that Boyles and Wasserman, while criticising methodology, at least agree that the LCHF diet may indeed become the new dietary paradigm for the control of T2DM, obesity and metabolic syndrome. Perhaps it is time that more people involved in patient care afforded their patients the information required to successfully follow this way of eating. Timothy David Noakes

To the Editor: In their recent correspondence to the SAMJ, Drs Boyles and Wasserman make four points regarding my survey on low-carbohydrate, high-fat (LCHF) intake published in the November issue of the SAMJ.[2] First, that my paper suffers from ‘major methodological flaws that are irreconcilable with basic scientific practice’. Twice in my paper I declared all the potential methodological weaknesses and made no claims. I did not assert that these findings support my ‘well-publicised conclusion’ or that they provide a ‘scientific basis for that conclusion’. Second, they imply that neither I, nor these subjects, can be trusted to tell the truth. Rather, the only plausible data are a ‘collection of medical cases seen by a doctor under controlled circumstances and reported from the clinical records’. But, neither author has a valid basis for their judgement since neither has seen the 127 ‘selected and unverified anecdotes’ included in my study. My conclusion is that these ‘anecdotes’ were provided by educated and thoughtful individuals, who wished to share the unexpected and, in some cases, extraordinary benefits they had experienced from the LCHF eating plan. Indeed, a number of the ‘selected and unverified anecdotes’ were from persons with medical training, including some who have achieved professorial status in medicine or allied disciplines. [1]

Department of Human Biology, University of Cape Town and Sports Science Institute of South Africa, Cape Town, South Africa timothy.noakes@uct.ac.za 1. Boyles TH, Wasserman S. Noakes’ low-carbohydrate, high-fat diet: Call for evidence. S Afr Med J 2013;103(12):882-883. [http://dx.doi.org/10.7196/SAMJ.7674] 2. Noakes T. Low-carbohydrate and high-fat intake can manage obesity and associated conditions: Occasional survey. S Afr Med J 2013;103(11):826-830. [http://dx.doi.org/10.7196/SAMJ.7302] 3. Montori VM, Brito JP, Murad MH. The optimal practice of evidence-based medicine incorporating patient preferences in practice guidelines. JAMA 2013;310(23):2503-2504. [http://dx.doi.org/10.1001/ jama.2013.281422] 4. Cooper T. Diet Related to Killer Diseases. Hearings Before the Select Committee on Nutritional and Human Needs of the US Senate. Washington, DC: US Government Printing Oﬃce, 1976:5-40. 5. Taubes G. Good Calories, Bad Calories. New York: Random House, 2008. 6. Minger D. Death by Food Pyramid. How Shoddy Science, Sketchy Politics and Shady Special Interests Have Ruined Our Health. New York: Primal Nutrition, 2014.

S Afr Med J 2014;104(2):95. DOI:10.7196/SAMJ.7855

LCHF: Response to Dr Evenepoel

To the Editor: The main point of Dr Evenepoel’s recent correspondence to the SAMJ[1] appears to be that I misrepresented Case 2’s real story.[2] To insure that readers of this journal are party to the true facts, I invited that patient to respond directly to Dr Evenepoel’s claims. This is the how the patient (Brian Berkman) responded: ‘As the person referred to as Case 2 in Prof. Tim Noakes’

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paper, I would like to clear up some of the inaccuracies and wrong conclusions that Dr Luc Evenepoel suggests in his letter. • While I did attend Dr Evenepoel’s talk about his new book presented to the bariatric support group meeting and did, indeed, ask a question, his talk had nothing to do with my decision not to have surgery. I have not read his book and any inference that I changed my lifestyle based on his suggestion is wrong. • The first scheduled date for bariatric surgery was postponed as the sleep apnoea discovered during pre-operative testing meant, I was told, that I was at too great a risk during anaesthesia unless the sleep apnoea was first addressed. The second date for surgery was postponed as not all the medical professionals had submitted their reports in time for my medical aid company to make a decision about a funding contribution. I voluntarily withdrew from the support group meetings and from making another surgery appointment after seeing my success at shedding weight on my own. • I never consulted Dr Evenepoel nor discussed my diet with him. • In the process of the pre-surgery testing, I finally got to grips with how ill I was and it was that fear that helped me to stick initially to a very strict diet supplied by Judy Kotze, a dietician on the panel. A high-fat, low-carbohydrate diet was never mentioned. • While shedding more than 70 kg, the only carbohydrate I initially ate was a bowl of porridge oats for breakfast. After hearing Prof. Noakes recommend eggs instead of oats during a radio interview, I experimented and found my satiety increased, and once I had purged myself from my addiction to sugar and carbohydrates, I no longer experience cravings for either. • Since March this year, I have maintained my weight at between 79 kg and 82 kg and continue to follow a diet with no starch, sugar or alcohol and with a low-carbohydrate intake mainly from green vegetables. I have never felt better. • As someone who was once addicted to sugar and carbohydrates, it was only after weaning myself from my addiction that it was possible to no longer have cravings and hunger pangs. I am no longer susceptible to the allure of the plate of biscuits to which Dr Evenepoel refers. • Prof. Noakes and others have popularised a new way of thinking, talking and eating about food and for that I am extremely grateful. Having failed at every other type of diet in the past, I would have had surgery to help me lose weight if this low-carbohydrate option had not worked as successfully as it has. I am a new man because of it. • I no longer require medication to control diabetes and hypertension. I can understand why some doctors are threatened by this.’ It is most unfortunate that Dr Evenepoel found it necessary to misrepresent Mr Berkman’s story in his letter to the journal. This raises the question of motive. Timothy David Noakes

Department of Human Biology, University of Cape Town and Sports Science Institute of South Africa, Cape Town, South Africa timothy.noakes@uct.ac.za 1. Evenepoel L. LCHF: Look at the full picture. S Afr Med J 2014;104(1):5. [http://dx.doi.org/10.7196/ SAMJ.7793] 2. Noakes T. Low-carbohydrate and high-fat intake can manage obesity and associated conditions: Occasional survey. S Afr Med J 2013;103(11):826-830. [http://dx.doi.org/10.7196/SAMJ.7302]

S Afr Med J 2014;104(2):95-96. DOI:10.7196/SAMJ.7846

LCHF: Response to Dr Kapp

To the Editor: In his recent correspondence to the SAMJ,[1] Dr Kapp argues that the case studies I reported in the November issue of the SAMJ[2] are ‘no more dramatic that the stories of patients we

clinicians experience on a regular basis … as a result of other diets, including the prudent diet’. This is not my experience. Most who wrote to me reported that they had tried numerous other diets, including the prudent diet, without lasting success and no obvious improvement in their health. The common complaint is that a hypocaloric, low-fat, prudent diet produces continual hunger that cannot be resisted for more than a few months by even the most strong-willed. In contrast, the carbohydrate-restricted diet produces satiation at a substantially lower calorie intake as already shown in 1970.[3] Cases 1 - 5 show this.[2] Because calories from carbohydrate or from fat/protein may not act identically in the human body,[4] greater weight loss may be achieved from a high-fat, protein diet than from an isocaloric, high-carbohydrate diet. This is the current focus of a major new study funded by the NuSi Foundation in the US.[5] In addition, those with insulin resistance (which may include most of the obese) have a reduced capacity to metabolise carbohydrate safely[6] and achieve metabolic and other benefits from a lowcarbohydrate diet that they will not achieve from an equicaloric lowfat, high-carbohydrate diet.[7,8] Thus, the prudent diet is not the equal of the low-carbohydrate diet for those with insulin resistance. This is a key differentiator that cannot blindly be ignored forever. I would challenge the assertion that I am criticising my colleagues and confusing the public. If anyone has been criticised it is me.[9] I have made reference to a number of properly conducted, randomised, controlled clinical trials (RCTs), the results of which have been published in peer-reviewed journals. As reported, these studies show that the lowcarbohydrate diet is ‘at least as effective’ as the 1977 prudent diet. Dr Kapp’s call for an RCT re-states the key recommendation from my paper. My colleagues and I have spent the last two years preparing and submitting funding proposals for just such RCTs and are currently studying the effects of carbohydrate-restricted diets on metabolism, including liver glucose production during prolonged exercise. Finally, I continue to be astonished by the patently obvious evidence, visible daily to anyone with a modicum of common sense, that our current nutritional advice is simply not working. Yet, as a profession we meekly refuse to acknowledge the obvious. Instead we continue to apply treatments and interventions that fail miserably to alter the disease trajectories of so many of our sickest patients with type 2 diabetes mellitus, obesity and metabolic syndrome. Instead, when a small tiny modicum of hope is presented the typical response seems to be to react viscerally by shooting the messenger, as does Dr Kapp. Timothy David Noakes

Department of Human Biology, University of Cape Town and Sports Science Institute of South Africa, Cape Town, South Africa timothy.noakes@uct.ac.za 1. Kapp RG. ‘A new dietary paradigm?’ – prove it. S Afr Med J 2014;104(1):5. [http://dx.doi.org/10.7196/ SAMJ.7729] 2. Noakes T. Low-carbohydrate and high-fat intake can manage obesity and associated conditions: Occasional survey. S Afr Med J 2013;103(11):826-830. [http://dx.doi.org/10.7196/SAMJ.7302] 3. Stock AL, Yudkin J. Nutrient intake of subjects on low carbohydrate diet used in treatment of obesity. Am J Clin Nutr 1970;23(7):948-952. 4. Ebbeling CB, Swain JF, Feldman HA, et al. Effects of dietary composition on energy expenditure during weight-loss maintenance. JAMA 2012;307(24):2627-2634. [http://dx.doi.org/10.1001/jama.2012.6607] 5. Nutrition Science Initiative. The effect of macronutrient composition on energy expenditure and fat balance – is it true that a calorie is a calorie? http://nusi.org/the-science/current-science-in-progress/ energy-balance-consortium-study/#.UqnHsJHAV_Y (accessed 10 December 2013). 6. Petersen KF, Dufour S, Savage DB, et al. The role of skeletal muscle insulin resistance in the pathogenesis of the metabolic syndrome. Proc Natl Acad Sci USA 2007;104(31):12587-12594. [http:// dx.doi.org/10.1073/pnas.0705408104] 7. Volek JS, Phinney SD. A new look at carbohydrate-restricted diets: Separating fact from fiction. Nutrition Today 2013;48(2):E1-E7. [http://dx.doi.org/10.1097/NT.0b013e31828814eb] 8. Volek JS, Fernandez ML, Feinman RD, Phinney SD. Dietary carbohydrate restriction induces a unique metabolic state positively affecting atherogenic dyslipidemia, fatty acid partitioning, and metabolic syndrome. Prog Lipid Res 2008;47(5):307-318. [http://dx.doi.org/10.1016/j.plipres.2008.02.003] 9. Bateman C. Inconvenient truth or public health threat? S Afr Med J 2013;103(2):69-71. [http://dx.doi. org/10.7196/SAMJ.6663]

S Afr Med J 2014;104(2):96. DOI:10.7196/SAMJ.7854

February 2014, Vol. 104, No. 2

Air Liquide Southern Africa Tel: +27 (0)11 389 7262, Celeste Gopaul (Executive Healthcare Assistant) Fax: +27 (0)11 389 7394 www.airliquide.co.za

IZINDABA

Activists warn: Don’t fall victim to our HIV successes

Prof. Alan Whiteside, outgoing head of the Health Economics and HIV/AIDS Research Division (HEARD) at the University of KwaZulu-Natal. Photos by: Chris Bateman.

treatment is always increasing while the rate of HIV infections stubbornly refuses to come down. Displaying graphs depicting ‘advocacy and epidemiological transition points’, Whiteside highlighted the intersection of the curve showing the numbers of people on treatment with that showing the number of

those needing treatment, commenting, ‘We need to celebrate our real successes.’ The second transition (or ‘tipping’) point will be where the number of people on treatment exceeds the number of new infections. What is ‘really interesting’ is seeing how the more people are put on treatment, the lower the rates of death and new infection (especially with treatment as prevention) become. ‘The intersecting lines move. Things happen faster and sooner than before, saving lives, money and time. That’s when we start moving to the end of AIDS.’ Whiteside said SA has lost four crucial years in which preventative measures weren’t taken and now simply ‘has to turn off the tap’ of AIDS infection, while treatment remains crucial ‘for medical, moral, ethical and economic reasons’.

‘We’re in control, but far from winning’ – Heywood

Mark Heywood of the TAC said that, for the first time, ‘we can see that we’re controlling the epidemic and it’s not controlling us’. However, talking about the end of AIDS is ‘misleading, potentially demobilising and irresponsible’. He appealed to UNAIDS to

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Debating whether the end of AIDS is ‘a reality or myth’ (given the 33% global reduction in deaths over the past decade, and the hugely successful up-scaling of treatment and prevention in South Africa) is ‘misleading and dangerous’, warn local civil society activists and researchers. Speaking at the launch of their review of the government’s National Strategic Plan (NSP) for HIV, sexually transmitted infections (STIs) and tuberculosis (TB) (2012 - 2016), were the Treatment Action Campaign (TAC) and Section 27, plus groundbreaking leaders in antiretroviral therapy (ART) Médecins Sans Frontières (MSF) and leading HIV clinician Prof. Francois Venter. They were partially backed by Prof. Alan Whiteside, the outgoing head of the self-funded Health Economics and HIV/AIDS Research Division (HEARD) at the University of KwaZulu-Natal. These bodies’ views provide a cold and often unwelcome counterpoint to the national department of health (NDoH’s) proud broadcasting of South Africa (SA’s) dramatic AIDS turnaround, and the premature global political trend of claiming imminent victory over the pandemic. The debate came during the International Conference on AIDS and STIs in Africa (ICASA) held in Cape Town in early December. Whiteside defined an end to AIDS as zero new infections or adult transmission, 100% prevention of mother-to-child HIV infection and total medical and blood safety, concluding that this is unlikely. ‘What’s most likely is that it will become a low-level endemic disease, unless we come up with a vaccine or a cure. No-one living with AIDS? Certainly not in my lifetime. Everyone on treatment? Possible, but unlikely.’ Touting what he called the ‘economic transition theory’, Whiteside said health is simply not on the global priority list, with neither enough resources nor political will available. SA, like several countries carrying similar, if lesser HIV burdens, is ‘locked in an economic trap’ with no economic transition apparent. International funding streams are uncertain, forcing countries like ours to plumb insufficient domestic resources. Ministries of health and finance live in a waking nightmare in which need for

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‘put this talk back in the can as quickly as possible’. He said that while a great deal had changed since the 1980s, the most recent (2012) United Nations report showed 2.3 million new infections and 1.6 million deaths worldwide, with 10 million Africans still waiting for treatment. Globally, HIV coverage of children remains half that of adults. While HIV is a virus, AIDS ‘has always been about the conditions that facilitate the transmission of the virus’, said Heywood. He identified obstacles such as sex work remaining criminalised, inequality and violence continuing unchecked, and stigma and discrimination, which he said are ‘slightly lower, but still hinder us’. He also warned that governments, riding the wave of AIDS successes, are pushing back civil society’s hold on the reins of accountability at global and national level. Many structures, such as AIDS councils in many countries, have become ‘ossified, corrupt and conservative’ – a real problem because they are most often the gatekeepers of global funds. UNAIDS has fundamentally shifted the focus of its response paradigm from human rights to investment returns, overemphasising the biomedical approach while only paying lip service to a societal response. Currently, non-govermental organisations (NGOs) are fighting for survival, thus lessening government accountability, while deeply socially entrenched and enduring problems facilitate the spread of AIDS. There is no guarantee of a steady exponential response to AIDS, Heywood stressed. ‘We didn’t campaign for a sufficient number of people to be on treatment, but for all people’s right to be on treatment. At best we are nowhere near the end of AIDS. There are

dark clouds ahead. We have to determine the social and political determinants of AIDS and weaknesses in our health systems like drug stock-outs. Civil society is being corporatised and co-opted. I guess I have to apologise for being a spanner in the end-ofAIDS works!’ he joked.

Mark Heywood, veteran TAC activist.

Learn how many are in care

SA’s National Health Minister Dr Aaron Motsoaledi acknowledges ‘logistical problems when it comes to drug distribution’, but notes that sometimes stock-outs are caused by the drug industry. Another issue is the thorny and largely unquantified question of retention in care, which HIV activists allege that government is deliberately avoiding to put the best spin on its success so far. Motsoaledi responds: ‘Look at our life expectancy figures that are increasing. I think they answer that question.’

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With 2.4 million people on ART (up from 923 000 in 2009), 3 540 HIV treatment sites established (up from 490 in 2009), and 23 000 nurses able to initiate patients on treatment compared with 250 four years ago, activists and researchers agree that the health department should take a bow. However Heywood and Venter, in their NSP review, say the lack of monitoring and evaluation could prove the Achilles’ heel of these major gains. They stress that the South African National AIDS Council (SANAC) still has no evaluation framework in place, so there’s no way of knowing how many people are dropping out of treatment, for whatever reason. South Africa’s national figures reflect the total number of people who have ever been initiated on treatment, but vitally fail to reveal the numbers of those currently in care. Says Heywood, ‘We cannot continue not knowing that for very much longer. Without this knowledge, what we’re accepting as truths could lead us into an entirely different space.’

Stock-outs burst treatment success bubble

Heywood said that while the TAC has received extensive praise for its role in battling denialism and forcing ART breakthroughs, recent experience has convinced him that government and SANAC believe that fight is now in the past, ‘and it’s all milk and honey – independent criticism should be muted. In fact, some provinces are showing a fierce intolerance of independence.’ He cited a raid on the SANAC office in Bloemfontein last year by Free State officials variously identifying themselves as either the Hawks or ‘security from the Health MEC’s office’, in which several computers were ‘confiscated’. Many members of the civil-society Stop Stock Outs coalition, who also serve on SANAC, operate from SANAC offices and had a pivotal role in exposing the fact that 54% of Free State facilities experienced drug stock-outs over the past three months. The Free State’s TAC leader also received anonymous death threats over the phone and was reassigned out of the province as a security precaution, Heywood revealed. He said the raid had been reported to Deputy President Kgalema Motlanthe via SANAC. In September and October last year the TAC and Section 27, under the umbrella of the Stop Stock Outs coalition, released the results of a nationwide telephonic survey showing that one in five facilities (459 of 2 139 or 21%) reported a stock-out or shortage in the preceding three months.

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Lean South African lamb and mutton, trimmed of subcutaneous (external) fat, contains less than 10% fat and can be included as part of a healthy, well-balanced diet. Lean South African lamb and mutton compare favourably to other South African animal products, including lean white meat such as chicken without skin. Comparison of the fat content of trimmed (lean) and untrimmed animal products 1,2,3

Food (100g, cooked) Fat (g) Trimmed Lamb, leg, roasted, lean 7.7 Lamb, loin, roasted, lean 7.8 Lamb, shoulder, braised, lean 9.9 Mutton, leg, roasted, lean 7.2 Mutton, loin, roasted, lean 9.8 Mutton, shoulder, braised, lean 8.7 Chicken, dark meat, roasted, without skin 9.8 Chicken, dark meat, boiled, without skin 9.7 Chicken, white meat, roasted, without skin 3.6 Chicken, white meat, boiled, without skin 4.1 Pork, loin, braised, lean 8.3 Untrimmed Lamb, leg, roasted, untrimmed 11.7 Lamb, loin, roasted, untrimmed 20.9 Lamb, shoulder, braised, untrimmed 15.8 Mutton, leg, roasted, untrimmed 10.1 Mutton, loin, roasted, untrimmed 25.4 Mutton, shoulder, braised, untrimmed 11.3 Beef, rump, roasted, untrimmed 14.4 Beef, prime rib, roasted, untrimmed 18.0 Beef, shoulder, braised, untrimmed 8.2 Chicken, meat and skin, boiled 12.6 Chicken, meat and skin, roasted 13.0 Pork, loin, grilled, untrimmed 13.9 Pork, thick rib/breast, braised, untrimmed 25.4

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Untrimmed

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Trimming has a major impact on the fat content of both raw and cooked meat cuts Many butchers trim the subcutaneous fat layer from the cut before selling it to the consumer. Many consumers trim the subcutaneous fat layer at home prior or after cooking If consumers choose not to eat any visible fat, only the muscle tissue is consumed Similar to the removal of the skin from chicken, removal of the subcutaneous fat layer of meat cuts significantly reduces the fat content of red meat.

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What about the type of fat? Despite common reference to animal fats as ‘saturated’, red meat contains both saturated and mono- and polyunsaturated fats. Nearly half of the fats in untrimmed South African lamb and mutton are healthy mono- and polyunsaturated fatty acids. South African lamb and mutton (more than 80% of these animals are raised naturally on the veld) are natural sources of Conjugated Linoleic Acid (CLA). Research suggests that CLA may protect the body against cancer and heart diseases and reduce cholesterol levels (Riserus et al, 2001). 4

FATTY ACIDS (g/100g)

Comparison of the saturated and unsaturated fatty acid content of untrimmed South African lamb, mutton and beef 1, 5

Saturated

Unsaturated

LAMB

MUTTON BEEF

REFERENCES 1. Schönfeldt, H.C.; Hall, N. & Van Heerden. 2012. The Nutrient Content of South African Lamb and Mutton. University of Pretoria & The ARC, Irene, South Africa. 2. Wolmarans P, Danster N, Dalton A, Rossouw K, Schönfeldt H. 2010. Condensed Food Composition Tables for South Africa. Medical research council. Cape Town. 3. Schönfeldt, H.C., Van Heerden, S.M., Van Niekerk, J.M, Visser, R.E. & Heinze, P.H. 1998. The nutrient content of South African fresh and frozen chicken. ARC-Animal Nutrition and Animal Products Institute, Irene. ISBN 0-620-22682-X. 4. Riserus, U., Berglund, L., & Vessby, B. 2001. Conjugated linoleic acid (CLA) reduced abdominal adipose tissue in obese middle-aged men with signs of the metabolic syndrome: a randomised controlled trial. International journal of obesity and related metabolic disorders: Journal of the International Association for the Study of Obesity, 25(8), 1129-1135. 5. Schönfeldt, H.C. & Welgemoed (1996). Composition of South African beef.

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IZINDABA

Half of these were still facing shortages at the time of the survey. Six out of the nine provinces had more than 17% of their facilities reporting shortages. Almost half of antiretroviral (ARV) stock-outs were of lamivudine, efavirenz or stavudine while the median duration of shortages was 30 days, ranging from one day to one year. In 20% of all facilities patients were sent home or referred elsewhere – without medicines. The report – worse than many feared – rocked the public health sector because of its grave implications for the health system and patients, including drug resistance, decreased immunity, increased risk of opportunistic infections and higher overall transmission rates.

NHLS the key – Venter and Rees

Prof. Venter, Deputy Executive Director at the University of the Witwatersrand’s Reproductive Health and HIV Institute, estimates that at every stage of HIV care (from the initial test, to receiving follow up CD4+ cell count results, to being placed on treatment) a staggering 50% of patients are lost. He cites studies showing that patients are more likely to fall out of the system between the time they are tested for HIV and the time they become eligible for treatment. Venter and his colleague Prof. Helen Rees make an impassioned plea in the NSP review for better use of data from the National Health Laboratory Service (NHLS) to understand how many people are falling off treatment, how many are virally suppressed and what their CD4+ cell counts are. Venter lashed out at provinces for playing ‘brinkmanship’ with the NHLS by not paying their bills, and said the level of defensiveness when provinces are confronted with disturbing facts makes it difficult to hold them accountable. ‘National [government] will admit to problems, but the minute you go down to the provinces, there’s a problem,’ he said. He said the NHLS is an invaluable ally in improving the performance of the Pearinda CME Strip.pdf

NSP, and called it ‘inexcusable’ that it has been undermined by the provinces to the point where its services are in danger of being shut down.

Department responds

Dr Yogan Pillay, Deputy Director General of HIV/AIDS, TB and Maternal, Child and Women’s Health at the NDoH scotched many of the activists’ claims. He told Izindaba that his department’s Tier.net system for monitoring the ARV rollout had ‘backcaptured’ data from 1 600 facilities to 2004, including loss-to-follow-up, viral loads, CD4+ counts and viral suppression. His plan is to roll Tier.net out to all 3 000 public sector ART-providing facilities, ‘in a virtual analogue of the TB register’.

South Africa’s national figures reflect the total number of people who have ever been initiated on treatment, but vitally fail to reveal the numbers of those currently in care. Using World Health Organization (WHO) registration guidelines, the department has migrated data from more than 1 600 facilities from Tier One (paper based) to Tier Two (electronic and easier to analyse). The next step (Tier Three) will provide an electronic medical record for each individual patient to allow clinicians to access their treatment history, wherever they present. ‘We’re now moving those facilities with a large number of patients to Tier Three, and within three years hope to embrace all our ART facilities,’ said Pillay. He said that Tier Two is currently being ‘bedded down’ at facility level. Both the President’s Emergency Plan For AIDS Relief (Pepfar) and the Global Fund are helping bankroll the hiring and training of data capturers. A full publication of ‘how we are doing’ is due shortly.

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Regarding activists’ claims about drug stockouts, Pillay said the NDoH has been working with a wide cross-section of civil society organisations ‘for a significant amount of time trying to solve the problems. To write a report as if this is not the case is a little bit disingenuous.’ He added, ‘I’m not suggesting for a moment that there are no stock-outs, but the reports analysis and methodology overestimates the extent.’ Pillay said monitoring systems are in place (via district pharmacists, provinces, the AIDS hotline and civil society, including the HIV Clinicians Society). There are a number of reasons for stock outs, not the least of which is the long supply chain. ‘Nobody wants patients moving onto second- and thirdline drugs, least of all us,’ he added. Asked to give examples of where the drug shortage survey was exaggerated, Pillay said ‘just a few’ include reporting stock-outs of 600 mg pills, when the same facility had identical 200 mg preparations (i.e. three pills dispensed instead of one), and alleging a shortage of stavudine when his staff are busy switching patients onto a replacement drug because of side-effects. ‘To call these stock-outs is just confusing. My big concern, which I’ve conveyed to Mark (Heywood), is that if you make too big a deal out of stock-outs, patients will read this and simply stop bothering to come – and we’ll end up with an unintended consequence, feeding into non-adherence.’ Pillay added, ‘We must work together to ensure there are no stock-outs.’ The battle is obviously far from over: provincial complacency, denialism and mistrust still drive death and sickness – though thankfully no longer on a holocaustlike scale. Meanwhile, however, engagement between previously implacable enemies comes as a welcome relief. Chris Bateman chrisb@hmpg.co.za S Afr Med J 2014;104(2):97-99. DOI:10.7196/SAMJ.7194

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OBITUARIES Louis Heyns

Dr Louis Heyns, a member of the Department of Paediatrics and Child Health at Tygerberg Hospital and Stellenbosch University (SU), died in tragic circumstances in May 2013 at the age of 59 years. After matriculating at Tygerberg High School in Cape Town in 1971, Louis undertook his medical studies at Stellenbosch University, obtaining his MB ChB degree in 1977. He did his military service from 1979 to 1981, serving in missionary hospitals and at 2 Military Hospital in Cape Town. He obtained the Diploma in Child Health of the College of Medicine of South Africa in 1986, a Diploma in Community Health at SU in 1988, BSc Hons in Epidemiology and Statistics at SU in 1990, MPhil in Maternal and Child Health at the University of Cape Town in 1996, and MPhil in Health Sciences Education at SU in 2011. Louis worked in the Paediatric Intensive Care Unit at Tygerberg Hospital for 30 years, initially as a medical officer and subsequently as a consultant. During this period he provided outstanding service to countless children, and was responsible for the postoperative care of numerous children who had undergone cardiac surgery. He taught many generations of paediatricians the skills required to look after critically ill babies and children. He

was also a vitally important member of the Tracheostomy Unit and the Tracheostomy Home Care Programme at Tygerberg Children’s Hospital. Louis was passionate about teaching. He was involved in both under- and postgraduate medical education at SU, and served as an examiner in the last two Diploma in Child Health examinations of the College of Paediatricians of South Africa. An experienced Advanced Paediatric Life Support (APLS) instructor, one of his passions was teaching resuscitation skills to students, doctors, nurses and paramedics. Louis loved to help undergraduate students develop their potential. He was active in student outreach activities and spent many weekends away from home helping students deliver healthcare to impoverished communities. To develop these outreach activities optimally, he served as a board member of the Matie Community Service. He was greatly admired and loved by the students as a mentor and for his dedication to these activities. He was chairman of the Tygerberg Hospital School Board as well as the Departmental Occupational Health and Safety representative for both the hospital and the medical faculty. At the time of his untimely death, Louis was the diplomate representative on the Council of the College of Paediatricians and had served on the Senate of the Colleges of Medicine of South Africa in the previous triennium. Louis was an amazingly caring person, well loved by patients, parents, students and staff. His love for all living creatures was evident in the numerous animals he rescued and nursed back to health. His passing has left a massive void in paediatrics in South Africa, and in our hospital and department in particular. He is survived by his wife Dalene, his daughter Eldalé and his sons Charl and Daneale. Robert Gie Sharon Kling Pierre Goussard Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Parow, Cape Town, South Africa sk@sun.ac.za

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Peter Jacobs

Dr Peter Jacobs was a pioneer of clinical and laboratory haematology in South Africa (SA). Although much of his career coincided with years of apartheid-related isolation, his enormous influence was felt internationally. He led the Department of Haematology at the University of Cape Town and later served as head of Clinical Haematology at Stellenbosch University. In the early 1970s, at a time when Cape Town was central to the field of organ transplantation, Jacobs’ major achievement was the introduction of experimental and clinical bone marrow transplantation (BMT). He published the seminal report of hepatic veno-occlusive disease after BMT in the SAMJ.[1] With colleagues at Cambridge University he developed techniques to reduce graft-versus-host disease through ex vivo application of the monoclonal antibody Campath 1G. He was also instrumental in the establishment of the South African Bone Marrow Registry. In recognition of his outstanding academic accomplishments, he was awarded the centenary medal by the South African Academy of Arts and Science in 2009. Throughout his career, Jacobs trained and mentored countless medical students, nurses, laboratory technicians, graduate physicians and basic scientists. In the midst of political

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and economic instability in SA, many of his trainees left the country to develop their academic careers worldwide. Jacobs remained in SA and continued to practise academic medicine with a tireless, systematic and inquisitive approach. His longstanding interest in lymphoma was influenced in recent years by the region’s HIV epidemic. Jacobs’ biennial South African Lymphoma Study Group conferences, initiated in 1982, were regularly attended by local and visiting lymphoma experts of international repute. The fifteenth of such meetings was held in 2012, where Jacobs’ closing remark was to eagerly invite the attendees to return to Cape Town in 2014. Despite his absence, they will very likely do so. Matthew Seftel Associate Professor, Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Canada matthew.seftel@uhn.ca 1. Jacobs P, Miller JL, Uys CJ, Dietrich BE. Fatal veno-occlusive disease of the liver after chemotherapy, whole-body irradiation and bone marrow transplantation for refractory acute leukaemia. S Afr Med J 1979 Jan 6;55(1):5-10.

Walter Hift

haematology for over three decades. He was loyal to the aspirations of the medical school and the university, a dedicated teacher and an expert clinician. His forte was in undergraduate teaching and formulation of teaching programmes, and he was passionate in the elicitation of physical signs at the bedside. He contributed substantially to research and to the medical literature on nutritional megaloblastic anaemia. The latter was the subject of the thesis for which he was awarded a DM from Oxford University. He was not only interested in the science of medicine but in the classics, and he revived this great love, which had begun in Austria and London, in his retirement. He did a BA in classics at the University of Natal, went on to receive a BA Hons, and then embarked on an MA, which was converted to a PhD because of its great merit. This thesis was entitled ‘Psychiatry and the plays of Euripides’. As a result of this later academic success, he was appointed Honorary Research Associate in Classics at the University of Natal. Walter met his wife Cynthia while serving in the Royal Air Force during World War II. After the war he settled in Durban and undertook some of his postgraduate training at the metropolitan hospitals in Durban, obtaining the Fellowship of the Colleges of Medicine of South Africa. He retired to Jeffreys Bay, joining one of his sons and his family. His charming wife Cynthia died about 3 years before him. He is survived by two sons, one of whom is Professor Richard Hift, Dean of UKZN’s School of Clinical Medicine, and a daughter who lives with her family in Sweden. Walter died of coronary artery disease. Y K Seedat Emeritus Professor of Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa seedaty1@gmail.com

Eleanor Nash

Professor Walter Hift, DM (Oxon), PhD, FCP (SA), died on 5 July 2013. He was born in Austria on 7 November 1921. Walter served the Department of Medicine at the University of KwaZulu-Natal (UKZN) as a consultant in general medicine and

Dr Eleanor Nash took up a position as a physician at Groote Schuur Hospital, Cape Town, in the 1970s. However, her interests changed in midcareer and she trained as a psychiatrist at the University of Cape Town, later becoming a senior and valuable member of the Department of Psychiatry. She made a significant contribution in helping to plan and organise psychiatric and educational programmes, was always available to help and gave wholeheartedly with advice and

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clinical expertise. For instance, she flew to the flood devastated Laingsberg in 1983 where she dealt with the psychological effects on survivors and those who had been devastated by the tragedy. Dr. Nash was passionate about teaching and education. She constructed systems of educational objectives for medical students and psychiatrists, and ran the Human Behaviour course at UCT for medical students - she brought understanding of the psychological aspects of physical illness and the person in the patient. Her book on the subject, a classic, is still in use today. She was particularly active in the postgraduate training of psychiatrists and taught and supervised the work of many trainees through the years. Eleanor did not like injustice or unfairness. She made her views plain and did not hesitate to disagree if she felt strongly about something. During the apartheid years, she strenuously objected to the stringent laws regarding detainees and those suffering the mental effects of incarceration or mistreatment. She pleaded for and treated them and also took part in many such activities impacting on her patients’ mental health. Eleanor had many excellences, but the greatest of them was caring. She was essentially a nurturing person and her students and projects all benefitted from her concern and encouragement. She cared for so many – her family, her colleagues, her friends and not least her patients. She did so much – some she helped to develop, others she supported and some she admonished to do better. She was particularly devoted to the care and guidance of medical students and trainee psychiatrists and psychologists, and there are many practising today, both here and overseas, who owe her a debt of gratitude. Eleanor’s last years were very trying, as she knew of her advancing dementia and fought against it. What more is there to say about Eleanor? She was a fine and decent person, a person of good practice and principle. She had a full professional and personal life and was greatly respected by her colleagues and patients alike. Her passing is a great loss to those who knew her and to her profession. Lynn Gillis Emeritus Professor of Psychiatry, University of Cape Town, South Africa lynn.gillis@uct.ac.za

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MEDICINE AND THE LAW

Withholding or withdrawing treatment and palliative treatment hastening death: The real reason why doctors are not held legally liable for murder D J McQuoid-Mason David McQuoid-Mason is Professor of Law at the Centre for Socio-Legal Studies, University of KwaZulu-Natal, Durban, and publishes and teaches in medical law. Corresponding author: D J McQuoid-Mason (mcquoidm@ukzn.ac.za)

Doctors who hasten the termination of the lives of their patients by withholding or withdrawing treatment or prescribing a potentially fatal palliative dose of medication satisfy the elements of intention and causation of a charge of murder against them. However, the courts have held that, for policy reasons based on ‘society’s legal convictions’, such conduct is not unlawful if the patient consented to it or medical treatment would be futile or palliative treatment may hasten death. Doctors are not held liable for murder because society regards their omissions or acts as lawful – not because they did not have the intention in law to kill or did not cause the death of their patients. S Afr Med J 2014;104(2):102-103. DOI:10.7196/SAMJ.7405

Doctors are generally not liable for murder if they withhold or withdraw treatment or provide palliative treatment that hastens death when the patient has made an advance directive, treatment is futile or the burdens and risks will outweigh the benefits of such treatment.[1] The usual view is that doctors are not liable because they do not intend to kill the patients in such circumstances, and the underlying illness, injury or condition causes the death.[2] Such acts and omissions are said to constitute passive euthanasia, which is not regarded as murder, rather than active euthanasia. However, the distinction is artificial because what is sometimes called ‘passive’ euthanasia involves a positive act, e.g. switching off a ventilator[3] or turning down a pacemaker.[4] To understand the real reason why doctors are not held legally liable in such circumstances we must examine the elements that constitute the crime of murder. It then becomes clear that doctors are not held liable for murder when they withhold or withdraw treatment or hasten the death of their patients through potentially fatal doses of medication, not because they do not have the legal intention to kill their patients or do not cause the death of their patients – but rather because society does not regard such conduct as wrongful.[5] This is demonstrated by considering the legal position regarding the elements of murder in the context of the withholding or withdrawal of treatment and using palliative treatment that hastens death.

Murder

Murder is the intentional and unlawful killing of another human being.[6] For a conviction of murder it must be proved beyond reasonable doubt that: the act or omission was intentional; the alleged perpetrator caused the death; the killing was unlawful; and a human being was killed. The fact that a human being was killed is not usually in contention, but difficulties arise concerning the elements of intention, causation and unlawfulness.

Intention

Intention must be established in murder cases and may be ‘actual’ or ‘eventual’. ‘Actual intention’ occurs where a person directs their will to

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kill a particular person.[7] ‘Eventual intention’ occurs where a person does not mean to kill a person but subjectively foresees the possibility of death because of their conduct and proceeds with such conduct. [7] For example, a doctor withholds or withdraws treatment or prescribes palliative treatment that hastens death despite subjectively foreseeing that the patient may die as a consequence. There is a need to distinguish intention from motive. A person’s motive good or bad is irrelevant to criminal intent.[7] The intention required for murder is the direction of one’s will to kill a person (actual intention) or subjective foresight that a person may be killed (eventual intention). Motive is the reason behind the intention and in law is irrelevant except for the purpose of sentencing in criminal cases or damages in civil cases where it may be an aggravating or mitigating factor. Thus an unlawful act can never become lawful because of a good motive, but may reduce the sentence in murder cases (e.g. active euthanasia).[8] A doctor who withholds or withdraws treatment or prescribes palliative treatment that hastens death may have a good motive – not to engage in futile treatment or to lessen pain for the patient – but legally has the eventual intention to kill the patient. However, the doctor cannot be held liable for murder if any of the other elements of the crime are missing.

