Medical Chronicle May Teaser 2020 by New Media Medical

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The doctor's newspaper

MAY 2020

Global Health Award

for SA’s pioneering professors Recognition for the discovery that antiretrovirals prevent sexual transmission of HIV, laid the foundations for re-exposure prophylaxis (PrEP). By Nicky Belseck, medical journalist

HEN TWO YOUNG graduates began the journey of a lifetime three decades ago, they couldn’t possibly have imagined the medical breakthroughs they’d have, or how their work would come to change the world. Thirty-two years later dynamic husband and wife duo, Professors Salim and Quarraisha Abdool Karim have been named the 2020 John Dirks Canada Gairdner Global Health Award laureates. Rewarding international excellence in fundamental research that impacts human health, the Canada Gairdner Awards recognise the world’s most creative and accomplished biomedical scientists who are advancing humanity and the world. The Abdool Karim’s were

TEAMWORK “The entire body of knowledge that we’ve been recognised for, comprises our work to find solutions and slow the HIV epidemic in young women,” said Professor Professor Salim Abdool Karim Professor Quarraisha Abdool Karim Salim Abdool Karim, director of CAPRISA (Centre for the AIDS Programme recognised “for their discovery that of Research in SA). “We don't chase the antiretrovirals prevent sexual transmission awards,” Professors Quarraisha Abdool of HIV, which laid the foundations for Karim (associate scientific director of pre-exposure prophylaxis (PrEP), the HIV prevention strategy that is contributing to the CAPRISA) SAID. “But it's nice when we reduction of HIV infection in Africa and around do get recognised. Awards like this are an affirmation of the importance of the work the world,” the Gairdner Foundation said.

we're doing. It's also affirmation for the large teams we work with, both scientists within CAPRISA and other health professionals that enable this research.” Salim, or Slim as he is affectionately known (a nickname he picked up in school – ‘Slim’ meaning clever in Afrikaans) agreed. “I think getting an award like this is recognition of the perseverance that it takes to make important medical breakthroughs. They don’t just happen overnight.“But we are merely representatives of a massive team. We have over 400 scientists from across the world working on this problem with us. Just our Durban team is over 200 scientists – we have about 50 PhDs, and 32 medical doctors in our team. That's what it takes to really do impactful research.” THE WORK UNAIDS estimates that 37 million people continued on page 2

COVID-19: Patience and perspective are key

GE A P

NEWS

MAY 2020

continued from page 1

were living with HIV and 1.8 million people acquired HIV in 2017. In Africa, which has over two thirds of all people with HIV, adolescent girls and young women have the highest rates of new HIV infections. ABC (Abstinence, Be faithful, and use Condoms) prevention messages have had little impact – due to gender power imbalances, young women are often unable to successfully negotiate condom use, insist on mutual monogamy, or convince their male partners to have an HIV test. “In sub-Saharan Africa there’s a disproportionate burden of the global number of infections,” said Quarraisha. “It’s home to about 70% of the global burden of infections. A unique feature and characteristic of this epidemic is that young women acquire the infection 5-7 years before their male peers. There’s a disconnect between what is available to prevent infection that women can use, and where the burden of the infection is. That gap is on women-initiated prevention technologies, which is what we have focused on.” Responding to this crisis, the Abdool Karims started investigating new HIV prevention technologies for women about 30 years ago. After two unsuccessful decades, their perseverance paid off when they provided proof-of-concept that antiretrovirals prevent sexually acquired HIV infection in women. Their ground-breaking CAPRISA 004 trial showed that tenofovir gel prevents both HIV infection and genital herpes. The finding was ranked in the ‘Top 10 Scientific Breakthroughs of 2010’ by the journal, Science, and was heralded by UNAIDS and the World Health Organization (WHO) as one of the most significant scientific breakthroughs in AIDS and provided the first evidence for what is today known as HIV pre-exposure prophylaxis (PrEP). Presenting the results at the AIDS conference in 2010 the Abdul Karims provoked an emotional response from the audience, expressed in a prolonged standing ovation. “The standing ovation was the first

of its kind. We'd never seen something like that,” said Slim. “People just spontaneously stood up, it wasn't orchestrated or anything.” “We were stunned,” said Quarraisha. “I mean you see that at rock concerts, at philharmonic orchestra performances, you don't see that at meetings, and definitely not at science meetings. We stood there in awe wondering what to do.” THE IMPACT CAPRISA 004 and several clinical trials of oral tenofovir led to the WHO recommending a daily tenofovir-containing pill for PrEP as a standard HIV prevention tool for all those at high risk a few years later. Several African countries are among the 68 countries across all continents that are currently making PrEP available for HIV prevention. The research has played a key role in shaping the local and global response to the HIV epidemic. “The direct impact is access to technologies that work,” said Quarraisha. The indirect impact is really what’s inspiring in terms of how the communities that have been devastated by this epidemic, have kept their resilience.” “We couldn’t have done any of it without the amazing women that participate in our studies,” said Slim. PATIENCE, PERSEVERANCE AND PASSION “Our research was the first to demonstrate that pre-exposure prophylaxes with antiretroviral drugs would prevent sexual transmission. But it took us 18 years before we had a first positive result. And you must admit, after 17 years of failure surely you should move on with your life?” Salim joked. “But it’s that kind of perseverance that’s needed if you are to make major breakthroughs.” Asked how they stayed motivated when result after result was negative Quarraisha said, “Science is not for the faint-hearted. If we had the answer then we wouldn’t need to do any research. These are not simple problems that you’re facing because quite often you’re not trying

The dawn

of a new normal IN A TIME WHEN the world has changed, and is facing great obstacles, there are many great innovations on the bubble. We celebrate power couple, the Karims, and the incredible work they have done in the field of HIV and PrEP. So many scientists and institutions have stepped up to the challenges that COVID-19 presents. We focus on the groundbreaking work led by Wits University. We explore the various academic leaders at Wits and their role in confronting corona. There is no denying that this pandemic has changed all of our lives. Virologist Prof Wolfgang Preiser of Stellenbosch

2 MAY 2020 | MEDICAL CHRONICLE

University and NHLS and Dr Indira Govender discuss the ‘new normal’ under this pandemic. One of the ways that life has changed is the emergence of telemedicine. In recognition of Burns Month, Dr Ethel Andrews, President of the South African Burn Society, looks at the importance of remote wound care. In the theme of doing things remotely, and virtually, we are excited to be hosting CPD-accredited webinars, starting on 26 May, where Prof Bonga Chiliza will present on schizophrenia. The next webinar will be on 2 June, where Dr Gary Hudson will discuss Obesus Novus: Pandemic on epidemic. Set aside an hour to view these live presentations, from the comfort (and safety) of your home or office.

Happy reading and stay safe!

to find solutions for today, it’s solutions for further down the road. Of course, we didn’t know it was going to be 10, 18 years,” she said smiling. “But that’s the joy of science. When you set out to answer questions, you never know what’s going to come out of it. Whether you get a positive or negative result, both send you back to the drawing board to ask why, and both answers help you to move forward.” “We spend most of our lives proving that we are wrong,” said Slim. “But on occasion when we have been right it's been amazing. We have altered people's understanding of the problem we've altered whole approaches to the problem, and we’re just deeply grateful we were given the opportunity to do that.” And the journey never ends. “Even when we did get the CAPRISA 004 results we didn't stop and say ahh we got our answer,” said Quarraisha. “We spent the next 10 years trying to understand why we got that answer. That has helped us advance in terms of the questions we're asking today.” “We hope that our research now, into the future, will be able to develop technologies that will be long acting,” said Slim. “Right now, we’re developing a technology that uses tenofovir in an implant that would last a whole year, that women can use comfortably, and we can get widespread implementation to make a real impact on the HIV epidemic. COVID-19, REMDESIVIR AND BCG Of late there’s been a lot of noise made around the use of the BCG vaccination and PrEP medications as potential COVID-19 treatments. “We've said right from the beginning that when you look at this coronavirus, there are very few drugs that work against coronaviruses,” said Slim who chairs the government's advisory committee on coronavirus. “While I think there's some merit in talking about training the immune system, you can do that with pretty much any vaccine, so it has little to do with BCG. And to believe that somebody who got BCG 40 years ago and somehow that is now protecting them from some disease today – when it doesn't even protect against TB – is a big stretch. I don't really buy it, but I keep an open mind as a scientist, and I’ll say it's an interesting hypothesis. But I need to see better evidence. “Right from the beginning we said we only know one drug that works against coronaviruses and that's remdesivir,” said Slim. “It just happened that the vice president of Gilead, the drug company that makes remdesivir, was visiting us, in January. She came to spend some time with us in Durban and we talked to her about remdesivir. She said they’d just started discussions with the Chinese government, with the National Institutes of Health, and we're running trial. “The first results came out on 29 May showing that the drug has some promise. It's the only drug so far that has shown any promise. It's reassuring, but now we need to find something better, that shows impact. Now we must put our shoulders to the wheel and keep working, there are no shortcuts.”

CONTENTS All content in Medical Chronicle is sourced independently and under no circumstances should articles be considered promotional unless specified.

NEWS Global Health Award for SA’s pioneering professors...........................................................1 Wits steps up in face of COVID-19 pandemic.............................................................4 NHI: Mistrust in government rife...........7 COVID-19: Dawn of a new normal..........8

PRACTICE MANAGEMENT

COVID-19: Patience and perspective are key................................................................10

CORPORATE SOCIAL INVESTMENT

Aspen donates 600 electronic devices to medical students....................................12

ONLINE CPDs

Etifoxine – a unique anxiolytic..............13 How can health workers manage their mental health during COVID-19?........29 First-trimester preeclampsia screening with biomarkers................... 44

OPHTHALMOLOGY

Discovery: Important additional function protective eye protein ..........14 Rare eye diseases: A glance at Stargardt disease and keratoconus ..........................................16

ETHICS

Covid-19: Dealiong with end of life issues ......................................................18

DIABETES

Does size matter? ......................................20

CARDIAC

Controlling hypertension during the COVID-19 pandemic...................................22

SMOKING CESSATION

It is never too early or too late to stop smoking.................................................24 D CP

DIABETES CPD

Insulin regiments in type 2 diabetes.. 26 Diabetes and fasting.................................36

WOUND CARE

Remote wound care during COVID-19 .......................................................34

RESPIRATORY

COVID-19 pneumonia procalcitonin for risk assessment...........................................28

RHEUMATOLOGY

Gout vs OA: Clash of the arthritic titans ..............................................30

PAIN

Therapeutic protocols for COVID-19 in SA .............................................32 Ibuprofen can be used for COVID-19 symptoms .................................41

GASTROENTEROLOGY

Medical vs surgical treatment for refractory heartburn................................33 Bowel Prep education app is effective......................................................38 Probiotic reduces crying in colicky infants......................................... 40 Crohn’s marker improves outcomes.........................................................42

WOMEN'S HEALTH

Does exercise ease dysmenorrhoea?.........................................45

OPINION

The challenge facing SA with the second wave of COVID-19 .............46

PLACEBO

Retinal cryoprobe celebrated on South African Mint's newest collectable coin.............................................47

You are invited Medical Chronicle

CCRPEDDITED

Schizophrenia Webinar

In partnership with

In acknowledgement of World Schizophrenia Day, Medical Chronicle will be hosting a free CPD-accredited 1-hour webinar on this topic. Join Prof Bonga Chiliza, president of the South African Society of Psychiatrists, who will present on this condition and give us an update on the biology and new trends.

Tuesday, 26 May 2020 Time: 10am Topic: Schizophrenia

Bonga Chiliza is an Associate Professor/Chief Specialist and Head of the Department of Psychiatry at the University of KwaZulu-Natal. He completed his medical degree and psychiatry specialisation at the University of KwaZulu-Natal and his PhD at Stellenbosch University. His research interests include schizophrenia, consultation-liaison psychiatry, health services and medical education. He is the president of the South African Society of Psychiatrists, as well as the deputy editor of the South African Journal of Psychiatry. Prof Chiliza has received several awards including the Hamilton Naki Clinical Research Fellowship and the South African Health Excellence Award. He has authored over 60 peer reviewed articles and book chapters. He has also served on a number of NGO Boards, including the SA YMCA and Life Choices. He is one of the Founding Directors of Harambee Medical Consulting and the Africa Global Mental Health Institute.

Presenter: Prof Boga Chiliza, President of SASOP

Online Registration https://bit.ly/mc-schizophrenia-webinar

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2020/05/07 11:54

MEDICAL CHRONICLE | MAY 2020 3

NEWS

Wits steps up

in face of COVID-19 pandemic Amongst the best in their fields, Wits experts are at the frontlines and behind-the-scenes in the fight against COVID-19.

HE COVID-19 pandemic has disrupted life as we know it. But it has also galvanised rapid adaptation to change and the adoption of new technologies. Eminent academics at Wits University in disciplines including epidemiology, medicine, public health, biomedical engineering, governance and others, are the unsung heroes leading the charge against COVID-19. In concert with the National Institute of Communicable Diseases (NICD), the Department of Health, and the South African government, an army of heroic scientists at Wits are helping to understand, predict, and contain COVID-19, manage the public health and socio-economic impact, and develop treatment and care regimens. The Wits heroes mentioned here represent just a fraction of the University’s community of clinical, academic, professional and support staff, alumni and students working tirelessly and contributing in multiple ways to mitigate this state of disaster. UNDERSTANDING THE ENEMY •P rofessor of Epidemiology in the Wits School of Public Health, Prof Cheryl Cohen is a medical doctor and co-head of the Centre for Respiratory Disease and Meningitis at the NICD. She is at the forefront of COVID-19 case-finding, diagnosis, management and public health response.

4 MAY 2020 | MEDICAL CHRONICLE

•P rofessor Adriano Duse is head of Department of Clinical Microbiology and Infectious Diseases at Wits. Closely associated with the National Health Laboratory Service (NHLS), in March, Prof Duse delivered a public lecture entitled, Myths and Facts about SARS-CoV-2: The COVID-19 Outbreak 2019-2020 – What you can do to reduce infection risk. In January he delivered a radio Masterclass on Superbugs. •W its lecturer, Dr Kerrigan McCarthy is a clinical microbiologist and head of the Division of Public Health, Surveillance and Response at the NICD. Her responsibilities include oversight of the Outbreak Response Unit, Notifiable Medical Conditions and GERMS-SA surveillance. •M icrobiologist Professor Lynn Morris is a research professor in the School of Pathology at Wits and the Interim Executive Director of the NICD. Prof Morris is internationally recognised for her work in understanding how the antibody response to HIV develops. A National Research Foundation A-rated scientist, she is amongst the most highly cited researchers in the world. Morris has a lifetime’s experience fighting viruses. UNDERSTANDING EACH OTHER •A Distinguished Professor of

spread originally via travelling, in articles for Daily Maverick, Prof Vearey cautioned against ‘hypocrisy in a time of COVID -19’ and advocated that ‘foreign migrants be included in the COVID -19 response’. She also discussed how SA’s impending winter, an historical HIV-AIDS pandemic, and xenophobic attitudes combine to generate surprising and unexpected responses to COVID-19 in a podcast.

Professor Lenore Manderson

Medical Anthropology and Public Health, Professor Lenore Manderson is internationally renowned for her work in anthropology, social history and public health. The advent of COVID-19 prompted the Institute of Plumbing South Africa (IOPSA) to contact Wits. Given the requirement of taps and plumbing for handwashing, hygiene and sanitation against the virus, coupled with social distancing, quarantining and isolation protocols, plumbers were understandably concerned. Prof Manderson delivered a Q&A webinar for their members. • Associate Professor Jo Vearey is the director of the African Centre for Migration and Society at Wits, and director of the African Research Universities Alliance (ARUA) Centre of Excellence on Migration and Mobility. Given that the coronavirus

Professor Helen Reese

TOWARDS TREATMENT • Professor Helen Rees is Executive Director of the Wits Reproductive Health and HIV Institute (Wits RHI). She chairs the World Health Organization’s (WHO) African Regional Immunisation Technical Advisory Group and she is CoChair of WHO’s Ebola Vaccine Working Group. SA is one of 10 countries involved in an urgent global trial,

NEWS 'Solidarity', announced by the WHO to identify the most effective treatment f or coronavirus.

2019, when news of the virus broke, been preparing her team and the hospital to care for the ill. BIG DATA BATTLE LINES • Predicting and anticipating the trajectory of the virus to mitigate casualties and inform policy requires number-crunching, modelling, and analysis of Big Data. In March, an interdisciplinary team of researchers at Wits launched the most comprehensive data dashboard to date on the COVID-19 virus in SA. Wits School of Physics Professor Bruce MelladoGarcier, who initiated the project, says: “We are experts in analysing

Professor Shabir Madhi

•P rofessor of Vaccinology and paediatrician, Professor Shabir Madhi is director of the Medical Research Council Respiratory and Meningeal Pathogens Research Unit (RMPRU) at Wits. Prof Madhi holds the NRF/ SARChI chair in Vaccine Preventable Diseases. His research has focused on the epidemiology and clinical development of lifesaving vaccines against pneumonia and diarrhoeal disease and has informed the WHO with recommendations on the use of the lifesaving pneumococcal conjugate vaccine, rotavirus vaccine, and influenza vaccination of pregnant women. He is the immediate past director of the NICD and former president of the World Society of Infectious Diseases. He has consulted to the WHO in the fields of vaccinology and

Professor Francois Venter

pneumonia and to the Bill and Melinda Gates Foundation on pneumonia. • Renowned HIV expert, Professor Francois Venter is director of Ezintsha and deputy executive director of Wits RHI. With an active interest in public sector access to HIV services, medical ethics and human rights, Professor Venter is attuned to the impact of COVID-19 on those with comorbidities such as HIV and TB. He is an advisor to the South African government, to the Southern African HIV Clinicians Society, and to the WHO. CARING FOR THE SICK •P rofessor Feroza Motara is Academic head of Emergency Medicine in the School of Clinical Medicine at Wits and at Charlotte Maxeke Johannesburg Academic Hospital - where the first COVID-19 patient in Gauteng was treated. Prof Motara has since December

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and interpreting big data, and we believe that it is important that someone put this data together and present a bigger picture of the impact of the virus on the country.”