Causation

For a conviction of murder it must be shown that the person caused the death of the deceased. ‘Causation’ refers to the act or omission that causes or accelerates death.[9] An accused person need not be the sole cause of the consequential death.[10] If one or more events contribute towards the death of a person, the event that finally hastens the death is regarded as its cause. Both types of causation – factual and legal – must be satisfied before a person will be held legally liable.[11] In homicides, factual causation occurs where a person’s death would not have resulted ‘but for’ the original act or omission that ended in the death of the person.[10] For instance, if a person is seriously injured by a car and subsequently the ambulance transporting him to hospital collides with another car, causing his death – ‘but for’ the negligent driving of the first driver the person would not have died. However,

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the first driver will not be liable unless he or she also legally caused the death of the person. Legal causation occurs where the act or omission that caused the death is either a foreseeable or a direct cause of the person’s death. The foreseeability approach holds that if a person in the position of the perpetrator would have reasonably foreseen the likelihood of death and persisted with their act or omission, then the perpetrator legally caused the death of the deceased.[12] For instance, in the ambulance example, a person in the position of the first driver would not have reasonably foreseen that their negligent driving might lead to an injured person being taken in an ambulance that crashes and kills the patient. The direct consequence approach holds that the perpetrator is liable unless some new act intervenes between the original act or omission that resulted in the ultimate death of the deceased. Therefore, in the example the accident involving the ambulance that killed the patient was a new intervening act. However, the courts have held that an abnormal event which would otherwise be a new intervening act is not such an act if it was actually foreseen[13] or planned by the accused person.[14] Similarly, the victim’s pre-existing physical susceptibilities are not regarded as a new intervening act – ‘the accused takes his victim as he finds him with all his pre-existing physical susceptibilities such as a weak heart or thin skull’.[15] The courts in the UK ‘have been anxious to ensure that the cause of death was attributed to natural disease in all these cases of nonvoluntary assistance in dying’.[2] However, there is no doubt that doctors who withhold or withdraw treatment or prescribe a potentially fatal dose of palliative medication, subjectively foresee that their omissions or acts may result in the death of the patient. Therefore, the death cannot be attributed to a new intervening cause because the ensuing death is not an abnormal or unexpected event. Likewise, the preexisting illness or injury of a patient that eventuates when treatment is withheld or withdrawn, or potentially fatal palliative medication is administered is not legally regarded as a new intervening cause. As a result, in law, doctors who hasten the death of a terminally ill or injured patient by withholding or withdrawing treatment or administering a potentially fatal dose of medicine will have legally caused the death of the patient – although if any of the other elements are not satisfied they cannot be held liable for murder.

Unlawfulness

Unlawfulness must be established for a person to be convicted of murder. Whether or not a person’s act or omission is unlawful will depend upon the legal convictions of the community at the time.[16] Although it is not possible for a person to consent to doctor-assisted suicide in the form of active euthanasia,[8] it is trite that it is lawful for a mentally competent patient to refuse medical treatment even if such refusal will result in their death.

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The courts have also held that it is not unlawful to withdraw treatment from patients where the prognosis is hopeless and medical interventions would amount to ‘a fruitless attempt to save the deceased’s life’.[3] Similarly, in an application to withdraw feeding from a patient in a persistent vegetative state with no hope of recovery who had been artificially fed for over three years, the court held that ‘judged by society’s legal convictions’ it would be reasonable, justifiable and not wrongful for the patient’s wife to be appointed as his curatrix and to order the withdrawal of such feeding even though it would lead to the patient’s death.[5] In cases where such treatment is withheld or withdrawn because: the patient has made an advance directive (e.g. a living will); the treatment would be futile; or the burdens and risks will outweigh the benefits of such treatment (e.g. the treatment may keep alive a severely braindamaged patient), the courts and society do not regard the conduct as unlawful[1] – despite the doctors knowing that their omissions or acts will result in the death of the patient. The courts have held that where the prognosis for a persistent vegetative patient is hopeless and their treatment ‘did not serve the purpose of supporting human life as is commonly known’, the legal convictions of the community would not regard the cessation of artificial feeding as unlawful.[5] Therefore, the real reason why doctors are not held liable for murder despite their intention to end the lives of their patients who are terminally ill or suffering unbearable pain, by withholding or withdrawing treatment or prescribing a potentially fatal palliative drug, is that their conduct is regarded as lawful – not because they did not intend their patients to die or did not cause their patients’ death. Legally, both these elements are present, but unlawfulness is not. As has been said in the UK: ‘When, however, a treatment is discontinued solely by reason of its futility, there is nothing to be lost – and much to be gained by intellectual honesty – in attributing death, correctly, to “Lawful withdrawal of life support systems which were necessitated by [the disease]”’.[2] 1. McQuoid-Mason DJ. Emergency medical treatment and ‘do not resuscitate’ orders: When can they be used? S Afr Med J 2013;103(4):223-225. [http://dx.doi.org/10.7196/SAMJ.6672] 2. Mason JK, Laurie GT. Mason and McCall Smith’s Law and Medical Ethics. 8th ed. Oxford: Oxford University Press, 2011:573-574. 3. S v. Williams 1986 (4) SA 1188 (A). 4. McQuoid-Mason DJ. Pacemakers and end-of-life decisions. S Afr Med J 2005;95(8):566-567. 5. Clarke v. Hurst NO and Others 1992 (4) SA 630 (D). 6. Burchell J. Principles of Criminal Law. 3rd ed. Lansdowne: Juta and Co. Ltd, 2006:667. 7. Burchell J. Principles of Criminal Law. 3rd ed: Lansdowne: Juta and Co. Ltd, 2006: 461-463. 8. S v. Hartmann 1975 (3) SA 532 (C). 9. Burchell J. Principles of Criminal Law. 3rd ed. Lansdowne: Juta and Co. Ltd, 2006:209. 10. S v. Daniels and Others 1983 (3) SA 275 (A). 11. S v. Mokgethi 1990 (1) SA 680 (A). 12. Neethling J, Potgieter JM, Visser PJ. Law of Delict. 4th ed. Durban: Butterworths, 2001:207. 13. S v. Goosen 1989 (4) SA 101 (A). 14. Ex parte Die Minister van Justisie: In re S v. Grotjohn 1970 (2) SA 355 (A). 15. Burchell J. Principles of Criminal Law. 3rd ed. Lansdowne: Juta and Co. Ltd, 2006:219. 16. Minister van Polisie v. Ewels 1975 (3) SA 590 (A).

Accepted 30 August 2013.

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CLINICAL PRACTICE

Strengthening pharmacovigilance in South Africa U Mehta, M Dheda, G Steel, M Blockman, A Ntilivamunda, G Maartens, Y Pillay, K Cohen Ushma Mehta is a consultant for the Division of Clinical Pharmacology, Department of Medicine, University of Cape Town (UCT), South Africa and an independent pharmacovigilance consultant based in Cape Town, South Africa. Mukesh Dheda is the national pharmacovigilance co-ordinator at the Pharmacovigilance Unit, Medicines Regulatory Authority, National Department of Health (NDoH), Pretoria, South Africa. Gavin Steel is Chief Director of Sector-wide Procurement with the Essential Drugs Programme, NDoH, Pretoria, South Africa. Marc Blockman is a senior specialist in the Division of Clinical Pharmacology, Department of Medicine, UCT, South Africa. Augustin Ntilivamunda is a medical officer with the World Health Organization, South Africa. Gary Maartens is Head of the Division of Clinical Pharmacology, Department of Medicine, UCT, South Africa. Yogan Pillay is Deputy Director General of HIV/AIDS, TB and Maternal and Child Health, NDoH, Pretoria, South Africa. Karen Cohen is a specialist in the Division of Clinical Pharmacology, Department of Medicine, UCT, South Africa. Corresponding author: K Cohen (karen.cohen@uct.ac.za)

This report outlines findings and recommendations of a national pharmacovigilance workshop held in August 2012 in South Africa (SA). A survey of current pharmacovigilance activities, conducted in preparation for the meeting, identified multiple programmes collecting drug safety data in SA, with limited co-ordination at national level. The meeting resolved that existing pharmacovigilance programmes need to be strengthened and consolidated to ensure that important local safety issues are addressed, data can be pooled and compared and outputs shared more widely. Pharmacovigilance activities should inform treatment guidelines with the goal of improving patient care. A variety of pharmaco-epidemiological approaches should be employed, including nesting drug safety studies within existing sentinel cohorts and the creation of a pregnancy exposure registry. The attendees agreed on key principles that will inform a national pharmacovigilance plan and compiled a list of priority pharmacovigilance issues facing public health programmes in SA. S Afr Med J 2014;104(2):104-106. DOI:10.7196/SAMJ.7517

Start where you are. Use what you have. Do what you can. â&#x20AC;&#x201C; Arthur Ashe

Pharmacovigilance is the science of adverse drug reactions (ADRs) and drug-related problems: their detection, assessment, management and prevention.[1] In 1992, South Africa (SA) was the first country in Africa to become a member of the World Health Organization (WHO) International Drug Monitoring Programme which co-ordinates international pharmacovigilance activities. Traditionally, pharmacovigilance activities were limited to spontaneous reporting of ADRs, which has been the mainstay of regulatory pharmacovigilance activities for many years. More recently, pharmacovigilance encompasses a growing range of quantitative and qualitative methods, which have become an integral part of the process for registration of medicines. Pharmacovigilance is recognised as an important component of monitoring and evaluation of public health programmes and medical institutions.[1] Pharmacovigilance is a responsibility shared with the medicine regulatory authority, public health programmes, the pharmaceutical industry, and the Essential Drugs Programme (EDP). As pharmacovigilance initiatives evolve and expand in SA, a national consolidated plan that integrates programmatic, regulatory and clinical/institutional pharmacovigilance is needed. This plan would strive to ensure that pharmacovigilance systems prioritise key national medicine safety concerns; are methodologically robust and ethical; and communicate their data and findings effectively to ensure that the data are used to inform policy and improve patient care. In August 2012, key stakeholders attended a national pharmacovigilance workshop hosted by the National Department of Health (NDoH) in collaboration with the University of Cape Town (UCT) supported by a grant from the US Centers for Disease Control

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and Prevention (CDC). The workshop aimed to obtain an overview of non-regulatory pharmacovigilance activities being conducted in the public sector, and to identify key strengths, shortcomings, and opportunities for strengthening and unifying these activities into a coherent national pharmacovigilance plan.

Status of pharmacovigilance activities in SA

Before the workshop, we conducted a survey of non-regulatory pharmacovigilance programmes run by government, academic and other non-governmental institutions. We identified pharmacovigilance systems for the immunisation, HIV and tuberculosis (TB) programmes (four provincial systems and two co-ordinated by the NDoH) and for specific clinical specialties (paediatric HIV and dermatology). Surveillance methods included targeted spontaneous reporting (TSR) for specific drugs or patient groups, active surveillance for adverse reactions nested within existing cohort studies (two provincial systems) and cohort event monitoring (CEM) (two systems for patients receiving antiretroviral (ARV) medicines). While these pharmacovigilance programmes generate potentially useful information, there is little collaboration between programmes, even where the same approach, medicines and patient populations were targeted. Case definitions for solicited adverse events and pharmacovigilance terms differ so that data could not be meaningfully pooled. Case record forms, criteria for reporting and the purposes of reporting differ between similar TSR systems. The two CEM projects initiated for ARVs in two provinces were suspended owing to resource constraints. An active hospital surveillance system at one tertiary

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hospital contributes data to a multicentre, international dermatology registry but there were no links between this system and provincial and national custodians of pharmacovigilance. Generally, outputs of existing systems are limited and were rarely used in policy decisionmaking. The TSR programmes for HIV and TB medicines in four provinces provide some feedback to reporters by means of annual newsletters, periodic multidisciplinary case audits or telephonic feedback. Improved analysis and communication of the data was recognised as an important area for strengthening in all cases. The survey highlighted the need for greater collaboration between the pharmacovigilance programmes so that expertise, experience and resources can be shared and data pooled and compared. There was acknowledgement that other pharmaco-epidemiological approaches, e.g. nesting drug safety studies within existing sentinel cohorts and case control studies, have improved our understanding of medicines safety in SA. Local studies exploring safety of stavudine, which contributed to changes in policy, highlighted the value of such investigator-initiated research.[2-8] Cohort studies are an important source of pharmacovigilance data as they determine ADR incidence, which is needed to inform policy.

Table 1. Programmatic pharmacovigilance priorities in SA HIV/AIDS • Safety of tenofovir as a first-line ARV – especially nephrotoxicity and bone/skeletal toxicity risk • Safety of ARVs in pregnancy – particularly EFV • S afety of medicines used for common comorbidities in HIV-infected patients (i.e. drug-drug interactions, e.g. with anti-diabetic) • Serious skin reactions with TB and HIV medicines TB

National pharmacovigilance plan

The meeting agreed that a national pharmacovigilance plan should be underpinned by five key principles: • Regulatory, programmatic and institutional pharmacovigilance (see box below) should be incorporated into a cohesive national system. To ensure complementarity between different pharmacovigilance programmes, including those of the Medicines Regulatory Authority (MRA), lines of data and communication flow must be clearly defined. An organogram that defines the roles, responsibilities of the MRA and pharmaceutical industry, the EDP and public health programmes and their relationship to each other is needed. • The national pharmacovigilance system should contribute to treatment policy decision-making and improved patient care. The pharmacovigilance system should prioritise safety issues that significantly impact on the health of South Africans. The meeting identified priority pharmacovigilance issues facing the HIV, TB, maternal and child health and immunisation programmes (Table 1). Existing SA pharmacovigilance programmes should be reviewed in terms of their performance in meeting their objectives, the scientific validity of the approach adopted and whether outputs address priority safety concerns. There was agreement that in the short-to-medium term pharmacovigilance surveillance should comprise the following approaches: • spontaneous reporting for all medicines co-ordinated by the MRA • TSR for public health programmes including HIV, TB and immunisation • Regulatory pharmacovigilance focuses on developing a greater understanding of the risk-benefit profile of all registered medicines, the focus being on assessing the merit of the products on the market. • Public health pharmacovigilance programmes target their activities towards minimising the risk of preventable harms associated with recommended treatments or regimens and maintaining public trust. • Institutional/clinical pharmacovigilance aims to minimise medicines-related morbidity and mortality and the costs incurred in managing ADRs at clinical institutions (i.e. clinics and hospitals).

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• improved collection of medicines safety data within existing cohorts (e.g. HIV cohorts) • a pregnancy exposure registry, which will be a sentinel surveillance system for medicines used in pregnancy. • The national pharmacovigilance system should incorporate both passive and active surveillance methods and should build on what already exists and has shown success. Both active and passive surveillance systems provide important medicines safety

• Safety of drugs for MDR- and XDR-TB: • issues of formulations and quality • paediatric MDR and XDR dosing • Drug-drug interactions with HIV drugs and treatments for comorbidities • Deafness (ototoxicity) associated with use of aminoglycosides (‘mycins’) • Hepatotoxicity associated with first- and second-line TB regimens Maternal and child health • Risk of medicine-related harm to pregnant woman and fetus, e.g. PMTCT regimens, co-trimoxazole, fluconazole, TB medicines and novel vaccines • EMB and ocular toxicity in children with TB • Long-term effects of first-line protease inhibitors in children • Safety of recommended ARV regimens in children • Safety of NVP and TDF in children • EFV and neurodevelopmental effects with in utero exposure Immunisation and vaccines • Efficacy and safety of vaccines in HIV/ immunocompromised patients • BCG vaccinated neonates of HIV-infected mothers – safety and implementation of current guidelines • Improved detection of serious events such as intestinal intussusceptions Cross-cutting issues • Poorly tolerated medicines and their impact on adherence • Drug resistance – early warning indicators* • Safety of traditional medicines ARV = antiretroviral; EFV = efavirenz; TB = tuberculosis; MDR = multi-drug resistant; XDR = extensively drug resistant; PMTCT = prevention of mother-to-child transmission; EMB = ethambutol; NVP = nevirapine; TDF = tenofovir. * Drug resistance and lack of efficacy of anti-infective drugs, while included as a pharmacovigilance issue, requires unique and specific expertise and surveillance. The National Health and Laboratory Service has already embarked on such work. This would need to be taken into account when a national pharmacovigilance system is developed further.

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information. Policy-makers and stakeholders need to appreciate the strengths and limitations of each approach. Passive surveillance systems for spontaneous reports of ADRs are useful in detecting signals of unknown or poorly understood ADRs and are important for improving patient care at institutional level. However, they cannot provide epidemiological information, such as incidence of ADRs, or compare the relative safety of two medicines, which is essential for changing public health policy. Active surveillance within sentinel cohorts can determine the incidence and risk factors for specific ADRs. The CEM system requires that a cohort of at least 20 000 patients per treatment regimen be monitored over time.[9] There was general agreement that this costly and labourintensive approach was not appropriate for the SA context. Instead, drug safety analyses should be nested within existing cohorts and cohort collaborations. • Investment in capacity building and training in pharmacovigilance and pharmaco-epidemiology is critical to the success of the system. The NDoH, training institutions and partners need to support clinical staff by providing drug information support and training. Training of relevant stakeholders (e.g. EDP, pharmacy and therapeutic committees, disease programme managers) in the analysis, interpretation and communication of pharmacovigilance data is a priority. Academic institutions should be supported to develop postgraduate courses in pharmacovigilance and pharmaco-epidemiology. • Feedback and communication to stakeholders (from community to government) must be prioritised to ensure success and sustainability of the pharmacovigilance programme. The survey identified poor communication and feedback as major weaknesses of the existing pharmacovigilance systems. Platforms, such as a national pharmacovigilance website, that facilitate information sharing between researchers, policy-makers, pharmaceutical industry, clinicians, patients and the public should be created and supported. The NDoH requires a robust data management system that can respond to the requirements of the national pharmacovigilance plan. The data management system should allow for routine analysis and reporting of data, including feedback to reporters and other relevant stakeholders.

Progress to date

The NDoH has already embarked on addressing the recommendations that arose from the workshop and has appointed a co-ordinator to facilitate implementation. A national decentralised TSR system for HIV and TB is being established and is at various phases of implementation in six provinces. Spontaneous reports are reviewed by a sub-district multidisciplinary health team to identify important reporting trends and preventable factors, including medication errors and system errors. It is hoped that this non-punitive multidisciplinary approach to reviewing ADR cases at institutional level will encourage spontaneous reporting, support clinical governance and improved management of patients with ADRs. The NDoH is implementing a national pregnancy exposure registry and birth defect surveillance programme at sentinel sites throughout the country to assess the safety of medicines commonly

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used in pregnancy. Instances of serious ADRs in pregnant woman and the incidence of adverse birth outcomes such as stillbirth, low birth weight, and congenital anomalies will be determined.[10] The first site is currently being initiated in KwaZulu-Natal province.

Way forward

The relationship between the MRA, public health programmes and clinical services management within the NDoH needs to be clarified and operationalised. A key recommendation of the workshop was the creation of a national pharmacovigilance policy that will underpin the SA pharmacovigilance system. Such a policy would set the stage for an ethical and scientifically sound national pharmacovigilance programme that could significantly benefit public health and patient care. Acknowledgements. The authors are grateful to the attendees of the meeting who contributed to the discussions and recommendations that are reflected in this report. The participants represented the following organisations: KwaZulu-Natal Department of Health, Management Sciences for Health, Medicines Control Council, MEDUNSA, Mpumalanga Department of Health, NDoH, Right to Care, the Joint United Nations Programme on HIV/AIDS, the CDC, US Agency for International Development, UCT, the University of KwaZulu-Natal, the University of the Free State, VP Health Systems, Wits Reproductive Health and HIV Research Institute, and the WHO. The national survey and meeting was jointly funded by the office of the Deputy DirectorGeneral: HIV/AIDS, TB and Maternal and Child Health of the NDoH and by the US President’s Emergency Plan for AIDS Relief through the CDC under the terms of the Cooperative Agreement #GH000371. The content of the report is solely the responsibility of the authors and does not necessarily represent the official views of the CDC.

1. WHO Collaborating Centre for International Drug Monitoring. The Importance of Pharmacovigilance. UK: WHO, 2002. http://apps.who.int/medicinedocs/en/d/Js4893e/ (accessed 3 December 2013). 2. Bolhaar MG, Karstaedt AS. A high incidence of lactic acidosis and symptomatic hyperlactatemia in women receiving highly active antiretroviral therapy in Soweto, South Africa. Clin Infect Dis 2007;45(2):254-260. [http://dx.doi.org/10.1086/518976] 3. Geddes R, Knight S, Moosa MYS, Reddi A, Uebel K, Sunpath H. A high incidence of nucleoside reverse transcriptase inhibitor (NRTI)-induced lactic acidosis in HIV-infected patients in a South African context. S Afr Med J 2006;96(8):722-724. 4. Boulle A, Orrell C, Kaplan R, et al. Substitutions due to antiretroviral toxicity or contraindication in the first 3 years of antiretroviral therapy in a large South African cohort. Antivir Ther 2007;12(5):753-760. 5. Westreich DJ, Sanne I, Maskew M, et al. Tuberculosis treatment and risk of stavudine substitution in firstline antiretroviral therapy. Clin Infect Dis 2009;48(11):1617-1623. [http://dx.doi.org/10.1086/598977] 6. Perez EH, Dawood H, Chetty U, Esterhuizen TM, Bizaare M. Validation of the Accutrend lactate meter for hyperlactatemia screening during antiretroviral therapy in a resource-poor setting. Int J Infect Dis 2008;12(5):553-556. [http://dx.doi.org/10.1016/j.ijid.2008.03.007] 7. Maskew M, Westreich D, Fox MP, Maotoe T, Sanne IM. Effectiveness and safety of 30 mg versus 40 mg stavudine regimens: A cohort study among HIV-infected adults initiating HAART in South Africa. J Int AIDS Soc 2012;15:13. [http://dx.doi.org/10.1186/1758-2652-15-13] 8. Schutz C, Boulle A, Stead D, Rebe, Osler M, Meintjies G. Reduced referral and case fatality rates for severe symptomatic hyperlactataemia in a South African public sector antiretroviral programme: A retrospective observational study. AIDS Res Ther 2010;7:13. [http://dx.doi.org/10.1186/1742-6405-7-13] 9. World Health Organization. A Practical Handbook on the Pharmacovigilance of Antiretroviral Medicines. Geneva: WHO, 2009. http://www.who.int/medicines/areas/quality_safety/safety_efficacy/ HIVhandbook.pdf (accessed 3 December 2013). 10. Mehta U, Clerk C, Allen E, et al. Protocol for a drugs exposure pregnancy registry for implementation in resource limited settings. BMC Pregnancy Childbirth 2012;12:89. [http://dx.doi.org/10.1186/14712393-12-89]

Accepted 17 September 2013.

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MEDICINE IN ART

Surgery and anaesthesia in art: The contribution of Dorothy Kay P C Gordon, A R Reed Emeritus Associate Professor Peter Gordon, Department of Anaesthesia, University of Cape Town, South Africa, is archivist to South African Society of Anaesthesiologists and curator of the Nagin Parbhoo History of Anaesthesia Museum, Cape Town, South Africa. Anthony Reed is Chief Specialist Anaesthesiologist at New Somerset Hospital, Cape Town, and a senior lecturer in the Department of Anaesthesia, University of Cape Town. Corresponding author: P C Gordon (peter.gordon@uct.ac.za)

Dorothy Kay, the acclaimed Irish-born Port Elizabeth artist, married Dr Hobart Kay, FRCSI, in Cape Town, South Africa, in 1910. She was an exceptional portrait painter, whose astute observation of detail and ability to empathise with her subject and convey character brought her much important work. Her traditional British realist-school style of painting, and ability to depict mechanical equipment accurately, led to several industrial commissions. In 1937 these skills combined to produce her largest painting, ‘Surgery’, which depicts a patient undergoing an abdominal operation in a Port Elizabeth hospital. The painting graphically captures the skill and care exhibited by the anaesthetist, together with the anaesthetic equipment used at that time. During the war Dorothy became an accredited war artist. Eight of her wartime paintings were purchased by the Union Government and are now housed in the Ditsong National Museum of Military History in Saxonwold, Johannesburg. Two of these paintings of medical interest are discussed. The first, entitled ‘Operation in a Base Hospital’, depicts surgery being performed in a base hospital and is very similar in composition to ‘Surgery’. The second, entitled ‘Blood to Save Lives’, portrays a volunteer donating blood. S Afr Med J 2014;104(2):107-109. DOI:10.7196/SAMJ.7247

Dorothy Kay (nee Elvery) was born in County Wicklow in Ireland in 1886, into a family richly endowed with artistic talent. She received formal training at the Metropolitan School of Art and the Royal Hibernian Academy School in Dublin. Through her brother Phillip, a student at the Royal College of Surgeons in Dublin, she met and fell in love with South African William Hobart Ashburner Kay, a Pretoria-born medical student who was specialising in surgery at the college. In 1909, after becoming the youngest student to qualify with the RCSI, he sailed for Cape Town. Dorothy followed soon afterwards and they were married in Cape Town the following year. After unsuccessfully opening a surgical practice in Pretoria, Hobart accepted an appointment as Medical Officer (MO) of Health for the Northern Transvaal and Zoutpansberg district based in Nylstroom, where the couple had their first child. In 1914 Hobart was ordered to return to Pretoria to take over as MO of the prisoner-of-war (POW) camp at Roberts’ Heights (later named Voortrekkerhoogte). He was later sent to Fort Napier in Pietermaritzburg when the POW camp was moved there. In 1915 Captain (Dr) Kay left for active service in German East Africa. Following his return in 1917, he was appointed District Surgeon and Port Health Officer of Port Elizabeth (as successor to a Dr Rees, who had died from typhus fever contracted while on duty). Dorothy, who was by this time a mother of four, established herself as doyenne of the arts in Port Elizabeth and was a founder member of the Eastern Province Society of Arts and Crafts. She was an exceptional portrait painter, whose astute observation of detail and ability to empathise with her subject and convey character brought her many important commissions, including portraits of General Jan Smuts and several of Port Elizabeth’s mayors. Her traditional British realist-school style of painting contrasted strongly with that of her

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contemporary, expressionist painter Irma Stern. During the 1920s Dorothy began to etch, receiving international acclaim. One of her etchings, exhibited at the Dominion Artists’ Exhibition in London in 1926 and entitled ‘Romance’, was purchased by Queen Mary.

‘Surgery’

Dorothy’s skill as a draughtswoman and her ability to draw technical, mechanical subjects led to her being commissioned by institutions such as General Motors, the Reserve Bank and Climax Rock Drills. Her ability to depict mechanical equipment accurately, as well as her gift for capturing her human subjects’ likenesses and personalities, led to a large, technically experimental work in which she portrayed surgeons, an anaesthetist and nurses at work in an operating theatre in which the patient was undergoing a cholecystectomy. In 1937, she visited three hospitals and observed at least a cholecystectomy and an appendectomy. She then completed 27 pages of preparatory sketches, recording detailed information on the staff, instruments and technical equipment used before producing the large oil-oncanvas painting ‘Surgery’ (Fig. 1). The painting graphically captures the care and vigilance exhibited by anaesthetists in their role as keeper of the bridge between life and death in the days before sophisticated monitoring. It also depicts in detail the anaesthetic equipment used in Port Elizabeth at the time. The anaesthetic consisted of oxygen, warm ether and chloroform, administered by means of a Shipway apparatus and a Schimmelbusch mask. The carbon dioxide canister was used to administer carbon dioxide to hasten the inhalational induction with ether. After Dorothy’s death in 1964, the painting was donated to the University of Cape Town (UCT) Medical School by the artist’s daughters and is now on display in the Department of Surgery. A high-resolution copy of the painting, together with examples of the anaesthetic apparatus used,

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can be found in the Nagin Parbhoo History of Anaesthesia Museum in the Department of Anaesthesia at Groote Schuur Hospital, Cape Town. Dr R A (‘Pom’) Moore-Dyke, the anaesthetist in ‘Surgery’, was born in Morija, Basutoland, in 1901, of missionary stock. Educated at Kingswood College, Grahamstown, he commenced his medical studies at UCT and qualified at Guy’s Hospital, London, in 1926. After a brief stint practising in South Africa, he travelled to London to specialise in anaesthesia. Returning to this country in 1930, he practised as a specialist anaesthetist in Port Elizabeth. During World War II, while serving at Baragwanath Hospital, Johannesburg, he was instrumental in the formation of the South African Society of Anaesthetists (SASA) when, at a regular informal meeting of anaesthetists in the Johannesburg area, he proposed the formation of the society. He was offered the chair of the new society but declined in favour of his senior, Dr Benjamin Weinbren. At the inaugural meeting held at Johannesburg Hospital on 1 August 1943, Weinbren was elected President and Major Moore-Dyke Secretary/ Treasurer of SASA. Moore-Dyke served his country with distinction in North Africa, the Western Desert and Italy and was mentioned in dispatches. He was elected President of SASA for 1956 - 1957 and represented the Union of South Africa at the first World Congress of Anaesthesiologists in Holland in 1956.

method. An ethyl chloride container is present; ethyl chloride could have been used to speed up induction of anaesthesia. The syringe would have probably been used for administering morphine for analgesia or atropine to dry up secretions. An intravenous infusion is running. The patient’s name is unknown, but according to notes in the Ditsong catalogue he was a perfectly fit member of the hospital staff who posed for the painting! The second painting (Ditsong War Museum Catalogue 1546) is entitled ‘Blood to Save Lives’ (Fig. 3). The painting was bought by the Union Government during the war, presumably to encourage blood donation.

Family life

To become a successful artist while bringing up four children (including twins) could not have been easy, and was only made

War artist

In 1941 Dorothy Kay made contact with Major J Wright, who facilitated her acceptance as an accredited war artist. She recorded aspects of military activities on the home front, which included painting the searchlights and heavy guns of coastal and harbour defences, and sketching at military field hospitals. Eight of these paintings, purchased by the Union Government, are stored in the Ditsong National Museum of Military History in Saxonwold, Johannesburg. Two of the paintings are of medical interest. The first (Ditsong War Museum Catalogue 1191), entitled ‘Operation in a Base Hospital’ (Fig. 2), was enacted in a tent in a base hospital at the Zonderwater Military Camp near Cullinan in September 1941. In keeping with the equipment available in a field hospital at the time, the Shipway apparatus has been removed and anaesthesia is being administered with a Schimmelbusch mask and ether using the drop

Fig. 2. ‘Operation in a Base Hospital’. Although the background and details differ from ‘Surgery’ (Fig. 1), the composition of the central figures is very similar and the artist evidently drew heavily on her previous painting. The anaesthetist is Major R A Moore-Dyke. The surgeon facing the observer is Dr Hobart Kay, assisted by Dr Tennyson Oates. The nurse on the right is recorded on the back of the painting to be Patricia Riley, Dorothy Kay’s daughter.

Fig. 1. ‘Surgery’. The surgery depicted in the painting was performed by Dr Bruce Macrae, assisted by Dr Tennyson Oates. The anaesthetist was Dr R A (‘Pom’) Moore-Dyke. In the finished work, Kay portrays members of her family. Her husband Hobart is clearly seen facing the viewer, the nurse on the left was posed by the artist’s daughter Patricia, and the scrub sister on the right represents a portrait of the artist herself. Dorothy’s inclusion of herself in ‘Surgery’ fits in with her philosophy that ‘Everything you do is a portrait of yourself ’.

Fig. 3. ‘Blood to Save Lives’. The artist used her daughters as models – Mrs Joan Wright, Voluntary Aid detachment, as the nurse and Mrs Patricia Riley as the donor.

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possible with the support of Dorothy’s husband Hobart and servant Annie Mavata. As her daughter Marjorie notes, ‘Dorothy could never have taken up a career in art had it not been for the unceasing assistance that Hobart so happily gave her. From the mid-1920s it was Hobart who undertook the provisioning of the household and by so doing, left Dorothy free from the distractions she detested: the fragmentation of concentration consequent on the running of a household.’[1] Hobart died in Port Elizabeth in October 1948 after a long illness. Dorothy died in Port Elizabeth in May 1964 and is buried in the family grave with her mother and Hobart. The history of medicine in South Africa is indebted to Dorothy Kay and artists like her, who bring the past to life in their paintings. Acknowledgements. Our thanks are extended to Mr Allan Sinclair, Curator, Military Art Aviation, Ditsong National Museum of Military History,

Saxonwold, Johannesburg, for assistance and permission to publish the paintings illustrated in Figs 2 and 3. 1. Reynolds M. ‘Everything You Do is a Portrait of Yourself ’: Dorothy Kay – a Biography. Cape Town: A M Reynolds, 1989.

Bibliography Arnold M. Women and Art in South Africa. Cape Town: David Philip Publishers, 1996. Gordon PC. Surgery by Dorothy Kay. Southern African Journal of Anaesthesia and Analgesia 2011;17(3):222-223. Parbhoo NP. Five Decades: The South African Society of Anaesthetists 1943 - 1993. Cape Town: National Book Printers, Cape Town, 1993. Parbhoo NP. The South African Society of Anaesthetists, 1943 - 1993. S Afr Med J 1993;83(4):283-285. Shipway FE. The advantages of warm anaesthetic vapours and an apparatus for their administration. Lancet 1916;1:70-74. Wright J. Dorothy Kay: Portrait, Figurative Artist and Illustrator 1886 - 196hz. Supplement to the South African Art Times, March 2010.

Accepted 25 July 2013.

MEDICAL EDUCATION

The ‘medical humanities’ in health sciences education in South Africa S Reid Steve Reid represents the Primary Health Care Directorate of the University of Cape Town. Corresponding author: S Reid (steve.reid@uct.ac.za) A new masters-level course, ‘Medicine and the Arts’, will be offered in 2014 at the University of Cape Town, setting a precedent for interdisciplinary education in the field of medical humanities in South Africa. The humanities and social sciences have always been an implicit part of undergraduate and postgraduate education in the health sciences, but increasingly they are becoming an explicit and essential component of the curriculum, as the importance of graduate attributes and outcomes in the workplace is acknowledged. Traditionally, the medical humanities have included medical ethics, history, literature and anthropology. Less prominent in the literature has been the engagement with medicine of the disciplines of sociology, politics, philosophy, linguistics, education, and law, as well as the creative and expressive arts. The development of the medical humanities in education and research in South Africa is set to expand over the next few years, and it looks as if it will be an exciting inter-disciplinary journey. S Afr Med J 2014;104(2):109-110. DOI:10.7196/SAMJ.7928

The University of Cape Town (UCT) will offer a new masters-level course through the Faculty of Humanities named ‘Medicine and the Arts’ for the first time in 2014, attracting interested humanities and health sciences students. The course aims to facilitate the exploration and engagement of the trans-disciplinary space between health sciences, social sciences and the arts. Twelve seminars over one semester will guide students through the life cycle from birth to death as seen from the perspectives of artists, medical doctors, and social scientists. Each seminar will be jointly presented by an artist, a social scientist, and a medical practitioner discussing a core theme, highlighting the multiple ways in which the body is conceptualised. Students will have the chance to think through the life cycle from genetics and conception to death; to share points of connection and difference; and, in the process, to develop relationship synergies between arts, social sciences and medicine. The seminars will be held in various

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locations, including health facilities and museums, each contributing a specific context to the discussion. It is anticipated that new projects and initiatives will arise from the inter-disciplinary study of relevant literature, discussions and assignments. The humanities and social sciences have always been an implicit part of undergraduate and postgraduate education in the health sciences, but increasingly they are becoming an explicit and essential component of the curriculum, as the importance of graduate attributes and outcomes in the workplace is acknowledged. [1] Specific sets of skills and attitudes are required for professional behaviour: the ability to work in a team, the application of medical ethics, meaningful communication, active listening, the facilitation of patients’ expectations and fears, developing partnerships with patients and families, and co-creating feasible management plans with patients.[2,3] No-one would disagree that our graduates need to be empathic,[4] able to communicate well with their patients and colleagues, and mindful of patient autonomy, and that they need

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to show respect for cultural diversity.[5,6] However, how to produce such noble educational outcomes is the subject of much debate: while some would claim that the humanities and the arts have a role to play in producing different kinds of health professionals, others see the medical humanities primarily as a critical intellectual space for reflexive contemplation of the power of medicine, the history of medicine and the cultural ways in which biomedical frameworks have been interpreted. What do we mean by the ‘medical humanities’ in the context of health sciences education? This phrase is in quotation marks because it is a starting point for discussion, and not quite the right term. There is a substantial body of literature associated with the medical humanities, including a number of dedicated journals based in Europe and the USA.[7,8] Firstly, since we are dealing with health sciences education and not just medical education, the issues need to be broadened to include the health sciences apart from medicine. Secondly, medical humanities frameworks may or may not be helpful in a South African (SA) context, where issues of social justice and health inequalities dominate delivery of healthcare. Since a medical humanities course was first proposed by Benatar[9] in 1997 as a formal component of SA curricula, little further development has taken place. Furthermore, most medical humanities studies are carried out by humanities scholars in the field of medicine, as opposed to medical or health sciences education, using a humanities or social science lens. Much as scholars of the humanities would prefer to maintain the integrity of their disciplines in an academic environment,[10] the empirical basis of Western medicine forms the dominant paradigm in health sciences education. Our students need an appreciation and respect for different ways of seeing and describing the same phenomenon, principally centred around the illness experience, and our graduates need to access appropriate skills and tools as the situation demands it. On the one hand they need the technical skills of biomedicine that have been shown to be helpful to populations through randomised controlled trials, but this needs to be tempered, as Olser said,[11] by a sensitivity to the individual who is the patient, so that the appropriate intervention can be tailored to the patient’s particular need. This requires a certain flexibility on the part of the student and the health professional: slipping in an out of different paradigms is a complex business better suited to certain personalities than others.[12] Traditionally, the medical humanities have included medical ethics, history, literature and anthropology. These disciplines use critical, interpretive or historical methods, in addition to the empirical approaches that dominate Western medicine. This can be very confusing for lecturers as well as students in the health sciences who take a positivist paradigm for granted, having been exposed to little else.[13] Less prominent in the literature have been the disciplines, together with their associated theoretical frameworks, of sociology, politics, philosophy, linguistics, education, and law, as well as the creative and expressive arts. The last have developed a special place in healthcare through music, art and drama therapy, which constitute a parallel stream of education and practice that is sometimes referred to as ‘complementary and alternative medicine’, with its own body of knowledge.[14] Occupational therapists have routinely included the arts in their curricula since this forms an important part of their work. A number of medical schools and faculties of health sciences have paid attention to the medical humanities in different forms. [15] At UCT, for example, a structured course in ‘Culture, Psyche and Illness’ in the second and third years of the medical undergraduate programme is run by a medical anthropologist, a psychiatrist and

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a social worker, bringing cultural and psychological perspectives to cases presented in a problem-based curriculum through an integrated process. In other countries,[16-18] a variety of courses introduce health sciences students to the self-development and reflective practice associated with literature,[19] visual art, drama and film media.[20] Special studies modules and electives offer students the opportunity to explore areas in the arts or humanities in which they are particularly interested, and which would otherwise have remained closed to them. Medical ethics now forms an important and examinable part of all curricula, often integrated into clinical courses. At a postgraduate level, a number of diploma and masters programmes in medical humanities exist overseas, but none apart from bioethics are offered in this country. The UCT masters-level course ‘Medicine and the Arts’ sets a precedent in the SA context, and it is important to establish the field appropriately in relation to existing literature and theory. In parallel with educational initiatives, in September 2013 the Wits Institute for Social and Economic Research (WISER) brought together the first-ever conference on the medical humanities in SA. Entitled ‘Body Knowledge’, the meeting stimulated the exchange of ideas across many different disciplines and set the stage for the development of the field. A follow-up conference is planned in Cape Town in 2014, addressing the theme of medical humanities in Africa. The National Research Foundation is supporting the development of a new research field of medical humanities through a grant aimed at defining exactly what we mean by the term in the SA context, and at expanding our networks to include scholars working in other countries in Africa. Rather than defaulting to the North American and European definitions and understandings of medical humanities, it seems important to explore the field within our own SA cultural, historic, geographical and political context. This may result in a greater emphasis on notions of community, or traditional forms of healing, or poverty and social justice, for example.[21] The development of the medical humanities in education and research in SA is set to expand over the next few years, and it looks as if it will be an exciting inter-disciplinary journey. 1. The Society for Health and Human Values. The Humanities and Medical Education. Academic Medicine 1995;70(9):745-852. http://journals.lww.com/academicmedicine/toc/1995/09000 (accessed 6 January 2014). 2. McManus IC. Humanity and the medical humanities. Lancet 1995;346:1143-1145. 3. Calman K, Downie R. Why arts courses for medical curricula? Lancet 1995;347(9014):1499-1450. 4. Shapiro J. Walking a mile in their patients’ shoes: Empathy and othering in medical students’ education. Philos Ethics Humanit Med 2008;3:10. [http://dx.doi.org/10.1186/1747-5341-3-10] 5. McNaughton J. The dangerous practice of empathy. Lancet 2009;373(9679):1940-1941. 6. Kleinman A. The art of medicine: Caregiving as moral experience. Lancet 2012;380(9853):1550-1551. [http://dx.doi.org/10.1016/S0140-6736(12)61870-4] 7. Springer. Journal of Medical Humanities. http://link.springer.com/journal/10912 (accessed 6 Jan 2014) 8. British Medical Journal. Medical Humanities. http://mh.bmj.com/ (accessed 6 January 2014) 9. Benatar S. The humanities in medicine at UCT. S Afr Med J 1997;87(12):1662-1663. 10. Wachtler C, Lundin S, Troein M. Humanities for medical students? A qualitative study of a medical humanities curriculum in a medical school program. BMC Med Educ 2006;6:16. [http://dx.doi. org/10.1186/1472-6920-6-16] 11. Burns C. In search of wisdom: William Osler and the humanities. Med Educ 2003;37(2):165-167. 12. Helman C. Culture, Health and Illness. 5th ed. London: Hodder Arnold Publication, 2007. 13. Kneebone R. Total internal reflection: An essay on paradigms. Med Educ 2002;36(6):514-518 14. International Society for Complementary Medicine Research. BMC Complementary and Alternative Medicine. http://www.biomedcentral.com/bmccomplementalternmed (accessed 6 January 2014) 15. Benatar S. The humanities in medicine at UCT. S Afr Med J 1997;87(12):1662-1663. 16. Jones T, Verghese A. On becoming a humanities curriculum: The Centre for Medical Humanities and Ethics at the University of Texas Health Science Center at San Antonio. Acad Med 2003;78(10):1010-1014. 17. Abdel-Halim R, Alkattan KM. Introducing medical humanities in the medical curriculum in Saudi Arabia: A pedagogical experiment. Urol Ann 2012:4(2):73-79. [http://dx.doi.org/10.4103/0974-7796.95549] 18. Humayun A, Herbert M. Towards behavioural sciences in undergraduate training: A core curriculum. J Pak Med Assoc 2011;87(8):800-807. 19. DasGupta, S. Reading bodies, writing bodies: Self-reflection and cultural criticism in a narrative medicine curriculum. Lit Med 2003;22(2):241-256. 20. Powley E, Higson R. The Arts in Medical Education: A practical guide. Milton Keynes: Radcliffe Publishing, 2013. 21. Parkinson C, White M. Inequalities, the arts and public health: Towards an international conversation. Arts & Health, 2013;5(3):177-189. [http://dx.doi.org/10.1080/17533015.2013.826260]

Accepted 8 January 2014.

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MEDICAL EDUCATION

The intercalated BSc (Med) Honours/MB ChB and integrated MB ChB/PhD tracks at the University of Cape Town: Models for a national medical student research training programme A A Katz, M Futter, B M Mayosi The authors form the management of the UCT Clinical Scholars’ Programme at the Faculty of Health Sciences, University of Cape Town, South Africa. Arieh Katz is in the Institute of Infectious Disease and Molecular Medicine and the Division of Medical Biochemistry at UCT, Bongani Mayosi is in the Department of Medicine, UCT and Groote Schuur Hospital, Cape Town, and Merle Futter is in the Department of Medicine, UCT. Corresponding author: A A Katz (arieh.katz@uct.ac.za)

The Faculty of Health Sciences at the University of Cape Town is addressing the shortage of clinician-scientists in South Africa by introducing two research training tracks in parallel with the professional MB ChB programme, namely the intercalated BSc (Med) Hons/ MB ChB track and the integrated MB ChB/PhD track. The BSc (Med) Hons/MB ChB track is available to MB ChB students who have completed the first two years of study. The track comprises a course in Molecular Medicine given concurrently with the MB ChB third-year curriculum, followed by a BSc (Med) Hons as a ‘year out’ of MB ChB. Subsequently students may enrol into the integrated MB ChB/PhD track that enables them to undertake a PhD concurrently with MB ChB studies, which will be spread over additional years, or alternatively to undertake a PhD after completion of the MB ChB. These tracks, which were launched in 2011, represent an opportunity to train a new cadre of young African clinician-scientists at the undergraduate level. S Afr Med J 2014;104(2):111-113. DOI:10.7196/SAMJ.7639

It is well documented that the academic health workforce in South Africa (SA) is ageing and steadily shrinking, resulting in a decline in clinical research capacity and outputs.[1] This is highlighted by a fall in publication counts in the category of Clinical Medicine from 2 280 in 2000 - 2004 to 1 556 in 2004 - 2008, and the fact that Clinical Medicine has fallen from being the disciplinary category with the highest number of publications to second after Plant Sciences.[2,3] The decline in clinical research productivity prompted the Academy of Science for South Africa (ASSAf) to conduct a study on clinical research and related training in the country. The report[1] identified that over the past two decades there had been disinvestment in publicly funded clinical research as a result of withdrawal of the health departments from academic activities due to underfunding of the Medical Research Council (MRC), which is mandated to develop and maintain clinical research in the country, and lack of direct funding to universities to support clinical research. This has led to medical researchers being obliged to turn to the pharmaceutical industry for the funding of clinical trials in which the companies concerned have an interest, or to international donors who conduct large-scale research projects in SA, which are often led by outsiders. Tertiary service units are struggling to remain active in research and to translate their expertise into improved health services.[4] Many clinical researchers have left SA to pursue their research interests elsewhere in the world,[5] with major economic implications for the country.[6] The high burden of disease in SA makes the revitalisation of clinical research even more urgent.[7] Increased clinical research capacity is essential to the well-being of its growing population and to the development of the country as a whole.[8] If clinical researchers are to be retained and research in health and environmental issues

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is to increase, as proposed by the Department of Science and Technology’s ‘Ten Year Innovation Plan to transform the country into a knowledge-based economy’,[9] it is crucial for universities, private sector and government to unite in an effort to train a critical mass of researchers for the future. The Ministry of Health has responded positively to the recommendation of the National Health Research Committee to train 1 000 clinician PhDs through the National Health Scholars Programme over the next ten years.[7,10] This programme offers scholarships for PhD studies for a period of 1 - 4 years, and the current value of the scholarship is equivalent to the salaries of health professionals employed by the Department of Health. This major financial investment is aimed at addressing the paucity of clinician-scientists in SA. In addition, measures should be put in place to increase these numbers by introducing research training at both undergraduate and postgraduate levels, as recommended in the ASSAf report on clinical research and related training.[1]

Research training of medical students through the intercalated BSc (Med) Hons/MB ChB and the integrated MB ChB/PhD tracks at UCT

The Faculty of Health Sciences at the University of Cape Town (UCT) has taken the initiative in addressing the critical shortage of clinician-scientists by introducing two clinical scientist research tracks that run in parallel with the professional MB ChB programme, namely the intercalated BSc (Med) Hons/MB ChB track and the integrated MB ChB/PhD track. These tracks are based on similar programmes offered in the UK and the USA. They have been found to be valuable in introducing future clinicians to research and in providing a cadre of highly trained physician-scientists who are likely to be attracted to and excel in careers in academic

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medicine.[11,12] Furthermore, the National Institutes of Health (NIH) in the USA offers a fully funded Medical Student Training Programme (MSTP), where students graduate with a MD/PhD.[13,14] It has been established that MD/PhD graduates are more likely than other medical school graduates to receive post-doctoral fellowships, to hold academic appointments, to receive external research funds and to apply for NIH grants, and they are also likely to have published more than their MD counterparts.[14] The intercalated BSc (Med) Hons/MB ChB track at UCT is available to MB ChB students who have completed the first two years of the MB ChB programme. It is targeted at the most talented and motivated medical students, who occupy the top 5 - 10% of the class. This track starts with an additional one-year course in Molecular Medicine. The course is given concurrently with the MB ChB third-year curriculum (Fig. 1) and was specifically developed to provide medical students with theoretical and practical knowledge as well as basic biochemical and molecular laboratory techniques, with outcomes equivalent to a BSc major. This, together with biosciences MB ChB courses, meets HEQS-F (Higher Education Qualification Sub-Framework) level and credit prescription for admission to BSc (Med) Hons. Having passed the Molecular Medicine course and the third-year MB ChB, the students take a ‘year out’ from MB ChB and enrol in one of the laboratory-based BSc (Med) Hons degree programmes offered by the Faculty of Health Sciences.[15] The BSc (Med) Hons consists of course work and a research project, and is an excellent opportunity for medical students to obtain first-hand experience of laboratory-based research. While registered for the Honours programme, they register concurrently for a specially designed clinical course to ensure continuation of their clinical MB ChB training. The Honours year provides the medical student with deeper insight into the biological sciences that will benefit their medical studies and mould them into clinicians who can better integrate basic and clinical sciences. Furthermore, the intercalated Honours track prepares the students for laboratory-based MSc (Med) and PhD dissertations. On completion of the Honours programme, students are awarded the BSc (Med) Hons degree, and on returning to fourth-year MB ChB they may enrol into the integrated MB ChB/PhD track (Fig. 1). They can apply to register concurrently for an MSc (Med). Their registration may be upgraded

Intercalated BSc (Med) Hons/ MB ChB

MB ChB

Integrated MB ChB/PhD 3 PhD

MB ChB MB ChB

Hons

Mol. Med.

PhD

Msc (Med)

5/6

4/5

1 MB ChB

Hons

Mol. Med.

MB ChB

Hons

MSc (Med)

PhD

Fig. 1. Diagram of MB ChB, intercalated BSc (Med) Hons/MB ChB track and integrated MB ChB/PhD track (Mol. Med. = Molecular Medicine; Hons = BSc (Med) Hons).

Table 1. Number, population group and gender of MB ChB students enrolled in intercalated BSc (Med) Hons/MB ChB track Year

Students enrolled in Molecular Medicine

Students enrolled in BSc (Med) Hons

2011

5 (2 WM, 1 WF, 1 BM, 1 BF)

2012

5 (1 WM, 2 BM, 2 BF)

4 (2 WM, 1 WF, 1 BF)

2013

9 (4 WM, 1 WF, 2 BM, 2 BF)

5 (1 WM, 2 BM, 2 BF)

WM = white male; WF = white female; BM = black male; BF = black female.

to PhD studies in the course of the MB ChB studies, and their MB ChB courses in years 4 - 6 may be spread over an additional year or years to enable them to undertake the MSc (Med) and/or PhD. On completion of the MB ChB, students will be able to complete their PhD and graduate. Alternatively, they may resume years 4 - 6 of the MB ChB and on completion embark on PhD studies that are expected to span three years.

Progress of the intercalated BSc (Med) Hons/MB ChB and the integrated MB ChB/PhD tracks at UCT

The intercalated BSc (Med) Hons/MB ChB was launched in 2011, with five MB ChB students undertaking the Molecular Medicine course during their third year (Fig. 1). Four continued with the BSc (Med) Hons programme in 2012 as a ‘year out’, while one decided to leave the intercalated research track and continued with year four of MB ChB. All four students completed Honours successfully. Two obtained a first-

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class pass and were the best students in their programmes (one in Physiology and the other in Infectious Diseases and Immunology). The other two completed Medical Biochemistry Hons, and obtained upper second-class passes. In 2013, three of the four resumed medical studies and enrolled in year four of MB ChB, while the fourth student decided to undertake MSc (Med) studies. This high performance confirms that the Molecular Medicine course is effective in preparing medical students for the Honours programme. In 2012, five third-year MB ChB students were admitted to the intercalated track, completing the Molecular Medicine course and continuing with the BSc (Med) Hons in 2013 (see Table 1 for summary of student enrolment since the intercalated track was launched, including a breakdown by population group and gender). It is gratifying to observe that the research track is developing a new cadre of clinicianscientists who are drawn from the full spectrum of the SA population. One of the students, who is currently completing Honours and is returning to year four of

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MB ChB in 2014, will be enrolling into the integrated MB ChB/PhD track and has applied for concurrent registration to do MB ChB year four and MSc (Med). In 2013, nine third-year MB ChB students were admitted to the intercalated track and are currently undertaking the Molecular Medicine course. All have applied to continue with BSc (Med) Hons in 2014. In addition, 24 second-year MB ChB students have applied to undertake the intercalated Honours track in 2014.

Sustainability, funding and the way forward

The increasing enrolment since 2011 is testament to the rising interest in these research training tracks. There are many talented students representing the diverse SA population eager to become clinician-scientists. Over the past decade, medical schools in SA have focused on intervention programmes for weaker students, while neglecting the top end of the medical class. Offering medical students research degrees in parallel with their medical studies is an ideal way to develop and nourish the best and brightest medical students, who will become the future clinical academics of SA.[11-14] The intercalated track adds an extra year to the MB ChB programme and involves additional costs for the students. Tuition fees (2013 prices) for the Molecular Medicine course are R18 700, for the BSc (Med) Hons programme R37 260, and for the clinical course during the Honours year R2 900. In addition, there are living costs for the duration of the BSc (Med) Hons (about R60 000 in 2013). The additional costs for the research degrees should ideally be covered by scholarships in order to guarantee equitable access to research training. To date these costs have been met through an annual award from the UCT Vice-Chancellor’s Strategic Award, an annual grant from the MRC, and a generous annual donation from Boehringer Ingelheim. These funds, however, are insufficient for all applicants, and the anticipated further expansion of these parallel research tracks will require additional funds. This proposal is in line with the MD/PhD programmes overseas where scholarships that cover the additional tuition fees and living costs for the additional study years are awarded. Furthermore, the NIH MSTP programme in the USA offers a fully funded MD/PhD programme. Scholarships for students admitted to the parallel research tracks at UCT are R120 000 per year in value, modest when compared with the fellowships offered for a qualified clinician to undertake PhD studies on a full-time basis (approximately R500 000 per year). Therefore, offering parallel research degree tracks for medical students may achieve the same outcome at a fraction of the cost of funding postgraduate clinicians. The most suitable time to undertake PhD studies is while a student is young and typically has no family responsibilities. These tracks provide clinicians-to-be with solid theoretical and practical basic sciences knowledge and skills, enabling them to undertake laboratory-based MSc and PhD dissertations. Furthermore, scientists (PhD) can supervise these PhD dissertations, and this can address the shortage of clinician-supervisors.

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These parallel research tracks (Fig. 1) extend the time to graduation for the MB ChB students. Internship and community service still await these graduates. We therefore propose that a PhD undertaken during medical studies, or immediately after completion of the MB ChB, be considered as community service.

Conclusions

The initiative of offering parallel research degrees to MB ChB students, spearheaded by UCT, offers excellent MB ChB students the opportunity to do an Honours degree, and subsequently a PhD degree, in parallel with their medical studies. Parallel research degrees to medical students are a proven route to train and produce cadres of young clinician-scientists. The Ministry of Health together with the MRC have prioritised PhD training of clinicians. [10] The support of these agencies is required for the implementation and expansion of these parallel tracks, which can form a sustainable conduit for training clinician-scientists to address the critical shortage of academic clinicians and revitalise medical research in SA. We invite other medical schools to collaborate with UCT in the development of a National Medical Student Research Training Track based on research degrees that are intercalated and integrated with the MB ChB degrees. Acknowledgements. We are grateful to the UCT Vice-Chancellor’s Strategic Award, the Medical Research Council of South Africa, and Boehringer Ingelheim for funding the first three years of the intercalated BSc (Med) Hons/MB ChB track. 1. Mayosi BM, Dhai A, Folb P, et al. Consensus Report on Revitalising Clinical Research: A Study on Clinical Research and Related Training in South Africa. Pretoria: Academy of Science of South Africa, 2009. http:// www.assaf.co.za/wp-content/uploads/2009/09/ASSAf-Clinical-Report-2009.pdf (accessed 21 October 2013). 2. Pouris A. South Africa’s research publication record: The last 10 years. S Afr J Sci 2003;99(9/10):425-428. 3. Kahn M. A bibliometric analysis of South Africa’s scientific outputs – some trends and implications. S Afr J Sci 2011;107(1/2):1-6 . [http://dx.doi.org/10.4102/sajs.v107i1/2.406] 4. Mayosi BM. The UCT Department of Medicine at 90 years: Continuity and change. S Afr Med J 2010;100(9):548-550. 5. Van Rensburg T. Realities of medicine in South Africa lie behind its brain drain. BMJ 2012;344:e201 [http:// dx.doi.org/10.1136/bmj.e201] 6. Mills EJ, Kanters S, Hagopian A, et al. The financial cost of doctors emigrating from sub-Saharan Africa: Human capital analysis. BMJ 2011;343:d7031 [http://dx.doi.org/10.1136/bmj.d7031] 7. Mayosi BM, Lawn JE, van Niekerk A, Bradshaw D, Abdool Karim SS, Coovadia HM. Health in South Africa: Changes and challenges since 2009. Lancet 2012;380(9858):2029-2043. [http://dx.doi.org/10.1016/ S0140-6736(12)61814-5] 8. Senkubuge F, Mayosi BM. The state of the national health research system in South Africa. In: Padarath A, English R, eds. South African Health Review 2012/13. Durban: Health Systems Trust, 2013:141-150. http:// www.hst.org.za/sites/default/files/Chapter11_NationalHealthResearch.pdf (accessed 21 October 2013). 9. Department of Science and Technology Ten-Year Innovation Plan. 2008. http://www.info.gov.za/view/ DownloadFileAction?id=94066 (accessed 21 October 2013). 10. Mayosi BM, Mekwa NJ, Blackburn J, et al. Strengthening research for health, innovation and development in South Africa, 2011. http://www.doh.gov.za/docs/reports/2012/summitreport.pdf (accessed 21 October 2013). 11. McManus IC, Richards P, Winder BC. Intercalated degrees, learning styles, and career preferences: Prospective longitudinal study of UK medical students. BMJ 1999;319(7209):542-546. [http://dx.doi. org/10.1136/bmj.319.7209.542] 12. Cleland JA, Milne A, Sinclair H, Lee AJ. An intercalated BSc degree is associated with higher marks in subsequent medical school examinations. BMC Med Educ 2009;9:24. [http://dx.doi.org/10.1186/14726920-9-24] 13. National Institute of General Medical Sciences. Medical scientist training program. http://www.nigms.nih. gov/Training/InstPredoc/PredocOverview-MSTP.htm (accessed 21 October 2013). 14. National Institute of General Medical Sciences. MSTP Study: The careers and professional activities of graduates of the NIGMS Medical Scientist Training Program, 1998. http://publications.nigms.nih.gov/ reports/mstpstudy (accessed 21 October 2013). 15. BSc (Med) Hons booklet for 2014. www.health.uct.ac.za/departments/cls/study/ (accessed 21 October 2013).

Accepted 11 November 2013.

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Palliative care in chronic disease The World Health Organization definition of palliative care[1] describes palliative care as ‘an approach that improves the quality of life of patients and their families facing problems associated with life-threatening illness’. It also states that palliative care ‘is applicable early in the course of illness, in conjunction with other therapies that are implemented to prolong life’, and in describing palliative care for children that ‘It begins when illness is diagnosed, and continues regardless of whether a child receives treatment directed at the disease.’ These statements contained with the definition of palliative care require that we review traditional concepts of palliative care as endof-life care for cancer patients, consider the provision of palliative care for people who have other chronic diseases, and address palliative care needs early in the disease trajectory. Two articles in this edition of SAMJ describe palliative care needs in patients with chronic illness. Farrant et al.[2] describe palliative care needs in HIVpositive patients on highly active antiretroviral therapy (HAART). The authors found a high symptom burden despite patients being on treatment, and recommend that detailed symptom assessment and control should be part of HIV care. The need for palliative care in HIV alongside HAART has been well established through research in different settings, including in HIV clinics in London, UK.[3] In the second article, Van Niekerk and Raubenheimer[4] report a survey of patients in public hospitals in Cape Town and identify palliative care needs in patients with chronic illness, commenting that ‘the greatest burden of disease was found in the general medical wards’. They report that 54.8% of patients admitted to medical wards met the requirements of need for palliative care. They comment particularly on the palliative care needs of young patients with renal failure. Although palliative medicine is a specialty in the UK and palliative care is provided in many hospitals in the developed world, in South Africa palliative care is largely viewed as a non-governmental organisation function and as such a community-based service. It is important to recognise that patients’ palliative care requirements should be assessed by a doctor, and the care plan to address palliative care needs in conjunction with treatment aimed at controlling the disease should be developed by the doctor assessing these needs. This assessment and initiation of a management plan should take place in hospital, and requires that clinicians are skilled in palliative care and have knowledge of community-based palliative care services that will provide continuity of care for patients with advanced illness. It also requires that staff in the community-based services are skilled in palliative care of patients with progressive advanced illness, whether this illness is organ failure, HIV, tuberculosis, progressive neurological disorders or cancer. The National Department of Health’s Strategic Plan for the Prevention and Control of Non-Communicable Diseases 2013-17[5] states that ‘Careful liaison and interaction between different levels of health care i.e. primary, secondary, and tertiary levels and with central and specialised hospitals is needed; including appropriate promotive, preventative, curative and palliative services at all levels.’ Currently there are few palliative care services in hospitals in South Africa. Early hospital-based services were established at Charlotte Maxeke Johannesburg Academic Hospital and Steve Biko Academic Hospital. Partnerships with local hospices have demonstrated effective models of hospital palliative care in Stellenbosch and Grahamstown.

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The Gauteng Centre of Excellence for Palliative Care at Chris Hani Baragwanath Academic Hospital (CHBAH) provides a particularly comprehensive and successful model of hospital-based palliative care with close collaboration with the Oncology Department at CHBAH, an effective training programme for undergraduates and in-service training at the hospital as well as an outreach service into the community.[6] The Abundant Life programme[7] established at Victoria Hospital in Cape Town and adapted for the South African setting from the UK Gold Standards Framework, as described by Van Niekerk and Raubenheimer,[4] has proved successful in assisting patients with organ failure and their family members and in reducing the number of hospital admissions for this group of patients. A report on this programme also demonstrated cost savings to patients and to the hospital.[7] The Abundant Life approach has also been assessed as a possible programme for patients with advanced progressive disease in the community health centre (CHC) to improve patient outcomes. With successful models of community-based palliative care (hospice services) and current best practice models of hospital and CHC palliative care, the time is ripe to extend these services so that palliative care is available to all patients requiring this care in conjunction with treatment directed at the disease. The Hospice Palliative Care Association of South Africa (HPCA), together with partners FHI 360, the Foundation for Professional Development and SA Partners, has recently been awarded a grant from the US Agency for International Development (USAID) to integrate comprehensive care and support-palliative care into the South African health system to achieve better patient outcomes. The Care and Support for Improved Patient Outcomes (CaSIPO) project will work closely with government departments to identify policies and procedures and to assist in implementing an integrated care and support-palliative care package for health and welfare structures in hospitals, clinics and communities. Recent global and local advocacy efforts have established recognition of palliative care and pain control as a human right.[8,9] In light of these efforts, the HPCA presented a petition[10] to the National Minister on Human Rights Day 2012, calling on the government ‘to ensure that palliative care is accessible, available and affordable to South Africans facing advanced illness, and to ensure that at the end of their lives patients are treated with dignity and experience relief of suffering’. At the recent palliative care conference co-hosted by the African Palliative Care Association and the HPCA, the South African Deputy Minister of Health, Dr Gwen Ramakgopa, hosted a meeting of delegates from African health ministries. These delegates included the ministers of health from Uganda and Kenya and the Deputy Minister of Health from Malawi, and representatives from 34 African health ministries. The outcome of the meeting was a consensus statement recommending six objectives for African governments. These objectives include development of policy frameworks for palliative care, including palliative care in health budgets, ensuring the availability of essential palliative care medicines, integrating palliative care training into medical and nursing schools, and sharing palliative care best practices. The research studies by Farrant et al.[2] and Van Niekerk and Raubenheimer[4] emphasise the need for palliative care for patients with chronic disease. Recognition by clinicians and National Department of Health (NDoH) officials of the importance of

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palliative care in providing a comprehensive service to patients with chronic disease, the experience and expertise of palliative care providers in South Africa and the support of funders such as USAID have come together at a time when the NDoH has embarked on an ambitious plan to improve health care for all South Africans. Collaboration between government, palliative care providers and funders will ensure a better quality of life for patients, both adults and children, living with chronic disease. Liz Gwyther Hospice Palliative Care Association of South Africa; School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa liz@hpca.co.za 1. World Health Organization. http://www.who.int/cancer/palliative/definition/en/ (accessed 30 October 2013). 2. Farrant L, Gwyther L, Dinat N, Mmoledi K, Hatta N, Harding R. Maintaining well-being for South Africans on antiretroviral therapy: The burden of pain and symptoms is greater with longer ART exposure. S Afr Med J 2014;104(2):119-123. [http://dx.doi.org/10.7196/SAMJ.7461]

3. Harding, R, Molloy T, Easterbrook P, Frame K, Higginson IJ. Is antiretroviral therapy associated with symptom prevalence and burden? Int J STD AIDS 2006;17(6):400-405. [http://dx.doi. org/10.1258/095646206777323409] 4. Van Niekerk L, Raubenheimer PJ. A point-prevalence survey of public hospital inpatients with palliative care needs in Cape Town, South Africa. S Afr Med J 2014;104(2):138-141. [http://dx.doi. org/10.7196/SAMJ.7262] 5. Strategic Plan for the Prevention and Control of Non-Communicable Diseases 2013-17. http://www. health-e.org.za/wp-content/uploads/2013/09/NCDs-STRAT-PLAN-CONTENT-8-april-proof.pdf (accessed 31 October 2013). 6. Hongoro C, Dinat N. A cost analysis of a hospital-based palliative care outreach program: Implications for expanding public sector palliative care in South Africa. J Pain Symptom Manage 2011;41(6):10151024. [http://dx.doi.org.ezproxy.uct.ac.za/10.1016/j.jpainsymman.2010.08.014] 7. DesRosiers T, Cupido C, Pitout E, et al. A hospital-based palliative care service for patients with advanced organ failure in sub-Saharan Africa reduces admissions and increases home death rates. J Pain Symptom Manage 2013; 21 August. [http://dx.doi.org/10.1016/j.jpainsymman.2013.05.021] 8. Radbruch L, de Lima L, Lohman D, Gwyther E, Payne S. The Prague Charter: Urging governments to relieve suffering and ensure the right to palliative care. Palliat Med 2013;27(2):101-102. [http://dx.doi. org/10.1177/0269216312473058] 9. Gwyther L, Brennan F, Harding R. Advancing palliative care as a human right. J Pain Symptom Manage 2007;38(5):767-774. [http://dx.doi.org/10.1016/j.jpainsymman.2009.03.003] 10. HPCA petition: Access to palliative care. http://www.hpca.co.za (accessed 30 October 2013).

S Afr Med J 2014;104(2):114-115. DOI:10.7196/SAMJ.7683

A new mental health policy for South Africa Worldwide there has been a growing awareness of the disability, suffering and economic costs associated with mental disorders, and of the availability of cost-efficient treatments. A range of authors,[1] as well as key institutions such as the World Health Organization (WHO),[2] have played an important role in producing data and reports which emphasise these points. After an extensive consultative process, in May 2013, a further step forwards was taken when the World Health Assembly adopted the Comprehensive Mental Health Action Plan 2013 - 2020, committing all United Nations member states to take specified actions to help reach agreed targets. Four key objectives are: ‘to strengthen effective leadership and governance for mental health; provide comprehensive, integrated and responsive mental health and social care services in communitybased settings; implement strategies for promotion and prevention in mental health; and strengthen information systems, evidence and research for mental health’.[3] In post-apartheid South Africa (SA), there has similarly been clear awareness that mental health has been neglected and that the transition to democracy requires paying much more attention to it. Local writers have emphasised these points,[4] and at a national level the Mental Health Act of 2002 made an important advance insofar as it emphasised the human rights of those with mental illness, including access to care.[5] After a major consultative process including provincial and national mental health summits between February and April 2012, a further important step forwards was taken in July 2013 when the National Health Council adopted the Mental Health Policy Framework (MHPF) for SA and the Strategic Plan 2013 - 2020. There are eight key objectives: ‘district-based mental health services and primary healthcare re-engineering; building institutional capacity; surveillance, research and innovation; building infrastructure and capacity of facilities; mental health technology,

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equipment and medicines; intersectoral collaboration; human resources for mental health; advocacy, mental health promotion and prevention of mental illness’.[6] First and foremost, these initiatives call for celebration and congratulation. They are the culmination of a great deal of work by many dozens of individuals, they address a significant gap in public health, and they offer hope for millions of people suffering from mental illness. The integration in the MHPF of a focus on scientific evidence and best practice, together with an emphasis on human rights and vulnerable populations (including pregnant women), is laudable. The careful alignment of the MHPF with the WHO framework speaks to the rigorous and sustained planning that took place locally, and also deserves commendation. At the same time, it is also important to reflect critically on what has been achieved, and on what remains to be done, particularly in the SA context. A first important question relates to the past: how were these successes achieved? Shiffman and Smith have argued that for political priority to be given to a health issue, various conditions must be met, including political support.[7] Tomlinson and Lund [7] have applied this framework to mental health, emphasising that although there has been a lack of political support in the area of mental health and insufficient mobilisation of civil society, cohesive leadership (by a network of individuals) and guiding institutions (such as the WHO) have contributed to bringing attention to mental health. This is an area that seems to beg further analysis, to better understand what has been achieved and how, but also to ensure a better understanding of what has not been achieved and why. Many challenges undoubtedly remain, but it is worth noting the remarkable number of contributions to psychiatry and clinical psychology that have emerged from SA.[8] While there is a growing interest in evidence-based policy making;[9] there is perhaps less attention paid to the question of the individual and social factors that promote the development and implementation of such policy making.

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A second important question is the precise components of these international and national frameworks. The eight objectives of the MHPF are associated with catalytic key activities, chosen to achieve results most effectively. In preparation for the MHPF, the Society of Psychiatrists of South Africa (SASOP) put forward a series of position statements and also deliberated on each of its eight objectives.[6,10] Although these focus a good deal on the status of the profession of psychiatry with respect to the MHPF, they also instructively address a number of its potential strengths and weaknesses. Thus, for example, with regards to district-based mental health services, SASOP commends community-based services, but also warns that the integration of mental health services should not mean the dismantling of expert mental health teams, and that there is a need for flexible co-operation and effective communication with secondary and tertiary levels of services. Indeed, much of the devil will be in the detail; while the rationale for the objectives and activities seems sound, as the process moves from broad brushstrokes to detailed plans, precise pros and cons will become evident. A third important question concerns the future: how should mental health clinicians best respond to the MHPF? Several points can be made. Importantly, while the MHPF indicates that there will be parity in the financing of mental health, provincial mental health plans still have to be developed and implemented. Thus, there is an ongoing need to bring attention to the importance of mental health at a provincial level. [7] There is also an urgent need for models of the delivery of mental health services at primary healthcare; there is growing research in developing countries on this issue, but relatively little work in low- and middle-income countries.[11] The development of such models arguably requires expertise not only in public mental health, but also in liaison psychiatry.[12] Another important need is for research on the various activities proposed by the MHPF. Thus, for example, while the policy understandably promotes a national education programme addressing mental health, the evidence base on whether and how such efforts impact mental illness deserves expansion.[13] Public health is complex enough when disorders are caused by a single mechanism, and respond to simple interventions (e.g. vaccination, mosquito nets). Public mental health is particularly complex, because mental disorders are produced by multiple mechanisms and require a broad range of interventions.[14,15] Current debates about the optimal classification of mental disorders,[16] and how best to foster psychiatric research,[17] reflect this complexity; it would be surprising, for example, if there was unanimous agreement that alcoholism was primarily a brain disease (rather than also reflecting a range of other factors) and that the key solution

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was for hospital-based clinicians to provide pharmacological and psychological interventions. Given this complexity, and the controversies that understandably surround it, it is remarkable that the world, including SA, has agreed to an action plan. That said, given these inherent complexities and resultant controversies, we can expect much further discussion as such planning moves forwards. It is timely for clinicians and researchers to get involved. Acknowledgments. I thank Gerhard Grobler, Bernard Janse van Rensburg, Crick Lund and Solomon Rataemane for their advice.

Dan J Stein Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa dan.stein@uct.ac.za 1. Desjarlais R, Eisenberg L, Good B, Kleinman A. World Mental Health: Problems and Priorities in LowIncome Countries. New York: Oxford University Press, 1995. 2. World Health Organization. The World Health Report 2001: Mental Health: New Understanding, New Hope. Geneva: WHO, 2001. http://www.who.int/whr/2001/en/whr01_en.pdf (accessed 13 January 2014). 3. Saxena S, Funk M, Chisholm D. World Health Assembly adopts Comprehensive Mental Health Action Plan 2013-2020. Lancet 2013;381(9882):1970-1971. [http://dx.doi.org/10.1016/S0140-6736(13)61139-3] 4. Foster D, Freeman M, Pillay Y. Mental Health Policy Issues for South Africa. Cape Town: South African Medical Association, 1997. 5. Lund C, Stein DJ, Flisher AJ, Mehtar S. Challenges faced by South African health services in implementing the Mental Health Care Act. S Afr Med J 2007;97(5):352-353. 6. Janse van Rensburg AB. Contributions from the South African Society of Psychiatrists (SASOP) to the National Mental Health Action Plan. South African Journal of Psychiatry 2013;19:205-212. [http:// dx.doi.org/10.7196/SAJP.501] 7. Tomlinson M, Lund C. Why does mental health not get the attention it deserves? An application of the Shiffman and Smith framework. PLoS Med 2012;9(2):e1001178. [http://dx.doi.org/10.1371/journal. pmed.1001178] 8. Stein DJ. Psychiatric contributions from South Africa: Ex Africa Semper Aliquid Novi. Afr J Psychiatry 2012;15(5):323-328. [http://dx.doi.org/10.4314/ajpsy.v15i5.39] 9. Oxman AD, Lavis JN, Lewin S, Fretheim A. SUPPORT Tools for evidence-informed health Policymaking (STP) 1: What is evidence-informed policymaking? Health Res Policy Syst 2009;7(Suppl 1):S1. [http://dx.doi.org/10.1186/1478-4505-7-S1-S1] 10. Janse van Rensburg BJ. The South African Society of Psychiatrists (SASOP) and SASOP State Employed Special Interest Group (SESIG) position statements on psychiatric care in the public sector. South African Journal of Psychiatry 2012;18(3):133-148. [http://dx.doi.org/10.7196/SAJP.374] 11. Lund C, Tomlinson M, De Silva M, et al. PRIME: A programme to reduce the treatment gap for mental disorders in five low- and middle-income countries. PLoS Med 2012;9(12):e1001359. [http://dx.doi. org/10.1371/journal.pmed.1001359] 12. Stein DJ, Szabo CP, Moussaoui D, Gureje O. Psychiatric sub-specialization in Africa – introduction to a series. Afr J Psychiatry 2010;13:157-159. 13. Phillips MR. Can China’s new mental health law substantially reduce the burden of illness attributable to mental disorders? Lancet 2013;381(9882):1964-1966. [http://dx.doi.org/10.1016/S01406736(13)61177-0] 14. Stein DJ. Is there a ‘mosquito net’ for anxiety and mood disorders? Curr Psychiatry Rep 2009;11(4):264265. [http://dx.doi.org/10.1007/s11920-009-0051-8] 15. Parker J. Recovery in mental health. S Afr Med J 2014;104(1):77. [http://dx.doi.org/10.7196/ SAMJ.7732] 16. Stein DJ, Lund C, Nesse RM. Classification systems in psychiatry: Diagnosis and global mental health in the time of DSM-5 and ICD-11. Curr Opin Psychiatry 2013;26(5):493-497. [http://dx.doi. org/10.1097/YCO.0b013e3283642dfd] 17. Stein DJ. Psychiatry and mental health research in South Africa: National priorities in a low and middle income context. Afr J Psychiatry 2012;15(6):427-431. [http://dx.doi.org/10.4314/ajpsy.v15i6.54]

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Failing to numb the pain: The untreated epidemic Africa, especially sub-Saharan Africa, carries a significant burden of communicable and noncommunicable diseases. The relative distribution of these is projected to shift by 2030.[1] By 2012, 25 million people in the sub-region were living with HIV/AIDS, comprising 70.8% of the global disease burden.[2] Regionally, cancer is an emerging public health problem.[3] In 2008 there were 715 000 new cases and 542 000 cancer-related deaths in Africa. This is projected to nearly double by 2030 due to population growth and ageing,[4] with 36% of cancers infection-related, twice the global average.[5] With this significant disease burden, compounded by other life-limiting illnesses, a clear public health argument exists for the availability of pain- and symptom-relieving medicines to enhance the quality of life of millions of affected people, maximise the clinical benefit of available treatments, and ensure freedom from unnecessary suffering.[6] Indeed, effective pain alleviation is a central pillar of the World Health Organization (WHO’s) enhanced public health approach for developing palliative care services[7] and well established in its three-step analgesic ladder.[8] In mid-September 2013, the first session of the African Ministers of Health on palliative care was held at the joint conference of the African Palliative Care Association/Hospice Palliative Care Association of South Africa, in Johannesburg, South Africa (SA). Delegates underscored this argument by adopting a consensus statement proposing, as part of six objectives: ‘The use of the already established global and regional frameworks provided by the African Union and World Health Organization, to ensure availability of, and access to, essential medicines and technologies for the treatment of pain and other symptoms being experienced by so many in Africa, including children. This includes the procurement and distribution of morphine, to ensure greater availability and access of this main opioid for the management of moderate to severe pain.’[9] However, despite advances in provision on the continent,[10] millions of people cannot access palliative care in general and effective pain medicines specifically, despite the significant prevalence of pain among those with life-limiting diagnoses. For example, Namisango et al.[11] found that among 302 ambulatory HIV/AIDS patients in Uganda, 47% reported pain in the seven days prior to the survey, while pain was a symptom at the time of diagnosis for 68%, and 27% reported severe pain on a 0-to-10 numeric scale, with a resultant debilitating effect on quality of life. These prevalence figures were echoed by Harding et al.,[12] who reported a seven-day period prevalence of pain at 82.6% among 224 HIV-infected patients in five palliative care centres in SA and Uganda. Similarly, Mphahlele et al.[13] compared predominantly black African and female HIV-positive patients attending rural and metropolitan outpatient clinics in SA and found that 72% of rural and 56% of metropolitan participants reported having pain at the time of interview which was comparably moderate to severe in intensity among both populations. Because of the very high prevalence of cancer patients presenting with advanced and incurable disease, to clinical services with limited infrastructure, many affected Africans endure a painful and distressing death. Indeed, Harding et al.’s[14] investigation of symptom prevalence and burden among advanced cancer patients in two African countries found that among 112 patients, pain was the most prevalent of a mean of 18 symptoms (87.5%), and ranked as most severe (23.2%).