Predicting and anticipating the trajectory of the virus to mitigate casualties and inform policy requires number-crunching, modelling, and analysis of Big Data • The Gauteng City-Region Observatory (GCRO) has developed an interactive map showing the province’s vulnerability to COVID-19. Dr Julia De Kadt, et al, devised this Map of the Month. The GCRO is a partnership between Wits University, the University of Johannesburg, and the Gauteng Provincial Government. Its mandate is building strategic intelligence through improved data, information, analysis and reflective evaluation for better planning, management and cooperative government. EXPERT COMMENTARY ADVANCING POLICY •P rofessor Karen Hofman is director of the SAMRC/Wits Centre for Health Economics and Decision Science (PRICELESS SA). A research-to6 MAY 2020 | MEDICAL CHRONICLE

policy unit that provides evidence, methodologies and tools for effective decision-making in health, PRICELESS SA analyses how scarce resources can be used effectively, efficiently, and equitably to achieve better health outcomes. Prof Hofman, with Susan Goldstein, deputy director of PRICELESS SA, wrote one of the earliest articles advocating hand-washing, which has since become COVID-19 protocol. •E conomist Professor Imraan Valodia, dean of the Faculty of Commerce, Law and Management at Wits, is currently coordinating an international study, in 10 cities, of the informal economy. His research interests include employment, the informal economy, gender and industrialisation. He is a part-time member of the Competition Tribunal and a commissioner on the Employment Conditions Commission and chair of the National Minimum Wage Advisory Panel. “The COVID-19 crisis is first and foremost a health and humanitarian crisis that we are all living through, which is likely to have lasting impacts on how we live. It is also likely to have a lasting impact, in the long term, on how we conduct our economic lives,” Prof Valodia wrote in an article analysing the risks on economic inaction of COVID-19. • I n the Wits School of Governance, adjunct Professor Alex van den Heever holds the chair in Social Security Systems Administration and Management studies. Prof van den Heever’s research interests span healthcare management, healthcare

quality, healthcare delivery, cost, and economic analysis, health equity, health inequality and disparities and preventive medicine. “We need a plan and action, not warnings of our impending doom. The actions pursued also need to do more than just shut SA down,” he wrote in an analysis of COVID-19: What the smart countries do… and we don’t.

The COVID-19 crisis is first and foremost a health and humanitarian crisis that we are all living through, which is likely to have lasting impacts on how we live. It is also likely to have a lasting impact, in the long term, on how we conduct our economic lives

INNOVATING AGAINST INFECTION • I n the Faculty of Science, head of the School of Molecular and Cell Biology, Professor Marianne Cronje and her team took the initiative to synthesise virus-killing surface disinfectant and provided limited quantities of this

disinfectant freely to university workers ahead of lockdown. The production plant has now been shifted to PIMD, while the school retains scientific oversight. In the school’s Protein Structure Function Research Unit, Professor Yasien Sayed coordinated the donation of 56 boxes of protective gloves to healthcare workers at the Chris Hani Baragwanath Hospital, after a Wits medical intern mentioned the shortage. •M ichael Lucas, a PhD candidate in the School of Mechanical Engineering has developed a revolutionary infection control solution. His self-sanitising surface coating will help to address nosocomial infections, as well as mitigate contamination of food processing plants, and public transport surfaces. The Antimicrobial Coating Technology is now in its fifth year of development, with implications of preventing infection beyond COVID-19. •A djunct Professor in Biomedical Engineering Professor David Rubin leads the Biomedical Engineering Research Group in the School of Electrical and Information Engineering at Wits. Prof Rubin and biomedical engineer and lecturer, Adam Pantanowitz are working on a model to show the effect of intermittent quarantines. It is currently very limited but may have some benefit in terms of maintaining essential services and some continuity of economic activity. “At this stage, we’re only demonstrating the concept on standard viral epidemic models rather than a specific COVID-19 model,” cautioned Prof Rubin.

NEWS

NHI

Mistrust in government rife Investors and the public alike question the government’s ability to execute NHI. By Nicky Belseck, medical journalist

LTHOUGH A NUMBER of key concerns have been raised about the NHI (National Health Insurance) Bill, including transparency of NHI structures, the extensive powers given to the Minister of Health, and the centralisation of authority in the National Department of Health (NDoH), mistrust of government was the pivotal point raised by panel experts discussing NHI at Daily Maverick’s 2020 The Gathering. UHC NOW There was unanimous agreement on the need for universal healthcare (UHC) in SA. “When delivered properly, UHC is the best gift a country can give its people,” said Dr Mark Britnell, global chairman and senior partner for healthcare, government, and infrastructure at KPMG International. “It’s good for society, it’s good for the economy, it’s good for people.” However, panel facilitator Mark Heywood, Maverick Citizen editor asked if “we’re going about it the right way?” He questioned whether government shouldn’t first fix the public healthcare sector before imposing NHI on the country? “SA has no choice but to embark on the NHI journey,” said head of SA's NHI Office, Dr Nicholas Crisp. “It is not an either/or debate. You can’t address either the public or private sector – or either the money or the system – it all has to be done at the same time. It is the sequencing of how those things happen, that matters.” Discussing the money available to the NDoH Dr Crisp said, “As taxpayers do not want to pay more money, it will have to be done through efficiencies. The problem in the public sector is that in the provincial

administrations we are spending 75-78% of our entire health budget on personnel, on cost of employment. That means we’ve crowded out the ability to buy medicines and devices,”

As taxpayers do not want to pay more money, it will have to be done through efficiencies. The problem in the public sector is that in the provincial administrations we are spending 7578% of our entire health budget on personnel, on cost of employment. That means we’ve crowded out the ability to buy medicines and devices Dr Britnell responded saying, "If you look at Indonesia, Thailand, and Mexico, they spend less than SA and have a system performing better than SA,” said Dr Britnell. “You can spend less than 8.5% of your GDP (SA’s current combined private and public healthcare expenditure) and get better outcomes — that’s a fact. But you have to build from what you have in stages. Be

pragmatic and ideological. “My sadness is that when people take dogmatic and premature positions on NHI, you are in danger of throwing out the baby with the universal healthcare bathwater,” said Heywood. “Government has a record of failure, which means people understandably prejudge the issue, but this has closed down informed discussion. I’m concerned that as a result, the government has closed itself to informed discussion.” THE PROBLEM OF TRUST, OR LACK THEREOF “South Africans are feeling overtaxed and overburdened,” said Steven Nathan, former managing director of Deutsche Bank. “The issue is one of trust and one of delivery. In an ideal world, we would want UHC. But what is the cost and what is the benefit?” Stressing investors’ apprehension Nathan said, “The track record that government has is incredibly poor. Government departments’ ability to deliver is very poor. So, it’s trust. It comes down to how can the government demonstrate to us that it has the capacity and the ability to add value to the system. Dr Crisp acknowledged Nathan’s concern: “The trust deficit is the issue we are working on as hard as we can. It’s a diverse set of stakeholders, but we need to find common ground in a way people don’t feel they are losing something but, in a way, they feel they are gaining something. “We know there’s distrust. And in light of the Zondo Commission I think right now is the best time to start the NHI,” he said. “We are more vigilant than we’ve ever been as civil society about corruption. Now is a good time to build institutions.”

“I’ve worked in a lot of countries where corruption and distrust were rampant,” said Dr Britnell, “like in South America and what they’ve done to demonstrate they want a professional UHC service. I’m not suggesting it happens here, but what you think you’re facing, and think is unique, is not. There are solutions that can take trust head-on and find different ways of finding accountability through actually having professional organisations to help you manage the fund. I’m just saying that where trust is broken there is usually a solution.” THE ROAD AHEAD “In the draft bill, there is a suggestion of a number of phases with time frames,” said Dr Crisp. “They go for more than 10 years. Getting there will be in a series of building blocks. When they started the NHI in the UK, 33% of hospital wings were broken after World War 2 and they are still building that system. "We are planning for the future and building the framework now to bolt the various pieces onto.” By 2026 the NHI Bill requires government to be ‘the single, strategic purchaser of personal health services for the population’. “Before that can happen, we need the IT-systems in place, the systems need to talk to each other,” said Dr Crisp. The Bill says the fund will purchase directly from the hospitals. Can you imagine in SA today how much work has to be done before we have our cost centres realigned in the government hospitals, our clinics aligned, train managers, and have delegated authorities because of the way our Public Finance Management Act works? It’s a huge amount of work.” MEDICAL CHRONICLE | MAY 2020 7

NEWS

COVID-19 Dawn of a new normal “We can’t return to normal or all we’ll have achieved is a temporary stay of execution and it will unleash exactly the havoc that we are trying to avoid,” said virologist Professor Wolfgang Preiser. By Nicky Belseck, medical journalist

EAD OF THE Division of Medical Virology, Faculty of Medicine and Health Science at the University of Stellenbosch and National Health Laboratory Service (NHLS) Tyberg, Prof Preiser and specialist in Public Health Sadad_ad.pdf 1 2014/05/22 12:41 PM Medicine, Dr Indira Govender spoke to Daily

Maverick Citizen editor Mark Heywood in a webinar last month. “There are two things in favour of SA,” said Prof Preiser. “Firstly, government acted decisively, early in our own curve of the epidemic which is wonderful. In terms of where we were when it arrived here, action

was taken as early as possible and it was clear. The guidelines were clear and it’s wonderful to be under the kind of leadership we’ve seen. The other thing in our favour is that our epidemic curve is a few weeks behind other countries so we will be able to see what works and what doesn’t work,

and how we can minimise the economic problems that the shutdown causes while avoiding the worst of any medical repercussions.” “Of course, control is still possible and in a sense that’s what we’re doing in SA, but all the measures we’re taking are to mitigate the situation rather than stop the disease. This new agent is very contagious, it’s very easily transmitted, and people may be infected before they show any symptoms, making it practically impossible to contain. In SA we’re trying to lessen the impact and flatten the curve so that hopefully the numbers of patients at any given moment in time will not exceed the capacity of the health system.”

In SA we’re trying to lessen the impact and flatten the curve so that hopefully the numbers of patients at any given moment in time will not exceed the capacity of the health system C

CMY

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THE NEW NORMAL “In the future when patients want to see a doctor because a flu-like illness, the whole procedure will have to change,” said Prof Preiser. “We are at the point now where going forward we will have to treat respiratory infections, even if they are minor in the person that presents, much more seriously and make sure they are not passed on to other patients who are vulnerable. “A vaccine may change the picture to some degree but I think for the foreseeable future, masks, and that doesn’t mean cloth masks that are nice that you would use to visit a supermarket - I’m talking about medical masks that will become part of the furniture in medical establishments.” “And there will be these small fires, or clusters of outbreaks that Prof Salim Abdool Karim (world-renowned infectious diseases epidemiologist and chair of the Ministerial Advisory Committee on Covid-19) has spoken about and we need to have rapid response to that. We need to have swift testing, we need isolation facilities, have contingency plans, and we need to be able to contain these clusters when they do crop up,” said Dr Govender. “Until we have a vaccine or a cure that is widely available, this is what we’ll be dealing with.”

Y E A RS

T WENT Y

SADAG

MENTAL HEALTH FACT SHEET

LIFE-TIME PREVALENCE OF MENTAL DISORDERS IN SA Compared with 14 other countries in the WMH Survey, South Africa is the:

2nd highest for substance abuse disorders (13.3%) 6th highest for anxiety disorders (15.8%) 7th highest for mood disorders (9.8%) PATIENT ADHERENCE AT A GOVERNMENT HOSPITAL

MENTAL HEALTH IN SOUTH AFRICA • 3rd biggest contributor to the burden of disease • 7.7% reduction in mental hospital beds across all provinces • 11% of all non-natural death in SA is due to suicide • 16.5% of South Africans suffer from common mental health problems • 43.7% of people with HIV/AIDS have a mental health condition • 75% of clinic staff does not have a caring attitude • South Africa is in the bottom 4 countries providing mental health treatment

Only 15.4% of patients take their meds as suggested by their dr 1 in 3 patients do not attend their dr’s appointments • Most common reasons are +/- 6 mil South African suffers from PTSD • Forgetfulness 28.6% +/- 8000 South Africans commit suicide each year • Lack of Support 24.2% • Adverse reactions 13% 82.1% cannot afford private health care • Unavailability 11% > 1% of health budget devoted to mental health

SOCIAL BURDEN FOR MENTAL HEALTH PATIENTS

Can’t take care of dependants

Separated/ Divorced

Lost friends

Negative Family Relationships

17%

26%

47%

49%

SEEKING TREATMENT FOR MENTAL HEALTH

RESOURCES FOR MENTAL HEALTH Per 100,000 of the population there are: 9.72 Nurses 0.4 Social workers 0.27 Psychiatrists 0.32 Psychologists 2.8 beds for in-patients 1% beds for children

Research compiled by SADAG – References: DoH, 2012; WHO, 2012, SASH, 2009; MHaPP, 2007; Freeman, 2007; MRC, 2006; ALLERS, 2009; Janse van Rensburg, 2013

PRACTICE MANAGEMENT

COVID-19

Patience and perspective are key We are currently experiencing what is possibly the biggest global event since World War II, and we have definitely witnessed the fastest inflection from bull market to bear market globally. We certainly live in very interesting times.

Andrew Dittberner, chief investment officer: Old Mutual Wealth Private Client Securities

HE EXTREME MARKET volatility that has ensued recently is unprecedented. The sell-off has been swift. Compounding the volatility, OPEC+ (The Organization of the Petroleum Exporting Countries, an intergovernmental organisation of 13 nations) failed to agree on the oil production cuts required to stabilise the falling oil price. This resulted in the oil price, along with anything oil-related, plummeting to record lows. Given the current environment, central banks around the world have reacted aggressively by cutting interest rates, while governments are ready to support the economy through fiscal stimulus measures of varying degrees. Yet, despite these efforts, equity markets continue to trend lower – an indication that market participants believe that these efforts may not sufficiently manage the crisis. Unsurprisingly, investor reactions vary widely. While we have received many questions, they all ultimately boil down to the same thing: what should we do? Offering a definitive view is no more than guesswork and is likely to be incorrect. In the short-term, whether markets go up or down from here will largely be driven by investor psychology, and we do not know what the immediate future holds. Every crisis is different, making it increasingly difficult to draw inferences from previous pandemics. It is important to remember that all market participants are human, and irrespective of the façade put forth, it is likely that everyone has had

10 MAY 2020 | MEDICAL CHRONICLE

a moment or two of panic. While this is a human reaction, it is important not to allow those emotions to drive our investment decisions. With central banks acting incisively, it is positive to see that fiscal stimulus is following suit. Fiscal stimulus is viewed as the more appropriate response given that the panic we are witnessing is due to a cash flow crisis. Business owners face mounting costs, yet cash flow is diminishing as the economy slows. Fiscal intervention and potential bailouts should therefore be viewed as positive developments in this environment. OUR VIEW ON MARKETS Heading into 2020, our view on both local and global equity markets was neutral. While we viewed SA equities as attractively priced, we were not confident that local corporates would be able to deliver sustainable earnings growth in a depressed economic environment. Globally, we were concerned about ever-rising valuations in a slowing global economy. Given the recent sell-off, the local market has become even more attractively priced. However, the likelihood of earnings growth from SA corporates this year is diminishing. Globally, equity markets certainly appear more attractively priced today. Similar to SA though, we expect to see steep declines in company earnings in the first half of 2020, and possibly into the second half too. We will be in a better position to gauge market levels relative to economic reality once data

becomes available and we begin to see the extent of the economic fallout. It is important to note that markets tend to bottom before the bad news does. Therefore, it is prudent not to sell out of the market during times of volatility, as one is likely to miss the recovery that ultimately ensues. Similarly, it is prudent not to invest all of ones’ capital in the first leg down of a bear market. Investors often forget how low markets can go; and as John Maynard Keynes famously said, “Markets can remain irrational longer than you can remain solvent”. PATIENTLY AWAIT AND ASSESS THE OPPORTUNITIES Going back to the question around what investors should do, our answer would be: exhibit patience and avoid panic. The market will present opportunities that we will look back at one day as once-in-a-lifetime bargains. Investors need to be ready and prepared to capitalise on them when they occur. In identifying opportunities, valuations will always remain important. However, in these circumstances, we believe that focusing on companies’ balance sheets is critical. Can companies survive a sustained downturn in the economy without having to raise further capital? This consideration should be at the top of the checklist. Secondly, is the impact of the coronavirus a transitory event, or is it likely to lead to a permanent impairment of all future earnings and cash flows? The answer to this question

needs to be considered when valuing the business. If it is transient, the longerterm impact on a company’s valuation is likely to be less significant. Similarly, certain companies will benefit in the current environment. Equally important is understanding whether consumer behaviour and preferences will change permanently, or whether behaviour reverts to normal post COVID-19. In these times, it is far easier to hold a pessimistic view. Hearing that the world is coming to an end is interesting, while hearing that things will get better in time is less so. Paraphrasing from an article by Morgan Housel (former columnist at The Wall Street Journal), “The difference between pessimism and optimism often comes down to time.” In the short term, there is a vast amount of uncertainty that lies ahead of us. However, history has repeatedly proven that long-term gains exceed short-term shocks. And, given our innate ability to evolve and adapt to situations, we see no reason why the ultimate outcome should be any different this time around.