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In spite of this overwhelming need, in many African countries access to even the simplest pain-relieving medication is restricted. While many countries have shown an increase in opioid consumption since 2000, all African countries, apart from SA, have very low consumption levels, as defined by the International Narcotics Control Board, with a defined daily dose of less than 200 mg/day/100 000 people.[15] Many barriers hamper the availability and accessibility of effective pain medications. Harding et al.’s[16] study of drug availability and prescribing practices in 12 sub-Saharan African countries found that, in addition to problems accessing non-opioids, less than half of the responding 62 service facilities were prescribing opioids of any strength. The striking gulf between clinical need and available supply of effective medicines in Africa was recently highlighted by an international study reporting that, globally, governments are leaving hundreds of millions of cancer patients to suffer needlessly because of their failure to ensure adequate access to pain-relieving medicines. [17] Published in the Annals of Oncology, the paper by Cleary et al.[17] is the product of the International Collaborative Project to Evaluate the Availability and Accessibility of Opioids for the Management of Cancer Pain.[18] Initiated by the European Society for Medical Oncology, the study was co-ordinated with the European Association for Palliative Care, the Pain and Policies Study Group at the US-based University of Wisconsin Carbone Cancer Center, the Union for International Cancer Control and the WHO, and assisted by the co-operation and participation of a further 17 international oncology and palliative care organisations, including the Uganda-based African Palliative Care Association. With data gathered between December 2010 and July 2012, 156 reports were submitted to the study team by experts in 76 countries and 25 Indian states, representing 58% of countries and 83% of 5.7 billion of the people living in Africa, Asia, the Middle East, Latin and Central America and the Caribbean. The African report incorporates data from 25 of the 52 countries surveyed, and covers 744 million of the region’s 1 127 million people (66%). The researchers found that codeine and morphine were the primary medicines on formulary, with no one country having all seven of the formulations considered essential for the relief of cancer pain: codeine, immediate- and slow-release oral morphine, injectable morphine, oral oxycodone, oral methadone and transdermal fentanyl. [19] Six countries (Côte d’Ivoire, Liberia, Libya, Rwanda, Sierra Leone and Tunisia) reported that they had no immediaterelease morphine, four had no sustained-release morphine (Libya, Sierra Leone, Tanzania and Zimbabwe), and two had no injectable morphine (Ethiopia and Malawi). Only 15 countries had all oral immediate-release, oral sustained-release and injectable morphine available. Sierra Leone and Tanzania had the most limited formulary, with only two medications on formulary. In approximately half the countries, most of the medicines were free. Otherwise the full cost of medications was borne by patients. Regulatory barriers, with evidence of over-regulation that impedes patient care, were widespread. Most countries used a wide number of regulatory restriction types to limit the accessibility of opioids, ranging from two in Botswana and Namibia, to seven in Egypt and Mauritius. More specifically, the majority of countries (16/25) required special authorisation for outpatients with cancer pain to receive an opioid prescription, and similar restrictions were reported in 14 countries for inpatients and in 11 countries even for hospice patients. Only six countries (Côte d’Ivoire, Malawi, Mauritius,

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Nigeria, Tanzania and Zimbabwe) allowed cancer patients to receive opioid medications without requiring registration or a special permit. Lastly, while few countries had restrictions limiting physician prescribing, three (Egypt, Liberia and Morocco) required a special permit for family doctors and surgeons and even for oncologists. Prescription limitations were commonplace and ten countries did not allow physicians to prescribe more than two weeks’ supply of opioid analgesics to a patient. The survey demonstrates that in many countries across Africa, government regulations are undermining the ability to provide pain relief to cancer patients, as well as those with other life-limiting illnesses. Many other issues affect the availability and use of appropriate pain-relieving medicines on the continent. These include problems of supply and distribution, a misplaced ‘opiophobia’ among both patients and providers, a related limited understanding of how and when to use opioids, and the restriction of prescribing powers to doctors, rather than extending them (as in Uganda) to appropriately trained nurses working in rural areas. Nevertheless, there is a growing recognition among national governments of the importance of palliative care and access to effective pain relief, as illustrated by the African Union’s issuance of a common position statement on controlled substances and access to pain management medicines in October 2012,[20] and the consensus statement of the health ministers meeting in 2013. [9] However, this can only be translated into action if and when known obstacles – such as the restrictive regulatory barriers described in the survey[17] – are addressed as part of the systemsstrengthening agenda. If not, the untreated epidemic of pain will continue. Conflict of interest. The authors were collaborators on the original global survey but declare that this does not constitute a conflict of interest.

Richard A Powell Formerly Director of Learning and Research, African Palliative Care Association, Kampala, Uganda Lukas Radbruch Chair of Palliative Medicine, University of Bonn, Director of Department of Palliative Medicine, University Hospital Bonn, Director of Palliative Care Centre, Malteser Hospital Bonn/Rhein-Sieg, Germany Faith N Mwangi-Powell Formerly Executive Director, African Palliative Care Association, Kampala, Uganda

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Jim Cleary University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, and Pain and Policy Studies Group, University of Wisconsin Carbone Cancer Center, Madison, Wisconsin, USA Nathan Cherny Director of the Cancer Pain and Palliative Care Service in Oncology Pain and Palliative Care Unit, Oncology Institute, Shaare Zedek Medical Centre, Jerusalem, Israel Corresponding author: R A Powell (richard2powell@yahoo.co.uk) 1. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006;3(11):e442. [http://dx.doi.org/10.1371/journal.pmed.0030442] 2. Joint United Nations Programme on HIV/AIDS. UNAIDS Report on the Global AIDS Epidemic. Geneva: UNAIDS, 2013. www.unaids.org/en/media/unaids/contentassets/documents/ epidemiology/2013/gr2013/UNAIDS_Global_Report_2013_en.pdf (accessed 23 November 2013). 3. Jemal A, Bray F, Forman D, et al. Cancer burden in Africa and opportunities for prevention. Cancer 2012;118(18):4372-4384. [http://dx.doi.org/10.1002/cncr.27410] 4. Ferlay J, Shin H-R, Bray F, et al. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 2010;127(12):2893-2917. [http://dx.doi.org/10.1002/ijc.25516] 5. Parkin DM. The global health burden of infection-associated cancers in the year 2002. Int J Cancer 2006;118(12):3030-3044. [http://dx.doi.org/10.1002/ijc.21731] 6. Mwangi-Powell F. Palliative care and public health, a perspective from the African Palliative Care Association. J Public Health Policy 2007;28(1):59-61. [http://dx.doi.org/10.1057/palgrave.jphp.3200123] 7. Stjernswärd J, Foley KM, Ferris FD. The public health strategy for palliative care. J Pain Symptom Manage 2007;33(5):486-493. [http://dx.doi.org/10.1016/j.jpainsymman.2007.02.016] 8. World Health Organization. WHO’s cancer pain ladder for adults. http://www.who.int/cancer/ palliative/painladder/en/ (accessed 1 November 2013). 9. African Palliative Care Association, South African Department of Health, Hospice Palliative Care Association. Consensus statement for palliative care integration into health systems in Africa: ‘Palliative Care for Africa’. http://www.hospicepalliativecaresa.co.za/pdf/consensus-statement.pdf (accessed 19 November 2013). 10. Powell RA, Harding R, Namisango E, et al. Palliative care research in Africa: An overview. European Journal of Palliative Care 2013;20(4):162-167. 11. Namisango E, Harding R, Atuhaire L, et al. Pain among ambulatory HIV/AIDS patients: Multicenter study of prevalence, intensity, associated factors, and effect. J Pain 2012;13(7):704-713. [http://dx.doi. org/10.1016/j.jpain.2012.04.007] 12. Harding R, Selman L, Agupio G, et al. Prevalence, burden, and correlates of physical and psychological symptoms among HIV palliative care patients in sub-Saharan Africa: An international multicenter study. J Pain Symptom Manage 2012;44(1):1-9. [http://dx.doi.org/10.1016/j.jpainsymman.2011.08.008] 13. Mphahlele NR, Mitchell D, Kamerman PR. Pain in ambulatory HIV-positive South Africans. Eur J Pain 2012;16(3):447-458. [http://dx.doi.org/10.1002/j.1532-2149.2011.00031.x.] 14. Harding R, Selman L, Agupio G, et al. The prevalence and burden of symptoms amongst cancer patients attending palliative care in two African countries. Eur J Cancer 2011;47(1):51-56. [http:// dx.doi.org/10.1016/j.ejca.2010.08.003] 15. International Narcotics Control Board. Report of the International Narcotics Control Board on the Availability of Internationally Controlled Drugs: Ensuring Adequate Access for Medical and Scientific Purposes. www.incb.org/documents/Publications/AnnualReports/AR2010/Supplement-AR10_availability_ English.pdf (accessed 25 November 2013). 16. Harding R, Powell RA, Kiyange F, et al. Provision of pain- and symptom-relieving drugs for HIV/AIDS in sub-Saharan Africa. J Pain Symptom Manage 2010;40(3):405-415. [http://dx.doi.org/10.1016/j. jpainsymman.2009.12.025] 17. Cleary J, Powell RA, Munene G ,et al. Formulary availabiwlity and regulatory barriers to accessibility of opioids for cancer pain in Africa: A report from the Global Opioid Policy Initiative (GOPI). Ann Oncol 2013;24(Suppl 11):xi14-xi23. [http://dx.doi.org/10.1093/annonc/mdt499] 18. Cherny NI, Cleary J, Scholten W, et al. The Global Opioid Policy Initiative (GOPI) project to evaluate the availability and accessibility of opioids for the management of cancer pain in Africa, Asia, Latin America and the Caribbean, and the Middle East: Introduction and methodology. Ann Oncol 2013;24(Suppl 11):xi7-xi13. [http://dx.doi.org/10.1093/annonc/mdt498] 19. De Lima L, Krakauer EL, Lorenz K, et al. Ensuring palliative medicine availability: The development of the IAHPC list of essential medicines for palliative care. J Pain Symptom Manage 2007;33(5):521-526. [http://dx.doi.org/10.1016/j.jpainsymman.2007.02.006] 20. African Union. African Common Position on Controlled Substances and Access to Pain Management Drugs. Fifth Session of the AU Conference of Ministers of Drug Control (Camdc5), Addis Ababa, Ethiopia, 8-12 October 2012.

S Afr Med J 2014;104(2):117-118. DOI:10.7196/SAMJ.7803

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Maintaining wellbeing for South Africans receiving ART: The burden of pain and symptoms is greater with longer ART exposure L Farrant,1 MB BCh, Dip HIV Man (SA), MPhil Pall Med; L Gwyther,1 MB ChB, FCFP, MSc; N Dinat,2 MD, FCOG, MPhil Pall Med; K Mmoledi,2 RN, MPH, Dip Pall Med; N Hatta,2 RN; R Harding,1,3 PhD School of Public Health and Family Medicine, University of Cape Town, South Africa Wits Palliative Care, School of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa 3 Department of Palliative Care, Cicely Saunders Institute, King’s College London, UK 1 2

Corresponding author: L Farrant (lindsayfarrant0074@yahoo.co.uk) Background. Physical and psychological symptom burden among people with HIV infection is associated with poor quality of life, poorer treatment adherence, viral rebound and risk behaviour. Symptomatology has not been investigated among outpatients in sub-Saharan Africa. Objective. To measure the seven-day period prevalence, burden and correlates of pain and other physical and psychological symptoms among HIV patients receiving antiretroviral therapy (ART). Methods. This was a cross-sectional self-report study. A total of 378 patients were interviewed using validated tools in three South African public sector clinics. Results. The most prevalent symptoms were feeling sad (64%), feeling irritable (61.6%), worry (60.8%), numbness and tingling in hands/ feet (59.8%), and sexual problems (51%). In multivariate analysis, later disease stage was associated with worse psychological symptom burden (β=0.359; 95% confidence interval (CI) 0.202 - 0.516; p≤0.001), global symptom burden (β=0.365; 95% CI 0.204 - 0.526; p<0.001) and number of symptoms (β=0.308; 95% CI 0.150 - 0.465; p<0.001). Those receiving treatment for a greater number of years also reported higher burden for physical (β=0.083; 95% CI 0.037 - 0.129; p≤0.001), psychological (β=0.068; 95% CI 0.019 - 0.117; p=0.007) and global symptoms (β=0.065; 95% CI 0.016 - 0.115; p=0.010), and a greater number of symptoms (β=0.081; 95% CI 0.032 - 0.130; p=0.001). Conclusions. The data reveal a high symptom burden despite treatment. Detailed symptom assessment and control continues to be required in the era of treatment. S Afr Med J 2014;104(2):119-123. DOI:10.7196/SAMJ.7461

Evidence from high-income settings has shown that HIV patients experience a high physical and psychological symptom burden in the presence of antiretroviral therapy (ART).[1,2] This symptom burden has been associated with sexual risk-taking,[3] poor adherence,[4] treatment switching[5] and viral rebound.[6] HIV patients perceive that their symptoms remain untreated.[7,8] This perception is supported by evidence that physicians detect threefold fewer HIV-related symptoms than their patients report.[9] Doctors tend to overlook the assessment of pain and other treatable symptoms, instead focusing on symptoms that are physically measurable such as fever and weight loss, and are more likely to ask about symptoms in HIV patients perceived to be severely ill.[10] The World Health Organization (WHO) advocates pain and symptom control as an essential component of HIV clinical care.[11] A significant proportion of patients receiving ART experience drug toxicities such as peripheral neuropathy and gastrointestinal problems,[12] requiring drug discontinuation or treatment change within, and between, classes of ART.[13] Investigation into prevalence and correlates of HIV-related symptoms is required to inform clinical practice and thereby improve clinical outcomes and quality of life in the presence of ART.[14,15] The vast majority of data on pain and symptom prevalence have been reported from the pre-ART era in patients in high-income countries with AIDS-defining illnesses. As there are fewer treatment options available in low- and middle-income countries, adherence must be optimised and movement between classes of drugs minimised.

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Given the relationship between symptom burden, poor adherence, treatment switching and viral rebound, symptom data are urgently needed to inform patient assessment and management in Africa. The prevalence and high burden/high frequency of symptoms for patients receiving ART and those not receiving ART have been reported previously.[16] We report the seven-day period prevalence, burden and correlates of pain, and other physical and psychological symptoms, among HIV patients receiving ART in three public sector HIV clinics in South Africa (SA).

Methods

Study design

The study design was cross-sectional self-report with additional clinical data extracted from patient records. The study was approved by the Committee for Research in Human Subjects (Medical) at the University of the Witwatersrand and by the Human Research Ethics Committee of the University of Cape Town.

Setting

The research was conducted in the outpatient adult HIV treatment clinics within three academic hospitals in Johannesburg, SA, which adhere to the most recent SA national ART guidelines. At the time of data collection, the clinics had implemented the recent change in the national guidelines to initiate ART in patients with a CD4+ count <200 cells/μl, regardless of stage; those with a CD4+ count <350 cells/ μl and pregnant or co-infected with tuberculosis (TB);

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those who are WHO stage 4 regardless of CD4+ count and all patients with drug-resistant TB.[17]

Recruitment

Inclusion criteria accounted for HIV outpatients aged 18 years or older receiving ART and able to give informed consent to participate in data collection in one of the three most common languages: English, isiZulu and Sesotho. Simple random sampling was used by inviting every fifth patient attending the clinic to participate, on days selected at random over an eight-month period in 2009 - 2010. Informed consent was obtained from participants.

Data collection

Data were collected using self-report (demographics, symptom prevalence and burden) and extraction of data from files (CD4+ count at treatment initiation, time since treatment initiation, most recent CD4+ count, most recent viral load, whether the patient had switched treatment, WHO disease stage). The seven-day period prevalence and associated burden of symptoms was measured using the Memorial Symptom Assessment Scale Short Form (MSASSF). [18] The MSAS-SF measures 28 physical and four psychological symptoms and provides three subscale indices of Physical Symptom Distress (MSAS-Phys), Psychological Symptom Distress (MSASPsych) and Global Distress Index (MSAS-GDI).[14] Each of these three subscales has a possible score range of 0 - 4. The MSAS-SF has been widely used in HIV populations.[1,2,19,20] Finally, the research nurse scored the patient on the Karnofsky Performance Scale, which is a measure of physical performance scored from 0 (dead) to 100 (normal) in bands of 10[21] and is a commonly used measure of performance in HIV populations.[22] Owing to potential literacy limitations in the population sampled, a research nurse read aloud each self-reported question and recorded the response to reduce any potential bias through mixed selfcompletion and researcher-administered questionnaires. Information and consent forms and the questionnaire were translated from English into isiZulu and Sesotho by forward and back translation and the interview was conducted in the patient’s language of choice.

Analysis

Descriptive data were generated for the sample characteristics. The most common symptoms have been previously reported.[16] The MSAS-SF subscales and total number of symptoms were calculated. Subsequently, the following analyses were conducted. Univariate linear regression analyses were conducted to test the association of independent covariates with the following four dependent variables: (i) MSAS-Phys; (ii) MSAS-Psych; (iii) MSAS-GDI; and (iv) total symptom burden. Each of these four dependent variables formed a separate model in the subsequent multivariate analyses described below. As the burden scores were not normally distributed (data plotting showing a left-skew), they were transformed into tertiles. Independent variables entered in univariate analysis were: age (continuous); gender (two levels of male/female); WHO stage (three levels of stage 1, 2, 3 or 4); CD4+ count at ART initiation transformed into quartiles; whether the patient had switched ART regimen (two levels: yes/no); current viral load (two levels: detectable/not detectable); current CD4+ count (continuous); and time receiving ART (years). Following each univariate regression, multivariate regressions models were constructed. Independent variables from the univariate analyses above were entered into the multivariate model if significant

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at the 25% level.[23] For each independent variable, the unstandardised β coefficient and the 95% confidence interval (CI) were calculated. For each multivariate model, the F-value for the model and the r2 were calculated. Cases with missing data were excluded from the multivariate models. All analyses were conducted using SPSS (version 19).

Results

Sample characteristics

A total of 378 patients participated (Table 1). The mean age of the patients was 40.3 years, the majority were female (76.2%) and of black ethnicity (98.1%). Participants had been receiving treatment for an average of three years and had a current average CD4+ count of 355.85 cells/μl (standard deviation (SD) ±219.26). According to the latest results available in the participants’ records, around onequarter of the sample (n=99; 28.6%) did not have viral suppression, and almost half (n=172; 45.5%) had switched ART regimen.

Symptomatology

The mean number of symptoms (of a possible total of 32) was 10.05 (SD ±5.66; range 1 - 28). The symptom prevalence and burden are presented in descending order of prevalence in Table 2. Three of the four psychological symptoms (sad, irritable and worrying) were among the ten most prevalent symptoms. The ten symptoms with the highest burden (i.e. scored using the worst two response categories) were: numbness and tingling in the hands/feet (37% of whole sample); feeling irritable (36.8%); problems with sexual interest or function (35.1%); worry (34.4%); not looking like myself (34.4%); feeling sad (30.7%); pain (29.1%); weight loss (24.8%); sweats (22.7%); and feeling nervous (20.6%). Table 1. Sample characteristics (N=378) Age (years), mean (±SD)

40.34 (±9.16)

Female gender, n (%)

288 (76.2)

Ethnicity, n (%) Black

371 (98.1)

Mixed ancestry

5 (1.3)

White

2 (0.5)

WHO stage, n (%) Stage 1

98 (25.9)

Stage 2

246 (65.1)

Stage 3

29 (7.7)

Stage 4

5 (1.3)

KPS, median (IQR)

90 (90 - 90)*

CD4+ count (cells/ml) Pre-ART, median (IQR)

93 (40.5 - 158.25)

Current, mean (±SD)

355.85 (±219.26)

Years receiving ART, mean (±SD)

3.04 (±1.83)

Patients with undetectable VL, n (%)

279 (71.4)†

Current VL for those detectable (copies/ml), median (IQR)

2500 (142 - 67 000)

Switched ART regimen (no), n (%)

206 (54.5)

WHO = World Health Organization; KPS = Karnofsky Performance Scale; IQR = interquartile range; ART = antiretroviral therapy; VL = viral load. *Data missing for 4 patients. † Data missing for 33 patients.

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Table 2. Seven-day period prevalence and burden of symptoms (N=378) Distress, n (%*) Physical symptoms

Prevalence

N/A

None

A little bit

Somewhat

Quite a bit

Very much

umbness/tingling in hands N and feet

226 (59.8)

152 (40.2)

16 (4.5)

28 (7.4)

42 (11.1)

36 (9.5)

104 (27.5)

roblems with sexual interest P or activity

196 (51.9)

182 (48.1)

14 (3.7)

18 (4.5)

31 (8.2)

27 (7.1)

106 (28)

Pain

190 (50.3)

188 (49.7)

15 (4.0)

29 (7.7)

36 (9.5)

27 (7.1)

83 (22)

‘I don’t look like myself ’

182 (48.1)

196 (51.9)

6 (1.6)

17 (4.8)

29 (7.7)

20 (5.3)

110 (29.1)

Lack of energy

151 (39.9)

227 (60.1)

8 (2.1)

25 (6.6)

45 (11.9)

20 (5.3)

53 (14.0)

Sweats

148 (39.2)

230 (60.8)

7 (1.9)

22 (5.8)

32 (8.5)

27 (7.1)

60 (15.6)

Weight loss

144 (38.1)

234 (61.9)

6 (1.6)

24 (6.3)

17 (4.5)

73 (19.3)

Feeling bloated

143 (37.8)

235 (62.2)

10 (2.6)

38 (10.1)

24 (6.3)

35 (9.3)

36 (9.5)

Feeling drowsy

135 (35.7)

243 (64.3)

15 (4.0)

41 (10.8)

20 (5.6)

23 (6.1)

6 (9.5)

Changes in skin

132 (34.9)

246 (65.1)

13 (3.4)

27 (7.1)

26 (6.9)

14 (3.7)

52 (13.8)

Difficulty concentrating

128 (33.9)

250 (66.1)

9 (2.4)

30 (7.9)

28 (7.4)

22 (5.8)

40 (10.6)

Constipation

118 (31.2)

260 (68.8)

9 (2.4)

29 (7.7)

27 (7.1)

222 (6.1)

31 (8.2)

Itching

111 (29.4)

267 (70.6)

8 (2.1)

24 (6.6)

24 (6.3)

21 (5.6)

34 (9.0)

Lack of appetite

95 (25.1)

283 (74.9)

6 (1.6)

12 (3.2)

21 (5.6)

19 (5.0)

37 (9.8)

Cough

94 (24.9)

284 (75.1)

21 (5.6)

29 (7.7)

15 (4)

8 (2.1)

21 (5.6)

Dizziness

91 (24.1)

287 (75.9)

8 (2.1)

24 (6.3)

16 (4.2)

12 (3.2)

31 (8.2)

Swelling of arms or legs

88 (23.3)

290 (76.7)

4 (1.1)

21 (5.6)

11 (2.9)

31 (8.2)

Difficulty sleeping

86 (22.8)

292 (77.2)

8 (1.9)

13 (3.4)

12 (3.2)

14 (3.4)

39 (10.3)

Dry mouth

83 (22.0)

295 (78.0)

9 (2.4)

19 (5.0)

14 (3.0)

17 (4.8)

24 (6.3)

Shortness of breath

68 (17.7)

310 (82.3)

3 (0.8)

12 (3.2)

13 (3.4)

13 (3.2)

27 (7.1)

Nausea

64 (16.9)

314 (83.1)

6 (1.6)

22 (5.8)

11 (2.9)

7 (1.9)

18 (4.8)

Diarrhoea

58 (15.3)

320 (84.7)

8 (1.9)

16 (4.2)

10 (2.6)

14 (3.7)

Problems with urination

54 (14.3)

324 (85.7)

0 (0)

12 (3.2)

11 (2.9)

8 (2.1)

23 (6.1)

Mouth sores

52 (13.8)

327 (86.2)

20 (5.0)

19 (5.0)

14 (3.7)

4 (1.1)

14 (3.7)

Change in the way food tastes

49 (13.0)

329 (87.0)

5 (1.3)

8 (2.1)

5 (1.3)

11 (2.9)

20 (5.3)

Hair loss

35 (9.3)

343 (90.7)

4 (1.1)

8 (2.1)

5 (1.3)

3 (0.8)

15 (4.0)

Vomiting

23 (6.1)

355 (93.9)

4 (1.1)

11 (2.9)

1 (0.3)

3 (0.8)

4 (1.1)

Difficulty swallowing

15 (4.0)

363 (96.0)

1 (0.3)

5 (1.3)

1 (0.3)

4 (1.1)

Psychological symptoms

Prevalence

N/A

Rarely

Occasionally

Frequently

Almost constantly

Feeling sad

242 (64.0)

136 (36.0)

61 (16.1)

65 (17.2)

31 (8.2)

85 (22.5)

Feeling irritable

233 (61.6)

145 (38.4)

39 (10.3)

55 (14.3)

40 (10.6)

99 (26.2)

Worrying

231 (60.8)

147 (39.2)

55 (14.8)

46 (12.2)

37 (9.8)

93 (24.6)

Feeling nervous

149 (39.5)

229 (60.5)

38 (10.6)

32 (8.5)

22 (5.8)

56 (14.8)

N/A = not present. *Do not all add to 100% due to rounding.

Regression analyses: Associations with symptom burden indices

The univariate analysis is presented in Table 3. In multivariate analysis (Table 4), for the first model (MSAS-Phys; F=4.878; p<0.001; r2=8%) the following independent associations were identified. Higher physical symptom distress was associated with greater age (β=0.009; 95% CI 0.001 - 0.018; p=0.036); female gender (β=-0.207; 95% CI -0.399 - -0.016; p=0.034); and greater number of years receiving ART (β=0.083; 95% CI 0.037 - 0.129; p≤0.001). For the second model (MSAS-Psych; F=6.967; p<0.001; r2=9%), higher psychological distress was associated with later WHO stage

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(β=0.359; 95% CI 0.202 - 0.516; p≤0.001) and greater number of years receiving treatment (β=0.068; 95% CI 0.019 - 0.117; p=0.007). For the third model (MSAS-GDI; F=5.152; p<0.001; r2=10%), higher global symptom distress was associated with later WHO stage (β=0.365; 95% CI 0.204 - 0.526; p<0.001) and greater number of years receiving ART (β=0.065; 95% CI 0.016 - 0.115; p=0.010). For the fourth model (total symptom distress, model F=6.407; p<0.001; r2=10%), higher total symptom distress was associated with later WHO stage (β=0.308; 96% CI 0.150 - 0.465; p<0.001) and greater number of years receiving ART (β=0.081; 95% CI 0.032 0.130; p=0.001).

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Table 3. Associations of covariates with symptom indices: Univariate analysis Independent variables Dependent variable

Age

Gender

WHO stage

CD4+ count pre-ART

-0.238

0.157

0.047

Years receiving ART

Current CD4+ count

Detectable VL

ART regimen switched

0.087

0.000

-0.110

0.115

Model 1: MSAS-Phys (N=335) β

0.009

95% CI

0.001 - 0.018

-0.425 - 0.051

0.017 - 0.298

-0.026 - 0.119

0.044 - 0.131

-0.001 - 0.000

-0.315 - 0.095

-0.046 - 0.276

p-value

0.036*

0.013*

0.029*

0.206*

0.014*

0.463

0.291

0.160*

-0.195

-0.373

0.023

-0.116

<0.001

-0.206

0.102

Model 2: MSAS-Psych (N=335) β

0.003

95% CI

-0.006 - 0.012

-0.39 - 0.00

0.231 - 0.515

-0.052 - 0.097

-0.078 - 0.31

0.000 - 0.001

-0.416 - 0.005

-0.065 - 0.269

p-value

0.567

0.050*

≤0.001*

0.553

0.240*

0.420

0.055*

0.229*

-0.194

0.365

0.046

0.065

-0.112

0.102

Model 3: MSAS-GDI (N=335) β

<0.001

95% CI

-0.010 - 0.009

-0.402 - -0.014

0.204 - 0.526

-0.032 - 0.123

0.016 - 0.115

-0.328 - 0.104

-0.168 - 0.192

p-value

0.951

0.067

<0.001*

0.245

≤0.010*

0.308

0.895

Model 4: Total symptom burden (N=335) β

0.012

-0.173

0.362

0.101

-0.154

0.198

95% CI

0.003 - 0.021

-0.368 - 0.022

0.220 - 0.504

0.056 - 0.146

-0.366 - 0.058

0.032 - 0.364

p-value

0.010*

0.081*

≤0.001*

0.153*

0.019*

WHO = World Health Organization; ART = antiretroviral therapy; VL = viral load; MSAS = Memorial Symptom Assessment Scale; MSAS-Phys = MSAS Physical Symptom Distress Index; MSAS-Psych = MSAS Psychological Symptom Distress Index; MSAS-GDI = MSAS Global Distress Index; CI = confidence interval. *Entered into multivariate model.

Table 4. Associations of covariates with symptom indices: Multivariate analysis Independent variables Dependent variable

Age

Gender

WHO stage

CD4+ count pre-ART

Years receiving ART

Current CD4+ count

Detectable VL

ART regimen switched -0.041

Model 1: MSAS-Phys (N=376) β

0.009

-0.207

0.111

0.041

0.083

95% CI

0.001 - 0.018

-0.399 - -0.016

-0.033 - 0.255

-0.031 - 0.113

0.037 - 0.129

-0.210 - 0.129

p-value

0.036*

0.034*

0.131

0.263

≤0.001‡

0.637

0.068

-0.121

0.051

Model 2: MSAS-Psych (N=377) β

-0.160

0.359

95% CI

-0.362 - 0.042

0.202 - 0.516

0.019 - 0.117

-0.327 - 0.086

-0.227 - 0.125

p-value

0.121

≤0.001‡

0.007†

0.252

0.567

0.046

0.065

-0.112

0.102

Model 3: MSAS-GDI (N=376) β

<0.001

-0.194

0.365

95% CI

-0.010 - 0.009

-0.402 - -0.014

0.204 - 0.526

-0.032 - 0.123

0.016 - 0.115

-0.328 - -0.104

-0.168 - 0.192

p-value

0.951

0.067

<0.001‡

0.245

≤0.010†

0.308

0.895

Model 4: Total symptom burden (N=375) β

0.008

-0.174

0.308

0.081

-0.032

0.037

95% CI

-0.001 - 0.018

-0.378 - 0.030

0.150 - 0.465

0.032 - 0.130

-0.244 - 0.180

0.140 - 0.214

p-value

0.087

0.095

≤0.001

0.001

0.767

0.679

‡

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Discussion

These data reveal a high prevalence and burden of symptoms among HIV patients receiving ART in SA, which persists despite relatively good physical function and the majority having been receiving treatment for several years. Seven symptoms were scored in the worst two categories of burden by around one-third of the sample, and these symptoms were psychological and physical, including a symptom indicative of peripheral neuropathy as well as other pain and sexual dysfunction. There were a number of associations with symptom burden. Although greater age and female gender were associated with physical symptom distress, a consistent relationship was identified between worse symptom indices and greater number of years receiving ART. This may be related to the greater number of years of having HIV infection, and to the toxicity of treatment. In addition to clinician monitoring of patient wellbeing when beginning treatment, these data suggest that those who are treatment-experienced should have their symptom burden assessed alongside measurement of virological efficacy. Although there was a high symptom burden for the whole sample, the data also suggest that those with more advanced disease (as measured by WHO staging) may experience a greater burden. A systematic review has demonstrated that palliative care can effectively control these burdensome problems in HIV populations. [24] It is essential that clinical medicine takes account of patient selfreported problems to improve quality of care.[25] Our data on pain and symptom prevalence, and associated distress, support the Joint United Nations Programme on HIV/AIDS (UNAIDS) and WHO policy that palliative care is necessary throughout the HIV disease trajectory alongside ART. [11,26] In light of the data suggesting that uncontrolled symptoms adversely affect quality of life[8,27] and are associated with poor adherence,[4] sexual risk-taking,[3] treatment switching[5] and viral rebound,[6] we recommend that clinicians regularly assess their patients’ physical and psychological self-reported symptoms.

Study limitations

There were a number of methodological limitations to our study. Firstly, the cross-sectional nature of the design meant that we could not draw causal relationships to symptom burden. Second, the reliance on file data, rather than collecting new primary data on clinical outcomes, may have introduced some inaccuracy.

Conclusion

Within Africa, symptom prevalence data have been reported in newly diagnosed HIV patients preparing for treatment,[19] and among patients with advanced disease.[1,20] Our study has built on the small body of prior evidence on prevalence and correlates of symptom burden in African patients[28-30] and supports prior findings that symptoms persist despite ART. Our data indicate that, alongside treatment to prolong life, clinical care should include detailed assessment and control of pain and symptoms to maximise quality of life and treatment benefit. In particular, our data suggest that although all patients should have their symptoms assessed regularly and controlled, those who have spent a longer time receiving ART, and those with more advanced disease, may require greater attention. Acknowledgements. We thank the patients who participated, the management and staff of Wits Palliative Care, Nthabiseng Clinic at Chris

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Hani Baragwanath Academic Hospital, Themba Lethu Right-to-Care Clinic at Helen Joseph Hospital, and the HIV Clinic at Charlotte Maxeke Johannesburg Academic Hospital. References 1. Harding R, Lampe FC, Norwood S, et al. Symptoms are highly prevalent among HIV outpatients and associated with poor adherence and unprotected sexual intercourse. Sex Transm Infect 2010;86(7):520524. [http://dx.doi.org/10.1136/sti.2009.038505] 2. Harding R, Molloy T, Easterbrook P, Frame K, Higginson IJ. Is antiretroviral therapy associated with symptom prevalence and burden? Int J STD AIDS 2006;17(6):400-405. [http://dx.doi. org/10.1258/095646206777323409] 3. Harding R, Clucas C, Lampe FC, et al. Behavioral surveillance study: Sexual risk taking behaviour in UK HIV outpatient attendees. AIDS Behav 2012;16(6):1708-1715. [http://dx.doi.org/10.1007/s10461011-0023-y] 4. Sherr L, Lampe F, Norwood S, et al. Adherence to antiretroviral treatment in patients with HIV in the UK: A study of complexity. AIDS Care 2008;20(4):442-448. [http://dx.doi.org/10.1080/09540120701867032] 5. Sherr L, Lampe F, Norwood S, et al. Successive switching of antiretroviral therapy is associated with high psychological and physical burden. Int J STD AIDS 2007;18(10):700-704. [http://dx.doi. org/10.1258/095646207782193821] 6. Lampe FC, Harding R, Smith CJ, Phillips AN, Johnson M, Sherr L. Physical and psychological symptoms and risk of virologic rebound among patients with virologic suppression on antiretroviral therapy. J Acquir Immune Defic Syndr 2010;54(5):500-505. [http://dx.doi.org/10.1097/QAI.0b013e3181ce6afe] 7. Karus D, Raveis VH, Alexander C, et al. Patient reports of symptoms and their treatment at three palliative care projects servicing individuals with HIV/AIDS. J Pain Symptom Manage 2005;30(5):408417. [http://dx.doi.org/10.1016/j.jpainsymman.2005.04.011] 8. Harding R, Molloy T. Positive futures? The impact of HIV infection on achieving health, wealth and future planning. AIDS Care 2008;20(5):565-570. [http://dx.doi.org/10.1080/09540120701867222] 9. Justice AC, Chang CH, Rabeneck L, Zackin R. Clinical importance of provider-reported HIV symptoms compared with patient-report. Med Care 2001;39(4):397-408. [http://dx.doi.org/10.1097/00005650200104000-00010] 10. Larue F, Fontaine A, Colleau SM. Underestimation and undertreatment of pain in HIV disease: Multicentre study. BMJ 1997;314(7073):23-28. [http://dx.doi.org/10.1136/bmj.314.7073.23] 11. World Health Organization. HIV/AIDS Topics: Palliative Care 2006. Geneva: WHO, 2006. http://www. who.int/hiv/topics/palliative/PalliativeCare/en/ (accessed 19 December 2013). 12. Heath KV, Montaner JS, Bondy G, Singer J, O’Shaughnessy MV, Hogg RS. Emerging drug toxicities of highly active antiretroviral therapy for human immunodeficiency virus (HIV) infection. Curr Drug Targets 2003;4(1):13-22. 13. Dieleman JP, Jambroes M, Gyssens IC, et al. Determinants of recurrent toxicity-driven switches of highly active antiretroviral therapy. The ATHENA Cohort. AIDS 2002;16(5):737-745. [http://dx.doi. org/10.1097/00002030-200203290-00009] 14. Selwyn P. Why should we care about palliative care for AIDS in the era of antiretroviral therapy? Sex Transm Infect 2005;81:2-3. [http://dx.doi.org/10.1136/sti.2004.011585] 15. The untapped potential of palliative care for AIDS. Lancet 2003;362(9398):1773. 16. Farrant L, Gwyther L, Dinat N, Mmoledi K, Hatta N, Harding R. The prevalence and burden of pain and other symptoms among South Africans attending highly active antiretroviral therapy (HAART) clinics. S Afr Med J 2012;102(6):499-500. 17. National Department of Health, South African National AIDS Council. The South African Antiretroviral Treatment Guidelines 2010. Pretoria: NDoH, 2010. http://www.uj.ac.za/EN/CorporateServices/ioha/ Documentation/Documents/ART%20Guideline.pdf (accessed 11 December 2013). 18. Chang VT, Hwang SS, Feuerman M, Kasimis BS, Thaler HT. The Memorial Symptom Assessment Scale Short Form (MSAS-SF). Cancer 2000;89(5):1162-1171. [http://dx.doi.org/10.1002/10970142(20000901)89:5<1162::AID-CNCR26>3.0.CO;2-Y] 19. Wakeham K, Harding R, Bamukama-Namakoola D, et al. Symptom burden in HIV-infected adults at time of HIV diagnosis in rural Uganda. J Palliat Med 2010;13(4):375-380. [http://dx.doi.org/10.1089/ jpm.2009.0259] 20. Harding R, Selman L, Agupio G, et al. Prevalence, burden, and correlates of physical and psychological symptoms among HIV palliative care patients in sub-Saharan Africa: An international multicenter study. J Pain Symptom Manage 2012 Jul;44(1):1-9. [http://dx.doi.org/10.1016/j.jpainsymman.2011.08.008] 21. Schag CC, Heinrich RL, Ganz PA. Karnofsky performance status revisited: Reliability, validity, and guidelines. J Clin Oncol 1984;2(3):187-193. 22. Morgan EE, Iudicello JE, Weber E, et al. Synergistic effects of HIV infection and older age on daily functioning. J Acquir Immune Defic Syndr 2012 61(3):341-348. [http://dx.doi.org/10.1097/QAI.0b013e31826bfc53] 23. Altman DG. Practical Statistics for Medical Research. London: Chapman and Hall, 1991. 24. Harding R, Karus D, Easterbrook P, Raveis VH, Higginson IJ, Marconi K. Does palliative care improve outcomes for patients with HIV/AIDS? A systematic review of the evidence. Sex Transm Infect 2005;81(1):5-14. [http://dx.doi.org/10.1136/sti.2004.010132] 25. Dawson J, Doll H, Fitzpatrick R, Jenkinson C, Carr AJ. The routine use of patient reported outcome measures in healthcare settings. BMJ 2010;340:c186. [http://dx.doi.org/10.1136/bmj.c186] 26. Joint United Nations Programme on HIV/AIDS. AIDS: Palliative Care: UNAIDS Technical Update. Geneva: UNAIDS, 2000. http://apps.who.int/medicinedocs/en/d/Jh2930e/ (accessed 11 December 2013). 27. Harding R, Clucas C, Lampe FC, et al. What factors are associated with patient self-reported health status among HIV outpatients? A multi-centre UK study of biomedical and psychosocial factors. AIDS Care 2012;24(8):963-971. [http://dx.doi.org/10.1080/09540121.2012.668175] 28. Mphahlele NR, Mitchell D, Kamerman PR. Pain in ambulatory HIV-positive South Africans. Eur J Pain 2012;16(3):447-458. [http://dx.doi.org/10.1002/j.1532-2149.2011.00031.x] 29. Peltzer K, Phaswana-Mafuya N. The symptom experience of people living with HIV and AIDS in the Eastern Cape, South Africa. BMC Health Serv Res 2008;8:271. [http://dx.doi.org/10.1186/1472-6963-8-271] 30. Namisango E, Harding R, Atuhaire L, et al. Pain among ambulatory HIV/AIDS patients: Multicenter study of prevalence, intensity, associated factors, and effect. J Pain 2012;13(7):704-713. [http://dx.doi. org/10.1016/j.jpain.2012.04.007]

Accepted 9 September 2013.

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A 5-year analysis of the helicopter air mercy service in Richards Bay, South Africa P A D’Andrea,1 MB ChB, DipPec (SA); D J van Hoving,1 MB ChB, DipPec (SA), MMed (Emerg Med), MSc Med Sci (Clin Epidemiol); D Wood,2 MB BCh, BPharm, MPhil, FCEM (UK), DipPEC, DA; W P Smith,3 MB ChB, EMDM, FCEM (SA) ivision of Emergency Medicine, Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa D Division of Emergency Medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa 3 Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, South Africa 1 2

Corresponding author: D J van Hoving (nvhoving@sun.ac.za) Background. A helicopter emergency medical service (HEMS) was established in 2005 in Richards Bay, KwaZulu-Natal, South Africa, to provide primary response and inter-facility transfers to a largely rural area with a population of 3.4 million people. Objective. To describe the first 5 years of operation of the HEMS. Methods. A chart review of all flights from 1 January 2006 to 31 December 2010 was conducted. Results. A total of 1 429 flights were undertaken; 3 were excluded from analysis (missing folders). Most flights (88.4%) were inter-facility transfers (IFTs). Almost 10% were cancelled after takeoff. The breakdown by age was 61.9% adult, 15.1% paediatric and 21.6% neonate. The main indications for IFTs were obstetrics (34.5%), paediatrics (27.9%) and trauma (15.9%). For primary response most cases were trauma (72.9%) and obstetrics (11.3%). The median on-scene time for neonates was significantly longer (48 min, interquartile range (IQR) 35 - 64 min) than that for adults (36 min, IQR 26 - 48; p<0.001) and paediatrics (36 min, IQR 25 - 51; p<0.02). On-scene times for doctor-paramedic crews (45 min, IQR 27 - 50) were significantly longer than for paramedic-only crews (38 min, IQR 27 - 57; p<0.001). Conclusion. The low flight-to-population ratio and primary response rate may indicate under-utilisation of the air medical service in an area with a shortage of advanced life support crews and long transport distances. Further studies on HEMSs in rural Africa are needed, particularly with regard to cost-benefit analyses, optimal activation criteria and triage systems. S Afr Med J 2014;104(2):124-126. DOI:10.7196/SAMJ.7310

Emergency medical care in Africa can have a significant impact on healthcare outcomes at a lower cost than other interventions. It basically consists of a pre-hospital and an in-hospital phase.[1] The pre-hospital phase includes two equally important components: (i) the care provided at the incident scene; and (ii) the actual transportation of patients to healthcare facilities.[1] The transportation phase occurs in an unstable out-of-hospital environment that could be deleterious to the patient’s condition; it should therefore be minimised as much as possible. Helicopters have been used in civilian operations since the 1960s, but despite their widespread use as part of emergency medical services (EMS), some debate continues regarding their cost-effectiveness and optimal utility.[2,3] There are multiple benefits of a helicopter EMS (HEMS): rapid transportation, direct transport to definitive treatment rather than the nearest medical facility, getting more highly skilled personnel to the scene, and access to areas inaccessible by road.[4] On the other hand, helicopters are expensive, cannot fly in adverse weather conditions, may be unable to fly at night, and cannot transport patients with certain conditions, e.g. women in active labour.[5] The optimal use of a HEMS (with regard to cost-effectiveness and patient benefit) depends on the broader EMS system in which the HEMS operates.[6] Determining how best to incorporate a HEMS in each system should be done at a local level, as patient populations differ from region to region. Rural HEMSs in Europe and Japan transported a preponderance of medical and trauma patients,[7,8] while obstetrics and gynaecology patients dominated in New Zealand.[9] Descriptive studies of this nature permit assessment of the utility of a

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HEMS and are therefore important when deciding whether to extend or improve services.[7,8] This study describes the use of a HEMS in a rural African setting during its first 5 years of operation.

Methods

Study setting

The South African Red Cross Air Mercy Service (AMS) operates eight bases in South Africa (SA). We evaluated data from the Richards Bay base in KwaZulu-Natal (KZN) that provides aeromedical services to northern KZN, a rural area with a population of 3.4 million[10] and severe shortages of appropriately trained pre-hospital staff and equipment. The average ambulance coverage in KZN is 1/44 000 people (recommended national standard 1/10 000), while only 5% of EMS staff are trained in advanced life support (ALS) (recommended national standard 15%).[10] The Richards Bay AMS base operates 365 days a year from 07h00 to sunset (as of 2012 the service has had limited night capability). The helicopter crew consists of a pilot and two healthcare providers, one of whom is at least an ALS paramedic. Every Tuesday, a doctor from the area’s referral hospital (Ngwelazana Hospital) forms part of the two-man medical crew.

Study design

A retrospective chart review of all activated flights from the first 5 years of the Richards Bay AMS base (1 January 2006 - 31 December 2010) was conducted. Ethics approval was obtained from the Stellenbosch University Health Research Ethics Committee (ref. S12/02/035) and permission was obtained from the SA Red Cross AMS management team.

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Study population

All flights activated for transporting a patient were included. Flights with missing records were excluded. In the event of incomplete documentation, the cases were not excluded; instead, only the specific missing variable was indicated as not specified.

Data collection and management

Data were collected from patient report forms and pilots’ flight logs. A summarised record of all flights is also kept at the AMS base and was compared with the patient report forms to identify any missing flights. The principal investigator entered the data onto an electronic spreadsheet (MS Excel). Patients were categorised according to the age group classifications used by the KZN Department of Health: adult >12 years, paediatric 28 days - 12 years, and neonate <28 days. The triage coding used was: red – immediate life-threatening condition; yellow – urgent but not immediately life-threatening condition; green – non-urgent condition; and blue – dead. This coding was based on the practitioner’s subjective assessment of the patient and was performed upon loading the patient into the helicopter. For clarity, the following definitions were used: (i) inter-facility transfer (IFT): flights that transported patients from one healthcare facility to another; (ii) primary response: flights where the helicopter was used to respond to a pre-hospital scene directly; (iii) stood-down flights: flights where the helicopter was activated but cancelled before landing at the scene; (iv) not-transported flights: flights where the helicopter landed at the scene but no patient was transported; and (v) on-scene time: the time between landing and taking off from the pre-hospital scene or healthcare facility.

Statistical analysis

Statistical analysis was performed by the Centre for Statistical Consultation at Stellenbosch University. STATISTICA version 10 was used. Descriptive statistics were used to fulfil the aim. Medians and interquartile ranges (IQRs) were used to describe the on-scene times. Categorical and binary data were presented using frequency tables and proportions. Inferential statistics were calculated using the Mann-Whitney U-test when comparing continuous binary variables and the Kruskal-Wallis test for comparing continuous nominal variables. Bonferroni adjustments were done for multiple comparisons. A p-value of ≤0.05 was considered significant.

Table 1. Indications for requesting helicopter transportation All flights n (%)

Inter-facility transfer Primary response n (%) n (%)

Obstetric

413 (32.1)

398 (34.5)

15 (11.3)

Paediatric

331 (25.7)

322 (27.9)

9 (6.8)

Trauma

280 (21.8)

183 (15.9)

97 (72.9)

Surgery

117 (9.1)

115 (10.0)

2 (1.5)

Medical

105 (8.2)

101 (8.8)

4 (3.0)

Other*

41 (3.2)

35 (3.0)

6 (4.5)

*Poisoning, environmental conditions and snakebites.

Results

A total of 1 429 flights were undertaken during the 5-year study period. Three records were missing, leaving 1 426 flights accessible for analysis. Of these, 165 flights (11.6%) were primary responses and 1 253 (88.4%) IFTs (8 flights had incomplete data). The number of flights peaked during 2007 (2006 n=195, 2007 n=396, 2008 n=348, 2009 n=252, 2010 n=278). A total of 1 287 flights transported patients (90.3%). Sixty-nine flights (4.8%) were stood down (IFT n=39, primary n=23, unknown n=7) and 70 flights (4.9%) did not transport any patients (IFT n=60, primary n=9, unknown n=1). Proportionally more stood-down and not-transported flights were in the primary response group (19% v. 8%). The main reasons for stood-down flights were bad weather (n=39) and patients already transported by other means (n=21), while for not-transported flights, 47 patients died before loading and 15 were not fit for flight. Adult patients were transported most (n=797, 61.9%), followed by neonates (n=278, 21.6%) and paediatric patients (n=194, 15.1%). Almost 19% of patients (n=243) were <7 days old. Neonates were predominantly IFTs (n=275, 98.9%). Age was not noted in 18 flights. The predominant indications for requesting the helicopter were related to obstetrics and gynaecology (n=413, 32.1%), paediatrics (n=331, 25.7%) and trauma (n=280, 21.8%) (Table 1). The majority of patients were triaged yellow (n=778, 60.5%; IFT 708, primary 70), just over a fifth were triaged red (n=291, 22.6%; IFT 246, primary 45), and only 9 (0.7%) were triaged green (IFT 7, primary 2). One patient died (0.1%), while 208 flights (16.2%) had incomplete data (IFT 193, primary 15). The median flight time from base to prehospital scene or healthcare facility was 35

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min (IQR 26 - 50) for IFTs and 22 min (IQR 14.5 - 33.5) for primary responses. The flight time from pre-hospital scene or healthcare facility to destination was 35 min (IQR 25 - 50) for IFTs and 15 min (IQR 8 - 25) for primary responses. The overall median on-scene time was 39 min (IQR 27 - 51). The median on-scene time for primary response (23 min, IQR 13 32) was shorter than the 40 min (IQR 30 - 53) for IFTs. There was no significant difference in median on-scene time between adult (36 min, IQR 26 - 48) and paediatric patients (36 min, IQR 25 - 51; p=1.0). However, neonates (48 min, IQR 35 - 64) had much longer on-scene times than paediatric (p<0.02) and adult (p<0.001) patients. The presence of a doctor on board was associated with a statistically significant increase in on-scene time (45 min, IQR 27 50) compared with flights without a doctor on board (38 min, IQR 27 - 57; p<0.001).

Discussion

The Richards Bay AMS base averaged 285 flights per year over the 5-year period. In terms of absolute numbers this is similar to other rural HEMSs (Japan 314 flights per year; Sweden 314 flights per year).[7,8] However, when the number of flights per population served was compared, the Richards Bay service has 1 flight per 11 930 people per year compared with 6 622 people per year in Japan and 828 people per year in Sweden.[7,8] There are several possible explanations for our low flight request rate. Firstly, the EMS system in rural KZN has severe staff shortages resulting in prolonged response times by ground crew (only 50% of rural response times for red-coded patients by road were less than 40 min in 2009).[10] Additionally, at the time of the study the helicopter could only be activated once road crew had reached the scene; it can therefore be argued that severely injured polytrauma patients were dying on-scene

RESEARCH

before the helicopter could be activated. Secondly, many of the hospitals are staffed by unsupervised junior doctors who may underestimate a patient’s condition, therefore not requesting HEMS.[11] Thirdly, many patients in this area prefer to seek help from traditional healers first and may present late in the course of disease, so that referral will no longer be of benefit.[12] Finally, doctors could be under the impression that the cost of HEMS is restrictive and therefore do not think to make use of it. The last statement reflects the lack of awareness of HEMS funding in the public service. The KZN Department of Health pays a fixed monthly fee that covers the fixed overheads of the HEMS service and includes the cost of 30 flight hours (at R22 667 per hour). Any additional flight hours only incur costs for fuel and aircraft maintenance (at R6 008 per hour). When this cost is compared with the cost of running an ALS-equipped road ambulance (at R25.51 per km), with greater distances, the helicopter becomes a cost-effective means of transporting patients (personal communication, Mr Neil Gargan, General Manager, South African Paramedic Services). In addition, utilising a HEMS leaves the ground crew present in the area to continue to handle local calls. Primary response comprises 65% of other rural HEMS activations, and is significantly higher than the 12% in this study.[7,8] As mentioned above, the HEMS in KZN currently uses a two-tiered system and alternative methods of primary activation of HEMS should be actively explored (subsequently, efforts have been undertaken to facilitate earlier activation). Algorithms have been designed to assist in deciding on the need for primary air transport in the UK, and the development of such an algorithm for an African setting should be investigated.[5] The percentage of stood-down and not-transported flights (10%) is similar to those in other countries (8 - 17%).[7-8] These flights add cost without patient benefit and should be limited as far as possible. Poor weather conditions cannot be avoided, but situations such as ‘no receiving bed’ for the patient requiring HEMS are not acceptable. Obstetrics and gynaecology, paediatrics and trauma were the three most common indications for flight (trauma was the most common in primary response). This was expected, as SA has a high injury-related burden of disease and obstetric and paediatric patients often require specialised care only available at referral hospitals.[13] Given the HIV/ AIDS epidemic, more medically related transfers might have been expected, but cases can generally be managed in peripheral centres. [13] The flight indications in rural KZN are similar to those in New Zealand, highlighting the fact that a HEMS should be integrated with a welldeveloped EMS system specifically designed for local epidemiology.[7,9] The proportion of patients with life-threatening conditions was low in this study (23% of patients triaged red) compared with 55% in other HEMSs.[7] Triage was done subjectively and severity might have been under-estimated, suggesting that a more objective triage scale is needed for HEMSs in SA. The prolonged on-scene time for a neonate (48 min) is comparable with international times (38 min) and reflects the difficulties of transporting patients in this age group.[14] There are several potential explanations for this prolonged on-scene time, including the helicopter crew not being well prepared to deal with neonates, inadequate equipment for neonates, and failure of hospital staff to prepare neonates adequately for transport. The optimal use of doctors as part of the HEMS crew has long been debated. Doctors can add benefit on-scene through their decisionmaking capabilities and by performing advanced interventions.[15] However, staffing an HEMS with a doctor increases costs and their presence is associated with slightly longer on-scene times.[4]

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Study limitations

There was no external method available to confirm the data as entered onto the database. Errors may have occurred in transcription from the patient report forms, and the data on the forms may have been inaccurate in the first place. While this may introduce error into the magnitude of the results, we do not believe that the overall conclusion is affected.

Conclusion

This study of a rural African HEMS has shown a much lower flight per population ratio than in other rural HEMSs around the world. There is also a much lower incidence of primary responses. This may indicate that the HEMS is an underutilised modality in a setting where it could have major impact, especially considering the shortage of ALS ground crew. The patient profile differed from other rural HEMSs, is representative of Africa’s burden of disease, and may be expected to be the same in other rural African HEMSs. Training and equipment, specific to the African environment, for the management of obstetrics, paediatrics (especially neonates) and trauma patients should be provided to flight crew. There is a need for further studies on HEMSs in rural Africa, looking at cost-benefit analyses, optimal activation criteria and triage systems in particular. Acknowledgement. This study was funded by a research grant from the Harry Crossley Foundation at Stellenbosch University.

References 1. Anderson P, Petrino R, Halpern P, Tintinalli J. The globalization of emergency medicine and its importance for public health. Bull World Health Organ 2006;84(10):835-839. [http://dx.doi. org/10.2471/BLT.05.028548] 2. Meier DR, Samper ER. Evolution of civil aeromedical helicopter aviation. South Med J 1989;82(7):885891. [http://dx.doi.org/10.1097/00007611-198907000-00022] 3. Taylor CB, Stevenson M, Jan S, Middleton PM, Fitzharris M, Myburgh JA. A systematic review of the costs and benefits of helicopter emergency medical services. Injury 2010;41(1):10-20. [http://dx.doi. org/10.1016/j.injury.2009.09.030] 4. Butler DP, Anwar I, Willett K. Is it the H or the EMS in HEMS that has an impact on trauma patient mortality? A systematic review of the evidence. Emerg Med J 2010;27(9):692-701. [http://dx.doi. org/10.1136/emj.2009.087486] 5. Black JJ, Ward ME, Lockey DJ. Appropriate use of helicopters to transport trauma patients from incident scene to hospital in the United Kingdom: An algorithm. Emerg Med J 2004;21(3):355-361. [http://dx.doi.org/10.1136/emj.2002.004473] 6. Plevin RE, Evans HL. Helicopter transport: Help or hindrance? Curr Opin Crit Care 2011;17(6):596600. [http://dx.doi.org/10.1097/MCC.0b013e32834c5655] 7. Vesterbacka J, Eriksson A. A rural ambulance helicopter system in northern Sweden. Air Med J 2001;20(3):28-31. [http://dx.doi.org/10.1016/S1067-991X(01)70026-0] 8. Tase C, Ohno Y, Hasegawa A, Tsukada Y, Shimada J, Ikegami Y. Helicopter emergency medical services (doctor-helicopter) in Fukushima Prefecture: Present state and problems. Fukushima J Med Sci 2010;56(1):71-79. [http://dx.doi.org/10.5387/fms.56.71] 9. Nagappan R, Barker J, Riddell T, et al. Helicopter in transit care of the critically ill – the Whangarei experience. N Z Med J 2000;113(1114):303-305. 10. KwaZulu-Natal Department of Health. Annual Performance Plan 2011/12 - 2013/14. Pietermaritzburg: KwaZulu-Natal Department of Health, 2011. http://www.kznhealth.gov.za/app2011-14.pdf (accessed 15 January 2013). 11. Reid SJ. Compulsory community service for doctors in South Africa – an evaluation of the first year. S Afr Med J 2001;91(4):329-336. 12. Van Niekerk J. Traditional healers formalised? S Afr Med J 2012;102(3):105-106. 13. World Health Organization. The Global Burden of Disease 2004 Update. Geneva: WHO, 2008. http:// www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf (accessed 15 January 2013). 14. Berge S, Berg‐Utby C, Skogvoll E. Helicopter transport of sick neonates: A 14-year populationbased study. Acta Anaesthesiol Scand 2005;49(7):999-1003. [http://dx.doi.org/10.1111/j.13996576.2005.00712.x] 15. Roberts K, Blethyn K, Foreman M, Bleetman A. Influence of air ambulance doctors on on-scene times, clinical interventions, decision-making and independent paramedic practice. Emerg Med J 2009;26(2):128-134. [http://dx.doi.org/10.1136/emj.2008.059899]

Accepted 17 October 2013.

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The cost of harmful alcohol use in South Africa R G Matzopoulos,1,2 BBusSci, MPhil (Epidemiology), PhD; S Truen,3 BEcon (Hons), MEcon; B Bowman,4 BA (Hons), PhD; J Corrigall,1 MB ChB, MMed (Public Health), FCPHM (SA) School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa Burden of Disease Research Unit, South African Medical Research Council, Parow, Cape Town, South Africa 3 DNA Economic Consultancy, Hatfield, Pretoria, South Africa 4 School of Human and Community Development, Faculty of Humanities, University of the Witwatersrand, Johannesburg, South Africa 1 2

Corresponding author: R G Matzopoulos (richard.matzopoulos@mrc.ac.za)

Background. The economic, social and health costs associated with alcohol-related harms are important measures with which to inform alcohol management policies and laws. This analysis builds on previous cost estimates for South Africa. Methods. We reviewed existing international best-practice costing frameworks to provide the costing definitions and dimensions. We sourced data from South African costing literature or, if unavailable, estimated costs using socio-economic and health data from secondary sources. Care was taken to avoid possible causes of cost overestimation, in particular double counting and, as far as possible, second-round effects of alcohol abuse. Results. The combined total tangible and intangible costs of alcohol harm to the economy were estimated at 10 - 12% of the 2009 gross domestic product (GDP). The tangible financial cost of harmful alcohol use alone was estimated at R37.9 billion, or 1.6% of the 2009 GDP. Discussion. The costs of alcohol-related harms provide a substantial counterbalance to the economic benefits highlighted by the alcohol industry to counter stricter regulation. Curtailing these costs by regulatory and policy interventions contributes directly and indirectly to social well-being and the economy. Conclusions. Existing frameworks that guide the regulation and distribution of alcohol frequently focus on maximising the contribution of the alcohol sector to the economy, but should also take into account the associated economic, social and health costs. Current interventions do not systematically address the most important causes of harm from alcohol, and need to be informed by reliable evidence of the ongoing costs of alcohol-related harms. S Afr Med J 2014;104(2):127-132. DOI:10.7196/SAMJ.7644

The economic, social and health costs associated with alcohol-related harms are important considerations for determining policies and regulation of alcohol access. In South Africa (SA) two estimates are frequently cited to characterise the various costs of alcohol-related harms. In 2003 Parry et al.[1] conservatively estimated these at R8.7 billion, or 1% of the gross domestic product (GDP), based on the method of Single et al.[2] Budlender[3] estimated that R17 billion was allocated by national and provincial government for expenditures related to addressing alcohol-related harms in 2010 compared with R16 billion in tax and excise revenue, an annual loss to the fiscus of R1 billion. However, the study underestimated social costs, as it omitted costs borne by local government and individuals. As useful as these studies have been for stimulating an evidence-based approach to addressing alcohol harms, their limited scope suggests that they underestimate the true costs to the economy. Parry et al.[1] provided estimates in the absence of other suitable costing studies, but questioned the applicability of methods derived from high-income countries. Budlender,[3] noting that government expenditures addressing alcohol harms occurred within general allocations, selected lower values from possible cost ranges and omitted several cost items to avoid overestimation. Government spending also only accounts for a fraction of the total costs incurred from harmful alcohol use. Government spending on mitigating the impact of alcohol abuse incurs significant opportunity costs in terms of foregone spending or investment in more socially desirable avenues. At an individual level, it is estimated that 13% of discretionary disposable income was spent on alcohol consumption in 2005,[4] which in a resource-constrained country such as SA could have been used more productively.

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We aimed to provide a more comprehensive cost estimate to inform evidence-based alcohol policy and legislation by applying cost calculation methods informed by current best practice frameworks. The research was commissioned by the National Liquor Authority, a division of the SA Department of Trade and Industry, which regulates the manufacturing and distribution of alcohol.

Methods

Møller and Matic[5] distinguish between three cost dimensions that comprise the full economic welfare costs of harmful alcohol use, namely: (i) health and crime expenditures, in which resources are allocated to address alcohol-related harms; (ii) labour and productivity costs, in which the effect of alcohol on economic output and production is quantified; and (iii) non-financial welfare costs, such as pain, suffering and loss of life or of ‘quality of life’, which do not have a monetary value. Another important distinction is made between costs borne by drinkers themselves (internal costs) and those borne by government or society at large (external costs).[5] The method of Single et al.[2] was applied to calculate costs attributable to alcohol use across these dimensions, supplemented by the avoidable costs of alcohol described by Collins et al.[6] As costing studies estimate the total cost to society (internal and external costs), care must be taken not to include separate estimates of internal and/or transfer costs, which would result in double counting. To illustrate, an individual disabled by alcohol abuse may receive disability payouts from government. This payout is a transfer cost – the money is transferred from the taxpayer to the disabled individual, but is not lost to the economy, and therefore should not be counted as a cost of alcohol abuse. Including such transfer costs would effectively double count the

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external costs of productivity losses and overestimate the social costs involved in harmful alcohol use.[7] Secondary health and economic data provided estimates for which no figures exist in the literature. Where no suitable local data were available, we applied data from comparable countries. Although not optimal, the use of estimates is preferable to omitting cost components entirely, which would result in systematic underestimation of total costs.[5] We applied a prevalence-based approach that estimates current costs of past harmful alcohol use, rather than an incidence-based approach that includes future costs of current consumption. Cost categories and the primary bearer for each are summarised in Table 1.

with neuropsychiatric disorders, including epilepsy and common mental disorders, the single largest component (12%).[11,12] Healthcare costs A common method used to derive healthcare costs is to calculate the alcohol-attributable fraction (AAF) for each health condition that is Table 1. Cost type by cost bearer Costing categories

Cost bearer

Health and welfare costs

Results

Impact on health

External

Impact on health Alcohol, the most widespread drug of abuse in SA, is the most harmful drug at a population level. It is the third-largest contributor to death and disability after unsafe sex/sexually transmitted infections and interpersonal violence, both of which are themselves influenced by alcohol consumption.[8] In total, 36 840 deaths (6.1% of total mortality), 787 749 years of life lost (7.4% of premature mortality) and 344 331 years lived with a disability (6.2% of total disability) were attributable to alcohol,[9] which together accounted for more than 1.1 million disability-adjusted life years (DALYs), or 7% of the total disease burden.[10] More recent analysis has included the contribution of alcohol to infectious diseases,[11-13] which increased the estimated total alcoholattributable DALYs for SA to more than 1.3 million in 2004.[11,12] Injury-related causes account for nearly half (41%), with the largest single contribution from intentional injuries, i.e. interpersonal violence and suicide, at 25%. Unintentional injuries, including road traffic injuries, accounted for 16% of DALYs. Infectious diseases accounted for a third of DALYs, with tuberculosis (18%) and HIV/ AIDS (13%) being the largest contributors. Non-communicable diseases accounted for the remaining alcohol-attributable DALYs,

Healthcare costs

External

Treatment, research and prevention

External

Social security

External

Drink-driving damage

External

Health and welfare costs

Labour costs Productivity at work

Contested

Absenteeism

Contested

Premature mortality

Contested

Unemployment/retirement

External

ther labour costs (traffic congestion, O imprisonment)

External

Costs of crime

Internal

Responses to crime

External

Consequences of crime

External

Anticipation of crime

External

Non-financial welfare costs

External

Source: Truen et al.,[36] adapted from Møller and Matic.[5]

Table 2. Comparison of Rehm et al.[12] with Schneider et al.,[9] with approximation for missing values Burden attributable to alcohol in South Africa Deaths Schneider et al.

DALYs Rehm et al.

Schneider et al.

AAFs Rehm et al.

Schneider et al.

Rehm et al.*

Rehm et al.†

Cancers

3 217

2 219

38 526

51 840

23.7

31.9

Low birth weight

1 269

871

0.3

0.2

Neuropsychiatric disorders

1 936

927

270 513

157 751

44.8

25.6

26.1

Cirrhosis liver

2 582

1 162

43 836

30 156

46.1

20.7

31.7

Cardiovascular diseases

6 200

‡

64 137

‡

8.2

‡

Unintentional injuries

8 454

7 512

230 159

211 012

34.4

24.9

31.5

Intentional injuries

14 415

13 514

483 640

329 652

42.6

39.5

29.0

Tuberculosis

N/A

8 557

N/A

242 928

N/A

HIV/AIDS‡

N/A

7 441

N/A

172 765

N/A

4.5

3.4

Lower respiratory tract infections

N/A

1 069

N/A

24 960

N/A

4.8

N/A

‡

[36]

[13]

[9]

Source: Truen et al., adapted from Rehm et al. and Schneider et al. DALYs = disability-adjusted life years; AAFs = alcohol-attributable fractions; N/A = not available. *Approximated from proportion of all deaths. † Approximated from proportion of all DALYs. ‡ [13] Rehm et al. only provide ‘net impact’, including beneficial impact on cardiovascular disease.

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caused by alcohol and then to apply the AAFs to the costs of treatment for cases presenting to the health system for each diagnosis.[14] Table 2 presents estimated AAFs for SA from recent burden of disease studies. Calculation of treatment costs is complicated by the absence of reliable national healthcare cost data that match health outcomes to healthcare expenditure. There is considerable cost variation across diagnoses and also between cases with the same diagnosis but treated in different levels of state facilities or in the private healthcare system. There are hospital-based cost studies,[15] but these are not representative of hospital admissions or health-seeking patterns. The private healthcare system collects suitable data,[16] but these are not available publicly.[17] Budlender[3] estimated the cost of alcohol-related treatment to public healthcare by applying an estimate of 9.2% for each province. This was based on the estimated 14.5% of net DALYs attributable to alcohol for males and 3.9% for females[13] and may be an underestimate,[3] but is preferable to others as it includes the burden of infectious disease. In generating an estimate of the cost of alcohol to the national and provincial health departments at R6 billion per annum, Budlender[3] identified several health sub-programmes where alcohol may have a more pronounced effect on cost, namely coroner services, emergency transport, tuberculosis hospitals and forensic services. The public health service, which treats 70 - 80% of the population, accounts for less than half of all health expenditure (42%), with per capita spending on healthcare in the private sector being 3.5 - 5.5 times higher.[18] The private sector is roughly equivalent to the public health sector in terms of total spending,[18] but to adjust the estimate for the different disease profiles we halved the estimated private sector spending for health outcomes treated primarily in the public sector, such as liver cancers, hypertensive disease and type 2 diabetes. This equated to private sector spending on alcohol-attributed causes of R3.33 billion. Together with public sector spending, the estimated total healthcare cost is R9.33 billion. However, this ignores outpatient and primary care costs, which, according to a European review,[19] ranged from 25% to 65% of total inpatient health costs. Applying the lowest of these estimates, 25%, implied a further R2.33 billion, bringing the total healthcare cost in 2009 to R11.66 billion. Treatment, research and prevention Alcohol-related health costs encompass the treatment of individuals with disorders, social costs for dependants, and costs related to research and prevention. Alcohol abusers account for more than half of all patients in treatment for drug addiction,[20] the costs of

which are partially borne by the Department of Social Development. Budlender[3] attributes these costs to national and provincial government treatment programmes. Budlender’s study omits costs of private treatment and treatment in partially subsidised centres and those maintained by local government agencies. The estimated research costs to government were limited to an estimated R6 million per annum across all science councils, which excluded direct ad hoc research spending by other provincial and national government departments (e.g. the current study) and projects undertaken by local government agencies, as well as alcohol treatment and prevention research by universities and non-governmental organisations, such as Soul City and the Open Society Foundation.[3] It would be preferable to attribute a percentage of all social welfare and health research spending to alcohol, but in the absence of suitable data, we applied an estimate of R18 million to take into account social welfare and private spending on research, a tripling of Budlender’s estimate for spending across all science councils. Social security To estimate the social care and welfare costs of alcohol to the state, Budlender[3] allocated 20% of the Social Development budget for the care and support of families, 1% of the youth development budget, 2% of the cost of services, 1% of disability grants and an undisclosed percentage of HIV/AIDS costs. We estimated alcohol-attributable allocations from government departments, applying an AAF of 4% for HIV/AIDS (Table 3). Drink driving damage The CSIR estimated the cost of traffic crashes to the national economy in 2002 at R42.5 billion, which equated to R67.6 billion in 2009.[21] This included human casualty costs (56%), already reflected in healthcare costs, and a further 44% in vehicle damage and incident costs, i.e. R29.7 billion. This is likely to be an underestimate, as the Council for Scientific and Industrial Research study omitted ancillary costs. A Californian study indicated that monetary costs account for less than half of the costs of alcohol-attributable crashes (47%), with the rest accruing from ‘quality of life’, including medical expenses, property damage, employer costs, costs to public services and travel delays.[22] An estimated 24% of SA driver deaths and non-fatal injuries would be prevented if drivers were not driving under the influence of alcohol.[23] As drunk drivers are also likely to be over-represented among those involved in collisions with pedestrians and cyclists

Table 3. Relevant allocations in budgets of provincial and national departments of social development (R million)

Total allocated

Attributable to alcohol

Sub-programme

Provincial

National

Amount (R million)

Substance abuse, prevention and rehabilitation

271.6

13.3

156.695

Disability grant*

N/A

17 218

172.180

Services to persons with disabilities

303.1

4.9

6.160

HIV/AIDS

599.2

61.5

26.428

Care and support services to families

160.9

6.5

33.480

Youth development

167.7

5.4

1.731

Total incl. disability grant*

396.674

Total excl. disability grant*

224.494

[36]

[3]

Source: Truen et al., adapted from Budlender. N/A = not applicable. [5] *Møller and Matic note that social security payments constitute transfer costs, which should not be included from a societal perspective but are relevant to external cost studies.

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Table 4. Summary of alcohol-attributable costs in South Africa, 2009 Cost category

Amount (R million)

Tangible costs Healthcare

9 330

Other healthcare costs

2 333

Treatment research and prevention

Social and welfare costs

397

Crime response

9 680

Crime consequence – transfers

4 500

Crime anticipation

3 750

Road traffic accidents – damage to motor vehicles

7 912

Total tangible costs

37 920

Intangible costs Premature mortality and morbidity – reduction in earnings

8 245 - 9 769

Premature mortality and morbidity – VSL

183 527 - 216 450

Absenteeism

141 - 448

Non-financial welfare costs

16 100

Total intangible costs

208 013 - 242 767

Insufficient data to estimate cost Hangovers and drunkenness at work

Uncertain

Unemployment and early retirement

Uncertain

Other labour costs

Uncertain

Miscellaneous other social and welfare costs

Uncertain

245 933 - 280 687

Total costs Source: Truen et al.[36] VSL = value of statistical life.

and in crashes in which motor vehicle passengers are killed, we proposed that all other collisions would be reduced to a similar extent. This is congruent with a US study that estimated alcohol-attributable costs to crash victims at 27%.[22] The alcoholattributable fraction of 27% was applied to the R29.7 billion total crash cost to estimate a R7.9 billion total annual vehicular damage cost of alcohol-involved crashes in SA.