REFERENCES de Marinis F et al. ASTRIS: a global real-world study of osimertinib in >3000 patients with EGFR T790M positive non-small-cell lung cancer. Future Oncology 2019 10.2217/fon-2019-0324. Wu,YL et al. CNS Efficacy of Osimertinib in PatientsWith T790M-Positive Advanced Non–SmallCell Lung Cancer: Data From a Randomized Phase III Trial (AURA3). 2018;26:2702-2709.

OLD MUTUAL WEALTH ADVERTORIAL

Are there tax planning opportunities

amid COVID-19?

In these uncertain times, the old adage, ‘Nothing is certain except for death and taxes’ rings true. But during these challenging times, the COVID-19 pandemic may provide an opportunity for savvy investors to reduce their taxes by taking advantage of the estate and tax planning opportunities at their disposal.

OVID-19 SENT THE global equity markets into freefall, including that of the Johannesburg Stock Exchange (JSE). At its lowest point in March, the JSE All Share Index had declined by over 30% since the beginning of the year and while it has since recovered some ground, the losses are still quite substantial. TRANSFERS TO TRUSTS Over the last few years, trusts have come under increased regulatory scrutiny and it is now much more expensive for individuals to transfer assets to trusts. More specifically, Section 7C of the Income Tax Act (effective 1 March 2017) has resulted in the transfer of growth assets – usually fixed properties and share portfolios – by way of an interest-free loan now being subject to tax. This has made it more costly to fund a trust by means of a loan account. The aim of section 7C is to prevent estate duty and donations tax avoidance using interest free or low interest loans to transfer assets to trusts. If a trust incurs: • No interest in respect of a loan or • Interest at a lower rate than the official rate of interest, then the difference in interest between the official rate of interest and what was charged will be

treated as a donation payable by the person who granted the loan to the trust. The official rate of interest is the repurchase rate plus 1%; currently 6%. If the client has not utilised the annual R100 000 donation, it can be offset against the “deemed donation” on the interest free loan. This means that only loans owed by the trust in excess of R1 600 000 will attract donations tax. However, with markets in rapid decline, the value of share portfolios has significantly decreased. Therefore, the current environment might represent a good opportunity to transfer share portfolios into a trust as the capital gains tax (CGT) payable would have reduced significantly. As markets recover, the share portfolio – now owned by the trust – should then increase in value to the trust’s benefit. USING THE OMI LIFE WRAPPER Similarly, an existing offshore share portfolio could be transferred to the Old Mutual International (OMI) life wrapper, thereby triggering a CGT event (a ‘deemed disposal’). As the value of the share portfolio would be lower because of the decline in global markets, less CGT would be payable. The maximum effective CGT

rate currently payable by an individual is 18%, which is much lower than the 40% situs tax payable on death should the portfolio remain in the individual’s name. The OMI life wrapper has many benefits for investors, including: • Lower CGT rates at 12% • No probate application necessary on direct offshore investments housed in the OMI wrapper • No offshore will be required, therefore no offshore executor and reduced fees • No executor’s fees are payable where there are nominated beneficiaries • No situs tax applicable on direct share portfolios within the wrapper. In the UK, 40% inheritance tax is payable on the value exceeding £325 000, and on the value exceeding US$60 000 in the US • Old Mutual is responsible for the tax reporting obligations and payment to SARS. THE VALUE OF ADVICE While the current turmoil across global markets presents numerous challenges, there are some valuable tax planning opportunities. As always, we encourage investors to seek professional advice in order to find the solution best suited to their unique circumstances.

WEALTH Old Mutual Wealth is brought to you through several authorised Financial Services Providers in the Old Mutual Group who make up the elite service offering.

Elbe Thatcher – fiduciary specialist, Old Mutual Wealth Fiduciary Services

The current environment might represent a good opportunity to transfer share portfolios into a trust

CORPORATE SOCIAL INVESTMENT

Aspen donates

600 electronic devices to medical students Aspen, a global multinational specialty pharmaceutical company headquartered in South Africa, has donated 600 internet-enabled electronic devices valued at R2.4m to support students from the Faculty of Health Sciences at the University of Pretoria (UP).

TAVROS NICOLAOU, Aspen Pharmacare Senior Executive: Strategic Trade said, “Aspen is humbled to serve South Africa in its

time of need, as we work together to fight the COVID-19 pandemic. The provision of these devices to students not only helps to ensure that they have continued access

to online education, but also limits their need for travel. This donation will help curb the transmission-risk of the virus as the new academic semester begins,

allowing students to undertake their studies remotely. We are deeply committed to supporting the sectors and communities in which we operate, both during the current crisis, and in the longer term, as we assist to create sustainable communities in South Africa.” Professor Robin Green, UP Chairperson of the School of Medicine said, “While the COVID-19 crisis has created a world of hurt and sadness, it has also allowed the kindness and generosity of the world to shine. We appreciate the generous donation that Aspen has made to the Faculty to assist students with distance learning and to enable them to continue with the 2020 academic year.”

IN PARTNERSHIP WITH

WE HAVE EMPTY RESTAURANT KITCHENS … BUT MORE AND MORE HUNGRY SOUTH AFRICANS Following a rigorous screening process by the UP, the devices were earmarked for selected registered Faculty of Health Sciences students who attend classes regularly and who are unable to purchase the device for themselves. The tablets were handed over under strictly controlled hygiene and safety protocols, ahead of the commencement of remote lectures and training that resumed on 4 May 2020. Nicolaou added that this donation is in line with the country’s ambitions of harnessing digital innovation to benefit disadvantaged students, during these difficult times and into the future. “The donation of equipment further complements the University of Pretoria’s efforts to ensure that students from medicine and the other health science disciplines are able to continue with their curriculum and to minimise disruptions to the academic year,” said Nicolaou.

WE’RE RAISING FUNDS FOR RESTAURANTS TO FEED THOSE IN NEED

DONATE AT HELP.EATOUT.CO.ZA EORRF AD.indd 3

12 MAY 2020 | MEDICAL CHRONICLE

2020/04/28 10:02

ONLINE CPD

Etifoxine – a unique anxiolytic Prescribing drugs for anxiety disorders is one of a psychiatrist’s most common tasks.

NXIETY DISORDERS ARE the most prevalent psychiatric disorders and are associated with a high burden of illness. Anxiety is an emotional experience that is characterised by a state of arousal and the expectation of danger. Anxiety and adjustment disorders are frequently comorbid with other medical conditions. It has an adaptive role, preparing the body to deal with future threatening stimuli arising from the environment. Nevertheless, processing of such aversive information by the brain, particularly by the amygdala circuits, is associated with a negative subjective state. When excessive, a pathological anxious condition may be diagnosed. In DSM-5, these states include panic disorder, generalised anxiety disorder, separation anxiety disorder, specific phobias, social anxiety disorder and adjustment disorder with anxiety.

adverse events mostly concern skin and subcutaneous tissue disorders, which generally resolve with treatment discontinuation. CONCLUSION Clinical studies have demonstrated the efficacy of etifoxine in the symptomatic

treatment of anxiety, particularly in patients with ADWA, with daily doses of 150-200mg. The tolerability profile of etifoxine is better than that of BZDs, notably because of a lack of effect on memory and vigilance. In addition, treatment cessation does not induce drug dependence, withdrawal, or rebound anxiety.

The anxiolytic efficacy of etifoxine, its good tolerability and the absence of drug dependence is strong arguments in favour of using etifoxine in the management of ADWA.

References available on request.

BRAND

Story Every day, thousands of South Africans make donations to the South African National Blood Service. These donors don’t just give us their blood. These remarkable human beings give so much more.

GABAAR Brain imaging studies have demonstrated that prolonged dysregulation of brain networks involving cortical and specific subcortical areas (amygdala, hippocampus, thalamus, prefrontal, and cingulate cortex) contributes to the expression of anxiety symptoms. In particular, reduced inhibitory GABAergic transmission in the CNS has been shown to be critical for the manifestation of anxiety. In this respect, the structure and function of the GABA A receptor have been under intense scrutiny. GABA AR is a heteropentamer made of five subunits delimiting a chloride/ bicarbonate-permeable channel. It is activated by at least two molecules of γ-aminobutyric acid (GABA), an amino acid neurotransmitter synthesised from glutamate in neurons expressing glutamate decarboxylase enzymes (i.e. GABAergic neurons). As for many ligand-gated receptor-channels the apparent affinity of GABA ARs for GABA varies from low to high micromolar range. This parameter strongly depends on the subunit composition and, more specifically, on α-β subunit dimers forming together the agonist binding site for GABA. The anxiolytic effect of drugs binding to the GABA A receptor is attributed to the facilitation of chloride channel opening, thereby amplifying neuronal inhibition in response to GABA. Over the last halfcentury, numerous GABA A receptor ligands have been developed as therapeutic agents, including anxiolytics, hypnotics, muscle relaxants, and antiepileptics. SAFETY OF ETIFOXINE Over the 30 years since etifoxine was first licensed, drug safety monitoring has confirmed the low risk of drug dependence or withdrawal symptoms following treatment cessation. The few reported

This is a summary of a longer, CPD accredited article available on www.medicalacademic.co.za

Selflessly, without praise or compensation, they donate experiences, opportunities and potential. They donate blank pages onto which others can now write new chapters. Thanks to our donors, an old woman has the chance to knit a jersey for her grandchild, a young man gets to marry his childhood sweetheart, and a little girl has the opportunity to win first prize at her school science fair. These stories are at the heart of everything SANBS does. It’s the reason we get up every morning and never look at a blood bag as just a pint of blood. Instead, we see a lifeline which extends from one human to another, and continues on to form the lines of the pages on which new stories can be told. A blood donation seems like such a small act and yet it has incredible significance. It allows stories like these to live.

BECAUSE AT THE END OF THE DAY, IT’S NOT BLOOD. IT’S LIFE.

MEDICAL CHRONICLE | MAY 2020 13

CLINICAL | OPHTHALMOLOGY

Discovery Important additional function of protective eye protein

The lens of the human eye comprises a highly concentrated protein solution, which lends the lens its great refractive power.

ROTECTIVE PROTEINS PREVENT these proteins from clumping together throughout a lifetime. A team of scientists from the Technical University of Munich (TUM) has now uncovered the precise structure of the alpha-A-crystallin protein and, in the process, discovered an

important additional function. The refractive power of the human eye lens stems from a highly concentrated protein solution. These proteins are created during embryonic development and must then function for a whole life, as the lens has no machinery to synthesise

TOLL FREE 0800 22 66 22

or degrade proteins. When lens proteins are damaged, the result is cataract – a clouding of the lens – or presbyopia. This is where protective proteins come in. They ensure that the proteins of the eye retain their form even under adverse environmental influences.

PROTECTION AGAINST OXIDATION The typical function of protective proteins is to help other proteins maintain their form when stressed, by high temperatures, for example. This is why they are also referred to as chaperones. Alpha-A- and alpha-B-crystallin, too, have this function. In addition, human alphaA-crystallin has two cysteine residues. The sulphur atoms in these residues can form disulphide bridges. In-depth biochemical studies have shown that this bridging has a significant impact on various properties of the protein molecule. "A common theory is that the disulphide bridges result from damage to the protein, for example through oxygen," says Johannes Buchner. "Our results suggest that alphaA-crystallin might play an active role in protecting other proteins from oxidation."

www.cansa.org.za

CANSA SUPPORT GROUPS Cancer Survivors

(living with, living through and living beyond cancer),

you are NOT alone!

CANSA also invites Survivors who would like to encourage fellow Survivors in their own community, to start a local CANSA support group.

A Caring Community for those Affected by Cancer

All Survivors in South Africa should have the opportunity to join a caring, supportive community, where their needs can be addressed, and to improve their quality of life.

Join a caring community

Join your local CANSA Support Group

www.cansa.org.za/cancer-counselling/ #CANSASupportGroups #CANSACares

STRUCTURE OF A MULTIFACETED PROTEIN Attempts to determine the structure of alpha-A-crystallin were unsuccessful for over 40 years. The breakthrough came for a research team led by the TUM professors Sevil Weinkauf, professor of electron microscopy and Johannes Buchner, professor of biotechnology, by combining cryo-electron microscopy, mass spectrometry, NMR spectroscopy and molecular modelling. "Alpha-A-crystallin is extremely multifaceted," says Sevil Weinkauf. “This makes it very difficult to determine its structure. It was only after developing a new strategy for data analysis that we were able to demonstrate that in solution it takes on different structures with 12, 16 or 20 subunits”.

or join our Facebook community of survivors and caregivers: @CANSA Survivors - Champions of Hope @CANSA Caring for the Caregivers

MOTIVATION FOR FURTHER RESEARCH Oxidised alpha-A-crystallin can even transfer the existing disulphide bridge to other proteins. "This ability corresponds to that of a protein disulphide oxidase," says Christoph Kaiser. “Alpha-A-crystallin can influence the redox state of other lens proteins. This function also explains why roughly half of the alpha-A-crystallin’s in embryos already have such disulphide bridges.” “Around 35% of all cases of blindness can be attributed to cataracts, says Sevil Weinkauf. “The molecular understanding of the functions of eye lens proteins forms an essential basis for developing prevention and therapy strategies. The realisation that alpha-A-crystallin also plays an important role in protecting against oxidation will now spawn further research."

Source: Technical University of Munich Support-Groups-AD-297x210.indd 1

14 MAY 2020 | MEDICAL CHRONICLE

2019/06/11 2:58 PM

FREE content for CPD Medical Chronicle readers

For more information, please contact us: Editor: Conrad.Strydom@newmedia.co.za Sales: Chantal.Adlard@newmedia.co.za

IT’S AS EASY AS: • Visit www.medicalacademic.co.za • Click on CPD Portal • Fill out form

CLINICAL | OPHTHALMOLOGY

Rare eye diseases: A glance at Stargardt disease and keratoconus

In this article we take a look at two rare eye diseases. Stargardt disease is a genetic disorder of the retina that typically causes vision loss during childhood or adolescence. Keratoconus occurs when the cornea thins and gradually bulges outward into a cone shape. This may result in blurry vision, double vision, nearsightedness, astigmatism, and light sensitivity.

THE FIRST EVER clinical trial for a rare genetic eye disease - Stargardt Disease - has begun in South Africa. This condition affects the retina. In Stargardt Disease [STGD] a genetic mutation in the ABCA4 gene, causes the death of cells in the central retina - the cone photoreceptors, which are responsible for fine focus vison such as reading, writing, face recognition and using electronic screens. The condition affects one in 10 000 in the population and is found in all racial groups. It is most commonly inherited from unaffected parents who are unknowing carriers of a single faulty gene. There is a 25% chance in each pregnancy that the child will inherit a copy of the faulty gene from both parents. STGD is untreatable but this new clinical trial hopes to reverse the situation. The drug being tested blocks the accumulation of a toxic waste product called lipofuscin in the retina, caused by the gene mutation. The trial is being conducted in South Africa, by Dr Liesl van Der Merwe. The recruitment of patients for the trial was done by the Division of Genetics at the University of Cape Town, among patients who were part of the research programme aimed at identifying the genetic basis of Stargardt disease, (headed by Prof Raj Ramesar), and Retina South Africa. This is an international multi-centre study that could lead to a registered treatment within the next few years. South Africa is the leading trial site in the number of patients that finally fulfilled all the clinical and genetic criteria for inclusion in the trial. Retina South Africa is the only NPO in South Africa dedicated to finding treatments for genetic retinal vision loss. They have been approached by another international company to recruit patients for a second genetic retinal condition.

ERATOCONUS Keratoconus is an eye disorder characterised by progressive thinning and changes in the shape of the cornea. Slowly progressive thinning of the cornea causes a cone-shaped bulge to develop towards the centre of the cornea in the areas of greatest thinning. Affected individuals develop blurry or distorted vision, sensitivity to light (photophobia), and additional vision problems. Keratoconus often begins at puberty and most often is seen in teenagers or young adults. The specific underlying cause is not fully understood and most likely the condition results from the interaction of multiple factors including genetic and environmental ones. One factor known to contribute to progression of keratoconus is eye rubbing. In some cases, keratoconus may occur as part of a larger disorder. It is treated with glasses or contact lenses early in the condition. A small number of individuals may require surgery. SYMPTOMS Signs and symptoms of keratoconus may change as the disease progresses. They include:

16 MAY 2020 | MEDICAL CHRONICLE

• Blurred or distorted vision • Increased sensitivity to bright light and glare, which can cause problems with night driving • A need for frequent changes in glasses prescriptions • Sudden worsening or clouding of vision. CAUSES The specific underlying mechanism(s) responsible for keratoconus are not fully understood. Most cases appear to occur randomly and sporadically. However, a positive family history of keratoconus has been established in some cases. Most researchers believe that multiple, complex factors are required for the development of keratoconus including both genetic and environmental factors. According to the National Organization for Rare Disorders, researchers believe that some individuals who develop keratoconus have a genetic predisposition to developing the disorder. A person who is genetically predisposed to a disorder carries a gene (or genes) for the disorder, but the condition may not be expressed unless it is triggered or “activated” under certain circumstances such as due to particular environmental

factors. Research is underway to identify specific genes associated with keratoconus. Environmental risk factors that may play a role in the development of keratoconus include contact lens use, repeated eyerubbing, or atopy - hypersensitivity reactions such as allergic rhinitis, atopic dermatitis, sleep apnoea, or allergic asthma. Traditionally, keratoconus has been considered a non-inflammatory disorder. In inflammatory disorders, there is an abnormal immune (inflammatory) response, which can lead to symptoms or specific disorders. Although keratoconus has been defined as a non-inflammatory disorder, recent evidence, including abnormally high levels of proteolytic enzymes, an association with free radicals and oxidative stress, or the presence of cytokines, specialised proteins secreted from certain immune system cells that either stimulate or inhibit the function of other immune system cells. More research is necessary to determine the complex, underlying causes of keratoconus. The condition may also sometimes occur in association with certain underlying disorders, such as Down syndrome, sleep apnoea, asthma, Leber congenital amaurosis, and various connective tissue disorders including Ehlers-Danlos

syndrome, Marfan syndrome, or brittle cornea syndrome. A direct cause-and-effect relationship between these disorders and keratoconus has not been established. RISK FACTORS These factors can increase the chances of developing keratoconus: • Having a family history of keratoconus • Vigorous rubbing of eyes • Having certain conditions, such as retinitis pigmentosa, Down syndrome, EhlersDanlos syndrome, hay fever and asthma. COMPLICATIONS In some situations, the cornea may swell quickly and cause sudden reduced vision and scarring of the cornea. This is caused by a condition in which the inside lining of the cornea breaks down, allowing fluid to enter the cornea (hydrops). In advanced keratoconus, the cornea may become scarred, particularly where the cone forms. A scarred cornea causes worsening vision problems and may require corneal transplant surgery.

Sources: Retina SA, Mayo Clinic, National Organization for Rare Diseases, National Eye Institute.

Breast Cancer DID YOU KNOW? Breast cancer is the most common cancer W A R N I N G

S I G N S

A puckering of the skin of the breast.

A lump in the breast or armpit.

A change in the skin around the nipple or nipple discharge.

Dimpling of the nipple or nipple retraction.

An unusual increase or shrinkage in the size of one breast or recent asymmetry of the breasts

One breast unusually lower than the other. Nipples at different levels.

An enlargement of the glands.

An unusual swelling in the armpit.

MYTH vs FACT I am too young to get breast cancer Being overweight/obese doesnâ&#x20AC;&#x2122;t matter

Many women who are under 40 are diagnosed with breast cancer Overweight women have a higher risk of being diagnosed with breast cancer, especially after menopause

Alcohol is not linked to breast cancer

Alcohol use increases the risk of breast cancer

Only women with a family history of breast cancer are at risk

All women are at risk, but family history increases the risk

I have never had children, so I canâ&#x20AC;&#x2122;t get breast cancer

Women who have never had children, or only had them after 30, have increased risk of breast cancer

Toll Free 0800 22 66 22 | www.cansa.org.za

EARLY DETECTION IS KEY Do monthly breast self-examinations Go for regular screening (clinical breast examinations) at CANSA Care Centres Symptom-free women aged 40 to 54 should go for a mammogram every year (women & years and older should change to every 2 years) CANSA has Mobile Health Clinics that do screening in communities Did you know? CANSA offers a variety of BREAST PROSTHESIS at our Care Centres, for those who had to undergo a mastectomy/lumpectomy

ETHICS

Covid-19:

Dealing with end of life issues By Dr Beth Walker and Dr Volker Hitzeroth, Medicolegal Consultants at Medical Protection Society

OUTH AFRICA IS a vast and diverse country with eleven official languages and many different cultures. Medical care is often provided in distant and unfamiliar surroundings, far from a patient’s home and away from the comfort of their loved ones. It is therefore, at times, a challenge to have direct contact with a patient’s family and relatives. The current Covid-19 lockdown and associated isolation measures have added to this difficulty as doctors may also have to face the challenge of breaking bad news to patients’ loved ones remotely over the telephone, rather than face-to-face. BREAKING BAD NEWS Before telephoning, ensure you are adequately prepared and well informed of the relevant clinical facts. Ideally, call from a quiet setting where you will not be disturbed. When communicating via telephone, you should identify the person you are calling and confirm their name and relationship to the patient, as well as the name of the deceased patient. Clarify whether the relative is prepared to have the conversation at this time; are they somewhere they can talk, and do they wish to have someone else with them. If you require the use of a translator, ensure that this is arranged timeously. It is best to introduce a translator to the relative at the beginning of the conversation, clarify their purpose and be aware that translated conversations may take substantially longer and create many opportunities for miscommunication and misunderstandings. Speak clearly, introduce yourself and your role. Begin by exploring what the relative knows about the situation so far. This allows you to gauge their understanding and concerns. Before conveying bad news, try to prepare the relative in a compassionate manner, for example, ‘I’m sorry, I have some serious news to discuss with you’. The tone of your voice becomes even more important when you are unable to use non-verbal communication and have to relay sensitive and complex medical information using a translator. Give the news simply and

18 MAY 2020 | MEDICAL CHRONICLE

honestly with empathy, using silence to allow the relative to react to, and process, each part of your discussion. Avoid using medical jargon or ambiguous terms. If appropriate, you may want to occasionally check that the relative is following the conversation or has any questions. If they are distressed, acknowledge this sensitively and give time and support before carrying on. Before closing the conversation, check whether the relative has any further questions and summarise what they may expect to happen next. Document your conversation clearly in the medical records and try to take a moment for yourself after these discussions; you may also wish to debrief with a colleague. There is no single ‘right’ way to do this; you can only do your best from a place of kindness. GRIEVING FAMILY MEMBERS One of the most distressing aspects of Covid-19 is that, in many cases, family members may be unable to spend time with dying loved ones in hospital or be with them when they take their last breaths. The lockdown, social distancing and selfisolation measures have also significantly altered the usual processes of expressing grief and mourning, including funeral arrangements. This disruption to the usual coping strategies and access to support networks after bereavement, may make grief more intense or harder to process. There are avenues to consider for support. Spiritual care, a key element of palliative care, may provide emotional and spiritual support to patients and loved ones. Relatives can also be signposted to information and support available from appropriate charities. These include the South African Depression and Anxiety Group (SADAG) and Khululeka Grief Support for child and teen grief and bereavement support. SADAG can be contacted on 0800 567 567 or 0800 456 789. Khululeka can be contacted by email at prog.manager@ khululeka.org to make an appointment. The distress that may be experienced by healthcare professionals witnessing

patients dying without family present, and the grief of their loved ones as a result, also cannot be underestimated. Supporting doctors’ psychological wellbeing has never been more important. The MPS Counselling service is available to all its members. Please contact MPS if you would like to access this. Alternatively, many professional societies may have access to further information and help. Similarly, SAMA and SADA may be able to advise or assist. DEATH NOTIFICATION In the current South African context, the provision of a death certificate, as well as funeral and mortuary services are declared an essential service. In the case of deaths from COVID-19, there is a reporting duty to the authorities as is the case with all communicable diseases. In addition, on 8 April 2020 the Minister of Health issued new directions regarding the handling and disposal of the mortal remains of COVID-19 sufferers. All municipalities must identify suitably authorised mortuaries with valid certificates of competence to accommodate COVID-19 patient mortal remains. The stipulations contained in the 2013 ‘Human Remains Regulations’ must also be adhered to . These relate to protective gear and safety measures. The laws and associated regulations governing the notification of a death are: 1. The Births and Deaths Registration Act 51 of 1992 2. The Inquest Act 58 of 1959 3. The National Health Act 61 of 2003. After a patient’s demise, it is a doctor’s duty to: 1. Pronounce the death 2. Report the cause of death 3. State whether the patient died of a natural or unnatural cause. In order to confirm a patient’s death, establish the cause of death and exclude unnatural causes; it is expected that a doctor considers the patient’s history, any appropriate collateral information,

completes an examination of the body, reviews the results of special investigations and peruses any other relevant records. It is always good practice to physically examine the patient’s body prior to pronouncing the death. On rare occasions, this may not be possible. In such a scenario the doctor may pronounce the patient’s death without examining the patient’s body if there existed a prior therapeutic relationship and the doctor is familiar with the patient’s health status and illness profile. However, it is mandatory to always examine a patient’s body if the deceased is not a known patient of the doctor concerned and has not been treated by them in the past, ie if there was no prior therapeutic relationship. If the doctor believes that the patient died of a natural cause they may issue a certificate. On the other hand, if the doctor believes that the patient died of an unnatural cause the doctor may not issue a certificate and must inform a police officer. Unnatural causes of death include: 1. Any death due to a physical or chemical influence, direct or indirect, and/or related complications 2. Any procedure or anesthetic related death 3. Any death, that in the opinion of the doctor, has been the result of an act of commission or omission, which may be criminal in nature 4. Any death that is sudden or unexpected, or unexplained or where the cause of death is not apparent. Please note that it is a criminal offence to submit false information to the authorities. DIRECTIONS ISSUED IN TERMS OF REGULATION 10(1)(a) OF THE REGULATIONS MADE UNDER SECTION 27(2) OF THE DISASTER MANAGEMENT ACT, 2002 (ACT No.57 OF 2002): MEASURES TO ADDRESS, PREVENT AND COMBAT THE SPREAD OF COVID -19, Para 7(1)- 8(5) https://www.gov.za/ documents/disaster-management-act-directionsmeasures-address-prevent-and-combat-spreadcovid-19-8 https://www.gov.za/documents/birthsand-deaths-registration-act https://www.gov.za/ documents/inquests-act-3-jul-1959-0000 https:// www.gov.za/documents/national-health-act

CLINICAL | DIABETES

Does size matter?

Insulin pens are growing in popularity, and many people with diabetes nowadays use a pen to administer insulin. The pens allow more simple, accurate and convenient delivery than using a vial and syringe.

OT EVERY PERSON with diabetes will need to take insulin. However, those that do sometimes find that sticking to an insulin schedule can be demanding, disruptive and draining.Some people prefer insulin pens as a way to make taking insulin less intrusive and inconvenient. In this article, we look at the types of insulin pens, how to use them, and the benefits and disadvantages of choosing an insulin pen over a vial and syringe. TYPES Different brands and models of insulin pen are available. Most fall into two distinct categories: disposable and reusable. • A disposable pen: This contains a prefilled insulin cartridge. Once used, the entire pen unit is thrown away • A reusable pen: This contains a replaceable insulin cartridge. Once empty, a person discards the cartridge and installs a new one. A person must replace the disposable needle after each injection of insulin. With proper care, reusable insulin pens can last for several years. CHOOSING AN INSULIN PEN There are several factors to consider when choosing an insulin pen. Choosing a brand, model, and category of pen will depend on several factors. Discuss this with a doctor

20 MAY 2020 | MEDICAL CHRONICLE

before making any purchase. Some general considerations about the pen include: • The type and brand of insulin available • The size of insulin dose it can hold • The increments by which a person can increase the dose of insulin • Material and durability, if choosing a reusable pen • How it indicates remaining insulin levels • Ability to correct dose levels that are put in wrong • Size of the numbers on the dose dial • Level of dexterity required to use the pen. Needle length and thickness are other considerations for choosing an insulin delivery product. Manufacturers measure the thickness of a needle using ‘gauge’. A gauge of 33 is thicker than a gauge of 22. Thicker gauges might cause more pain but also deliver insulin more quickly. Needles can be between four and 12.7 millimetres (mm) in length. A shorter needle might reduce the risk of accidentally injecting insulin into the muscle instead of the fat just under the skin, or subcutaneous fat. WHAT NEEDLES SHOULD BE USED FOR INJECTING INSULIN? Needles come with a different diameter and length. Those with a higher gauge number have a smaller needle diameter. Needles are available in 4-, 5-, 6- or 8mm. Needles with

a length of 12.7mm have an increased risk of intramuscular injection. It is often assumed that a heavier person, with a higher BMI, may require a longer needle. However, we now know that 4-, 5- or 6mm needles are suitable for all people with diabetes, regardless of their BMI. Studies have shown that shorter needles of 4mm are as safe and welltolerated in comparison to longer ones. Insulin therapy should ideally be started using shorter length needles and these injections should be given at 90 degrees to the surface of the skin. ADVANTAGES Insulin pens might also help people stick to their insulin therapy routine. Advantages include: • Ease of use, particularly for older adults and children • The ability of a person with diabetes to fine-tune and deliver highly accurate doses using an insulin pen • The portable, discreet and convenient nature of the pens • Small and thin needle sizes that reduce fear and pain • The ability to accurately pre-set doses using a dial • Time-saving benefits, due to prefilled and pre-set insulin levels • Memory features that recall the timing and amount of the previous dose

• A range of accessories to allow for easier storage and use. The ADA advises doctors to prescribe an insulin pen for people who have issues with finger dexterity problems and reduced vision. An insulin pen can support a more accurate dose of insulin than a vial and syringe. ‘Smart’ pens also exist that can calculate appropriate doses of insulin and provide a report on insulin usage for the user to download. SUMMARY While insulin pens might be more expensive than a vial and syringe, they are more convenient, less painful, and easily storable and transportable. They essentially combine the vial and syringe, allowing greater dose accuracy and easier administration of doses. Be sure to closely follow the instructions on the packaging and store insulin in a cool dry place once open. Insulin alone can help manage diabetes but maintaining a balanced diet and exercise regimen alongside any prescribed medications is an effective route to controlling blood sugar. Sources: Diabetes South Africa, Healthline.com

*The article is in no way linked to any advertising around it.

NO-ONE SHOULD DIE BECAUSE THERE IS NO MATCH

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CLINICAL | CARDIAC

Controlling hypertension during the COVID-19 pandemic

How should clinicians navigate clinical uncertainty for patients who are taking angiotensinconverting-enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs)?

susceptibility to coronavirus already have asked whether to continue taking their prescribed ACE inhibitors and ARBs, and patients who test positive for the virus will

likely have the same concern. Experts have postulated both potentially harmful and potentially beneficial effects of these drugs on the natural history of DDB SA 45388

ANY PATIENTS AND clinicians are aware of the relationship between COVID-19 and the renin-angiotensin system. Patients concerned about

It’s not just blood. It’s saving a nation.

COVID-19. Membrane-bound angiotensinconverting enzyme 2 (ACE2) participates in the entry of SARS-CoV-2 into human cells. Conversely, some researchers speculate that ACE inhibitors and ARBs could benefit patients with COVID-19 through various mechanisms. For example, ACE2 converts angiotensin II to angiotensin-(1–7), which has potentially beneficial vasodilatory and anti-inflammatory properties, upregulating ACE2 (with ACE inhibitors or ARBs) could enhance this process. Observational studies have not yielded compelling data on whether COVID-19 patients who take these drugs fare better or worse than otherwise similar patients. Professional societies have navigated this uncertainty by recommending that patients receiving ACE inhibitors and ARBs should continue taking them. For example, a statement from the American College of Cardiology and American Heart Association (ACC/AHA) notes that, “There are no experimental or clinical data demonstrating beneficial or adverse outcomes with background use of ACE inhibitors [or] ARBs.” The statement recommends continuing these drugs if they are being prescribed for valid cardiovascular indications and advises clinicians not to add or remove them, “Beyond actions based on standard clinical practice.” The ACC/AHA statement provides a good starting point when patients inquire about continuing or stopping ACE inhibitors and ARBs; discussing it with patients often will settle the issue. Nevertheless, some patients might not be reassured by impersonal recommendations from professional societies and will still ask their clinicians “so what do you advise?” A sensible position for overworked and stressed clinicians facing a global pandemic is to recognise that, for now, the effect of ACE inhibitors and ARBs on the natural history of COVID-19 is unknown. Clinicians should attempt to make decisions that will minimise future regret for themselves and for their patients if the decision eventually is proven ‘wrong’. REFERENCES Allan S. Brett, MD and David M. Rind, MD reviewing Patel AB and Verma A. JAMA 2020 Mar 24 Gurwitz D. Drug Dev Res 2020 Mar 4 American College of Cardiology. 2020 Mar 17.

Donate blood. Your blood saves lives.

22 MAY 2020 | MEDICAL CHRONICLE

Patel AB and Verma A. COVID-19 and angiotensinconverting enzyme inhibitors and angiotensin receptor blockers: What is the evidence? JAMA 2020 Mar 24; [e-pub]. (https://doi.org/10.1001/jama.2020.4812).

You are invited Medical Chronicle

OBESITY WEBINAR In partnership with

CCRPEDDITED

Join Medical Chronicle and Dr Gary Hudson as he presents a free CPD-accredited 1-hour webinar with new insights on obesity especially with the dual pandemic of obesity and COVID-19

Date: Thursday, 4 June 2020

Time: 19h00 Topic: Obesus Novus: Pandemic on epidemic Dr G M Hudson is a Specialist Physician with a special interest in Immunity and Metabolism. He graduated MBBCh (magna cum laude) 1987 from the University of Witwatersrand. An internship followed at Hillbrow hospital. He was placed onto the Johannesburg registrar circuit in 1989. Completed MMed exam 1993. He initiated the immune and rheumatology clinics at the then JG Strydom/ Coronation hospital as a consultant. He is a founding member of the HIV Clinicians society. In 2003 he completed FCP(SA). He is a senior lecturer for the FPD. He practiced as a private practitioner in Johannesburg North for many years and relocated to Bettyâ&#x20AC;&#x2122;s Bay where he now practices. He is a guest lecturer for numerous pharmaceutical companies with related topics metabolic syndromes, obesity, thyroid disease, immune diseases.