Labour costs

Productivity at work Alcohol misuse is a risk factor for work-related injuries, increased absenteeism and high employee turnover.[24] A significant proportion of school-age adolescents (29%) also misuse alcohol,[25] which can be linked to absenteeism and academic failure. Another systematic review[26] found that alcohol abuse increased the likelihood of drug abuse and risky sexual behaviour, which reduced human capital development and thus the ability of citizens to participate in and contribute to society. Møller and Matic[5] suggest that the impact of harmful use of alcohol on labour supply and overall productivity is discernible through the

following four channels: lower productivity due to hangovers or drunkenness at work; absenteeism due to hangovers; unemployment and retirement effects; and other labour costs. While common sense suggests that a drunken individual, or one suffering from a hangover, is likely to be less productive than a sober individual, in practice studies have not yielded the expected results. Rather there is an inverse U-shaped relationship between wage levels and alcohol consumption.[27-29] The relationship between problem drinking and wages suggests a reduction in productivity, but the evidence is mixed.[29] In the absence of conclusive research, an estimate of the impact on productivity in SA is not warranted. Absenteeism There is a paucity of research on the proportion of sick-days attributable to harmful alcohol use. A typical assumption is that 4 - 6% of absenteeism is due to harmful alcohol use.[5] A single study conducted by a commercial firm and covering 7 000 employees in 60 firms found that absentee rates average 2.3% in workers earning R1 000 or less per month,

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and 1.3% in workers earning R10 000 15 000 per month. We calculated the cost of absenteeism by multiplying employee compensation by absenteeism rates, by the fraction of absenteeism attributable to alcohol, and finally by the productivity loss factor. Given total employee compensation costs of R1 081.4 billion in 2009, the alcoholattributable fraction approach suggests that the cost of alcohol-attributable absenteeism ranges from R140.6 million to R447.7 million annually. Premature mortality and morbidity One method of calculating the cost of mortality and morbidity is to estimate the net present value of the earnings stream that an individual would have earned if it had not been for the event that resulted in premature death or disability. A key problem with this approach is that it produces different values for deaths between, and even within, countries. In SA, where unemployment levels are high, low-skill workers can be replaced relatively easily, and the cost to the economy of premature death may be limited to the friction associated with finding a new employee.[5] We sought to measure the economic value of premature mortality by estimating the average amount an individual would be willing to pay to prevent death, which generates a value of statistical life (VSL). VSLs must be treated with some caution,[30] but they do estimate the value society places on averting premature mortality, which takes into account the emotional costs of such mortality. Using average per capita employee compensation as a proxy, based on 2009 GDP[31] and mid-year population estimates,[32] the economic benefits lost as a result of premature mortality in SA equate to R21 632 per death. The total impact on society is substantially higher if emotional costs are included. Miller[30] suggests that the best estimate of VSL is 143 times the per capita GDP. Lindhjem et al. [33] provide a more conservative estimate of mean VSL of 73.8 times the per capita GDP in countries with similar purchasing power parity-adjusted per capita GDPs to that of SA. At 2009 per capita GDP levels, Lindhjem et al.’s [33] VSLs suggest that the average SA citizen would pay R3.5 million to prevent their death. The total VSL-projected costs of the 36 840 - 46 153 alcohol-attributable deaths calculated by Schneider et al.[9] and Rehm et al.[13] amount to between R128.9 billion and R161.5 billion, or 5.0 - 6.8% of the GDP. As approximately 22.5 years of life are lost per alcohol-attributable death, the estimated 339 263 years lost to disability are

RESEARCH

equivalent to 15 075 premature deaths, or a VSL of R53.3 billion (an additional 2.2% of GDP). Unemployment and early retirement There are several ways in which harmful alcohol use can impact on the probability of a person’s finding employment. However, in practice the extent to which problem drinking is associated with unemployment may depend on whether intoxication is felt to be socially acceptable, and on absolute poverty levels. For example, poverty could constrain the purchase of alcohol among the poor, making problem drinking the preserve of the employed. However, the nature of the relationship is unclear.[5] Other labour costs Most sources of alcohol-related decreases in labour productivity reflect the reduction in the amount of time available to work. Examples include delays in getting to work due to traffic congestion caused by alcohol-attributable accidents, time spent incarcerated due to crimes committed under the influence of alcohol, and time spent caring for those disabled by alcohol-attributable health problems.[5] Data to estimate the size of these impacts on labour productivity in SA are not available.

Costs of crime

Alcohol-attributable crime imposes a significant cost burden. A US study estimated that alcohol-attributable crimes cost more than double those attributable to drugs, with alcohol-related violent crimes accounting for more than 85% of total costs for alcohol and drug-related crimes.[34] Neither violent crimes nor alcohol-related harms are as pronounced in the USA as in SA, which implies that these costs may be yet higher in SA. A recent study using accounting methodology provided an aggregated cost of crime in SA of US$22.1 billion or 7.8% of the GDP in 2007 (R155 billion at an approximate 2007 exchange rate of R7:$1).[35] This study’s superficial burden of disease analysis significantly underestimates the true extent of homicide, and it is likely that the cost of crime is similarly underestimated. Crime costs in low- to middle-income countries in Latin America with high crime levels, such as Colombia, Brazil or Venezuela, range from 5% to 15% of the GDP. Møller and Matic[5] distinguish between three categories of costs related to crime in order to avoid double counting and then apportion a share of these costs to alcohol: (i) costs in response to crime; (ii) costs as a consequence of crime; and (iii) costs in anticipation of crime. Costs in response to crime Alda and Cuesta[35] estimated the institutional costs incurred by SA government agencies in responding to crime, including correctional services, justice and police and public security, at $7.169 billion in 2007 (R50 billion at an exchange rate of R7:$1), equivalent to 2.55% of the GDP. Applying Budlender’s[3] AAFs of 22.5% for police and public security, 38.5% for correctional services and 2% for justice costs, it is estimated that costs of R9.68 billion were attributable to alcohol. [36] Consequences of crime Alda and Cuesta[35] calculated health costs relating to crime to have been $7.37 billion (R52 billion) in 2007, equivalent to 2.6% of the GDP. Twothirds accrued from the contribution to disease burden and productivity losses and the rest primarily from emotional costs, with medical costs accounting for less than 1%. The estimated economic costs of foregone foreign direct investment of $1.287 billion (R9 billion) and transfer costs of $3.426 billion (R24 billion) from theft of residential property, vehicles, weapons and livestock also need to be included. Assuming that 75% were

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relevant to alcohol use, Budlender’s[3] AAF of 25% suggests that R1.7 billion was lost in foreign direct investment and R4.5 billion in transfer costs. In addition, Budlender estimated the cost of victim empowerment, among social development costs, at R109 million across national and provincial departments in 2009. Anticipation of crime Economic costs of crime are also incurred in anticipation of criminal activity, via expenditures on security measures such as anti-theft devices and guards. Møller and Matic[5] could identify only one comprehensive study that included these costs, which were found to be of a similar scale to costs in response to crime. Alda and Cuesta[35] estimate that $2.83 billion (R20 billion) was spent on private security for businesses and households in 2007. Applying a fraction of 75% for alcohol-relevant costs and Budlender’s AAF of 25%[3] provides an estimate of R3.7 billion for costs attributable to alcohol in anticipation of crime.

Non-financial welfare costs

The emotional costs placed on premature mortality and morbidity associated with alcohol are obtained from the amounts that individuals would pay for their prevention. Additional non-financial welfare costs accrue to people affected by the actions of others who misuse alcohol. It is not possible to estimate the value of all nonfinancial welfare costs associated with alcohol consumption, but in the SA context the following two examples, relating to traffic crashes and crime, suggest that these are likely to be substantial. Miller[22] and Rosen et al.[37] suggest that the cost of emotional pain associated with traffic crashes and violent crime, respectively, is approximately the same as the economic costs, which would equate to R12.9 billion for traffic crashes. Alda and Cuesta[35] estimate that one-third of health costs relating to crime can be attributed to emotional costs. Applying 75% of their total healthcare cost of $7.37 billion in 2007 (R52 billion) for ‘alcohol-relevant’ costs and an AAF of 25% suggests that emotional costs of alcohol-related crime are approximately R3.2 billion.

Summary of total alcohol-attributable costs

A summary of the costs attributable to harmful alcohol use, based on the analysis of secondary sources described in the preceding section, is shown in Table 4. Total tangible and intangible costs represent 10 12% of 2009 GDP. The tangible financial costs of harmful alcohol use alone amount to an estimated R37.9 billion, or 1.6% of the 2009 GDP.

Discussion

The SA alcohol industry poses complex challenges for policy makers. While it makes a considerable contribution to the domestic economy through employment, output and export earnings, it imposes enormous social and emotional costs. Alcohol ranks as the most harmful of a selection of 20 drugs, based on the magnitude of harms the drug causes both to drinkers and those affected by drinking.[38] Inclusion of the intangible, non-financial costs of the trauma associated with alcoholrelated illness, injury and violence goes some way towards indicating how much value citizens place on any intervention that would help to mitigate this trauma. VSL estimates in particular suggest that South Africans would be willing to pay R183.5 - 216.5 billion, or 8 - 9% of the GDP, to avoid the deaths, illnesses and disabilities caused by alcohol. These figures still underestimate the total cost of alcohol, as there were insufficient data to estimate several entire cost categories, and the VSL estimates excluded many sources of psychological trauma. There will always be gaps in locally relevant data requiring the imputation of costs. Costing studies will continue to produce underestimates of harms if generation of the type and quality of data

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required for costing exercises is not considered important in the dayto-day routines of both the public and private sectors. For example, the current study could not include estimates of the costs related to employee hangovers or drunkenness at work. Given the high rates of alcohol consumption, these are likely to be frequent outcomes with a significant impact on the SA economy. The systematic collection and release of such data are therefore crucial to estimating the full socio-economic impacts of alcohol-related harms. Expressing these in economic terms provides necessary leverage to drive the political will, and gain popular support, for evidence-based interventions at both national and provincial levels. Ideally, interventions should be designed so as to minimise the social and economic costs of alcohol abuse, while limiting the impact on the industry’s generation of economic benefits. The figures in this study point to a disproportionate investment in intervention strategies that seek to address alcohol-related harms that are not the major contributors to the country’s burden of disease.[36] For example, the alcohol industry, via its statutorily required antiabuse initiatives, invests heavily in fetal alcohol syndrome (FAS) prevention, driver safety messaging, and educational campaigns targeting adolescents. However, FAS constitutes less than 6% of the total alcohol-attributable burden of disease, whereas violence, followed by tuberculosis, unintentional injuries and HIV/AIDS, are the major contributors, together accounting for nearly three-quarters of the burden.[9] Pedestrians rather than drivers are most at risk for alcohol-related traffic fatalities. The group at highest risk for alcoholrelated harms is aged 18 - 35 years. Current interventions are less likely to yield the return on investments in economic terms than if the focus were shifted to those risk factors, and at-risk groups, that together account for the high costs of alcohol-related harms. Despite its limitations, this study provides a comprehensive assessment of the cost of alcohol-related harms. It clearly shows that harm-related consumption of alcohol has economic effects that extend beyond many of the factors often used to justify the economic benefits of retaining the existing legislation that governs the alcohol market. The unavailability of essential costing data results in an underestimate of the true economic, social and health costs of alcohol in SA. Providing a more accurate assessment of these costs will require a cross-sectoral commitment to funding and research aimed at providing the kinds of data absent from this study.

Conclusion and recommendations

Much more can be done to mitigate the costs of harmful alcohol use and its impact on economic growth. Given the prevalence and magnitude of drinking in SA, it is not surprising that companies on the supply side of the alcohol market are powerful and influential. Their economic influence means that the existing frameworks that guide the regulation and distribution of alcohol are founded on claims about maximising their contributions to the local economy. Industry claims must always be assessed against the economic, social and health costs associated with the end use of their products. Furthermore, consideration should be given to who is benefiting from the industry and who is paying its costs. Regulatory and policy interventions have the potential to substantially curtail the costs of harmful alcohol use, and in doing so make a direct contribution to the well-being of the average SA citizen, and to the economy. However, such regulation will only be effective if informed by good evidence provided by ongoing economic, social and health research into the effects of alcohol. Acknowledgements. The current study formed part of a larger costing project[36] commissioned by the National Liquor Authority, a division of

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the National Department of Trade and Industry of SA, to assist future development of evidence-based policy and law. References 1. Parry CDH, Myers B, Thiede M. The case for an increased tax on alcohol in South Africa. S Afr J Econ 2003;71(2):265-281. [http://dx.doi.org/10.1111/j.1813-6982.2003.tb01308.x] 2. Single E, Robson L, Xie X, Rehm J. The economic costs of alcohol, tobacco and illicit drugs in Canada, 1992. Addiction 1998;93(7):991-1006. [http://dx.doi.org/10.1080/09652149835170] 3. Budlender D. National and Provincial Government Spending and Revenue Related to Alcohol Abuse. Johannesburg: Soul City Development Institute, 2009. 4. A & T Consulting. Industry Study: The South African Liquor Industry. Pretoria: Department of Trade and Industry, 2005. http://www.restaurant.org.za/downloads/SALiquorIndustryJune05.pdf (accessed 10 December 2013). 5. Møller L, Matic S. Best Practice in Estimating the Costs of Alcohol: Recommendations for Future Studies. Copenhagen: WHO Regional Office for Europe, 2010. 6. Collins D, Lapsley H, Brochu S, et al. International Guidelines for the Estimation of the Avoidable Costs of Substance Abuse. Ottawa: Health Canada, 2006. 7. Jones L, Bates G, McCoy E, et al. The Economic and Social Costs of Alcohol-related Harm in Leeds 2008-09. Liverpool: Liverpool John Moores University, 2010. 8. Norman R, Bradshaw D, Schneider M, et al. Estimating the burden of disease attributable to interpersonal violence in South Africa in 2000. S Afr Med J 2007;97(8):653-656. 9. Schneider M, Norman R, Parry C, Bradshaw D, Plüddemann A. Estimating the burden of disease attributable to alcohol use in South Africa in 2000. S Afr Med J 2007;97(8):664-672. 10. Bradshaw D, Groenewald P, Laubscher R, et al. Initial Burden of Disease Estimates for South Africa, 2000. Parow, Cape Town: Burden of Disease Research Unit, Medical Research Council of South Africa, 2003. 11. Parry C, Rehm J, Poznyak V, Room R. Alcohol and infectious diseases: An overlooked causal linkage? Addiction 2009;104(3):331-332. [http://dx.doi.org/10.1111/j.1360-0443.2008.02500.x] 12. Rehm J, Anderson P, Kanteres F, Parry CD, Samokhvalov AV, Patra J. Alcohol, Social Development and Infectious Disease. Stockholm: Swedish Ministry of Health and Social Affairs, 2009. Report No. 978-1-77052-444-6. 13. Rehm J, Kehoe T, Rehm M, Patra J. Alcohol Consumption and Related Harm in WHO Africa Region in 2004. Toronto: Centre for Addiction and Mental Health, 2009. 14. Single E, Collins D, Easton B, et al. International Guidelines for Estimating the Costs of Substance Abuse. Geneva: World Health Organization, 2003. 15. Marszalek J, De Villiers PJT. Morbidity profile of admissions to GF Jooste Hospital, Manenberg, Cape Town. S Afr Fam Pract 2006;48(6):15a-e. 16. Bowman B. Towards a South African injury costing model: A review of the literature for the development of a process path. African Safety Promotion 2002;1(1):55-64. 17. Bowman B, Stevens G. Injury costing in South Africa: The state of the sector. In: Suffla S, Van Niekerk A, Duncan N. Crime, Violence and Injury Prevention in South Africa: Developments and Challenges. Cape Town: MRC Press, 2004:170-183. 18. World Health Organization Statistical Information System (WHOSIS). 2012. http://www.who.int/ whosis/en/ (accessed 5 January 2012). 19. Anderson P, Baumberg B. Alcohol in Europe: A Public Health Perspective. London: Institute of Alcohol Studies, 2006. http://ec.europa.eu/health-eu/news_alcoholineurope_en.htm (accessed 8 January 2013). 20. Plüddemann A, Dada S, Parry C, et al. Monitoring Alcohol & Drug Abuse Trends in South Africa (July 1996 - December 2008). Cape Town: Medical Research Council, 2009. 21. De Beer EJH, Van Niekerk EC. The Estimation of Unit Costs of Road Traffic Accidents in South Africa. Pretoria: National Department of Transport, 2004. 22. Miller TR, Lestina DC, Spicer RS. Highway crash costs in the United States by driver age, blood alcohol level, victim age, and restraint use. Accid Anal Prev 1998;30(2):137-150. [http://dx.doi.org/10.1016/ S0001-4575(97)00093-6] 23. Peer N, Matzopoulos R, Myers JE. The Number of Motor Vehicle Crash Deaths Attributable to Alcohol-impaired Driving and its Cost to the Economy Between 2002 and 2006 in South Africa. Cape Town: University of Cape Town, 2009. 24. Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Alcohol and Global Health 1: Global burden of disease and injury and economic cost attributable to alcohol use and alcoholuse disorders. Lancet 2009;373(9682):2223-2233. [http://dx.doi.org/10.1016/S0140-6736(09)60746-7] 25. Reddy S, James S, Sewpaul R, et al. The 2nd South African National Youth Risk Behaviour Survey: 2008. Cape Town: Medical Research Council, 2010. 26. Townsend L, Flisher AJ, King G. A systematic review of the relationship between high school dropout and substance use. Clin Child Fam Psychol Rev 2007;10(4):295-317. [http://dx.doi.org/10.1007/ s10567-007-0023-7] 27. French MT, Zarkin GA. Is moderate alcohol use related to wages? Evidence from four worksites. J Health Econ 1995;14(3):319-344. [http://dx.doi.org/10.1016/0167-6296(95)90921-R] 28. Berger MC, Leigh JP. The effect of alcohol use on wages. Appl Econ 1988;20(10):1343-1351. [http:// dx.doi.org/0.1080/00036848800000105] 29. Lye J, Hirschberg J. Alcohol consumption and human capital: A retrospective study of the literature. J Econ Surv 2010;24(2):309-338. [http://dx.doi.org/10.1111/j.1467-6419.2009.00616.x] 30. Miller TR. Variations between countries in values of statistical life. Journal of Transport, Economics and Policy 2000;34(2):169-188. http://www.jstor.org/stable/20053838[0] (accessed 10 December 2013). 31. South African Reserve Bank. Full Quarterly Bulletin, December 2013, No. 270. Pretoria: SARB, 2013. 32. Statistics South Africa. Mid-year Population Estimates 2010. Statistical Release P0302. Pretoria: Statistics South Africa, July 2010. 33. Lindhjem H, Navrud S, Braathen NA, Biausque V. Valuing mortality risk reductions from environmental, transport, and health policies: A global meta-analysis of stated preference studies. Risk Anal 2011;31(9):1381-1407. [http://dx.doi.org/10.1111/j.1539-6924.2011.01694.x] 34. Miller TR, Levy DT, Cohen MA, Cox KLC. Costs of alcohol and drug-involved crime. Prev Sci 2006;7(4):333-342. [http://dx.doi.org/10.1007/s11121-006-0041-6] 35. Alda E, Cuesta J. A comprehensive estimation of costs of crime in South Africa and its implications for effective policy making. J Int Dev 2010;23(7):926-935. [http://dx.doi.org/10.1002/jid.1721] 36. Truen S, Ramkolowan Y, Corrigall J, Matzopoulos R. Baseline Study of the Liquor Industry Including the Impact of the National Liquor Act 59 of 2003. Pretoria: Department of Trade and Industry, 2011. http://www.thedti.gov.za/business_regulation/docs/nla/other_pdfs/dna_economics_nla_act.pdf (accessed 10 December 2013). 37. Rosen SM, Miller TR, Simon M. The cost of alcohol in California. Alcohol Clin Exp Res 2008;32(11):1925-1936. [http://dx.doi.org/10.1111/j.1530-0277.2008.00777.x] 38. Nutt DJ, King LA, Phillips LD. Drug harms in the UK: A multicriteria decision analysis. Lancet 2010;376(9752):1558-1565. [http://dx.doi.org/10.1016/S0140-6736(10)61462-6]

Accepted 28 November 2013.

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Attitudes to organ donation among some urban South African populations remain unchanged: A cross-sectional study (1993 - 2013) H R Etheredge,1 MSc (Med); R E Turner,2 MSc (Nursing); D Kahn,3 MB ChB, FCS (SA), ChM Health Communication Research Unit, University of the Witwatersrand, Johannesburg, South Africa Department of Nursing, Faculty of Medicine and Health Sciences, Stellenbosch University, Parow, Cape Town, South Africa 3 Department of Surgery, Faculty of Health Sciences, University of Cape Town, South Africa 1 2

Corresponding author: D Kahn (delawir.kahn@uct.ac.za)

Background. A 1993 paper in the SAMJ suggested that public attitudes to organ donation in South Africa were positive. However, statistics reveal a decline in the annual number of transplants in this country. Objective. To repeat the 1993 survey as far as possible and determine whether public attitudes to organ donation in some South African populations have changed over the past 20 years. Methods. The 1993 study was replicated in 2012 to generate a current data set. This was compared with the raw data from the 1993 study, and an analysis of percentages was used to determine variations. Results. Generally attitudes to organ donation have not changed since 1993, remaining positive among the study population. However, individuals are significantly more hesitant to consider donating the organs of a relative without being aware of that personâ&#x20AC;&#x2122;s donation preference. Individuals in the black African study population are currently more willing to donate kidneys than in 1993 (66% v. 81%; p<0.0001), but less willing to donate a heart (64% v. 38%; p<0.0001), a liver (40% v. 34%; p<0.036) and corneas (22% v. 15%, p<0.0059). Conclusions. Publicity campaigns aimed at raising awareness of organ donation should emphasise the importance of sharing donation preferences with oneâ&#x20AC;&#x2122;s family in order to mitigate discomfort about making a decision on behalf of another. These campaigns should be culturally and linguistically sensitive. The study should be repeated in all populations over time to continually gauge attitudes. S Afr Med J 2014;104(2):133-137. DOI:10.7196/SAMJ.7519

Transplantation is available in almost all major centres around the world. The principles are fairly standardised and outcomes are generally good. Transplantation is currently considered the treatment of choice for most patients with endstage organ failure. South Africa (SA) has an established track record in transplantation, as well as a network of active transplant programmes.[1] One of the major challenges in transplantation, both internationally and locally, is the shortage of donor organs. Several factors are thought to contribute to this problem in SA, including lack of public awareness about organ donation. Numerous strategies have been employed in an attempt to address this problem. These include promotions and advertising in the lay media and education programmes in schools and other institutions.[1] Despite these efforts, the overall number of transplants performed each year has decreased.[1] Of particular concern is a decrease in the consent rate among families of brain-dead potential donors, from 55% in 1991 to 50% in 2001 and 32% in 2011.[2] The question arises whether the decline in the consent rate for organ donation is related to changes in the attitudes of the general public towards transplantation. In a 1993 survey,[3] the majority of the study population expressed a willingness to donate both their own organs and the organs of a family member after death, should the circumstances arise. The aim of the present study was to repeat the 1993 survey as far as possible to ascertain whether public attitudes to organ donation in certain sectors of SA have changed. A cross-sectional study design and statistical analysis were employed.

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Historical background

Before 1994, segregation and discrimination on the basis of ethnicity in SA were widespread. Since then, several basic characteristics of SA have changed.[4] These changes pose challenges for time-based replication studies, the present study included. The 1993 study (hereafter referred to as study 1) forms the baseline data for the current analysis. It surveyed the attitudes of two SA populations, black African and white, to organ transplantation.[3] Individuals of Indian, Asian or mixed race origin were not included. At the time of study 1, political segregation in the country provided a unique opportunity to explore the views of two distinct socioeconomic groups within a single demographic area. The white group represented a developed population, while the black African group represented developing-world views.[4] The 2012 study (hereafter referred to as study 2), which forms the comparison data set, was drawn from a representative sample of the SA urban population. It pays heed to population diversity, with sample size and demographics calculated according to census data. Study 2 is therefore not subject to the limitations of study 1. It is estimated that 21% of individuals living in urban areas are members of a medical scheme and accessing healthcare in the private sector, which is comparable to healthcare in developed countries.[5] The remainder (79%) access healthcare in the state-run public sector, which provides services more similar to those of developing countries. These figures can be extrapolated to the study 2 population. The views of the study population reported in study 2 therefore also represent both a First-World and a developing-world perspective on attitudes toward organ donation, albeit through a different stratification of variables.

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Study 2

Data for study 2 were obtained in 2012. The same market research company conducted the fieldwork. Techniques used were identical to those of study 1, with the exception of sampling. Study 2 comprised a representative sample of 1 048 adults in the five major SA metropolitan areas. Metropolitan areas are typically wealthier than rural areas, and they are also home to a large migrant workforce from the rest of the country and further afield.[6] Written informed consent was obtained from all participants once they had agreed to take part and before administration of the questionnaire. All the questionnaires were anonymous, and the nature of the fieldwork process ensured that no individual participant could be identified. Data were captured, cleaned and converted into SPSS format by TNS. The data were

KwaZulu-Natal Eastern Cape and Free State Western Cape

Total sample

KwaZulu-Natal Eastern Cape and Free State Western Cape

Total sample

Gauteng

Sesotho

Setswana

IsiXhosa

IsiZulu

Afrikaans

English

Study 2

50+ years

25 - 34 years

35 - 49 years

18 - 24 years

Female

Study 1

Male

Fig. 1. Comparison of the study samples for the black African study population.

1 400

Study 1

1 200

Study 2

1 000 800 600 400 200

Gauteng

Sesotho

Setswana

IsiXhosa

IsiZulu

Afrikaans

English

50+ years

35 - 49 years

25 - 34 years

18 - 24 years

Female

Data for study 1 were obtained during a collection period from 1987 to 1990. A quantitative methodology was employed. A structured, interviewer-administered questionnaire was utilised to measure attitudes among a sample of 2 125 South Africans. The sample was derived from both urban and rural areas, and only black African and white individuals were invited to participate. The fieldwork was undertaken by TNS, a market research company, as part of a larger general market research survey. TNS fieldworkers were trained by one of the researchers and supervised by field managers. Individuals were approached to participate on a ‘door-to-door’ basis. All the questionnaires were anonymous, and the nature of the fieldwork process ensured that no individual participant could be identified. Age, gender, race, first language, geographical region and economic status were recorded for each participant. The questions asked of participants were: • Would you accept an organ for transplant if you needed one? • Would you be willing to have your own organs donated to other people after you die if circumstances allow it? • If a close family member had a fatal accident, would you be willing to donate his or her organs if circumstances allow it? • Which organs would you be willing to donate (heart, lungs, liver, kidney, pancreas, cornea)?

900 800 700 600 500 400 300 200 100 0

Male

Study 1

Respondents, n

The research was approved by the human research ethics committees of the University of the Witwatersrand (M120532), the University of Cape Town (309/2012) and Stellenbosch University (WITS 2).

Respondents, n

Methods

Fig. 2. Comparison of the study samples for the white study population.

analysed using SAS version 9.3.7.[7] Data from study 1 were compared with those from study 2 using an analysis of percentages. Only data from the black African and white population groups were used for the comparison, as there were no data for the other groups in study 1. Furthermore, a large body of literature suggests that attitudes towards organ donation differ according to ethnic classification, and owing to data coding in the first study, this was the only way to compare the two data sets.

Study population

Figs 1 and 2 illustrate the demographics of the samples from the two studies. Although there were differences across samples, these were not deemed to be significant and a comparison was still possible.

Results

There were 2 125 participants in study 1 compared with 1 048 in study 2. In the black

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African cohort, the gender, age, language and regional distributions were similar across the studies. In the white cohort, there were relatively more females, more Englishspeaking respondents and more respondents from Gauteng in study 1. Across the two samples, the majority of respondents held positive views about organ donation. Most (70 - 91%) appeared willing to potentially donate their own organs (Table 1). Many (67 - 83%) also expressed willingness to donate the organs of a relative. It appeared that these attitudes had remained largely unchanged over the past two decades. Across the two studies, there was no difference between male and female respondents with regard to willingness to have their own organs donated and to donate the organs of a relative (Table 1). Among white respondents, age did not influence willingness to donate their own organs or to donate the organs of a relative. This was

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Table 1. Overall results of the comparison study White Own organs

Black African Relative’s organs

Own organs

Relative’s organs

Positive attitudes to organ donation (%)

Study 1

Study 2

Study 1

Study 2

Study 1

Study 2

Study 1

Study 2

Overall

Male

Female

18 - 24

25 - 34

35 - 49

>50

English

Afrikaans

IsiZulu

IsiXhosa

Setswana

Sesotho

Gauteng

KwaZulu-Natal

Eastern Cape and Free State

Western Cape

Gender

Age (years)

Language group

Area

Table 2. Reasons for unwillingness to donate own organs White Reasons for unwillingness (%)

Study 1

Study 2

Black African Study 1

Study 2

It is against my beliefs/do not believe in it

Just could not agree to it/would not like it

I do not want anything removed

I am too old/nothing would be useful

Only when physically dead

I would be very sick so my organs would be no good

None

Don’t know/not sure

Other

consistent across both studies. However, among black African respondents, older respondents (>50 years) were more willing to donate the organs of a relative in study 2 than in study 1 (71% v. 55%; p=0.049) (Table 1). There were some differences in attitudes towards organ donation in terms of language (Table 1). Black African IsiZulu-speaking participants were more willing to donate the organs of a relative in study 2 than in study 1 (70% v. 60%; p<0.0001). In contrast, black African IsiXhosa-speaking respondents were less willing to donate the organs of a relative in study 2 (69% v. 79%; p=0.026). There were no significant differences in attitudes towards organ donation in Englishand Afrikaans-speaking respondents between the two studies.

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Overall, 11% of white respondents and 24% of black African respondents in study 1 indicated that they would be unwilling to donate their own organs, compared with 9% and 30%, respectively, in study 2. The reasons for unwillingness are shown in Table 2, and included ‘it is against my beliefs’, ‘just could not agree to it’, and ‘I do not want anything removed’. Overall, 23% of white respondents and 32% of black African respondents in study 1 expressed an unwillingness to donate the organs of a relative, compared with 17% and 31%, respectively, in study 2 (Table 1). These differences are not significant. The respondents who indicated unwillingness to donate the organs of a

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Table 3. Reasons for unwillingness to donate relative’s organs White

Black African

Reasons for unwillingness (%)

Study 1

Study 2

Study 1

Study 2

It is not up to me to decide/not my responsibility/it is not my body

The relative may not like this

Depends on what their wishes were/only if they have agreed to it

He would have to be physically dead/only God knows when we are dead

It is against my beliefs/it is not our custom to remove organs

You cannot just cut someone up like that/people should be buried as they are

It will not help the other person

Other

Table 4. Organs that black African respondents were willing to donate Organs willing to donate (%)

Study 1

Study 2

p-value <0.0001

Kidneys

Lung

Heart

0.0001

Liver

0.036

Pancreas

Cornea

relative were asked why this was the case (Table 3). In study 1, 24% of the white respondents and 29% of the black African respondents indicated that ‘it is not up to me to decide’, ‘it is not my responsibility’, or ‘it is not my body’. In study 2 this reasoning increased to 60% for the white respondents (p<0.0001) and to 41% for the black African respondents (p<0.0001). Religious or cultural beliefs were also cited to a greater extent by the black African respondents in study 2 (9% v. 28%; p<0.001). Black African respondents were also concerned about keeping the body intact after death, with 12% of the respondents in study 1 feeling uneasy about the perceived damage to the body, compared with 22% in study 2 (p=0.0056). One per cent of the white respondents in study 1 reasoned that the relative ‘might not like to be an organ donor’, and this increased to 20% in study 2 (p<0.0001). Many white respondents (44%) in study 2 indicated that the wishes of the deceased were very important. This increased from 17% in study 1 (p=0.003). Black African respondents were more willing to donate kidneys in study 2 (66% v. 81%; p<0.0001), but less willing to donate a heart (64% v. 38%; p<0.0001), a liver (40% v. 34%; p<0.036) and corneas (22% v. 15%; p<0.0059) (Table 4).

Discussion

Evidentially, there is no significant difference in expressed attitudes of the study populations towards organ donation over the period analysed. Study 2 reveals that the majority of the population studied still felt positive, with many respondents willing to donate their own organs and those of a relative should circumstances allow. Although it cannot be formally analysed, it appears that the white population is still more willing to donate organs, their own and those of a relative, than the black African population. This may be because the white cohort is better informed and educated than their black African counterparts, despite rapid urbanisation since democracy in 1994.[8] We noted some changes with regard to donating the organs of relatives. All participants appeared as willing to donate the organs

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0.0059

of relatives in study 2 as they were in study 1. However, across the two studies there were notable changes in the justifications for unwillingness to do so. Members of both the black African and the white populations expressed reluctance to make a decision on behalf of another person. In both populations, this sentiment was expressed significantly more often in study 2. There are several hypothetical explanations for this shift in reasoning. For instance, a better educated and more rights-aware population may prize autonomy and free agency more than their counterparts in study 1.[9] This is especially relevant in the healthcare context, where patient-centred care has overtaken a more traditional, paternalistic approach.[10] The decision to donate organs on another’s behalf may therefore seem objectionable. Another possibility is that migration and immigration have broken down familial proximity, and thus traditional lines of communication,[9] so individuals are not as familiar with the sentiments of their relatives as they were 20 years ago. Furthermore, and in spite of many families being geographically dispersed, family structure in African culture appears to play an important role. Decision making is the purview of the elders, and other family members may be unwilling to make decisions on donation without elder approval.[11] In practice, we have often observed that family members who are asked to consider organ donation are unaware of the wishes of their relatives. SA has an opt-in system of organ donation. This means that organs of a deceased individual may not be donated without informed consent from the next of kin. This applies even when the individual is a registered organ donor.[1] In an attempt to mitigate low donor numbers, some countries have adopted presumed consent systems whereby all individuals are presumed willing organ donors unless they have complied with formal processes to express unwillingness to donate organs.[12] It may be argued that adopting a presumed consent system in SA could alleviate factors regarding disinclination to donate the organs of a relative, as familial consent would not necessarily be sought. We postulate, however, that a presumed

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consent system would not be workable in the SA context, as it is not consistent with fundamental SA freedoms, including religious and cultural freedom, as well as informed consent and its corollary, informed refusal. A presumed consent policy could jeopardise these rights, as it is currently unlikely to be possible to disseminate sufficient information to constitute an ‘informed’ refusal owing to communication limitations posed by language and literacy barriers as well as access to information. Furthermore, practice in countries with presumed consent suggests that relatives have the final say as to whether organs are to be donated.[12] More should be done to influence communication about organ donation among family members. Looking at organs that participants are willing to donate, it is interesting to note that black African respondents reported a greater willingness to donate kidneys in the current study than in 1993. We cannot definitively attribute the cause of this shift to any specific factor or factors, which may include knowing someone who has received a kidney transplant[13] or be related to advertising campaigns regarding living kidney donation. However, kidney transplantation has also been portrayed negatively in the SA press.[14] A similar case in Germany led to a sharp decline in living organ donation.[15] A decrease in willingness to donate heart, liver and corneas was expressed by the black African population. This is consistent with cultural beliefs that emphasise the role of the ancestors after death, and the notion that the body should remain intact for spiritual reasons.[11] However, there may be more subtle reasons for the shift. Hearts are sometimes imbued with mythologies that might influence perceptions. Furthermore, heart transplantation may be considered an option only for the more affluent, so it is not prominent among black Africans, many of whom are less wealthy than whites. For instance, in Gauteng Province the only heart transplant centre is in the private sector, requiring that individuals are members of a medical scheme, or pay for clinical management.[1] Negative sentiments about liver transplantation may be linked to perceptions of the liver and alcoholism, which is a source of contention in SA society.[16]

Recommendations

This research presents a comparison of attitudes towards organ donation in sections of the SA population. It is recommended that the study be repeated to include the Asian, Indian and mixed-race populations after a suitable time lapse in order to continually gauge attitudes – the 2012 data would serve as the baseline for groups not included in the 1993 study. It is also recommended that the study be repeated in a rural population. Our previous research suggests that television advertising is one of the most effective ways of communicating information about organ donation to the SA public.[13] It is recommended that lobbying organisations consider family communication regarding preferences

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for donation as a message that must be widely disseminated. This may assist in improving consent rates, as relatives will not feel they are making a decision on behalf of a loved one without knowing their preferences. Demographic factors such as language and literacy levels of the target population should be carefully considered for such campaigns to dispel some of the negative sentiment found in this research. The authors are of the opinion that some of the content in SA organ donation campaigns is not clear. While a discussion of this is beyond the scope of this paper, the advertisement by the Australian Government[17] provides a good example of clear, concise promotional advertising in support of organ donation. Acknowledgements. The authors gratefully acknowledge TNS for assistance with field work, as well as Astellas Transplant and Roche for unrestricted educational grants. References 1. Organ Donor Foundation of South Africa. Statistics, How we create public awareness, Transplant centres in South Africa. 2013. http://www.odf.org.za (accessed 18 September 2013). 2. Kahn D, McCurdie F, Michaelides A. Socioeconomic factors, as well as race, impact on consent rates for organ donation. Proceedings of the 25th Southern African Transplantation Society Congress, 29 July - 2 August 2013. Durban: South African Transplant Society, 2013. 3. Pike RE, Odell JA, Kahn D. Public attitudes to organ donation in South Africa. S Afr Med J 1993;83(2):91-94. 4. Ozler B. Not separate. Not equal. Poverty and inequality in post-apartheid South Africa. Econ Dev Cult Change 2007;55(3):487-529. 5. Statistics South Africa. General Household Survey 2011. Pretoria: Statistics South Africa, 2011. http:// www.statssa.gov.za/Publications/P0318/P0318April2012.pdf (accessed 24 January 2013). 6. Health Systems Trust. Forty Million South Africans without Medical Aid. Durban: Health Systems Trust, 2009. http://www.hst.org.za/publications/forty-million-south-africans-without-medical-aid (accessed 24 January 2013). 7. SAS Institute Inc. SAS Software, Version 9.3 for Windows. Cary, NC: SAS Institute Inc., 2002. 8. Statistics South Africa Census 2011. Pretoria: Statistics South Africa, 2012. http://www.statssa.gov.za/ Publications/P03014/P030142011.pdf? (accessed 11 September 2013). 9. Schulze C. Press Release: Racial transformation not ‘complete failure’. 12 September 2013. Johannesburg: South African Institute of Race Relations, 2013. http://www.sairr.org.za/media/mediareleases/PRESS%20RELEASE%20-%20Racial%20transformation%20not%20complete%20failure.pdf/ view (accessed 11 September 2013). 10. Little P, Everitt H, Williamson I, et al. Preferences of patients for patient centred approach to consultation in primary care: Observational study. BMJ 2001;322(7284):468. [http://dx.doi. org/10.1136/bmj.322.7284.468] 11. Kometsi KJ, Louw J. Deciding on cadaveric organ donation in black African families. Clin Transplant 1999;13(6):473-478. [http://dx.doi.org/10.1034/j.1399-0012.1999.130606.x] 12. Abadie A, Gay S. The impact of presumed consent legislation on cadaveric organ donation: A crosscountry study. Health Econ 2006;25(4):599-620. [http://dx.doi.org/10.1016/j.jhealeco.2006.01.003] 13. Etheredge HR, Turner RE, Kahn D. Public attitudes to organ donation amongst a sample of urbandwelling South African adults: A 2012 study. Clin Transplant 2013;27(5):684-692. [http://dx.doi. org/10.1111/ctr.12200] 14. Sidley P. South African doctors arrested in kidney sale scandal. BMJ 2005;331(473):1. [http://dx.doi. org/10.1136/bmj.331.7515.473] 15. Schmidt F. Organ donation in Germany hindered by transplant scandal (Online). Bonn: Deutsche Welle (German National News Channel), 2013. http://www.dw.de/organ-donation-in-germanyhindered-by-transplant-scandal/a-17027343 (accessed 16 September 2013). 16. Govender JP. The proposed banning of alcohol advertising in a developing economy. Economics and Behavioural Studies 2013;5(4):210-220. 17. Australian Government. 2012. Organ Donation Advert. http://www.youtube.com/ watch?v=C8FYC8lMopA (accessed 28 January 2013).