Online Registration: https://bit.ly/mc-obesity-webinar

MEDICAL CHRONICLE | MAY 2020 23

CLINICAL | SMOKING CESSATION

It is never too early or too late to stop smoking

Prof James Ker

ERADICATE TOBACCO TO PROTECT HUMAN RIGHTS TO HEALTH

Cardiovascular disease remains the leading cause globally for premature mortality and morbidity.

HERE ARE A number of well-known cardiovascular risk factors including hypertension, dyslipidaemia, elevated blood glucose, lack of physical exercise, obesity (especially central obesity) and poor diet. A major modifiable cardiovascular risk factor is smoking. The known effects of smoking on cardiovascular disease and the reports about the effect of smoking is mainly based on investigations of coronary artery disease. It is however, recognised that smoking is a particular strong risk factor for peripheral arterial disease (PAD). Despite this recognition there are relatively few studies done prospectively comparing PAD and coronary heart disease (CHD) as complications of current smoking status. The objective of this study was to quantify the long-term association of cigarette smoking and its cessation with the incidence of the three major atherosclerotic diseases namely coronary heart disease, cerebrovascular disease and peripheral artery disease.1 This study used data from the ARIC study (Atherosclerosis Risk in Communities) and patients were followed up for nearly 30 years. A total of 13 355 people aged between 45 and 64 years of age were examined between 1987 and 1989 and then followed up for a median period of 26 years. A comprehensive surveillance of hospitalisations and deaths from coronary heart disease, cerebrovascular disease and peripheral artery disease were conducted by the authors. In this period of 26 years there were 492 cases of PAD, 1798 CHD cases and 1106 cases of stroke. The findings overall confirmed that smoking is a major cardiovascular risk factor increasing substantially the risk of developing all three atherosclerotic outcomes. The increased risk was consistent for both the duration of smoking and the intensity of smoking (number of cigarettes smoked per day).

24 MAY 2020 | MEDICAL CHRONICLE

After adjustment for other risk factors, smoking risk had a hazard ratio of 5.36 for PAD, Hazard Ratio 2.37 for heart attack and Hazard Ratio 1.92 for stroke. Thus, there were a much higher risk of PAD than the two other atherosclerotic outcomes. After smoking cessation, the reduction of risk for all atherosclerotic outcomes of all three vascular beds were within five years but to reach such a low risk as those of never-smokers took a much longer time. The reduction of the risk of PAD was also higher than for any of the two other atherosclerotic outcomes. After quitting, more time was needed for the risk of PAD to reach the level of risk of a never-smoker (more than 30 years was necessary) as compared to about 20 years for the risk of coronary heart disease to reach the level of CHD risk of a never-smoker. The findings of this study are also consistent with the hypothesis that traditional cardiovascular risk factors have distinct effects on different arterial beds suggesting that atherosclerosis is not a homogenous process.2 The composition of atherosclerotic plaques also differ between the different vascular beds with the femoral artery having more fibrosis and the coronary and cerebral arteries more lipid and more inflammatory cells. CONCLUSION 1. Smoking is significantly associated with a substantial increased risk of atherosclerotic disease events in all three vascular beds: coronary, cerebral and peripheral. 2. Smoking cessation is associated with significant reduction in the risk of atherosclerotic disease events. 3. It is never too late to stop smoking because of the relative rapid reduction of cardiovascular events (within five years). 4. It is never too early to stop smoking because it takes several decades to reach the risk level of a never-smoker (20-30 years).

Savera Kalideen, Executive Director of the National Council Against Smoking (NCAS), on behalf of NCAS, The Heart and Stroke Foundation, CANSA. In the grip of the COVID-19 pandemic, we are seeing governments all over the world, including our own, act to protect public health. We are in full support of this action to protect public health. There are other epidemics that we live with every day. Tobacco harm is one of them, causing 115 deaths each day in South Africa. We call for bold action on tobacco control, as the protection of public health through tobacco control is inextricably linked with human rights to life, health and a healthy environment. This Human Rights month, we call on our leaders to recognise that halting the spread of the tobacco epidemic is an obligation as South Africa is a signatory to the World Health Organisation Framework Convention on Tobacco Control (FCTC). Passing South Africa’s Control of Tobacco and Electronic Delivery Systems Bill, for which the public consultation ended more than 18 months ago, would be a good step in the direction of the ‘right to health’. PROTECTING CHILDREN FROM SECOND-HAND SMOKE Exposure to second-hand smoke, particularly for children, leads to middle ear infections, respiratory diseases including asthma, the worsening of serious conditions such as cystic fibrosis and asthma, and in some cases, death. The dangers posed by second-hand smoke violate the rights of non-smokers and children, affecting their rights to life, health and a clean and safe environment. The Bill requires that any enclosed public area is 100% smoke-free and will make certain outdoor public places smoke-free too. It removes the current requirement to provide for smoking areas in all enclosed public places, workplaces and on public conveyances and applies the 100% smoking ban to common areas of multi-unit residences. It further bans smoking in private dwellings used for commercial childcare/ education and in cars carrying children under 18. People caught smoking or vaping or using e-cigarettes in no-smoking zones could face a hefty fine and/or up to three months in prison. PROTECTION FROM ACTIVE SMOKING AND ADDICTION Human rights principles also justify protecting individuals from the harms of smoking and nicotine addiction. We have a right to enjoy the highest attainable standard of physical and mental health, including the prevention, treatment and control of epidemic, endemic, occupational and other diseases. Tobacco products are the only legally available consumer products that kill over 50% of users when used exactly as intended. Many adolescents are tempted into experimentation with cigarette smoking, and now e-cigarettes, at a fragile time when they can’t fully grasp the addictive grip of nicotine and the health impacts, they will later experience. The body of research showing the health harm arising from e-cigarette use, which are popular among young people, continues to expand. The Bill introduces uniform plain packaging for all brands and pictorial warnings on all packages. The Bill bans cigarette advertising at tills, removing the loopholes in existing provisions for advertising displayed at points of sale. It further bans the sale of cigarettes through vending machines. Current tobacco control legislation predates the introduction of e-cigarettes and needs to be urgently updated to include the regulation of e-cigarettes. The Bill does include regulation of e-cigarettes and when passed, e-cigarettes will finally fall under the same regulations as cigarettes. REFERENCES 1. Ding N, Sang Y, Chen J et.al. Cigarette smoking, smoking cessation and long-term risk of 3 major atherosclerotic diseases. J Am Coll Cardiol 2019; 74(4):498-507. 2. Rigotti NA, McDermott MM. Smoking cessation and cardiovascular disease: It’s never too early or too late for action. Editorial comment J Am Coll Cardiol 2019;74:508-511.

A unit of blood is drawn from a volunteer donor.

Blood is transfused to patient in need. Just one blood donation has the potential to save three lives.

Blood products are stored prior to transfusion. The shelf life of blood is limited. Platelets expire in 5 days. Red blood cells expire in 42 days. Plasma has a 1 year shelf life from the day of collection. Blood is collected into a sterile bag and labelled.

Local hospitals place orders with SANBS for blood products based on their needs.

Units are transported to the nearest SANBS testing and processing lab.

Your blood saves lives.

Blood is tested to ensure that it is safe for transfusion.

In the processing laboratory, blood is spun down in a centrifuge and then separated into its different components.

Plasma Contains proteins and clotting factors used to treat patients with massive bleeding or clotting factor deficiencies.

Red blood cells Contain haemoglobin, a protein that carries oxygen throughout the body. Used to treat patients with anaemia or blood loss due to trauma or surgery.

Platelets Crucial in helping blood clots. Patients with low platelet levels often suffer from bruising and bleeding.

CPD | DIABETES

*Supplied content

Practical Guidance on the Use of Premix Insulin Analogs in Initiating, Intensifying, or Switching

Insulin Regimens in Type 2 Diabetes

Ted Wu, Bryan Betty, Michelle Downie, Manish Khanolkar, Gary Kilov, Brandon Orr-Walker, Gordon Senator, Greg Fulcher. Diabetes Ther 2015;15:6:273-287.

Premix insulin analogues are a well-established treatment for type 2 diabetes (T2D). However, there is a lack of simple, clear guidance on some aspects of their use. A number of overarching criteria need to be taken into consideration. These include the need to target both fasting plasma glucose (FPG) and postprandial glucose (PPG) to achieve optimal glycaemic control; the importance of individualising therapy; and the need to intensify the insulin regimen to compensate for the progressive nature of diabetes. The panel’s objective was to formulate guidance on how to undertake: initiating therapy with premix insulin analogues; recognising when patients need intensification of their insulin therapy; and switching from basal – bolus to premix insulin analogue therapy when appropriate.

ETHODS: An independent expert panel formulated recommendations on the use in T2D of the premix insulin analogue formulations, based on the available evidence and their own experience. The panel chose to focus on the premix insulin analogue formulations : biphasic insulin aspart and biphasic insulin lispro. The guidance in this statement covers T2D only and does not include type 1 diabetes or other forms of diabetes. RESULTS: Glycaemic targets that are suggested for most patients, are with the understanding that individualisation of targets is imperative. Choosing an appropriate insulin type and regimen should also be based on specific patient attributes, and many guidelines now recognise both basal and premix insulin as options for initiating/ intensifying insulin therapy in T2D. Unlike basal insulin, premix insulin targets both FPG and PPG, which is essential for addressing postprandial hyperglycaemia and

achieving optimal glycaemic control. EVIDENCE BASE FOR PREMIX INSULIN ANALOGUES IN INITIATION, INTENSIFICATION, AND SWITCHING Initiation of Insulin: Premix Insulin Analogues vs Basal Analogues The efficacy and good safety profiles of BIAsp 30 and lispro mix 25 in the initiation and intensification of insulin therapy have been reviewed. Systematic reviews of the available evidence suggest that treatment with premix insulin analogues as first-line insulin therapy results in significantly better overall glycaemic control, but slightly greater risk of hypoglycaemia and weight gain, compared with basal insulin. Intensification of Insulin: Premix Insulin Analogues vs Basal-Plus or Basal–Bolus Regimens A meta-analysis published in 2011 compared premix insulin analogues with basal–bolus therapy based on three trials. The authors concluded that patients treated with a basal-bolus regimen had a higher

chance of reaching their HbA1c goal, with no difference in incidence of hypoglycaemia or weight gain between the two regimens. These results have to be interpreted cautiously, as the trial populations included insulin-naive patients as well as patients already receiving basal insulin at the start of the treatment periods. Switching from Basal–Bolus to Premix Therapy While basal-bolus therapy is considered the ‘gold standard’ for patients with advanced T2D, two groups of patients may need to switch to premix insulin analogues either BID or TID. These are patients who are unable or unwilling to cope with the complexity of a basal-bolus regimen, and patients who commence treatment with basal-bolus therapy in hospital and no longer require such an intensive regimen following discharge. There is minimal published evidence on how to make this switch. Some evidence shows that selected patients inadequately controlled on a basal-bolus regimen can

CONSIDERATIONS AT INITIATION FAVOURS PREMIX FAVOURS BASAL > 3 mmol/L

What is the postprandial increment?

< 1 mmol/L

Is the patient likely to manage basal-bolus therapy when intensification is needed?

Yes

Is there a large carbohydrate intake at one or two meals?

Yes Is the patient’s lifestyle predictable (e.g., eating pattern, working hours)?

Prefers fewer injections Patient preference regarding number of injections Comfortable with more frequent injections Prefers less frequent Patient preference regarding self monitoring of blood Comfortable with more frequent glucose monitoring Poor Patient ability to inject (e.g., cognitive ability, manual dexterity, need for carer) Good 26 MAY 2020 | MEDICAL CHRONICLE

benefit by switching to a premix insulin analogue. The improved results may have arisen from better therapy adherence due to the simpler regimen with BIAsp 30. Conclusions from the Available Evidence The results from the trials in both initiation and intensification of insulin show that, in general, a better HbA1c reduction was accompanied by a higher rate of hypoglycaemia, and both arms were accompanied by weight gain. No single insulin or regimen was best on all endpoints. It is clear that improved glycaemic control can be expected, irrespective of which regimen is used. Individual patient factors and preferences become more important, and the focus must be on selecting the regimen that is best for the particular patient - including any features likely to aid adherence. One study showed that the main predictor of adherence was patients’ ratings of the burden of therapy, and that the patients’ perceived burden of therapy increased as the number of injections increase. RECOMMENDATIONS Initiating Insulin Therapy with Premix Insulin Analogues in Primary Care Patient factors to consider when deciding whether to use premix insulin analogue or basal insulin for initiation. CONCLUSIONS This guidance is intended to help both general and specialist practitioners make informed choices and provide optimal care for patients with T2D. It emphasises the importance of taking into account individual patient This is a CPD-accredited article, to do the questionnaire and earn points go to www.medicalacademic.co.za

CPD | DIABETES CHOOSING THE MOST APPROPRIATE INSULIN REGIMEN FOR THE PATIENT Dosing Titration and Monitoring Box 1: Dosing/titration guidelines for initiating insulin with premix insulin analogs OD (based on consensus) • When choosing an insulin dose, and for dose titration, err on the side of safety and convenience. • I nitiate with premix insulin analog OD, immediately before or soon after the start of the meal with the highest prandial load (usually the evening meal). • Initiate with a dose of 10 - 12 units and titrate. Dose adjustment Lowest premeal blood glucose level

Adjustment for the next dose

≥ 7.0 mmol/L 4.1 - 6.9 mmol/L ≤ 4.0 mmol/L

+ 2 units 0 units - 2 units Sadad_ad.pdf

factors and preferences so that the choice of insulin regimen is individualised to the patient in the same way that glycaemic targets are now individualised.

2014/05/22

Box 4: Titration algorithm for switching from basal–bolus to premix insulin analog (based on consensus) •G eneral guidance: as always, titration must be tailored to the individual patient. •T hese guidelines do not override clinical judgment and knowledge. •R educe total daily dose of all insulin by 20 - 30 %. •T hen split this value 50/50 to give you the starting dose of premix insulin analog at breakfast and evening meal. •U nusual meal patterns may lead you to reconsider the initial dose ratio. •T itrate the dose preferably once or twice a week (see ‘‘Box 1’’). Adjust the evening meal dose first, followed by the breakfast dose. • Safety is key: go slowly.

12:41 PM

Adapted from Wu T, et al. Box 2: Use of other glucose-lowering drugs (based on consensus) • All combination use is subject to local registration rules. • Metformin should always be continued unless it is poorly tolerated or contraindicated (e.g., patient with renal dysfunction). • Consider maintaining sulfonylureas with once-daily premix insulin. However, they should not be given at the same time of day as the premix insulin dose. Discontinue sulfonylureas once patients intensify to twice-daily premix insulin. • Dipeptidyl peptidase-4 inhibitors/ sodium-glucose cotransporter-2 inhibitors/alphaglucosidase inhibitors can be continued together with insulin. • Thiazolidinediones: combining these agents with insulin may exacerbate oedema. • Glucagon-like peptide-1 agonists may be insulin sparing and can be used. • Consider lowering the dose of the noninsulin drug, other than metformin, at insulin initiation.

CMY

Box 3: Practical guidance for switching from basal insulin [once daily (OD) or twice daily (BID)], or from premix insulin analog OD, to premix insulin analog BID (based on consensus). • From basal: 1:1 total dose switch to premix insulin analog. Split the dose 50/50 breakfast and dinner. • From premix insulin analog OD: split the OD dose 50/50 breakfast and dinner. • Administer premix insulin analog immediately before or soon after the start of a meal. • Titrate the dose preferably once or twice a week (see ‘‘Box 1’’). • Adjust the evening meal dose first, followed by the breakfast dose.

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MEDICAL CHRONICLE | MAY 2020 27

CLINICAL | RESPIRATORY

COVID-19 pneumonia Procalcitonin for risk assessment

The biomarker Procalcitonin (PCT) is widely used to assess the risk of bacterial infection and progression to severe sepsis and septic shock in conjunction with other laboratory findings and clinical assessment. Further, the change of PCT over time is used to determine the mortality risk. *Content supplied

N PATIENTS WITH suspected or confirmed lower respiratory tract infections (LRTI), including community-acquired pneumonia (CAP),

acute bronchitis and acute exacerbations of COPD (AECOPD), PCT is an aid in decision making on antibiotic therapy for inpatients or patients in the emergency department

(ED). Procalcitonin has now been shown to be also a valuable tool in the current COVID-19 pandemic to early identify patients at low risk for bacterial coinfection

NO-ONE SHOULD DIE BECAUSE THERE IS NO MATCH

and adverse outcome. New analysis of 1099 COVID-19 patient data sets from a range of medical centres in China2 show that PCT was low (<0.5μg/L) in > 96% of cases with low disease severity and absence of adverse outcome (combined endpoint of ICU admission, invasive ventilation, death). Most of COVID-19 patients even had PCT values below 0.25μg/L or even below 0.1μg/L. This confirms findings from previous viral epidemics (influenza H1N1, SARS, MERS) that PCT is usually low (<0.1 - <0.5μg/L) in hospitalised patients with pure viral infection.8 9 10 11 12 13 In case of bacterial coinfection and higher severity of disease PCT has been found >0.5μg/L. Thus, according to a recent meta-analysis of published COVID-19 patient data, PCT >0.5μg/L corresponds to an almost five times higher risk of severe infection (OR, 4.76; 95% CI, 2.74-8.29) compared to patients with lower PCT14. Acute Respiratory Distress Syndrome (ARDS) and septic shock were most frequent complications of COVID-19; secondary infections during hospital stay were an additional risk factor. Death was in almost all patients associated with sepsis/septic shock and respiratory failure/ARDS. PCT ON ADMISSION Test PCT as an aid for early risk assessment and prioritisation of high-risk patients: <0.5 μg/L* - low risk for bacterial coinfection and adverse outcome >0.5 μg/L - high risk patients, bacterial coinfection likely. PCT DURING HOSPITAL STAY Monitor PCT to detect secondary infections and progression of disease. * The Majority of patients with mild disease had PCT values <0.25μg/L or even <0.1μg/L. The likelihood of bacterial infection and recommendation to start antibiotics in patients with LRTI at PCT >0.25μg/L. TAKE HOME MESSAGE: PCT testing on admission seems to be a valuable additional piece of information for early risk assessment and rule-out of bacterial coinfection in COVID-19 patients. Monitoring of PCT was recommended to identify secondary infections and progression to more severe disease state like sepsis / septic shock.

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References available on request.

ONLINE CPD

How can health workers manage their mental health during COVID-19?

This is a summary of a longer, CPD accredited article available on www.medicalacademic.co.za

While the rest of the country deals with the challenges of lockdown, healthcare providers are dealing with their own burdens.

ADAG RECENTLY ADDRESSED the topic of how health workers can manage their mental health during COVID-19, with the advice of Zamo Mbele, clinical psychologist at Tara hospital and Wits Donald Gordon.

If you feel overwhelmed, know that there are ways to get support. Talk to your colleagues, your manager, or someone else that you trust about how you are feeling.

You are not alone in this situation – your colleagues are likely to be experiencing similar things to you, and you can support each other. Be compassionate to yourself

and others. It is OK to say you are not OK. References available on request.

WHAT ARE WE DEALING WITH? According to Mbele, there are many issues that healthcare workers are currently dealing with, including PPE issues, shifts that will keep everyone safe, and not knowing how to continue to deliver their service and still keep themselves and their families safe. “Many HCWs are also in a state of anticipatory anxiety, not know what is to come and how they will manage though being aware of something looming,” he added. WHAT CAN HCWS DO? Talk to your colleagues, your manager, or someone else that you trust about how you are feeling. You are not alone in this situation – your colleagues are likely to be experiencing similar things to you, and you can support each other. It is OK to say you are not OK. Remember this is a marathon, not a sprint. Even though this is a marathon, it will not last forever and the epidemic will end. WHAT HELP IS AVAILABLE? Mental Health Care for COVID-19 Health Care Workers (covidcaregauteng.co.za) is a group of volunteer mental health professionals offering a dedicated mental health service to clinical and administrative managers, unit heads, and clinical team leaders in Gauteng hospitals and clinics. According to the group, there are things that you can do to help you take care of yourself. Give yourself permission to take regular breaks during your shifts. It is important to try to eat, drink and sleep properly. Try to think about and use strategies that have helped you in the past to cope with stressful situations. Make sure that you try to take some time out between shifts, slow down and bring levels of arousal back to normal. It is being responsible, not selfish, to look after yourself. Stay in touch with your friends and family – even if you can’t see them in person, you can have video and phone calls. Engage in physical activity. Maintain a routine as much as you can. Plan regular activities that help you feel good. Avoid using unhelpful coping strategies like smoking, alcohol or other drugs. Try to limit the time you spend watching, reading or listening to the news. Spend time deliberately engaging with tasks that take your mind away from the current crisis.

NO-ONE SHOULD DIE BECAUSE THERE IS NO MATCH

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CLINICAL | RHEUMATOLOGY

Gout vs OA Clash of the arthritic titans Although osteoarthritis and gout often occur together, there’s a ‘chicken or the egg‘ scenario. Osteoarthritis (OA) joint damage might create the right conditions for uric acid crystals to deposit. Or the crystals might cause inflammation, making joints more susceptible to cartilage breakdown typical of OA.

OUT RESULTS FROM deposits of needle-like crystals of uric acid in connective tissue, joint spaces or both. These deposits lead to inflammatory arthritis, causing swelling, redness, heat, pain and stiffness in the joints. On the other hand, OA is not an autoimmune disease. It is a condition of wear and tear associated with ageing or injury. The immune system is not affected. Both gout and OA are common forms of arthritis that inflict a huge burden to an ageing population with the increasing prevalence of obesity. Clinicians have long observed the link between these two conditions. The recent new understanding on monosodium uric acid crystal-induced inflammation has given insight into probable shared pathogenesis pathways for both conditions. SYMPTOMS Being overweight is a common risk factor for both conditions. OA stiffness tends to get worse with use throughout the day whereas stiffness due to gout is present only at the time of the attack. OA is associated with asymmetrical (not ‘matching’) swelling in individual joints that are not part of a pair — eg, one knee and an elbow, instead of both knees whereas Gout either involves a single joint or involves the joints in an asymmetric pattern. Generally, OA symptoms include joint stiffness, pain and enlarged joints and it does not have any systemic symptoms. Gout patients suddenly experiences a hot, red, swollen joint, caused by the formation of uric acid crystals between the joints. The attack often occurs at night and in a single joint, with the pain becoming more severe. Chills and a mild fever along with a general feeling of malaise may also accompany the severe pain and inflammation. In gout, although the pain and swelling disappear with treatment, it almost always returns in the same joint or in another one. Whereas OA is a continuous and progressive disease with no remissions. LOCATION OF JOINTS INVOLVED With OA, inflammation generally occurs at the joint closest to your fingernail. On the other hand, gout usually affects the joints in the big toe. Some other parts that could get affected by gout are ankle, heel, knee, wrist, fingers, elbow, etc. PREVALENCE Gout is the most common crystal arthritis and its prevalence is rising in South Africa. Men, particularly those between the ages of 40 and 50, are more likely to develop gout than women, who rarely develop the disorder before menopause. People who

30 MAY 2020 | MEDICAL CHRONICLE

have had an organ transplant are more susceptible to gout. Sources: Arthritis Foundation, Diffen

THE DIFFERENCES BETWEEN GOUT AND OA Gout Osteoarthritis Joint symptoms Arthritic joint pain, swelling, redness, Joints painful but without swelling; warmth and extreme tenderness. In some cases, affects joints asymmetrically; the development of tophi affects bigger joints such as hips and knees. Localised with variable, progressive course Treatment Resting the joint and applying ice, NSAIDS, corticosteroids, colchicine (a painkiller), medications that target uric acid production or excretion, healthy diet low in purines (from alcohol, meat, fish).

NSAIDs (short term use) paracetamol, analgesics, exercise

Diagnosis Imaging tests, drawing fluid from the swollen X-ray, pain assessment- periarticular and joint for analysis, blood tests articular source of pain, presence of deformity, evidence of muscle wasting, local inflammation asymmetrical joints Presence of symptoms affecting Chills and a mild fever along with a general Systemic symptoms are not present. the whole body (systemic) feeling of malaise may also accompany the Localised joint pain (knee and hips) severe pain and inflammation but NO swelling. Pain severity is important (mechanical, inflammatory, nocturnal, sudden) Cause Hyperuricemia — overabundance of Wear and tear associated with crystalline monosodium urate (uric acid) aging or injury, also caused by deposits in the blood and joint fluid injuries to the joints, obesity, heredity, overuse of the joints from sports Associated symptoms Tophi may form. These are large masses (No systemic symptoms) fatigue, of uric acid crystals, which gets muscle weakness, fever, organ collected in the joints and damage it. involvement; Bony enlargement, They also collect in the bone and cartilage, deformity, instability, restricted such as in the ears. movement, joint locked, sleep disturbance, depression, comorbid conditions (bursitis, fibromyalgia, gout) Disease process Metabolic disease Normal wear and tear (chronic degenerative) Gender More common in men than women; Common in both men and women. in women after menopause Before 50 more men than women, after 50 more women than men Pattern of joints that are affected Joint of the big toe most commonly affected. Asymmetrical and may spread to other joints affected are of ankle heel, knee, wrist, the other side. Symptoms begin gradually fingers, elbow etc. and are often limited to one set of joints, usually the finger joints closest to the fingernails or the thumbs, large weight bearing joints. Age of onset Usually over 35 years of age in men and after menopause in females

Over 60

Speed of onset Sudden onset Slow, over years

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A Caring Community for those Affected by Cancer

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Join a caring community

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CLINICAL | PAIN

Therapeutic protocols for COVID-19 in SA

Wits Journal of Clinical Medicine have brought out a special issue with the first COVID-19 clinical data in SA.

N AN EDITORIAL BY Pravin Manga, editor in chief, WJCM, “Despite this growing data set of COVID-19 infection worldwide, there are no published local clinical data that have studied the impact

of different aspects of COVID-19 infection in South Africa. The editorial team of Wits Journal of Clinical Medicine decided that it would be an opportune time to review many aspects of this viral pandemic in

South Africa and provide information and direction for health-care professionals in South Africa.” In Article 2, COVID-19 and the Rationale for Pharmacotherapy: A South African Perspective by Prof Guy Richards

BLOOD FACTS

FACTS

Donate because it saves lives

Who receives the blood? Medical treatment (cancer, aplastic anaemia)

Are between 16 and 65 years of age and over 50kg

28%

Birth 27%

Replenish their blood within 2 weeks of donating

Scheduled surgery

Can save 3 lives with each unit of blood donated

21%

Paediatrics 10% Orthopaedics 10% Accidents 4%

Most donors donate blood 1.7 times a year

About 8 out of 10 people will receive a blood donation once in their lifetime

FACTS

1 unit of blood

Red blood cells

Platelets

Plasma

LASTS 5-6 weeks

LASTS 5 days

FROZEN LASTS 1 year

Type O blood can be given to anyone

NEEDS ABOUT 3 000 UNITS OF BLOOD A DAY ONLY 1% OF PEOPLE DONATE

APPLIES THE MOST STRINGENT TESTS TO ENSURE THAT ALL BLOOD IS SAFE

For more information and to see where you can donate, visit SANBS.ORG.ZA

Because at the end of the day it’s not just blood. It’s

32 MAY 2020 | MEDICAL CHRONICLE

SA HAS MORE THAN 79 DONATION CENTRES COUNTRYWIDE

et al (2020) the authors convey that the SARS-CoV-2 is a pathogen phylogenetically similar to two previous zoonotic coronaviruses: severe acute respiratory syndrome coronavirus 2002 (SARS-CoV-1) and the Middle East respiratory syndrome coronavirus 2012 (MERS-CoV), the case fatality rates (CFRs) of which were 7%– 10% and 30%, respectively. While the CFR of the current pandemic is considerably less than these prior epidemics (approximately 1%–2% of confirmed cases), the huge numbers of global patients that have contracted the disease has meant that the overall mortality has surpassed the other coronavirus infections. For this article we will look at the therapeutic protocols only. The full article can be accessed at https://journals.co.za/ content/journal/wjcm/browse THERAPEUTIC PROTOCOLS The authors recommend that in the first phase of the disease for patients with mild upper respiratory symptoms, age <65 years, no comorbid conditions, not hypoxaemic (saturations normal as monitored by pulse oximetry): Isolate at home if possible; paracetamol 1g PO 6–8 hourly as required; vitamin D (calciferol) 50 000 IU PO STAT; zinc 100–200mg PO daily for five days. It is possible that CHQ may be helpful at this stage, but resource limitations preclude this. In the second phase of the illness in which pulmonary infiltrates and hypoxaemia begin to occur, try agents such as CHQ, azithromycin, colchicine and zinc as combinations or singly. The authors remind us that the aim would be to use anti-inflammatory therapies early in the pulmonary phase to reduce progression to mechanical ventilation. In conclusion, we are dealing with a pandemic unprecedented in the era of modern health-care technology. We are hamstrung by a lack of an effective vaccine or of effective therapies to halt spread of disease and progression to the potentially lethal hyperinflammatory phase of this illness. Some agents appear promising in this regard and those that inhibit IL-6, which frequently appears to be the driver of the inflammatory process. Given the high mortality of those in this phase of the disease, therapy with these agents and potentially other anti-inflammatory agents such as pooled immunoglobulin would appear to be justified. REFERENCE Richards G, Mer M, Schleicher G, Stacey S. COVID-19 and the Rationale for Pharmacotherapy: A South African Perspective Wits Journal of Clinical Medicine, 2020, 2(SI) 11–18 http://dx.doi. org/ 10.18772/26180197.2020.v2nSIa2.

CLINICAL | GASTROENTEROLOGY

Medical vs surgical

Treatment for refractory heartburn Antireflux surgery may be beneficial for refractory gastro-oesophageal reflux disease (GORD), but only for a highly selected group of patients, according to a New England Journal of Medicine study.

EARTBURN THAT PERSISTS despite proton-pump inhibitor (PPI) treatment is a frequent clinical problem with multiple potential causes. Treatments for PPI-refractory heartburn are of unproven efficacy and focus on controlling gastroesophageal reflux with refluxreducing medication or antireflux surgery or on dampening visceral hypersensitivity with neuromodulators. Roughly 370 Veterans Affairs patients with heartburn refractory to proton-pump inhibitors were enrolled, but 288 were excluded for various reasons (eg, testing revealed non-GORD causes of heartburn). Ultimately, 78 patients were randomised to receive either laparoscopic fundoplication, medical treatment (omeprazole, baclofen, desipramine), or control medication (omeprazole plus placebo). At 12 months, the proportion of patients who had treatment success (at least a 50% improvement in the GORD Health-Related Quality of Life score) was significantly higher in the surgery group (67% vs. 28% for active medication and 12% for control medication). An editorialist cautions: "The findings should not translate into more patients with refractory heartburn being offered surgery without each case being judiciously evaluated on its merits, and only after extended trials of medical therapy." METHODS Patients who were referred to Veterans Affairs (VA) gastroenterology clinics for PPI-refractory heartburn received 20mg of omeprazole twice daily for two weeks, and those with persistent heartburn underwent endoscopy, oesophageal biopsy, oesophageal manometry, and multichannel intraluminal impedance–pH monitoring. If patients were found to have reflux-related heartburn, we randomly assigned them to receive surgical treatment (laparoscopic Nissen fundoplication), active medical treatment (omeprazole plus baclofen, with desipramine added depending on symptoms), or control medical treatment (omeprazole plus placebo). The primary outcome was treatment success, defined as a decrease of 50% or more in the GORD– Health Related Quality of Life score (range, 0 to 50, with higher scores indicating worse symptoms) at one year. RESULTS A total of 366 patients (mean age, 48.5 years; 280 men) were enrolled. Prerandomisation procedures excluded 288 patients: 42 had relief of their heartburn during the two-week omeprazole trial, 70 did not complete trial procedures, 54 were excluded for other reasons, 23 had nonGORD oesophageal disorders, and 99 had

functional heartburn (not due to GORD or other histopathologic, motility, or structural abnormality). The remaining 78 patients underwent randomisation. The incidence of treatment success with surgery (18 of 27 patients, 67%) was significantly superior to

Y E A RS

T WENT Y

SADAG

that with active medical treatment (seven of 25 patients, 28%; P=0.007) or control medical treatment (three of 26 patients, 12%; P<0.001). The difference in the incidence of treatment success between the active medical group and

the control medical group was 16% points (95% confidence interval, −5 to 38; P=0.17).

References available on request.

MENTAL HEALTH FACT SHEET

LIFE-TIME PREVALENCE OF MENTAL DISORDERS IN SA Compared with 14 other countries in the WMH Survey, South Africa is the:

2nd highest for substance abuse disorders (13.3%) 6th highest for anxiety disorders (15.8%) 7th highest for mood disorders (9.8%) PATIENT ADHERENCE AT A GOVERNMENT HOSPITAL

SOCIAL BURDEN FOR MENTAL HEALTH PATIENTS

Can’t take care of dependants

Separated/ Divorced

Lost friends

Negative Family Relationships

17%

26%

47%

49%

SEEKING TREATMENT FOR MENTAL HEALTH

RESOURCES FOR MENTAL HEALTH Per 100,000 of the population there are: 9.72 Nurses 0.4 Social workers 0.27 Psychiatrists 0.32 Psychologists 2.8 beds for in-patients 1% beds for children

Research compiled by SADAG – References: DoH, 2012; WHO, 2012, SASH, 2009; MHaPP, 2007; Freeman, 2007; MRC, 2006; ALLERS, 2009; Janse van Rensburg, 2013

MEDICAL CHRONICLE | MAY 2020 33

CLINICAL | WOUND CARE

Remote wound care during

COVID-19

COVID-19 is an ongoing worldwide pandemic that has created a global health crisis.

N 23 MARCH 2020, President Cyril Ramaphosa announced a new measure to combat the spread of the Covid-19 coronavirus in South Africa, which was a nationwide lockdown with severe restrictions on travel and movement. As of 29 April 2020, the total number of confirmed cases (at the time of going to print) is now 5 350 and 103 Coronavirus COVID-19 related deaths. The lockdown coincides with our winter season which normally sees in increase in burns due to heating appliances used, shack fires due to fallen candles, paraffin-related burns and overloading of plugs. According to the World Health Organization (WHO) burns occur mainly in the home and workplace. Children and women are usually burned in domestic kitchens from hot liquids or flames, or from cookstove explosions while men are most likely to be burned in the workplace due to fire, scalds, chemical and electrical burns.1 With the onset of lockdown there has been in increase in paediatric burns in South Africa. Hospitals across the country have tried to reduce the risk to patients

34 MAY 2020 | MEDICAL CHRONICLE

Dr Ethel Andrews, President of the South African Burn Society

THICKNESS DEGREE DEPTH CHARACTERISTIC PATIENT QUESTIONS Superficial First Epidermis Dry, red, blanches, painful

Is it dry, intact and painful?