Accepted 17 October 2013.

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A point-prevalence survey of public hospital inpatients with palliative care needs in Cape Town, South Africa L van Niekerk, MB ChB, MSc (Public Health); P J Raubenheimer, MB ChB, FCP (SA) Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa Corresponding author: P J Raubenheimer (peter.raubenheimer@uct.ac.za)

Objectives. To assess the need for palliative care among inpatients occupying acute beds in the public sector hospitals of the Cape Town Metropole. Methods. A cross-sectional, contemporaneous, point-prevalence study was performed at 11 public sector hospitals in the Cape Town Metropole using a standardised palliative care identification tool. Data were collected on the socio-demographic characteristics, diagnoses, and prior and current care planning of patients. Results. The case notes of 1 443 hospital inpatients were surveyed, and 16.6% were found to have an active life-limiting disease. The mean age of the group was 56 years. The diagnoses were cancer in 50.8%, organ failure in 32.5%, and HIV/tuberculosis in 9.6%. The greatest burden of disease was in the general medical wards, to which an overall 54.8% of patients meeting the requirements for palliative care were admitted. Conclusions. This study provides evidence for the need for palliative care services in public sector hospitals and in the health system as a whole. The young age of patients and the high prevalences of end-stage renal failure and HIV are unique, and the burden in the general medical wards suggests a focus for initial inpatient programmes. S Afr Med J 2014;104(2):138-141. DOI:10.7196/SAMJ.7262

Palliative care involves a shift in the approach from curative modalities to comfort-focused care, which aims to improve the person’s quality of life by providing relief of symptoms through psychological and supportive care, alongside medical treatment, in the last stage of life. This care is not exclusive to the person affected by the disease, but includes holistic care and support for the family. It aims to provide a person with a dignified death in his/her preferred place.[1] The need for palliative care is increasing globally, but is especially critical in developing countries. This need has mainly been informed from mortality statistics and disease prevalence. Of the 58 million annual deaths in 2008, 45 million occurred in developing countries.[2] The World Health Organization (WHO) estimates that approximately 9.67 million people are in need of palliative care across Africa.[3] A multi-country study conducted in Africa (Tanzania, Botswana, Ethiopia, Uganda and Zimbabwe) found the proportion of people requiring palliative care to be at least 0.5 - 1% of the total population.[3] South African (SA) statistics on mortality suggest that a large number of patients might potentially benefit from palliative care. In the Western Cape, for example, 65.3% of deaths can be attributed to three main disease groups: AIDS, cancer and non-communicable diseases (NCDs).[4] It has been estimated that 80% of cancer patients and 25 - 50% of HIV/AIDS patients will have pain in the terminal phase of their disease,[5] and it is increasingly recognised that the need for palliative care among those with NCDs is rising. Of global deaths, 80% of deaths due to NCDs are in low- and middle-income countries, and it is estimated that there will be a 300% increase in requirement for palliative care in such patients over the next 20 years.[2,6] The need for palliative care among hospital inpatients has been well documented in Europe, but is not well established in Africa and SA.[7-10] In 2012, the prevalence of palliative need among Ugandan inpatients was published by Lewington et al.;[11] 46% of inpatients

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were assessed as having an active life-limiting disease (ALLD), with HIV/AIDS being the commonest diagnosis. A recent survey at a large referral hospital in SA found that the inpatient mortality of medical patients admitted to the general medical service was 11%, with a 12-month post-discharge mortality of 35%; in many cases this was predictable on discharge, reflecting the burden of patients requiring palliative care in the acute medical service.[12] In the face of resource constraints and the increasing demand for healthcare, it is becoming imperative for the SA health system to use existing resources efficiently and effectively. Research from Canada has found that in the last 6 months of their life people consume 21% of healthcare costs and occupy 24% of hospital days.[13] In the UK, every £1 spent on palliative cancer care was found to release a further £2 of hospital funds.[14] Significant cost savings from hospital-based palliative care consultation teams have been demonstrated, but even more savings are estimated to be achievable by providing patients with the necessary support to die at home.[15,16] A cost analysis conducted to evaluate the SA N’Doro hospital-based and outreach palliative care programme (Chris Hani Baragwanath Academic Hospital, Johannesburg) found that the cost per outreach visit was 50% less than the average cost of a patient day equivalent for district hospitals.[17] The primary aim of this study was to measure the proportion of inpatients with ALLD who would be appropriate for palliative care intervention in the public hospitals of the Cape Town metropole.

Methods

A cross-sectional, contemporaneous, case note point-prevalence study was performed at each of the 11 public sector hospitals in the Cape Town metropole. The research was conducted between November 2011 and February 2012, excluding the 4 weeks of the December holiday period, as the hospital population is significantly lower during this time.

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All occupied adult inpatient beds in the medical, surgical, gynaecology, oncology and short-stay emergency wards were included. This study focused on adult inpatients, and excluded obstetric and paediatric beds. Intensive care beds were also excluded, because prognostic prediction in this group is unreliable. All were acute-care beds, no longstay or step-down beds being included. An independent medical practitioner performed the data collection. The sampling of inpatient beds in each hospital occurred on a single day where possible; for larger hospitals, sampling took place over 2 - 4 consecutive days. Weekends and Fridays were excluded. A standardised tool for identification of patients with palliative care need was developed based on the UK Gold Standards Framework Prognostic Indicator Guidance and adapted for the SA context through consultation with local palliative and medical experts (Table 1). This tool has previously been piloted and used as a referral tool in a regional hospital in Cape Town.[18] The criteria for need for palliative care were based on two variables: an affirmative answer to the prognostic predictive question ‘Would you not be surprised if the patient dies within the next 12 months?’ and the presence of ALLD. For all patients sampled, case notes were reviewed at the bedside and data were extracted on the socio-demographics, diagnosis, and presence of appropriate past and future care plans. The research was commissioned by the Western Cape Department of Health, and ethical approval was obtained from the University of Cape Town Research Ethics Committee.

1. Would you not be surprised if the patient dies within the next 12 months? AND 2. Condition from list below: Condition

Referral criteria

Congestive cardiac failure

Symptoms despite maximal medical therapy Disabling SOB at rest (NYHA IV) ≥5 admissions in past 6 months Other associated organ involvement

Chronic obstructive Disabling SOB at rest (NYHA class IV) pulmonary disease ≥5 admissions in past 6 months Associated cardiac failure Renal failure

Not suitable/declined for dialysis End-stage renal disease (GFR <15 ml/min) (stage 5 CKD) Symptoms of renal failure (anorexia, nausea, pruritus, intractable fluid overload, decreased functionality)

Stroke

Severe disabling Severe dysphagia Recurrent fever and sepsis

Cancer

Stage IV malignancy (metastatic) Not for (further) definitive treatment Spends >50% of time in bed

AIDS

Stage III or IV disease with dementia, cachexia, neoplasm or failure of HAART

Other

Intracranial haemorrhage not for surgical management/on ventilator Post cardiopulmonary arrest with CNS damage

SOB = shortness of breath; NYHA = New York Heart Association; GFR = glomerular filtration rate; CKD = chronic kidney disease; HAART = highly active antiretroviral therapy; CNS = central nervous system.

60 10

The case notes of 1 443 patients in hospital beds were surveyed across 11 public hospitals providing acute care in the Cape Town Metropole. The average age of inpatients was 48 years (standard deviation ±17.5); 50.1% were male.

Using the defined survey tool, 240 patients were identified, comprising 16.6% of the total inpatient population sampled. This prevalence ranged from 7.1% to 28.7% across the various hospitals. The highest prevalence (44.4%) was in the oncology wards, followed by the medical wards (20.3%). It should be noted that only 2 of the hospitals sampled have oncology wards, the service being largely focused on providing curative care. However, the greatest burden of disease was found in the general medical wards: 54.8% of patients

The majority of patients (50.8%) had cancer, irrespective of which ward in the hospitals they were admitted to. In 32.5% of cases

Table 1. Palliative care need identification tool

Results

5 0

e e as ok ise Str gd n lu ic on hr

ilu

l fa

Prevalence of patients with an ALLD, potentially requiring palliative care

Patient characteristics

meeting the requirements for palliative care were admitted to medical wards, 31.2% to surgical wards, 10.1% to oncology wards, and 3.3% to gynaecology wards.

a en

F re CC failu r e v Li

Organ failure — diagnosis

0 Cancer

Organ failure

HIV/TB

Other

Diagnosis

Fig. 1. Main diagnoses of patients with active life-limiting disease (CCF = congestive cardiac failure; TB = tuberculosis).

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the life-limiting disease was a form of major organ failure, the most common being renal failure (10.4%), 9.6% of cases were attributable to HIV/tuberculosis (TB), and 7.1% of patients had other diagnoses, e.g. intracranial haemorrhage (Fig. 1). More than half of the patients had an associated co-morbidity (diabetes, hypertension, HIV or TB) requiring additional care, and 37.9% had a Karnofsky Performance Scale rating of <50% (‘patient requiring considerable assistance and frequent medical care’). In 3.3% of cases death was imminent (<24 hours). Of the patients, 17.5% had a documented admission or casualty visit in the 6 months prior to their current admission: 12.5% of admissions were attributed to an acute exacerbation of pre-existing terminal disease (e.g. exacerbation of heart failure), 35.4% were due to a new but potentially expected complication related to the patient’s preexisting terminal disease (e.g. a hip fracture in a patient with prostate cancer), and 38.3% were unrelated to the pre-existing terminal disease (e.g. a motor vehicle accident in a patient with renal failure).

Treatment and discharge planning

Of the patients 11.7% required inpatient palliative care (e.g. hospice facility or hospital palliative care bed), either because of severe symptoms or very poor social circumstances. Palliative needs could be met through appropriate outpatient home-based support in 79.2% of cases, while 9.2% of patients required a combination of services (e.g. initial acute symptom management in hospital/hospice followed by supportive further care at home). Only 21.3% of patients had existing documented advanced care directives in their case records.

Discussion

This is the first cross-sectional, contemporaneous, case note pointprevalence survey to assess palliative care need among hospital inpatients in SA. The data were collected from a variety of district, regional and central hospitals and are likely to be representative of other cities in SA. The results from this study demonstrated that 1 in 6 (16.7%) of adult inpatients in the Cape Town metropole had an ALLD necessitating palliative care. This finding is comparable with similar surveys conducted in Europe and Australia, in which the point prevalence among inpatients ranged between 9.4% and 35%.[7-10] Of note, in these studies the mean age of patients requiring palliative care was over 70 years, in contrast to the mean of 56 years in our study. The single survey of palliative care needs in sub-Saharan Africa reported a 40% prevalence of palliative need among inpatients sampled in two Ugandan hospitals. This was largely ascribed to the HIV/AIDS burden in a setting where access to antiretroviral therapy is limited compared with the SA environment.[11] In the present study, the primary diagnosis of the majority of patients needing palliative care was cancer. A third of patients identified had a primary diagnosis of organ failure. End-stage organ failure reflects the NCD burden experienced by SA.[19] A substantial number of patients had the diagnosis of end-stage renal failure (ESRF). In SA this is a life-limiting condition, even among younger patients, as resource constraints in the public healthcare system mean that access to chronic dialysis is limited. These patients, having a preventable condition with a treatment that is not accessible, have a very particular need for both intense counselling and forward planning for death. A lower than anticipated percentage of patients with palliative need had HIV/AIDS as a terminal diagnosis, which could be explained by the increase in access to and availability of antiretroviral treatment. A previous study of hospital inpatients in a large central hospital suggested that HIV status was not a predictor of poor outcomes in Cape Town, suggesting that most patients who

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survive their initial admission would be expected to have a favourable long-term prognosis.[12] The greatest burden of disease was in the general medical wards, where cancer was the predominant diagnosis. There are several reasons for this: ‘medical beds’ usually serve as ‘diagnostic beds’, so patients with undifferentiated disease are admitted there and cancer or end-stage organ disease is then diagnosed; there are limited oncology beds available, so the focus of oncology departments is on curative services or patients in whom good outcomes may be expected; and treatment options for patients with ALLD are largely limited to medical therapy. These patients admitted with end-stage chronic disease place an additional burden on acute medical beds in hospitals, already under strain with very high occupancy rates. Initial hospital-based programmes of palliative care treatment and co-ordination may want to focus on medical wards/beds. The present survey reveals that long-term care of many patients will require resources and clear planning, especially since over half of the patients had additional chronic co-morbid disease such as diabetes, hypertension or HIV and over a third had a Karnofsky Performance Scale rating of <50%. All require clear long-term plans (about the intensity and kind of therapy that should be continued) that must be communicated to the long-term carers and other home-based care personnel to support families. There is a need for outpatient management and adequate home-based support for patients and their families, as the majority of patients are fit for discharge home. In most resource-constrained countries, a homecare model of palliative care predominates because of its affordability and acceptability to patients and family.[9] This survey did not specifically set out to assess whether admissions could have been avoided. Given the pressure on acute beds in hospitals, the risks of hospital admission and patients’ preferences not to be admitted, it is important to ask whether patients with palliative needs could be managed outside the hospital and whether admission could have been prevented. The combined high percentage of patients with previously diagnosed ALLD, with recent visits to the emergency department or with exacerbation of a pre-existing condition, suggests that such opportunities exist. In addition, to use existing acute hospital beds most efficiently, access to and availability of intermediate/step-down facilities must be improved. Patients with life-limiting disease benefit from future care planning and advanced care directives (e.g. preferred place of death). Notably, only a fifth of patients in this survey with a clear palliative need had documented evidence of advanced care directives. In the UK, dying at home is the expressed wish of around 65% of people at the beginning of cancer and organ failure trajectories.[1] Assisting patients with formulating and documenting advanced care directives, for which improved training in palliative care among health professionals is necessary, will support future care planning and prevent unnecessary referral, hospital admission and inappropriate investigations at the end of life.

Conclusion

This survey documents the high prevalence of patients with palliative care needs occupying acute-care beds in the Cape Town Metropole. A notable finding of our study was the much younger average age of patients with palliative need compared with international samples, reflecting the dual burden of disease in general medical wards in particular, where patients with NCDs, cancer and HIV/ AIDS are admitted. Resource constraints result in patients requiring palliative care for conditions treatable in other international settings, e.g. ESRF. There are potential areas for great improvement in quality of patient care, with possible cost savings deriving from

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establishing palliative care programmes in primary care, improving care co-ordination across the different platforms of care, increasing training and exposure to palliative care for teams looking after inpatients, particularly in general medical wards, and establishing expert palliative care co-ordinating teams in large hospitals. Providing palliative care to patients not only relieves symptoms and improves patient satisfaction, but may also reduce admission rates and length of stay, and decrease the overall cost of care. References 1. Murray SA, Kendall M, Boyd K, et al. Illness trajectories and palliative care. BMJ 2005;330(7498):10071011. [http://dx.doi.org/10.1136/bmj.330.7498.1007] 2. World Health Organization. Global Status Report on Noncommunicable Diseases 2010. http://www. who.int/nmh/publications/ncd_report_full_en.pdf (accessed 4 November 2013). 3. World Health Organization. A Community Health Approach to Palliative Care for HIV/AIDS and Cancer Patients in Sub-Saharan Africa. Geneva: WHO, 2005. 4. Bourne D, Matzopoulos R, Bradshaw D, et al. Western Cape Burden of Disease Reduction Project. Final report 2007. http://www.westerncape.gov.za/Text/2007/6/cd_volume_2_mortality_surveillance. pdf (accessed 4 November 2013). 5. Harding R, Higginson IJ. Palliative care in sub-Saharan Africa: An appraisal. Lancet 2005;365(9475):1971-1977. [http://dx.doi.org/10.1016/S0140-6736(05)67094-8] 6. Grant L, Dowing J, Namukwaya E, et al. Palliative care in Africa since 2005: Good progress but much further to go. BMJ Support Palliat Care 2011;1(2):118-122. [http://dx.doi.org/10.1136/ bmjspcare-2011-000057] 7. Desmedt MS, de la Kethulle YL, Deveugele MI, et al. Palliative inpatients in general hospital: A one day observational study in Belgium. BMC Palliat Care 2011;10:2. [http://dx.doi.org/10.1186/1472684X-10-2] 8. Morize V, Nguyen DT, Lorente C. Descriptive epidemiological survey on a given day in all palliative care patients hospitalised in a French university hospital. Palliat Med 1999;13(2):105-117.

9. To TH, Greene AG, Agar MR, Currow DC. A point prevalence survey of hospital inpatients to define the proportion with palliation as the primary goal of care and the need for specialist palliative care. Intern Med J 2011;41(5):430-433. [http://dx.doi.org/10.1111/j.1445-5994.2011.02484.x] 10. Sigurdardottir KR, Haugen DF. Prevalence of distressing symptoms in hospitalised patients on medical wards: A cross-sectional study. BMC Palliat Care 2008;7:16. [http://dx.doi.org/10.1186/1472684X-7-16] 11. Lewington J, Namukwaya E, Limoges J, Leng M, Harding R. Provision of palliative care for life-limiting disease in a low income country national hospital setting: How much is needed? BMJ Support Palliat Care 2012;2(2):140-144. [http://dx.doi.org/10.1136/bmjspcare-2011-000188] 12. Stuart-Clark H, Vorajee N, Zuma S, et al. Twelve-month outcomes of patients admitted to the acute general medical service at Groote Schuur Hospital. S Afr Med J 2012;102(6):549-553. 13. Menee V, Lix L, Steinbach C, et al. Patterns of Health Care Use and Cost at the End of Life. Winnipeg, MB: Manitoba Centre for Health Policy, 2004. 14. Burke K. Palliative care at homes to get further funds if it saves money. BMJ 2008;328(7439):544. [http://dx.doi.org/10.1136/bmj.328.7439.544-b] 15. Morrison RS, Penrod JD, Cassel B, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med 2008;168(16):1783-1790. [http://dx.doi.org/10.1001/ archinte.168.16.1783] 16. Hatziandreu E, Archontakis F, Day A, National Audit Oﬃce. The potential cost savings of greater use of home- and hospice-based end of life care in England. RAND Corporation. 2008. http:// www.rand.org/content/dam/rand/pubs/technical_reports/2008/RAND_TR642.pdf (accessed 4 November 2013). 17. Hongoro C, Dinat N. A cost analysis of a hospital-based palliative care outreach program: Implications for expanding public sector palliative care in South Africa. J Pain Symptom Manage 2011;41(6)10151024. [http://dx.doi.org/10.1016/j.jpainsymman.2010.08.014] 18. DesRoisiers T, Cupido C, Pitout E, et al. A hospital-based palliative service for patients with advanced organ failure in sub-Saharan Africa reduces admissions and increases home death rates. J Pain Symptom Manage 2013;21 August. [Epub ahead of print] [http://dx.doi.org/10.1016/j. jpainsymman.2013.05.021] 19. Mayosi BM, Flisher UG, Sitas F, et al. The burden of non-communicable disease in South Africa. Lancet 2009;374(9693):934-947. [http://dx.doi.org/10.1016/S0140-6736(09)61087-4]

Accepted 7 October 2013.

This month in the SAMJ ...

Richard Matzopoulos* is a specialist scientist at the Medical Research Council’s Burden of Disease Research Unit and an honorary research associate at the Centre for Occupational and Environmental Health of the University of Cape Town’s School of Public Health and Family Medicine. He advises the Provincial Government of the Western Cape (PGWC) on its interpersonal violence and injury prevention and surveillance activities through the Burden of Disease Reduction Project, which seeks to reduce the burden of disease in the province. Richard is one of two South African focal points for the International Violence Prevention Alliance and chairman of the PGWC’s transversal Injury Prevention Working Group. *Matzopoulos RG, Truen S, Bowman B, Corrigall J. The cost of harmful alcohol use in South Africa. S Afr Med J 2014;104(2):127-132. [http://dx.doi.org/10.7196/ SAMJ.7644]

Liz Gwyther*,† is the CEO of the Hospice Palliative Care Association of South Africa and senior lecturer in palliative medicine in the School of Public Health and Family Medicine, Faculty of Health Sciences at the University of Cape Town. She is a Fellow of the College of Family Practitioners of South Africa and holds an MSc in Palliative Medicine. She is a director of the African Palliative Care Association of the Worldwide Hospice Palliative Care Alliance and of the Networking AIDS Community of South Africa and a council member of PainSA. Her research interests are palliative care in HIV and palliative care as a human right. *Gwyther L. Palliative care in chronic disease. S Afr Med J 2014;104(2):114-115. [http://dx.doi.org/10.7196/SAMJ.7683] † Farrant L, Gwyther L, Dinat N, Mmoledi K, Hatta N, Harding R. Maintaining wellbeing for South Africans receiving ART: The burden of pain and symptoms is greater with longer ART exposure. S Afr Med J 2014;104(2):119-123. [http://dx.doi.org/10.7196/SAMJ.7461]

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2014/01/20 8:54 AM

GUEST EDITORIAL

Vascular disease – everyone’s problem There has been a significant rise in the burden of non-communicable diseases (NCDs) in the past 20 years.[1] Atherosclerotic peripheral arterial disease (PAD) is one of the most prevalent, morbid and mortal of all the NCDs, with more than 202 million people, conservatively estimated, affected by PAD.[2] This is about six times the 34 million people estimated to be living with HIV at the end of 2011.[3] PAD does not only affect high-income countries. As population demographics change in low- and middleincome countries, patients are exposed to the sustained effects of exposure to the risk factors of smoking, hypertension, diabetes and dyslipidaemia.[2] PAD also affects both young and old individuals in low- and high-income countries. Globally, there has been an increase of about 24% in PAD from 2000 to 2010.[3] This rise in prevalence comes at a significant cost, as many low- and middle-income countries are combating the scourges of numerous debilitating communicable diseases. The risk of ischaemic stroke increases by a factor of 1.5 for every 10 years of increase in age.[4] The increased prevalence of heart failure, hypertension and atrial fibrillation (AF) in the older population explains the rising incidence of stroke with age. Over the age of 85 years, the prevalence of AF is as high as 10%, and 25% of strokes in patients >80 years of age are attributable to AF.[5,6] The absolute effect of intervention with anticoagulation using warfarin in the elderly is far greater than in younger patients owing to the greater incidence of AF in the former population group.[7] As with AF, so too does the prevalence of deep vein thrombosis (DVT) or pulmonary embolus (PE) increase with age. In those <50 years old, the incidence of a new DVT or PE is about 1/1 000 person-years, but this rises dramatically to 6/1 000 person-years in patients >80 years old.[8] For a number of years intervention and anticoagulation have been utilised to modify future risk.[9] DVT prophylaxis is important, especially in patients undergoing major orthopaedic surgery, who represent a high-risk group for the development of DVTs and PEs. The novel anticoagulants, which show some promise for the prevention of thrombotic complications of surgery, have been studied extensively in this group of patients. Warfarin and multiple other drugs are attractive therapeutic agents to limit the damages of numerous vascular NCDs, and their

development has broadened our understanding of homoeostasis. These anticoagulants are not without side-effects, which may carry a significant morbidity and mortality. The vascular NCDs affect the disciplines of general and orthopaedic surgery, internal medicine and general practice worldwide. These diseases, and the agents used to manage them, are an evolving field, which has shown many rapid advances during the last 15 years. As newer anticoagulants come to the market, their advantages and disadvantages need to be explored to clearly define the niche which these often expensive agents occupy. Clearly, the convenience afforded by the newer agents is novel and exciting when compared with the more traditional vitamin K antagonists (VKAs), but this advantage will need to be weighed up against their significant cost and lack of reversibility. Greg Symons Guest editor gregsymons76@gmail.com 1. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2095-2128. [http://dx.doi.org/10.1016/S0140-6736(12)61728-0] 2. Fowkes FGR, Rudan D, Rudan I, et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: A systematic review and analysis. Lancet 2013;6736:1-12. [http://dx.doi.org/10.1016/S0140-6736(13)61249-0] 3. Hirsch AT, Duval S. The global pandemic of peripheral artery disease. Lancet 2013;6736:13-14. [http://dx.doi.org/10.1016/S0140-6736(13)61576-7] 4. Van Walraven C, Hart RG, Connolly S, et al. Effect of age on stroke prevention therapy in patients with atrial fibrillation: The atrial fibrillation investigators. Stroke 2009;40:1410-1416. [http://dx.doi. org/10.1161/STROKEAHA.108.526988] 5. Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults: National implications for rhythm management and stroke prevention: The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA 2001;285:2370-2375. 6. Wolf P, Abbott R, Kannel W. Atrial fibrillation as an independent risk factor for stroke: The Framingham Study. Stroke 1991;22:983-988. http://stroke.ahajournals.org/content/22/8/983.short (accessed 13 January 2014). 7. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: Antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 2007;146:857-867. 8. Naess IA, Christiansen SC, Romundstad P, Cannegieter SC, Rosendaal FR, Hammerstrøm J. Incidence and mortality of venous thrombosis: A population-based study. J Thromb Haemost 2007;5:692-699. 9. Shameem R, Resident S, Hill L, Ansell J, York N. Disadvantages of VKA and requirements for novel anticoagulants. Best Pract Res Clin Haematol 2013;26:103-114.

S Afr Med J 2014;104(2):142. DOI:10.7196/SAMJ.7946

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REVIEW

Anticoagulation: Where have we come from and where are we going? The evidence for and against novel anticoagulants G Symons, MB ChB, FCP (SA), Cert Pulm (SA) Corresponding author: G Symons (gregsymons76@gmail.com) Division of Pulmonology, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa

Warfarin, one of the vitamin K antagonists, has been used since 1940, when it was first approved for the treatment of venous thromboembolism. It is currently the most commonly used anticoagulant, although alternative drugs are available, such as aspirin, clopidogrel and dipyridamol, which have been studied in a number of scenarios. The newest agents available to clinicians are the broad group of novel anticoagulants, such as direct thrombin and direct factor Xa inhibitors, including molecules such as dabigatran, rivaroxaban, apixaban and edoxaban. S Afr Med J 2014;104(2):143-146. DOI:10.7196/SAMJ.7873

History

Warfarin, one of the vitamin K antagonists (VKAs), has been used since 1940, when it was first approved for the treatment of venous thromboembolism (VTE).[1] The first novel anticoagulant (NOAC) and direct thrombin inhibitor (DTI), lepirudin, originates from 1998, when its intravenous form was approved for the use of clinically relevant heparin-induced thrombocytopenia (HIT).[2] Ximelgatran, the first oral DTI, had a similar clinical efficacy to warfarin, but was withdrawn from the market in 2006 owing to an increased risk of liver toxicity.[3,4] Dabigatran came to the fore in 2009 after the publication of the RE-LY trial in the New England Journal of Medicine.[5] This landmark study compared two different doses of dabigatran, 110 mg and 150 mg given twice daily, versus warfarin, in patients with non-valvular atrial fibrillation (NVAF). In summary, this non-inferiority trial showed that dabigatran administered at 150 mg twice daily was associated with lower rates of stroke and systemic embolisation. However, similar rates of major haemorrhage were observed. The RE-LY trial was followed in 2011 by the ROCKET-AF trial, validating the use of rivaroxaban versus warfarin in NVAF. This large randomised controlled trial of more than 14 000 patients confirmed the non-inferiority of rivaroxaban versus warfarin in preventing stroke or systemic embolisation. While there were similar side-effect profiles in each group, the rivaroxaban group appeared to have less intracranial and fatal bleeding. Similar results were shown with apixaban in the ARISTOTLE trial in 2011.[6]

Mechanism of action

Thrombin is central to the clotting cascade and converts fibrinogen to Pearinda CME Strip.pdf 1 2014/01/20 8:10 AM fibrin, thereby creating the framework for clot formation. Thrombin

has a number of positive feedback loops that enhance its effect by increasing the effects of factors V, VIII and XI, and also has a procoagulant effect on platelets.[7,8] Furthermore, its procoagulant effects activate factor XIII, which enhances the formation of bonds between fibrin, thereby aiding clot stabilisation. The advantage of DTIs over the indirect thrombin inhibitors such as the heparins is that they are not dependent on antithrombin III. As such, the DTIs can inhibit both free and bound thrombin.[9] Rivaroxaban, apixaban and edoxaban are very specific antagonists of activated factor Xa, which directly converts prothrombin to thrombin, thus leading to clot formation. Thrombin, in turn, goes on to activate the platelets necessary for the development of a mature clot. Because of the amplifying nature of the clotting cascade, a single molecule of factor Xa is able to generate more than 1 000 molecules of thrombin. Moreover, factor Xa bound to prothrombinase is 300 000 times more active than unbound factor Xa.[10] In summary, activation and binding of factor Xa create a ‘clotting explosion’, generating massive amounts of thrombin.

Pharmacokinetics

Dabigatran, the prototypical DTI, is a small, highly lipophilic molecule that is rapidly absorbed from the gastrointestinal tract (GIT).[11] Dabigatran undergoes extensive hydrolysis by serum esterases, resulting in only 7% bioavailability.[12] Dabigatran is predominantly metabolised by the kidneys, with 80% being renally excreted as an unchanged molecule.[12] The mean half-life of dabigatran is 8 hours after a single dose and up to 14 hours with multiple twice-daily dosing.[13] As dabigatran is renally eliminated, the half-life increases

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dramatically to >24 hours once the creatinine clearance decreases to <30 ml/min.[14] Factor Xa inhibitors are small molecules that are rapidly absorbed, have good bioavailability after absorption and are highly protein bound, making elimination by dialysis difficult. The factor Xa inhibitors are slightly different from the DTIs in that they are predominantly metabolised in the liver, with 50 - 73% of the dose of the former being excreted via the liver.[15] An often overlooked pharmacokinetic property of dabigatran and the other factor Xa inhibitors is the effect of an efflux pump on the luminal aspect of the gastrointestinal mucosa. This efflux permeability glycoprotein transporter pump (P-gp) exports dabigatran back into the lumen of the GIT.[13] It would therefore make sense that P-gp inhibitors such as amiodarone, verapamil and quinidine increase the serum concentrations of dabigatran. Conversely, rifampicin, an enzyme-inducer, lowers plasma concentrations by up to 66%.[16]

Monitoring

Warfarin has a narrow therapeutic window with a wide variability in anticoagulant effect, the latter being highly inter- and intrapatient variable.[17] Despite appropriate monitoring, 30 - 50% of international normalised ratios (INRs) remain outside the therapeutic window.[18] One of the main benefits of the pharmacokinetic profile of dabigatran is its predictable renal excretion, with low inter- and intra-individual variability.[11] Clinically, this characteristic allows renal-based dosing without routine monitoring, which is a significant advantage over the VKAs. Dabigatran affects the prothrombin time (PT) and INR, but this is not predictable. While it also affects the activated partial thromboplastin time (aPTT), the concentration-response curve flattens out at higher concentrations and therefore becomes less reliable.[19] Similar pharmacokinetic and monitoring profiles have been found with the other NOACs) such as rivaroxaban and apixaban.[20] While factor Xa inhibitors do affect the PT, this is unpredictable and unreliable as a quantitative marker of the degree of anticoagulation.

Reversal

Currently, there are no specific reversal agents for dabigatran or the factor Xa inhibitors. As mentioned above, even multidose dabigatran has a relatively short half-life. The most prudent course of action in reversing the effects of the DTIs is to stop administering the agent. The DTIs, including dabigatran, have relatively low protein binding properties; hence a significant amount may be removed during a short session of dialysis.[11] Considering the mechanism of action of the DTIs, it would be appropriate to administer recombinant activated factor VII or prothrombin concentrates. However, these interventions are very expensive and not readily available. Reversal of VKAs for urgent or invasive surgical procedures is always difficult. Guidelines recommend discontinuing VKAs and

starting low molecular weight heparin (LMWH),[11] the latter being discontinued periprocedurally. This results in an approximately 2-week window period during which the patient has variable interruptions in systemic anticoagulation. Interesting results were obtained in the RE-LY trial, analysing a subgroup of patients on dabigatran or warfarin who required an invasive procedure. Patients receiving warfarin were off systemic anticoagulation for a mean of 114 hours. There was no difference in the rates of periprocedural bleeding.[21] In patients requiring emergency surgery, there was a trend to more favourable outcomes in those receiving dabigatran.[21] The results of a randomised controlled trial (BRUISE-CONTROL) of bridging therapy with warfarin versus continuous anticoagulation should provide more direction in the area.[11]

Indications and evidence Atrial fibrillation

Atrial fibrillation (AF) is the commonest arrhythmia, with an overall prevalence of 5.5%, increasing up to almost 18% in patients >85 years of age.[22] AF is a well-known risk factor for stroke and increases stroke risk approximately 5-fold.[23] More than 20% of strokes are attributable to AF. The 30-day mortality risk is as high as 28% if the condition is left untreated.[24] VKAs have been the standard of care to reduce future risk of stroke. Warfarin decreased the risk of cerebrovascular accidents (CVAs) by 67% and 37% compared with placebo and antiplatelet therapy, respectively.[25] A recent meta-analysis of 50 000 patients requiring anticoagulation for AF provided good evidence for the use of NOACs, with an overall reduction of 11% in mortality and cardiovascular system (CVS)-specific mortality. The number needed to treat (NNT) to prevent one death overall and one cardiovascular death was 244 and 500, respectively.[25] Large trials such as the RE-LY (dabigatran), ROCKET-AF (rivaroxaban) and ARISTOTLE (apixaban) provide the data supporting the use of NOACs in secondary stroke prevention in NVAF. These trials excluded patients with prosthetic valves, mitral stenosis and decompensated heart failure who may have needed valve replacement. The data from these landmark trials cannot therefore be applied to these clinical scenarios. The most recent trial (ENGAGE TIMI-AF 48 trial), studying one of the NOACs (edoxaban), showed non-inferiority of high- and low-dose edoxaban compared with warfarin, but less bleeding and fewer safety end-points in the investigational product groups.[26] Currently, there are no ‘head-to-head’ trials comparing dabigatran, rivaroxaban, apixaban and edoxaban. A recent meta-analysis suggests that NOACs are not more effective than warfarin in the secondary prevention of strokes in cases of NVAF. Importantly though, there seems to be a lower risk of intracranial bleeding. In one specific meta-analysis, there did not appear to be a difference in mortality rates.[27] Conflicting data exist and other meta-analyses advocate the use of NOACs, stating that they are more efficacious than warfarin for the prevention of

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stroke and systemic embolisation, with a decreased risk of intracranial haemorrhage. There is clearly a knowledge gap that requires a large, comparative, randomised controlled trial to answer these questions. There are no data to support the use of NOACs in patients with a prior history of intracranial, intraocular, spinal, retroperitoneal and intraarticular bleeding, as such patients were excluded.[5,6,28] Many of the large trials, such as RE-LY and ROCKET-AF, excluded major strokes as well as early strokes in their enrolment of subjects for these novel agents. There seems to be limited literature supporting the early use of these agents in preventing recurrent CVAs or transient ischaemic attacks (TIAs) in patients with AF. A small study reviewed 41 patients who were started on NOACs at a median of 2 days and showed no increase in the incidence of intracranial haemorrhage. However, further data are needed. In patients who are not candidates for warfarin for stroke prevention in the setting of NVAF, aspirin is often used as an alternative. The AVERROES trial reviewed the use of apixaban versus aspirin in this specific group of patients. The study was discontinued early as there was a clear benefit in favour of apixaban, with similar rates of major bleeding episodes for the two drugs.[29] There is much debate about whether these agents are cost-effective, particularly in resource-constrained environments. These costs may be US$3Â 000 per annum for NOACs and US$48 per annum for warfarin.[17] Even taking into account the cost of INR testing and provider visits, the NOACs may be prohibitively expensive. The efficacy data are often clouded by the many single-centre small studies that have often reported no overall or cardiovascular mortality benefit for dabigatran. The risk profile for major bleeding events seemed to be agent specific. Dabigatran and apixaban were associated with reduced rates of major bleeding, while rivaroxaban was not. [25] Recent evidence in the ENGAGE TIMI-AF 48 trial suggests that edoxaban is not inferior to warfarin with regard to stroke prevention and that it is significantly associated with lower rates of bleeding and death from cardiovascular causes.[26]

Venous thromboembolism Prophylaxis

There is mounting evidence for the use of dabigatran as a DTI to prevent VTE. The RE-MODEL and RE-NOVATE trials showed that once-daily dabigatran was not inferior to enoxaparin.[30,31] There were no significant differences in the rates of bleeding complications in either knee or hip replacement. The RECORD-4 trial provided evidence for the use of rivaroxaban prophylaxis in the setting of total knee arthroplasty and was found to be superior to twice-daily enoxaparin in VTE prophylaxis following knee arthroplasty. The ADVANCE study showed that apixaban was non-inferior Pearinda CME Strip.pdf 1 2014/01/20 8:10 AM to twice-daily enoxaparin in thromboprophylaxis for knee and

hip arthroplasty.[32] However, apixaban was superior to once-daily enoxaparin for thromboprophylaxis, with no difference in bleeding events with knee and hip arthroplasty.[32,33] Venous thrombosis is common in medical patients. Untreated, the incidence of venographically detected thrombosis is about 15%. Unfractionated heparin and LMWH have both been validated for thromboprophylaxis in the medical setting.[34,35] They are highly efficacious, safe, and cost-effective.[36] The role of NOACs in chemical thromboprophylaxis has also been studied. The ADOPT trial was a double-blinded, double-dummy trial comparing apixaban with daily enoxaparin. While there were fewer patients who met the criteria for the primary outcome in the apixaban group, this was not statistically significant. Furthermore, by day 30, there was a significant increase in bleeding complications, including both major and clinically significant non-major bleeding.[37] The MAGELLAN study reviewed a similar role for rivaroxaban in chemical thromboprophylaxis and it would appear that the investigational group showed a reduced rate of thrombo-embolic events. However, this group was treated significantly longer than the control arm that received enoxaparin (35 days of rivaroxaban versus 10 days of enoxaparin).[38] These studies may raise more questions than answers.