Superficial Second Papillary dermis Blisters, weeping, red, Is it red, blistered, Partial blanches, painful swollen, and very painful? Deep Third Reticular dermis Blisters, wet or waxy dry, Can you see hair follicles or Partial reduced blanching, painful blisters? Full Fourth All layers of skin Charred, waxy white, Is it whitish, charred, or due to thickness destroyed. May leathery does not translucent? involve fascia, blanch absent pain Is the skin peeling off, muscle and/ or sensation (Pain present with minimal bone surrounding area) sensation in the area?

by discharging patients earlier and opting to make use of outpatient facilities where available, deflecting smaller burns to other hospitals and making use of telehealth and telemedicine. With restrictions on movement, not all burns need to be admitted to hospital with minor burns are being treated at home or on an outpatient basis. The American Burn Association defines minor burns in a disaster as those

involving noncritical sites and less than 10% TBSA for partial-thickness burns. Critical sites are all major joints, hands, feet, face and perineum. Excluded from this category are patients with minor burns who also have smoke inhalation or associated traumatic injuries.2 Burn units in South Africa have not changed the admission criteria and if a health care practitioner is in doubt its best to contact the referral hospital directly.

MANAGING MINOR BURNS REMOTELY. 1. First Aid Burn first aid includes: Cooling the burn by running under cool water for 20 minutes, or cold compress if running water is not available, take off jewellery and clothes from the burned area and protect the wound by covering it.3 Manage pain with paracetamol.

CLINICAL | WOUND CARE 2. Wound assessment remotely Size and depth matters. If possible, a visual image of the wound allows for better assessment and decision making. Telemedicine in South Africa is required to be in line with applicable legislation, in particular the National Health Act No. 61 of 2003 (as amended). The National Department of Health’s e-Health Strategy South Africa (20122016) specifically refers to telemedicine as ‘a tool that could bridge the gap between rural health and specialist services.4 On 27 March 2020, the Board of Health Care Funders have informed healthcare providers that telehealth and telemedicine may be practised as a result of South Africa's State of Disaster.5 A. Location of the wound: Is the burn on face, hands, feet, perineum, circumferential or over a joint? B. Size: The Rule of Nines uses a rough estimate that represent multiples of 9%. In adults the head and neck are roughly 9%, the anterior and posterior chest are 9% each, the anterior and posterior abdomen are 9% each, each upper extremity is 9%, each thigh is 9%, each leg and foot is 9% and the remaining 1% represents the genitalia.6, 7,8 ,9

The palmar surface of the patient’s hand is approximately 1% of their body surface over all age groups; visualising the patient’s hand covering the burn wound approximates the percentage of body surface area involved6, 7, 10,11. This is an easier method and is more often used in paediatrics and will similarly be an accurate method for measuring wound size remotely especially if no visual is available remotely C. Depth: Burn depth is assessed according to the layers of skin that are damaged by heat source. These are epidermal or superficial (first-degree), partialthickness (second-degree), which may also be classified as superficial or deep partial-thickness) and full-thickness (third-degree) burns (may also be classified as a deep full-thickness).12 D. Presence of infection: Burn wound surfaces are sterile immediately following thermal injury for a short time.13 But humans carry significant numbers of bacteria that will quickly contaminate the open wound.14 The clinical signs of infection in wounds are cellulitis, malodour, increase in pain, delayed healing or deterioration in the wound or wound breakdown and increase in exudate volume (15). Early recognition of infection is important because

infection is by far the most frequent complication encountered by patients with burn injuries and it is therefore imperative that practitioners and patients recognise when care needs to be escalated.

Superficial burns heal within a few days, partial thickness burns heal within three weeks and full thickness burns require surgical management for closure

E. Signs of none healing: The wound edges can serve as an important parameter to determine whether or not the present wound treatment is effective over time.16 Wound healing occurs when the wound edges of a deep wound show signs of new granulation tissue and a superficial wound’s edges epithelialise and epithelium islands are visible.16 Superficial burns heal within a few days, partial thickness burns heal within three weeks and full thickness burns require surgical management for closure.17 If the wound does not progress according to the expected time-line it might be due to burn conversion, infection or current treatment not being effective in which case the decision for home-based care must be reviewed, adjusted or abandoned and patient referred to hospital. 3. Treatment Requirements • Dressing pack or gauze, gloves, clean bowl and waste bag • Scissors cleaned prior to use • Wound dressings • Previously boiled cooled down water METHOD • Take or administer analgesics • Wash hands thoroughly especially between fingers and palms of hands • Dry hands with a clean towel/kitchen roll • Open dressing pack or create a clean surface with towel • Pour water into dressing tray/ bowl • Position waste bag for dirty dressings close to wound • Open new wound dressings and drop into clean opened dressing pack/ clean towel surface • Remove dressing without touching the inside of the dirty dressing or the wound bed, you might have to wet dressing with tap water if dressing is stuck to wound, do not pull if stuck as this will damage the healing wound • Place dirty dressing into the waste bag • Wash hands again • Apply clean gloves • Clean the wound bed by gently wiping

to remove any wound residue and then surrounding skin with tap water and gauze • Ensure that you clean the wound before the surrounding skin and use a new piece of gauze for the surrounding skin • Dependent upon the location of the wound it may be more appropriate to shower, which will ensure that the wound bed and surrounding skin are clean prior to dressing • Pay attention to the condition of wound; colour and size of the wound; new wounds; signs of infection; condition of wound margin; colour, amount and viscosity of wound fluid • Apply dressing • Dispose waste bag safely • Document dressing change and call health professional if you have any concerns. Remote consultations are not as a replacement for normal ‘face-to-face’ healthcare but an add-on meant to enhance access to healthcare during these difficult times and minimises the risk of being exposed to COVID-19. Successful remote management of burns is dependent on patient selection, selection of an appropriate dressing which minimises pain and frequency of dressing changes, and open communication between the health care practitioner and the patient. REFERENCES 1. https://www.who.int/news-room/fact-sheets/ detail/burns). 2. Cancio, L.C., Barillo, D.J., Kearns, R.D., et al. (2016). Guidelines for Burn Care Under Austere Conditions: Surgical and Nonsurgical Wound Management Journal of Burn Care & Research. 2016. DOI: 10.1097/BCR.0000000000000368 3. Ahuja,R.B., Puri, V., Gibran, N., et al. (2016) ISBI Practice Guidelines for Burn Care. Burns. 42(5):953–1021. 4. https://www.hpcsa.co.za/Uploads/Press%20 Realeses/2020/Guidelines_to_telemedicine_in_ South_Africa.pdf 5. https://www.bhfglobal.com/2020/03/27/covid-19telehealth-telemedicine-result-south-african-stateof-disaster/ 6. Sheridan, R. L.2012. Burns. A Practical approach to immediate treatment and long term care. Manson publishing. 7. Malik, K. I., Malik, M. A. N. & Aslam. A. 2010. Honey compared with silver sulphadiazine in partialthickness burns. International Wound Journal. vol. 7, pp. 413–417. 8. Wachtel, T. L., Berry, C. C., Wachtel, E. E., et al. 2000. The inter-rater reliability of estimating the size of burns from various burn area chart drawings. Burns. vol. 26, no. 2, pp. 156–170 9. Wallace, 1951. The exposure and treatment of burns. Lancet. no. 6653, pp. 501-504 10. Butcher, M. & Swales, B. 2012. Assessment and management of patients with burns. Nursing Standard. vol. 27, no. 2, pp. 50-56. 11. Sheridan, R. L., Petras, L., Basha, G., et al. 1995. Planimetry study of the percent of body surface represented by the hand and palm: sizing irregular burns is more accurately done with the palm. Journal of Burns Care and Rehabilitation. vol. 6, no. 6, pp. 605-606. 12. Culleiton AL, Simko LM. Caring for patients with burn injuries. Nursing Critical Care:January 2013 - Volume 8 - Issue 1 - p 14–22 doi: 10.1097/01. CCN.0000423824.70370.fa. 13. Church, D, Elsayed, S, Reid, O., et al., 2006. Burn Wound Infections. Clinical Microbiology Reviews. vol. 19, no. 2, pp. 403-434. 14.Santy, J. 2008. Recognising infection in wounds. Nursing Standard. vol. 23, no. 7, pp. 53-60. 15. Cutting, K., White, R. & Mahoney, P. (2005). Clinical Identification of Wound Infection: a Delphi Approach. 32. S26. https://www.researchgate.net/ publication/275381440 16. Mulder, M. (2009). The selection of wound care products for wound bed preparation Wound Healing Southern Africa.2(2):76-78 17. Karim, A.S., Shaum, K and Gibson, A.L.F. (2020). Indeterminate-Depth Burn Injury-Exploring the Uncertainty. J Surg Res. Jan;245:183-197. doi: 10.1016/j.jss.2019.07.063. Epub 2019 Aug 14 MEDICAL CHRONICLE | MAY 2020 35

CPD | DIABETES

*Supplied content

Original paper:

Efficacy and safety analysis of insulin degludec/insulin aspart compared with biphasic insulin aspart 30: A phase 3, multicentre, international, open-label, randomised, treat-to-target trial in patients with type 2 diabetes fasting during Ramadan Mohamed Hassanein, Akram Salim Echtay, Rachid Malek, Mahomed Omard, Shehla Sajid Shaikh, Magnus Ekelund, Kadriye Kaplan, Nor Azmi Kamaruddin. Diabetes Res Clin Pract 2017; https://doi.org/10.1016/j.diabres.2017.11.027

Approximately 1.6 billion people worldwide are Muslims. Ramadan is the ninth month of the Islamic calendar, and fasting (total abstinence from food or drink) from dawn to sunset during Ramadan month is required. Each period of fasting may last up to 20 hours. The daily Ramadan fast starts after the pre-dawn meal – suhur, which is normally a small meal, and is concluded with a meal at sunset (iftar), which often includes a large amount of high-carbohydrate foods. In addition, at the end of Ramadan, there is a 3-day festival – Eid ul-Fitr, during which, overindulgence in food consumption is common even among patients with diabetes. Fasting during Ramadan is associated with an increased risk of dehydration and hypoglycaemia. In particular, patients with diabetes are at high risk of postprandial hyperglycaemia, diabetic ketoacidosis and thrombosis. Patients with very high or high risk include those with type 2 diabetes mellitus (T2DM) treated with premixed insulin or multiple daily insulin injections, many of whom choose to fast during Ramadan irrespective of knowing their risk of diabetic complications.

IM: To compare the efficacy and safety of insulin degludec/insulin aspart (IDegAsp) and biphasic insulin aspart 30 (BIAsp 30) before, during and after Ramadan in patients with type 2 diabetes mellitus (T2DM) who fasted during Ramadan. METHODS: In this multinational, randomised, treatto-target trial, patients with T2DM who intended to fast and were on basal, pre- or self-mixed insulin +- oral antidiabetic drugs (OADs) for ≥ 90 days were randomised (1:1) to IDegAsp twice daily (BID) or BIAsp 30 BID. Treatment period included preRamadan treatment initiation (with insulin titration for 8 - 20 weeks), Ramadan (4 weeks) and post-Ramadan (4 weeks). Insulin doses were reduced by 30 - 50 % for the pre-dawn meal (suhur) on the first day of Ramadan, and readjusted to the preRamadan levels at the end of Ramadan. ENDPOINTS: The efficacy endpoints were change in HbA1c and fructosamine levels from baseline to the end of Ramadan (12 - 24 weeks) and from baseline to the end of post Ramadan (16 - 28 weeks), HbA1c responders (< 7 %) and 8-point self-measured plasma glucose (SMPG) profile at the end of Ramadan and post Ramadan. Hypoglycaemia was analysed as overall (severe or plasma glucose < 3.1 mmol/L), nocturnal (00:01 - 05:59) or severe (requiring assistance of another person). RESULTS: Glycaemic control was maintained in both treatment arms over the whole treatment

36 MAY 2020 | MEDICAL CHRONICLE

This is a CPD-accredited article, to do the questionnaire and earn points go to www.medicalacademic.co.za

CPD | DIABETES

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HYPOGLYCAEMIA: Hypoglycaemia rate ratios of the IDegAsp arm compared with the BIAsp 30arm during the 16- to 28-week treatment period and 4-week Ramadan period. The rate of nocturnal hypoglycaemia was also statistically significantly lower in the IDegAsp arm compared with the BIAsp 30 arm (p < 0.0001), which translated into an 83 % reduction in the rate of nocturnal hypoglycaemia in patients receiving IDegAsp.

period, despite the reduction in insulin doses during Ramadan. The mean HbA1c values fell from 8.5 % at baseline to 7.4 % at end of Ramadan and to 7.5 % at the end of 4 weeks post-Ramadan in both treatment arms, with almost all of the reduction occurring during the pre-Ramadan period. Similarly, there was no significant difference between IDegAsp and BIAsp 30 arms in terms of the change of fructosamine levels from baseline to end of Ramadan (p = 0.9382) or end of 4 weeks post-Ramadan (p = 0.8893). During the 4-week Ramadan period, the mean pre-iftar SMPG values were significantly lower in the IDegAsp arm compared with the BIAsp 30 arm (ETD: -0.54 mmol/L; [-1.02; -0.07]95% CI, p = 0.0247). C

CMY

DISCUSSION: The data indicate that glycaemic control was maintained in both treatment arms across the whole study period. The insulin dose was reduced at the beginning of Ramadan, and reverted to the pre-Ramadan dose at the end of Ramadan, in accordance with the IDF-DAR Practical Guidelines. During the treatment period, IDegAsp had significantly lower overall and nocturnal hypoglycaemia rates with similar glycaemic efficacy, versus BIAsp 30. As demonstrated by the results of this trial, at least 4-month preparation prior to Ramadan fasting may be beneficial.

CONCLUSION: IDegAsp is a suitable therapeutic agent for patients who need insulin for sustained glucose control before, during and after Ramadan fasting, with a significantly lower risk of hypoglycaemia, versus BIAsp 30.

011 234 4870 | 0800 70 80 90 sms 31393 | www.sadag.org

Adapted from Hassanein M, et al. MEDICAL CHRONICLE | MAY 2020 37

CLINICAL | GASTROENTEROLOGY

Bowel prep

education app is effective A study just released by Walter B et al, showed that patients who used a smartphone application in addition to standard instructions had improved bowel preparation quality.

PTIMAL BOWEL PREPARATION is an essential feature of high-quality colonoscopy, but inadequate preparation is still a common clinical problem. The success of colonoscopy is linked closely to the adequacy of bowel prep. Inadequate colon preparation is associated with reduced adenoma detection rates. Despite its importance, around 20 -25 % of bowel preparations in clinical practice remain inadequate. Modifiable risk factors that can be crucial to ensure an adequate prep include patient guidance and education. In a study conducted last year, Desai Madhav et al evaluated the evidence with regard to the impact of education via smartphone app on bowel preparation. They performed pooled analysis of 1665 patients undergoing colonoscopy and found that using a smartphone-based app was effective in improving bowel cleansing. Their meta-analysis showed that a 10 % higher adequate bowel preparation was achieved in the smartphone app group compared with the standard patient instruction group alone. Patients using the smartphone app had higher bowel preparation scale scores compared to controls. The studies included were heterogeneous in terms of study design, study population, methodology and most importantly, type of bowel prep as well as type of smartphone application used. Interventions in the form of simple cards with photographs and text explaining the rationale for bowel preparation have often failed to improve the quality of bowel preparation for colonoscopy. However, other studies using visual aids or an educational video, as interventions, have shown a positive effect on quality of bowel preparation. The use of telephone and

38 MAY 2020 | MEDICAL CHRONICLE

mobile messages to enhance education on diet restrictions and bowel preparation and serve as reminders have also led to improvements in bowel preparation. These results indicate that education by more interactive audiovisual methods may be needed to improve bowel cleansing. A smartphone app is another way of accomplishing that by displaying text instructions, visual aids, and alerts to the patient with regard to the diet restrictions required, a reminder to start the prep as well as the timing of the split dosing. With the increasing use of smartphones, apps for bowel prep have the advantage of delivering information in a more user friendly format than some of the other educational methods. Another advantage is the use of automatic alerts, reminders, and notifications as well as the ability to go back to review the instructions about the bowel prep. The time interval between a scheduled colonoscopy and the initial delivery of instructions about bowel prep is often quite long. As a result, patients can easily forget the essential and pertinent instructions and can also misplace any written instructions that were provided at the initial contact. Here is where the smartphone apps or mobile social media apps have an edge, as these will always be available to the patient along with the ability to serve reminders. There can however, also be impediments to the implementation of smartphone apps for bowel cleansing. It requires a smartphone with a service network that may not be available or accessible to all. Smartphones may have a lower penetration in developing countries and possibly in uninsured populations in developed countries. Patients may not be familiar with social media or smartphone apps, and they may need

STUDY In a multicentre, randomised, controlled trial, investigators in Germany assessed the effect of a commercially available smartphone application on bowel preparation quality in 500 patients undergoing screening or surveillance colonoscopy. All participants received standard oral and written instructions. Those randomised to the intervention group downloaded an application that provided additional education, visual aids, and push notifications in the three days prior to colonoscopy. Compared with the control group, patients in the app group had the following improved outcomes: • A significantly higher mean Boston bowel preparation scale (BBPS) score (7.6 vs 6.7) and higher segmental scores in the left, transverse, and right colon • A significantly higher rate of excellent preparation, defined as BBPS score ≥8 (61% vs 35%) • A significantly lower rate of inadequate preparation, defined as BBPS score <6 (8% vs 17%). • A significantly higher adenoma detection rate (36% vs 27%) • Improved compliance with purgative and dietary instructions • A higher level of satisfaction with the bowel preparation process. The results of this study apply only to motivated patients who own smartphones, but several other interventions are currently available to augment standard bowel preparation instructions, including text messaging and social media. The digitalisation and automation of the bowel prep instruction process appears inevitable and is associated with measurably better outcomes. assistance to navigate these making it more tedious and cumbersome than other simpler ways of education. There is a lack of a standardised smartphone app that is widely available for use and in use. Several different apps were used in the studies included in this meta-analysis and probably contributed to the clinical heterogeneity. CONCLUSION In conclusion, use of a smartphone-based app improves bowel preparation and possibly patient satisfaction. This is an attractive option to improve the quality

of bowel prep but further research is needed to develop a standardised platform for uniformity. REFERENCES Walter B et al. Smartphone application to reinforce education increases high-quality preparation for colorectal cancer screening colonoscopies in a randomized trial. Clin Gastroenterol Hepatol 2020 Mar 30; [e-pub]. (https://doi.org/10.1016/j. cgh.2020.03.051) Desai, Madhav et al. Use of smartphone applications to improve quality of bowel preparation for colonoscopy: a systematic review and meta-analysis. Endoscopy international open vol. 7,2 (2019): E216-E224. doi:10.1055/a-0796-6423.