Management of confirmed VTE

Dabigatran has also been studied in acute VTE. The RECOVER-I and -II trials showed that fixed-dose management of the condition with dabigatran was non-inferior to warfarin and did not require the intensive monitoring necessary with VKAs.[39,40] In patients diagnosed with symptomatic deep vein thrombosis (DVT) as well as pulmonary thrombo-embolus (PTE), oral rivaroxaban was non-inferior to warfarin, with similar rates of bleeding.[41,42] Similar evidence now exists for the use of fixed-dose apixaban to treat VTE.[43]

Acute coronary syndromes

Major adverse cardiovascular events (MACEs) are common after acute coronary syndromes (ACSs), notwithstanding optimal care.[44] This is possibly due to the high platelet reactivity, despite dual antiplatelet therapy (DAPT), which may persist for weeks to months after the event.[45,46] While warfarin has been studied as an antiplatelet adjunct post-ACS, this drug had an unacceptable bleeding risk even though it lowered the rate of MACEs.[47] It is therefore important to investigate the role of NOACs in DAPT to prevent MACEs post-ACS. A significant amount of data is now available to study the effects of dabigatran, rivaroxaban, apixaban and darexaban. The addition of NOACs in this setting would seem to confer an unacceptably high risk of haemorrhage, with a 2 - 4-fold increase in the risk of bleeding. There appears to be no clinically significant benefit to the addition of NOACs to DAPT. Further investigation is required to clearly delineate the role of NOACs in ACSs and potentially beneficial combinations

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of warfarin, clopidogrel, aspirin, NOACs and new generation P2Y12receptor inhibitors, such as prasugrel and ticagrelor.

Conclusion

While warfarin and other VKAs have been the gold standard of anticoagulation for over half a decade, the evolution of NOACs has been met with much excitement and has stimulated renewed interest and ongoing research. While biologically attractive, the clinical role of these agents raises many questions regarding how best to integrate them into current treatment regimens. NOACs are more convenient, reliable and predictable than the gold standard. Limitations of using these agents include the cost, lack of a reversal agent and lack of reliable monitoring. With the evidence at hand and considering the cost implications of these drugs, the use of NOACs in a resource-constrained environment seems limited. Should the utility of convenience outweigh the real risks and cost implications of NOACs? The evidence seems to speak for itself. References 1. Pudusseri A, Shameem R, Spyropoulos AC. A new paradigm shift in antithrombotic therapy. Front Pharmacol 2013;4:133. 2. Greinacher A, Eichler P, Lubenow N, Kwasny H, Luz M. Heparin-induced thrombocytopenia with thromboembolic complications: Meta-analysis of 2 prospective trials to assess the value of parenteral treatment with lepirudin and its therapeutic aPTT range. Blood 2000;96:846-851. 3. Olsson SB. Stroke prevention with the oral direct thrombin inhibitor ximelagatran compared with warfarin in patients with non-valvular atrial fibrillation (SPORTIF III): Randomised controlled trial. Lancet 2003;362:1691-1698. 4. Mohapatra R, Tran M, Gore JM, Spencer FA. A review of the oral direct thrombin inhibitor ximelagatran: Not yet the end of the warfarin era. Am Heart J 2005;150:19-26. [http://dx.doi. org/10.1016/j.ahj.2005.02.012] 5. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361:1139-1151. [http://dx.doi.org/10.1056/NEJMoa0905561] 6. Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011;365:981-992. [http://dx.doi.org/10.1056/NEJMoa1107039] 7. Eriksson BI, Quinlan DJ, Eikelboom JW. Novel oral factor Xa and thrombin inhibitors in the management of thromboembolism. Annu Rev Med 2011;62:41-57. [http://dx.doi.org/10.1146/ annurev-med-062209-095159] 8. Becker RC. Cell-based models of coagulation: A paradigm in evolution. J Thromb Thrombolysis 2005;20:65-68. [http://dx.doi.org/10.1007/s11239-005-3118-3] 9. Weitz JI, Hudoba M, Massel D, Maraganore J, Hirsh J. Clot-bound thrombin is protected from inhibition by heparin-antithrombin III but is susceptible to inactivation by antithrombin IIIindependent inhibitors. J Clin Invest 1990;86:385-391. [http://dx.doi.org/10.1172/JCI114723] 10. Werth S, Halbritter K, Beyer-Westendorf J. Efficacy and safety of venous thromboembolism prophylaxis with apixaban in major orthopedic surgery. Ther Clin Risk Manag 2012;8:139-147. [http:// dx.doi.org/10.2147/TCRM.S24238] 11. Ellis CR, Kaiser DW. The clinical efficacy of dabigatran etexilate for preventing stroke in atrial fibrillation patients. Vasc Health Risk Manag 2013;9:341-352. [http://dx.doi.org/10.2147/VHRM.S28271] 12. Stangier J. Clinical pharmacokinetics and pharmacodynamics of the oral direct thrombin inhibitor dabigatran etexilate. Clin Pharmacokinet 2008;47:285-295. [http://dx.doi.org/10.2165/00003088200847050-00001] 13. Eisert WG, Hauel N, Stangier J, Wienen W, Clemens A, van Ryn J. Dabigatran: An oral novel potent reversible nonpeptide inhibitor of thrombin. Arterioscler Thromb Vasc Biol 2010;30:1885-1889. [http://dx.doi.org/10.1161/ATVBAHA.110.203604] 14. Stangier J, Rathgen K, Stähle H, Mazur D. Influence of renal impairment on the pharmacokinetics and pharmacodynamics of oral dabigatran etexilate: An open-label, parallel-group, single-centre study. Clin Pharmacokinet 2010;49:259-268. [http://dx.doi.org/10.2165/11318170-000000000-00000] 15. Heidbuchel H, Verhamme P, Alings M, et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651. [http://dx.doi.org/10.1093/europace/eut083] 16. Nutescu E, Chuatrisorn I, Hellenbart E. Drug and dietary interactions of warfarin and novel oral anticoagulants: An update. J Thromb Thrombolysis 2011;31:326-343. [http://dx.doi.org/10.1007/ s11239-011-0561-1] 17. Adam SS, McDuffie JR, Ortel TL, Williams JW Jr. Comparative effectiveness of warfarin and new oral anticoagulants for the management of atrial fibrillation and venous thromboembolism: A systematic review. Ann Intern Med 2012;157:796-807. [http://dx.doi.org/10.7326/0003-4819-157-10-201211200-00532] 18. Currie CJ, Jones M, Goodfellow J, et al. Evaluation of survival and ischaemic and thromboembolic event rates in patients with non-valvar atrial fibrillation in the general population when treated and untreated with warfarin. Heart 2006;92:196-200. [http://dx.doi.org/10.1136/hrt.2004.058339]

19. Van Ryn J, Stangier J, Haertter S, et al. Dabigatran etexilate – a novel, reversible, oral direct thrombin inhibitor: Interpretation of coagulation assays and reversal of anticoagulant activity. Thromb Haemost 2010;103:1116-1127. [http://dx.doi.org/10.1160/TH09-11-0758] 20. Eriksson BI, Quinlan DJ, Weitz JI. Comparative pharmacodynamics and pharmacokinetics of oral direct thrombin and factor Xa inhibitors in development. Clin Pharmacokinet 2009;48:1-22 [http:// dx.doi.org/10.2165/0003088-200948010-00001] 21. Healey JS, Eikelboom J, Douketis J, et al. Periprocedural bleeding and thromboembolic events with dabigatran compared with warfarin: Results from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) randomized trial. Circulation 2012;126:343-348. [http://dx.doi. org/10.1161/CIRCULATIONAHA.111.090464] 22. Heeringa J, van der Kuip DA, Hofman A, et al. Prevalence, incidence and lifetime risk of atrial fibrillation: The Rotterdam study. Eur Heart J 2006;27:949-953. [http://dx.doi.org/10.1093/ eurheartj/ehi825] 23. Wolf P, Abbott R, Kannel W. Atrial fibrillation as an independent risk factor for stroke: The Framingham Study. Stroke 1991;22:983-988. [http://dx.doi.org/10.1161/01.STR.22.8.983] 24. Hylek EM, Go AS, Chang Y, et al. Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation. N Engl J Med 2003;349:1019-1026. [http://dx.doi.org/10.1056/NEJMoa022913] 25. Dentali F, Riva N, Crowther M, Turpie AG, Lip GY, Ageno W. Efficacy and safety of the novel oral anticoagulants in atrial fibrillation: A systematic review and meta-analysis of the literature. Circulation 2012;126:2381-2391. [http://dx.doi.org/10.1161/CIRCULATIONAHA.112.115410] 26. Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2013;369:2093-2104. [http://dx.doi.org/10.1056/NEJMoa1310907] 27. Sardar P, Chatterjee S, Wu W-C, et al. New oral anticoagulants are not superior to warfarin in secondary prevention of stroke: Insights from a meta-analysis of randomized trials and indirect treatment comparisons. J Am Coll Cardiol 2013;61:E318. [http://dx.doi.org/10.1016/S0735-1097(13)60318-6] 28. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011;365:883-891. [http://dx.doi.org/10.1056/NEJMoa1009638] 29. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: Antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 2007;146:857-867. [http://dx.doi. org/10.7326/0003-4819-146-12-200706190-00007] 30. Eriksson BI, Dahl OE, Rosencher N, et al. Dabigatran etexilate versus enoxaparin for prevention of venous thromboembolism after total hip replacement: A randomised, double-blind, non-inferiority trial. Lancet 2007;370:949-956. [http://dx.doi.org/10.1016/S0140-6736(07)61445-7] 31. Eriksson BI, Dahl OE, Rosencher N, et al. Oral dabigatran etexilate vs. subcutaneous enoxaparin for the prevention of venous thromboembolism after total knee replacement: The RE-MODEL randomized trial. J Thromb Haemost 2007;5:2178-2185. [http://dx.doi.org/10.1111/j.1538-7836.2007.02748.x] 32. Lassen MR, Raskob GE, Gallus A, Pineo G, Chen D, Portman RJ. Apixaban or enoxaparin for thromboprophylaxis after knee replacement. N Engl J Med 2009;361:594-604. [http://dx.doi. org/10.1056/NEJMoa0810773] 33. Lassen MR, Raskob GE, Gallus A, Pineo G, Chen D, Hornick P. Apixaban versus enoxaparin for thromboprophylaxis after knee replacement (ADVANCE-2): A randomised double-blind trial. Lancet 2010;375:807-815. [http://dx.doi.org/10.1016/s0140-6736(09)62125-5] 34. Samama MM, Cohen AT, Darmon JY, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in Medical Patients with Enoxaparin Study Group. N Engl J Med 1999;341:793-800. 35. Leizorovicz A, Cohen AT, Turpie AGG, Olsson CG, Vaitkus PT, Goldhaber SZ. Randomized, placebocontrolled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation 2004;110:874-879. 36. Vardi M, Haran M. Venous thromboembolism prophylaxis of acutely ill hospitalized medical patients. Are we over-treating our patients? Eur J Intern Med 2012;23:231-235. [http://dx.doi.org/10.1016/j. ejim.2011.11.006] 37. Goldhaber SZ, Leizorovicz A, Kakkar AK, et al. Apixaban versus enoxaparin for thromboprophylaxis in medically ill patients. N Engl J Med 2011;365:2167-2177. [http://dx.doi.org/10.1056/NEJMoa1110899] 38. Cohen AT, Spiro TE, Büller HR, et al. Rivaroxaban for thromboprophylaxis in acutely ill medical patients. N Engl J Med 2013;368:513-523. [http://dx.doi.org/10.1056/NEJMoa1111096] 39. Schulman S, Kearon C, Kakkar AK, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med 2009;361:2342-2352. [http://dx.doi.org/10.1056/NEJMoa0906598] 40. Schulman S, Kearon C, Kakkar AK, et al. Extended use of dabigatran, warfarin, or placebo in venous thromboembolism. N Engl J Med 2013;368:709-718. [http://dx.doi.org/10.1056/NEJMoa1113697] 41. Bauersachs R, Berkowitz SD, Brenner B, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med 2010;363:2499-2510. [http://dx.doi.org/10.1056/NEJMoa1007903] 42. Prins MH, Lensing AW, Bauersacks R, et al. Oral rivaroxaban for the treatment of symptomatic venous thromboembolism. A pooled analysis of the einstein DVT and einstein pe studies. Thromb J 2013;11(1):21. [http://dx.doi.org/10.1186/1477-9560-11-21] 43. Agnelli G, Büller HR, Cohen A, et al. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med 2013;369:799-808. [http://dx.doi.org/10.1056/NEJMoa1302507] 44. Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009;361:1045-1057. [http://dx.doi.org/10.1056/NEJMoa0904327] 45. Sofi F, Marcucci R, Gori AM, Giusti B, Abbate R, Gensini GF. Clopidogrel non-responsiveness and risk of cardiovascular morbidity. An updated meta-analysis. Thromb Haemost 2010;103:841-848. [http:// dx.doi.org/10.1160/TH09-06-0418] 46. Merlini PA, Bauer KA, Oltrona L, et al. Persistent activation of coagulation mechanism in unstable angina and myocardial infarction. Circulation 1994;90:61-68. [http://dx.doi.org/10.1161/01.CIR.90.1.61] 47. Rothberg MB, Celestin C, Fiore LD, Lawler E, Cook JR. Warfarin plus aspirin after myocardial infarction or the acute coronary syndrome: Meta-analysis with estimates of risk and benefit. Ann Intern Med 2005;143:241-250. [http://dx.doi.org/10.7326/0003-4819]

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Chronic venous disorders N Cloete, MB ChB, FCS (SA), Cert Vascular Surgery Department of Surgery, University of Cape Town, South Africa Corresponding author: N Cloete (njcloete@yahoo.ca)

Chronic venous disease (CVD) is a very commonly occurring clinical condition. The significant economic impact caused by the morbidity of unrecognised and/ or poorly managed CVD that progresses to more advanced stages has been well documented. The clinical assessment of this type of vascular pathology requires a good understanding of both venous anatomy and its physiology. Maintaining normal ambulatory venous pressure depends on the integrity of three essential functions, i.e. competency, patency and the calf muscle pump. More advanced and complex conditions often represent dysfunction or failure of these three aforementioned entities, usually in combination, requiring a systematic, stepwise diagnostic appraisal. Current international consensus dictates that all advanced chronic venous disorders can be graded according to CEAP (clinical, (a)etiological, anatomical, pathophysiological) criteria. CEAP 3 â&#x20AC;&#x201C; 6 gradings require iliac vein assessment to exclude outflow obstruction (Table 1). The diagnostic assessment of venous pathology has improved substantially during the last two decades, with the ongoing evolution of new technologies. Venous duplex imaging has become the

cornerstone of initial venous diagnostic assessment, replacing more invasive modalities used in the past. Currently, more sophisticated tools such as computed tomography, magnetic resonance imaging and intravascular ultrasound have improved both the diagnostic yield and the understanding of the complexity of more advanced pathology. Compression therapy is mandatory for all symptomatic patients, provided significant arterial disease has been excluded. Pharmacological agents have a limited role, but further studies are being conducted at present. Currently, there are a host of very attractive and competitive modalities available to treat superficial venous incompetence, including radiofrequency and laser ablation as well as novel agents, e.g. steam and glue for ablating the great saphenous vein. Foam sclerotherapy and open surgical treatments will in future probably be reserved for cases not suitable for ablative therapies. It is imperative that proximal outflow obstruction be managed appropriately before treating superficial reflux.

S Afr Med J 2014;104(2):147. DOI:10.7196/SAMJ.7918

Table 1. The severity grading of venous disease (international consensus) (CEAP) Symptoms

Clinical signs

Heavy legs, pain in the legs, pruritus, but no clinical signs

Telangiectasia or reticular veins

Visible and palpable Venous oedema varicose veins without trophic changes

Trophic changes of venous origin: atrophie blanche, pigmented purpuric dermatitis, varicose eczema

Healed ulcer with trophic changes

Presence of one or more active venous leg ulcers, often with trophic changes

C0 - C6 = description of the progression of the disease on the basis of the clinical signs present; CEAP: C = clinical signs; E = (a)etiological classification; A = anatomical distribution; P = pathophysiological dysfunction.

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Screening for peripheral arterial disease B Natha, MB ChB, FCS (SA), Cert Vascular Surgery (SA) Division of Vascular Surgery, Department of Surgery, Groote Schuur Hospital, Cape Town, South Africa Corresponding author: B Natha (bhaveshnatha@gmail.com) Atherosclerosis is the leading cause of coronary, cerebrovascular and peripheral arterial disease (PAD) worldwide. A sedentary lifestyle, stress and high-fat/carbohydrate diets have contributed significantly to the rising prevalence of atherosclerosis in most populations. Preventive strategies are aimed at curbing the socio-economic burden of atherosclerotic disease and its consequences in healthcare systems. While myocardial infarction and cerebrovascular accidents are the two leading causes of mortality and longterm morbidity, atherosclerotic PAD remains an accurate marker of more generalised disease. Screening programmes for at-risk individuals with undiagnosed PAD should therefore be beneficial in preventing future cardiovascular and cerebrovascular events. This article reviews the evidence for and benefits of selective screening for PAD. PAD is an umbrella term used to describe a group of disorders that result in structural and functional alteration of arteries supplying blood to the viscera and limbs (excluding coronary and intracranial arteries). It is also predominantly recognised as a chronic ischaemic condition that leads to progressive stenosis and possible occlusion of arteries. For the purposes of daily clinical and practical application, PAD can be classified as asymptomatic intermittent claudication or critical limb ischaemia. However, for a more detailed clinical classification the Fontaine or Rutherford classification systems are appropriate. Between 50% and 80% of people with PAD are asymptomatic or have vague

atypical leg pain. This can be explained by the observation that they adapt to their physiological and anatomical limitations. They reduce their walking speeds, adopt a more forgiving sedentary lifestyle or are impaired by other comorbidities that reduce their ambulatory activity and hence mask the underlying PAD symptoms. Therefore, the majority of people with PAD will not seek medical advice because the disease is seemingly benign and asymptomatic. However, this apparently benign presentation is not a true reflection of this aggressive disease. Atherosclerosis does not selectively affect one arterial vascular bed in isolation; it is a generalised multivessel disease process. The association between peripheral, coronary and cerebral arterial disease is clearly demonstrated when the long-term sequelae of PAD are assessed.

S Afr Med J 2014;104(2):148. DOI:10.7196/SAMJ.7919

Natural history of atherosclerotic lower extremity PAD syndromes PAD population (â&#x2030;Ľ50 years) Initial clinical presentation Asymptomatic PAD (20 - 50%)

Other leg pain (30 - 40%)

Typical claudication Critical limb ischaemia (10 - 35%) (1 - 3%) 1-year outcomes Alive with two limbs Amputation (45%) (30%)

Mortality (25%)

5-year outcomes Limb morbidity Stable claudication (70 - 80%)

Worsening claudication (10 - 20%)

CV morbidity and mortality Critical limb ischaemia (5 - 10%)

Amputation (see critical limb ischaemia data)

Non-fatal cardiovascular Mortality event (MI or stroke) (10 - 15%) (20%) CV causes Non-CV causes (75%) (25%)

The association between peripheral, coronary and cerebral artery disease. (PAD = peripheral arterial disease; CV = cerebrovascular; MI = myocardial infarction.) (Source: Hirsch AT, Haskal ZJ, Hertzer NR, et al. J Am Coll Cardiol 2006;47:1239-1312.)

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The most accurate bedside investigation for the screening of PAD is the ankle brachial index (ABI). A good clinical assessment and an ABI measurement are probably the most sensitive ways to screen for PAD. However, the United States Preventative Service Task Force and the American Heart Association do not advocate general population screening because the prevalence of PAD in asymptomatic patients without cardiovascular risk factors is insignificant. General population screening is not costeffective and may induce unnecessary stress in patients. Those with traditional atherosclerotic risk factors would benefit most from a screening programme.

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ABSTRACTS

Botswana’s national HIV/ AIDS treatment programme: 2002 - 2010

Farahani et al. analysed the effect of the implementation of Botswana’s national antiretroviral treatment programme (Masa (‘new dawn’)), which was started in January 2002, up to 2010. It is known that short-term mortality among HIV patients receiving antiretroviral therapy in subSaharan Africa is higher than that recorded in high-income countries. So far, no systematic long-term comparisons have been made because of the scarcity of available data. Data for patients who were eligible for antiretroviral therapy, according to Botswana’s national guidelines, were collected prospectively through a clinical information system developed by the Botswana Ministry of Health. A dataset of all available electronic records for adults patients (>18 years old) who had enrolled by 30 April 2010 was anonymised, extracted and used for analysis by the study team. The primary outcome was mortality. Loss to follow-up was established using a sensitivity analysis, which assumed that varying proportions of the population lost to follow-up had died The study team analysed the records of 126 263 patients, of whom 102 713 had documented initiation of antiretroviral therapy. The median follow-up time was 35 months, with a median of 8 follow-up visits. More than half (63%) of the study population were women, with a median age at baseline of 34 years. The median age for men was 38 years. During the 9 years of the study 10 230 deaths were recorded and mortality was highest during the first 3 months after treatment had started, but this decreased in the second year of treatment, decreasing still further during the next 7 years of follow-up. In each calendar year after the start of the Masa programme, average CD4+ cell counts at enrolment increased (from 101 cells/μl in 2002 to 191 cells/μl in 2010). In each year, the proportion of the total enrolled population who died in that year decreased, from 63% (88 of 140) in 2002 to 0.8% (13 of 1 599) in 2010. A sensitivity analysis, assuming that 60% of the population lost to follow-up had died, showed 3 000 additional deaths, increasing overall mortality from 8% to 11 - 13%. The conclusion was that the Botswana national HIV/AIDS treatment programme reduced mortality among adults with HIV

to levels that were similar to those of other low-income or middleincome countries. Farahani M, Vable A, Lebelonyane R, et al. Outcomes of the Botswana national HIV/AIDS treatment programme from 2002 to 2010: A longitudinal analysis. Lancet Global Health 2014;2(1):e44-e50. [http:// dx.doi.org/10.1016/S2214-109X(13)70149-9]

Diuretics, beta-blockers and statins and new-onset type 2 diabetes

Beta-blockers, diuretics and statins are established drugs in the management of cardiovascular disease and there is general consensus that statins reduce risk factors for coronary artery disease. However, there continues to be debate about their role in primary prevention in lower-risk populations. One of the main areas of controversy is the association of statins with new-onset type 2 diabetes. Shen et al., writing in the British Medical Journal, examined the degree to which using beta-blockers, statins and diuretics in patients with impaired glucose tolerance and other cardiovascular risk factors is associated with new-onset diabetes. Their study focused on a re-analysis of data from the Nateglinide and Valsartan in Impaired Glucose Tolerance Outcome Research (NAVIGATOR) trial. This trial enrolled patients who, at baseline, were treatment naïve to beta-blockers, diuretics, statins and calcium channel blockers, the latter being used as metabolically neutral controls. Their main outcome measure was the development of new-onset diabetes diagnosed using standard plasma glucose levels in all participants, which was confirmed with glucose tolerance testing within 12 weeks. During five years of follow-up, beta-blockers were prescribed to 915 patients, diuretics to 1 316, statins to 1 353 and calcium channel blockers to 1 171. After adjusting for confounders, the analysis found that both diuretics and statins were associated with an increased risk of new-onset diabetes, but beta-blockers and calcium channel blockers were not. This study adds to the body of evidence that suggests that in highrisk patients with impaired glucose tolerance the use of diuretics and statins may be associated with an increased risk of new-onset diabetes. Shen L, Shah BR, Reyes EM, et al. Role of diuretics, β blockers, and statins in increasing the risk of diabetes in patients with impaired glucose tolerance: Reanalysis of data from the NAVIGATOR study. Br Med J 2013;347:f6745. [http://dx.doi.org/10.1136/bmj.f6745]

The full version of each article is available online. Use the QR codes above to access. Pearinda CME Strip.pdf

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ADVERTORIAL

Discovery’s HealthID boost unlocks a world of enhancements Discovery Health’s increasingly popular multi-purpose HealthID, available on iPad and Samsung, is now being used by 1 300 doctors countrywide to access instantly highly relevant information on 300 000 consenting patients, and has just been enhanced further to make the physician’s job even easier. From enabling doctors to access instantly a consenting patient’s full medical record, prescribe medicines, order pathology tests, refer, view medical aid benefits and educate patients (among other things), the app has now been further enhanced since its launch a mere eight months ago. Knowing how vital meaningful clinical information is to doctors’ interactions with their patients, Discovery Health has added several more hugely useful features: a health record dashboard; pathology test result notifications; a prescribing tool; standard treatment plans for specific diagnoses; and an easy navigation tab. Discovery Health executives Dr Jonathan Broomberg (CEO) and Dr Maurice Goodman (Head of Health Professional Strategy) say the app can virtually eliminate doctors’ after-hours administration work and substantially improve doctor/patient relationships, saving everyone precious time and money. All available patient data are uploaded to an ‘information cloud’ tended by Discovery Health, giving doctors previously undreamt of versatility and mobility, and bringing the local private health sector up to speed with best international ‘cyber practice’. There is also an additional consultation payout of R50 for GPs and R75 for specialists who qualify and see Discovery Health Medical Scheme members (R15 for certain restricted medical schemes).*

New dashboard, path results and scripting tools

With the new dashboard view of your patient’s health records, including episodes of care, you will be able to see the full history of a patient’s condition including diagnosis date, treating doctors, hospital admissions and all pathology related to the condition. Together with ongoing enhancements, this provides major clinical advantages and streamlines patient care. As pathology tests are completed and uploaded, the results become instantly available, providing a useful consolidated view of your patients’ care. The improvements to the HealthID scripting tool allow you to prescribe medicine with just a few screen touches, the newest intuitive innovation being onetouch buttons for dosage, instructions and routes of administration. The scripting tool can also accommodate multiple diagnoses and International Classification of Diseases (ICD)-10 codes and indicate whether they are relevant to the patient’s sex or age. It is also now easier to select treatment for a specific condition and, if appropriate, apply that plan to all your patients who have the same condition. A convenient tab allows you to refer to your patient’s health record at any point, regardless of which screen you are currently in. With thousands of applications available to doctors, Discovery has vastly simplified matters by cherry-picking the seven best basic categories that, through diligent analysis of local doctor feedback (HealthID pilot study group 2011), they most highly recommend. These are decision-support, reference/look-up, patient education/ consultation, patient support, patient tracking, continued education (CE, for doctors) and what so often goes missing in patient care. collaboration. The decision-support applications are the Blausen Human Atlas for iPad with a 360-degree rotatable human body and narrated 3D animations of asthma, delivery, diabetes, rheumatoid arthritis of the hand, and stroke. There is a 1 500-plus term medical glossary and 1 200 cross-referenced, related, still images.

Informed, evidence-based decisions never easier

The other decision-support app is the iPharmacist for iPad, which provides up-to-date information and tools to manage your practice, whenever and wherever. One example (besides the existing plethora of diagnosis and treatment-accelerating apps) of a tool that can help build relationships and put a patient’s mind at ease (or at the very least give them a more thorough understanding of the treatment or intervention you propose) is the discipline-specific DrawMD. This helps explain complex issues and their possible solutions by allowing you to show patients where you will insert devices, as well as email all notes and diagrams to them for reference. Other new apps include 3D4Medical Images (with over 400 medical images), MediMath – 144 of the most important medical calculators and scoring tools for your iPad, iPhone or iPod touch – has a fast native interface and comprehensive results that help you spend less time crunching numbers and more time caring for your patients. There are also a host of clinically-tailored, discipline-specific applications, including Medscape with its wealth of clinical information, and MIMS for iPad that puts at your fingertips 50 years of traditional, top-grade information on UK-licensed drug dosages, warnings, contraindications and adverse events.

PubMed, Medpage, MedHand library – all on tap

PubMed on Tap searches PubMed to find and display a universe of reference information and has a handy clip application for reference studies, while MedPage Today makes breaking medical news, comprehensive reference information and free continuing medical education/CE credits instantly available, with daily coverage of over 30 specialities and annual coverage of over 60 meetings and symposia. If this isn’t enough to have you scratching your head and wondering why you haven’t considered these apps before, or to be delighted by the major expansion of apps that you are already using, then consider three further improvements. These include what is today considered a lifeline for busy GPs since the first edition was published in 2002 – the Oxford Handbook of General Practice (MedHand Mobile Libraries). Covering the whole of general practice, with hands-on advice from experienced practitioners, this app offers rapid access to help with any day-to-day problems that might arise in general practice. The other two apps are the Davis Drug Guide – delivering trusted, updated and practical information on over 5 000 trade names and generic drugs – and iPharmacy Pro – akin to having an electronic copy of MIMS. So far Discovery Health has recorded 13 000 consultations in which the patient’s electronic health record is viewed in HealthID, with 1 100 chronic illness benefit applications submitted and instantaneously approved via HealthID. Speak to your colleagues who already have HealthID – you will more than likely hear that it is like catching the perfect professional wave, increasing efficiencies, patient (and doctor) satisfaction and gifting you with that most precious thing of all – time. *To qualify for the additional consultation fee (measured over a month) as an ‘engaged doctor,’ you need to use HealthID to access your patients’ electronic health records for at least 20% of your Discovery Health consultations and submit 75% or more of your chronic illness benefit applications using HealthID (effective from 1 January 2014). Your personal (treating) BHF practice number (see the treating doctor field) must be on the claim to secure the additional payment. Consultations by psychiatrists and pre-anaesthetic assessments are included. A list of restricted medical schemes that qualify is available upon request.

Enquiries: healthidfeedback@discovery.co.za

February 2014, Vol. 104, No. 2

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the future of your patients’ medical history. Introducing HealthID. The technology that puts your patients’ health records in your hands. Once they have given consent, you will have access to their medical history, insight into the benefits of their medical aid plan, and be able to make referrals to other healthcare professionals. You can also study their blood test results, write electronic prescriptions and complete Chronic Illness Benefit applications, all with the touch of your finger. It’s what healthcare will look like in the future, today. To learn more about how this innovation can benefit you, go to www.discovery.co.za/healthID or use your smartphone to scan the QR code. Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised financial services provider. TM and © 2012 Apple Inc. All rights reserved.

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CPD

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CPD questionnaires must be completed online via www.cpdjournals.co.za After submission you can check the answers and print your certificate.

True (A) or false (B): A point-prevalence survey of public hospital inpatients with palliative care needs in Cape Town, South Africa (SA) 1. In this survey, reflecting the burden of disease of non-communicable diseases, cancer and HIV/AIDS, medical patients needing palliative care were much younger in age compared with international samples. 2. The World Health Organization estimates that approximately 10 million people are in need of palliative care across Africa. Maintaining wellbeing for South Africans receiving antiretroviral therapy (ART): The burden of pain and symptoms is greater with longer ART exposure 3. HIV patients experience a high prevalence and burden of psychological and physical symptoms despite relatively good physical function and satisfactory treatment with ART. The cost of harmful alcohol use in SA 4. Alcohol is the most widespread drug of abuse in SA and the most harmful drug at a population level. 5. Half of all SA driver deaths and non-fatal injuries would be prevented if drivers were not driving under the influence of alcohol. 6. The combined total of tangible and intangible costs of alcohol harm to the economy is estimated at 10 - 12% (of the 2009) gross domestic product. 7. A third of school-age adolescents (29%) misuse alcohol, linked, in turn, to absenteeism and academic failure. Attitudes to organ donation among some urban South African populations remain unchanged: A cross-sectional study (1993 - 2013) 8. SA has an established track record in transplantation, as well as a network of active transplant programmes. 9. Male respondents showed greater willingness than their female counterparts to have their own organs donated and to donate the organs of a relative.

A 5-year analysis of the helicopter air mercy service in Richards Bay, SA 10. The predominant indications for requesting the helicopter emergency medical services rapid transportation were related to obstetrics and gynaecology, paediatrics and trauma, in decreasing order. Anticoagulation: Where have we come from and where are we going? The evidence for and against novel anticoagulants 11. A non-inferiority trial comparing warfarin with dabigatran showed that dabigatran (150 mg twice daily) was associated with lower rates of stroke and systemic embolisation. 12. Rivaroxaban, apixaban and edoxaban are highly specific antagonists of activated factor Xa. 13. Atrial fibrillation is a well-known risk factor for stroke and increases stroke risk approximately five-fold. Screening for peripheral arterial disease (PAD) 14. General population screening is recommended for PAD. 15. In an effective screening programme, early treatment or secondary prevention of PAD is recommended. 16. Population-based surveys demonstrate that 50 - 80% of people with PAD are asymptomatic, or have vague atypical leg pain, despite the aggressive nature of underlying PAD. Chronic venous disorders 17. Venous ulcers are the most serious complication of chronic vascular disease. 18. The clinical venous examination should include an evaluation in both the supine and upright positions to ensure maximal venous distention. 19. The venous duplex reflux examination is considered the mainstay of non-invasive evaluation of chronic venous insufficiency. 20. Venoactive drugs decrease venous tone, thereby reducing capillary permeability and the tendency to oedema.

CPD questions include articles from CME. The full versions of each article can be found on the SAMJ website (http://www.hmpg.ac.za)

A maximum number of 5 CEUs will be awarded per correctly completed test.

INSTRUCTIONS 1. Read the journal. All the answers will be found there. 2. Go to www.cpdjournals.co.za to answer the questions. Accreditation number: MDB001/007/01/2014 (Clinical)

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Xarelto an extensively studied oral anticoagulant now has more indications!

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The ESSENTIAL MEDICAL REFERENCE for every healthcare professional!

◆ Treatment of pulmonary embolism2 ◆ Treatment of deep vein thrombosis2 ◆ Prevention of recurrent deep vein thrombosis2 ◆ Prevention of recurrent pulmonary embolism 2

The convenient pocket-sized design enables you to fit it comfortably into your hospital bag or coat pocket, so it can always be at hand for ready reference. South African Medicines Formulary (SAMF), produced by the Division of Clinical Pharmacology of the University of Cape Town, provides easy access to the latest, scientifically accurate information, including full drug profiles, clinical notes and special prescriber’s points. The thoroughly updated 11th edition of SAMF is your essential reference to the rational, cost-effective and safe use of medicines.

◆ Prevention of venous thromboembolism in patients undergoing major orthopaedic surgery of the lower limbs1

www.thrombosisadvisor.com www.xarelto.co.za

Simple Protection for More Patients REFERENCE: 1. Xarelto® 10 Registered Package Insert of South Africa. 2. Xarelto® 15 and 20 Registered Package Insert of South Africa. For full prescribing information, refer to the package insert approved by the Medicines Regulatory Authority (MCC). S4 XARELTO® 10 (Film-coated tablets). Reg. No.: 42/8.2/1046. Each film-coated tablet contains rivaroxaban 10 mg. PHARMACOLOGICAL CLASSIFICATION: A.8.2 Anticoagulants. INDICATION: Prevention of venous thromboembolism (VTE) in patients undergoing major orthopaedic surgery of the lower limbs. S4 XARELTO® 15 and XARELTO® 20 (Film-coated tablets). Reg. No.: XARELTO® 15: 46/8.2/0111; XARELTO® 20: 46/8.2/0112. Each film-coated tablet contains rivaroxaban 15 mg (XARELTO® 15) or 20 mg (XARELTO® 20). PHARMACOLOGICAL CLASSIFICATION: A.8.2 Anticoagulants. INDICATIONS: (1) Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (SPAF); (2) Treatment of deep vein thrombosis (DVT) and for the prevention of recurrent deep vein thrombosis (DVT) and pulmonary embolism (PE); (3) Treatment of pulmonary embolism (PE) and for the prevention of recurrent pulmonary embolism (PE) and deep vein thrombosis (DVT). HCR: Bayer (Pty) Ltd, Reg. No.: 1968/011192/07, 27 Wrench Road, Isando, 1609. Tel: 011 921 5044 Fax: 011 921 5041. L.ZA.GM.12.2013.0871 © Bayer HealthCare Pharmaceuticals December 2013

Please direct all order queries to: Edward – Fax: 086 600 6218 email: edwardm@hmpg.co.za Tax invoice to be posted on dispatch of order.