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CLINICAL | GASTROENTEROLOGY

Probiotic reduces crying in colicky infants

Evidence is mounting that probiotics can give babies relief from colic, a functional gastrointestinal disorder believed to be tied to disturbances in the gut microbiota.

LTHOUGH THE PATHOGENESIS of colic is unclear, a new study reports that the probiotic Bifidobacterium animalis subspecies lactis BB-12 effectively

eases infant colic. In a randomised, doubleblind, placebo-controlled trial, Rita Nocerino, CPN, of the Department of Translational Medical Science at the University of Naples

Federico II, in Italy, and colleagues found that treatment with BB-12 for 28 days was associated with a greater rate of reduced daily average crying time (≥50%) compared

with placebo. The effect on crying time emerged as early as the first week of BB12 supplementation. The probiotic also appeared to have beneficial effects on sleep duration as well as stool frequency and consistency. The trial results were published in Alimentary Pharmacology and Therapeutics. The researchers randomly assigned 80 healthy but colicky infants no older than seven weeks who were exclusively breastfed to receive placebo or a daily dose of BB-12 1 x 10 colony-forming units. The mean age of the babies was a little more than one month, and more than 50% were boys. The mean daily duration of crying bouts was consistently shorter in the BB12 group at each week and decreased from week to week. Mean change from baseline in the intention-to-treat population was significantly greater in the BB-12 group than the placebo group: –129.9 ± 43.7 and –84.3 ± 51.4, respectively (P = .0001). In the per-protocol analysis, 80% of BB-12 recipients showed a ≥50% reduction in crying duration after 28 days, compared with 31.5% of those in the placebo group (P < .0001). The mean number of daily crying episodes was lower in the BB-12 group at each study week. The mean change from baseline to the last week was –4.7 ± 3.4 in the intervention group vs –2.3 ± 2.2 in the placebo group (P = .001). Infants' sleeping time in both groups increased from baseline, with a mean change at the last week of 36.5 ± 98.8 minutes per day in the BB-12 group (range, –225.7 to 345.0 minutes) and 47.9 ± 108.6 minutes per day (range, –265.0 to 225.0 minutes) in the placebo group. BB-12 recipients showed an increase in anti-inflammatory biomarkers in stool, including an abundance of Bifidobacterium as well as an increase in levels of butyrate, HBD-2, LL-37 and sIg, which are associated with a decrease in levels of the inflammatory marker calprotectin. That finding suggests that this probiotic strain has an immunomodulatory action in the infant gut. Its beneficial effect could stem from both immune and nonimmune mechanisms that modulate the structure and function of the microbiota, the authors explain. The researchers note that their results align those of an open-label trial in which BB-12, when added to a lowlactose, partially hydrolysed whey formula, decreased the duration of crying time in infants with colic. Other probiotics as well have reportedly had a beneficial effect on colic.

Source: Medscape, Mediclinic Infohub 40 MAY 2020 | MEDICAL CHRONICLE

CLINICAL | PAIN

Ibuprofen can be used for

COVID-19 symptoms

UK medicines agencies have changed their advice on ibuprofen to say that the drug can be used to treat patients with symptoms of COVID-19, although the evidence that prompted the revision has not been made public.

HE CHANGE FOLLOWS a review by the Commission on Human Medicines’ expert working group on COVID-19 which, along with previous reviews of evidence, concluded that there is currently insufficient evidence to establish a link between use of ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDs), and contracting or worsening of COVID-19. The National Institute for Health and Care Excellence (NICE) has updated their advice to say that patients can take paracetamol or ibuprofen for symptoms of COVID-19, such as fever and headache. In its guidance updated on 14 April, NICE says that policy decisions on whether NSAIDs should be used in COVID-19 will need to consider studies of the use of NSAIDs for other acute respiratory tract infections and pharmacoepidemiological studies.

Acute use of NSAIDs is related to increased risk of developing COVID-19 “The available evidence suggests that, although the anti-inflammatory effects of NSAIDs reduce acute symptoms (such as fever), they may either have no effect on, or worsen, long-term outcomes, possibly by masking symptoms of worsening acute respiratory tract infection. Further evidence is needed to confirm this, and to determine whether these results also apply to infections such as COVID-19.” The change of policy suggests that the Commission on Human Medicines’ expert working group had more up-to-date data available, perhaps data from NSAID use in COVID-19, or took other factors into account such as a shortage of paracetamol. But neither the MHRA or NICE would identify the reason for the change of policy. A spokesperson for the MHRA said that the expert working group considered the available evidence on the use of ibuprofen and other NSAIDs and the outcome of worsening of infections, including from published studies. “The evidence considered by the expert working group did not include information on the availability of ibuprofen or other drugs and did not include representations from companies holding licences for ibuprofen or other drugs,” they said. In a statement, NICE said it “could not find any evidence to suggest whether acute use of NSAIDs is related to increased risk

of developing COVID-19 or increased risk of a more severe illness. NHS England has developed a commissioning policy for acute use of NSAIDs for people with or at risk

of COVID-19. As this is a rapidly changing situation, we’re regularly reviewing our guidance and will update in line with the best available evidence.”

REFERENCE Torjesen I. Covid-19: ibuprofen can be used for symptoms, says UK agency, but reasons for change in advice are unclear BMJ 2020; 369 doi: https://doi. org/10.1136/bmj.m1555 (Published 17 April 2020)

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MEDICAL CHRONICLE | MAY 2020 41

CLINICAL | GASTROENTEROLOGY

Crohn’s marker improves outcomes

A research group led by the Technical University of Munich (TUM) has discovered a marker at a microscopic level, which can be used to identify patients that show a high probability of suffering from an inflammation recurrence in the immediate future.

NTESTINAL STEM CELL metabolism is facilitated by mitochondria – the in-cell power plants. Chronic inflammation processes inhibit the

cells’ metabolism and lead to functional loss of these stem cells. In collaboration with the Helmholz Zentrum München and the Université de Paris, a TUM research team

has discovered this connection by analysing intestinal epithelial cells of Crohn’s disease patients and comparing them to mouse model findings.

Breast Cancer DID YOU KNOW? Breast cancer is the most common cancer W A R N I N G

S I G N S

A puckering of the skin of the breast.

A lump in the breast or armpit.

A change in the skin around the nipple or nipple discharge.

Dimpling of the nipple or nipple retraction.

An unusual increase or shrinkage in the size of one breast or recent asymmetry of the breasts

One breast unusually lower than the other. Nipples at different levels.

An enlargement of the glands.

An unusual swelling in the armpit.

MYTH vs FACT I am too young to get breast cancer Being overweight/obese doesn’t matter

Many women who are under 40 are diagnosed with breast cancer Overweight women have a higher risk of being diagnosed with breast cancer, especially after menopause

Alcohol is not linked to breast cancer

Alcohol use increases the risk of breast cancer

Only women with a family history of breast cancer are at risk

All women are at risk, but family history increases the risk

I have never had children, so I can’t get breast cancer

Women who have never had children, or only had them after 30, have increased risk of breast cancer

THE INTERRELATED ROLE OF STEM AND PANETH CELLS Stem cells are indispensable for the maintenance and regeneration of tissues. Intestinal stem cells inside the intestines are intermingled with so-called Paneth cells, which are responsible for the local immune defence and for creating an environment in which the stem cells can prosper, thus termed guardians of the stem cell niche. Patients suffering from Crohn’s disease have fewer Paneth cells and furthermore, these are limited in their functionality. The research group examined the causes for alterations in Paneth cells and attempted to determine the importance of stem cell metabolism in this context. In addition to mouse studies, the researchers analysed intestinal biopsies from Crohn’s disease patients, characterising the stem cell niche meticulously. After six months, the patients’ intestines were examined again endoscopically focusing on finding signs of inflammation. PREDICTING CROHN’S DISEASE RECURRENCE The study showed that microscopic alterations in stem cell niche were particularly prevalent in those patients who showed symptoms of a relapse of inflammation after six months.“These changes in the stem cell niche are a very early indicator for the start of inflammatory processes. This presents a reasonable starting point for therapeutic intervention,” explained Dirk Haller, Professor for Nutrition and Immunology at TUM.

Toll Free 0800 22 66 22 | www.cansa.org.za

RESTORING STEM CELL FUNCTION In both human patients and mouse models, alterations in Paneth and stem cells coincided with decreased mitochondria functionality. Knowing that a lowered mitochondrial respiration leads to alterations in the stem cell niche, the researchers used dichloroacetate (DCA), a substance applied in cancer therapy leading to an increase in mitochondrial respiration. The shift in cellular metabolism induced by DCA was able to restore the intestinal stem cell functionality of mice suffering from inflammation, as demonstrated in intestinal organoids, organ-like structures cultured ex vivo. THERAPEUTIC APPROACH “These findings point to a new therapeutic approach for prolonging the inflammationfree remission phases of Crohn’s disease,” said Eva Rath, scientist at the TUM School of Life Sciences Weihenstephan and coauthor of the study. Source: University of Munich

WH-AD297x130.indd 1

2019/06/11 2:57 PM

Your blood saves lives A pint of blood is drawn from a volunteer donor.

O+

Blood Donor

Blood is transfused to patients in need. Just one blood donation has the potential to save three lives!

Blood is collected into a sterile bag and labelled.

South African National Blood Service

CK 06

Units are transported to the nearest SANBS testing and processing lab.

In the processing laboratory, blood is spun down in a centrifuge and then separated in to its diďŹ&#x20AC;erent components.

What happens to your blood

donation

Red Blood Cells Contain haemoglobin, a protein that carries oxygen throughout the body. Used to treat patients with anaemia or blood loss due to trauma or surgery.

Plasma Contains special proteins and clotting factors required to assist platelets to form blood clots and to treat patients with serious blood disorders.

Blood products are stored prior to transfusion. The shelf life of blood is limited. Platelets expire in 5 days. Red blood cells expire in 42 days. Plasma has a 2 year shelf life from the day of collection.

Local hospitals place orders with SANBS for blood products based on their needs.

Blood is tested to ensure that it is safe for transfusion.

Platelets Crucial in helping blood clot. Patients with low platelet levels often suďŹ&#x20AC;er from bruising and bleeding.

Toll free: 0800 11 9031 www.sanbs.org.za

ONLINE CPD

First-trimester preeclampsia screening

with biomarkers

Preeclampsia is a grave threat to maternal and infant health, with a growing prevalence in the developing world. But are current screening methods for the condition adequate?

N ALTERNATIVE APPROACH to screening, developed by The Fetal Medicine Foundation (FMF), allows estimation of individual patient-specific risks of preeclampsia requiring delivery

Y E A RS

T WENT Y

SADAG

before a specified gestation, with the use of Bayes' theorem to combine the a-priori risk from maternal factors, derived by a multivariable logistic model, with the results of various combinations of biophysical

and biochemical measurements. A recent multicentre study of 8775 singleton pregnancies confirmed the validity of this algorithm and reported detection rates of 100% (95% CI, 80–100%), 75% (95% CI,

MENTAL HEALTH FACT SHEET

LIFE-TIME PREVALENCE OF MENTAL DISORDERS IN SA Compared with 14 other countries in the WMH Survey, South Africa is the:

2nd highest for substance abuse disorders (13.3%) 6th highest for anxiety disorders (15.8%) 7th highest for mood disorders (9.8%) PATIENT ADHERENCE AT A GOVERNMENT HOSPITAL

SOCIAL BURDEN FOR MENTAL HEALTH PATIENTS

Can’t take care of dependants

Separated/ Divorced

Lost friends

Negative Family Relationships

17%

26%

47%

49%

SEEKING TREATMENT FOR MENTAL HEALTH

RESOURCES FOR MENTAL HEALTH Per 100,000 of the population there are: 9.72 Nurses 0.4 Social workers 0.27 Psychiatrists 0.32 Psychologists 2.8 beds for in-patients 1% beds for children

Research compiled by SADAG – References: DoH, 2012; WHO, 2012, SASH, 2009; MHaPP, 2007; Freeman, 2007; MRC, 2006; ALLERS, 2009; Janse van Rensburg, 2013

44 MAY 2020 | MEDICAL CHRONICLE

This is a summary of a longer, CPD accredited article available on www.medicalacademic.co.za

62–85%) and 43% (95% CI, 35–50%) for preeclampsia delivering < 32, < 37 and ≥ 37 weeks, respectively, at a 10% false positive rate. In the study, by O’Gorman et al, blood serum markers, PlFG and PAPP-A, in conjunction with maternal risk factors such as maternal characteristics, mean arterial blood pressure (MAP) and uterine artery pulsatility index (UAPI) achieved a detection rate of >90% at a false positive rate of 5%. This study clearly showed that the detection rate for high-risk patients increases when combining multiple parameters. The detection rate increases from 82% (when using maternal factors, MAP and UAPI) to 94% (when using maternal factors, MAP, UAPI, NT, PLGF and PAPP-A). To study the use of the FMF algorithm in clinical practice, the ASPRE trial was designed to propose aspirin as a treatment for primary prevention of preeclampsia in all patients considered to be at high risk following first-trimester combined screening. This trial evaluated the effect of prophylactic low-dose aspirin administered in the first trimester of pregnancy on the incidence of delivery with preeclampsia before 37 weeks of gestation in patients at high risk. The secondary objectives were to study the effects of aspirin on the incidence of early preeclampsia, the incidence of intrauterine growth restriction, foetal death, perinatal death, admission to neonatal intensive care, a composite measure of neonatal morbidity and mortality and placental abruption. Patients were randomised to aspirin or a placebo. The occurrence of preterm preeclampsia (< 37 weeks) was significantly reduced by aspirin (0.38; 95% CI 0.20–0.74; p = 0.004). Preterm preeclampsia occurred in 13 of 798 participants (1.6%) in the aspirin group, as compared with 35 of 822 (4.3%) in the placebo group. A dose of 150mg of aspirin per day was selected on the basis of previous evidence of a dose-dependent benefit. The trial demonstrated that aspirin reduces the risk of preterm pre-eclampsia, but not term pre-eclampsia only when initiated at ≤16 weeks of gestation. CONCLUSION The performance of first-trimester screening for preeclampsia by the FMF algorithm is far superior to the methods advocated by NICE and ACOG. Early identification of women at risk for pre-eclampsia testing serum biomarkers PAPP-A and PlGF allows for timely intervention with low dose aspirin (<16 weeks) to significantly reduce the incidence of preeclampsia. Early screening allows for closer monitoring of high-risk patients for optimal patient care. References available on request.

CLINICAL | WOMEN'S HEALTH

Does exercise ease

dysmenorrhoea?

Exercise has a number of health benefits and has been recommended as a treatment for primary dysmenorrhoea (period pain), but the evidence for its effectiveness is unclear.

OCHRANE AUTHORS REVIEWED the evidence on the effectiveness and safety of exercise in women with primary dysmenorrhoea

risk of side effects reported in the general population, women may consider using exercise, either alone or in conjunction with other modalities, such as NSAIDs, to

manage menstrual pain. It is unclear if the benefits of exercise persist after regular exercise has stopped or if they are similar in women over the age of 25.

REFERENCES: Armour M, Naidoo D, Ayati Z, et al. Exercise for dysmenorrhoea. Cochrane Database of Systematic Reviews 2019, Issue 9. Art. No.: CD004142. DOI: 10.1002/14651858.CD004142.pub4.

SEARCH METHODS The authors found 12 studies including 854 women that examined the effect of exercise in women with dysmenorrhoea. The evidence is current to August 2019. Two trials did not report data suitable to be included in the meta‐analysis, so the authors included 10 trials with 754 women in the meta‐analysis. Eleven trials compared exercise with no treatment and one compared exercise with NSAIDs. SELECTION CRITERIA The authors included studies if they randomised women with moderate‐to‐severe primary dysmenorrhoea to receive exercise vs no treatment, attention control, non‐ steroidal anti‐inflammatory drugs (NSAIDs) or the oral contraceptive pill. EXERCISE vs NO TREATMENT Exercise may have a large effect on reducing menstrual pain intensity compared to no exercise (standard mean difference (SMD) ‐1.86, 95% confidence interval (CI) ‐2.06 to ‐1.66; 9 randomised controlled trials (RCTs), n = 632; I2= 91%; low‐quality evidence). This SMD corresponds to a 25mm reduction on a 100mm visual analogue scale (VAS) and is likely to be clinically significant. It is uncertain if there is any difference in adverse event rates between exercise and no treatment. EXERCISE vs NSAIDs The authors were uncertain if exercise, when compared with mefenamic acid, reduced menstrual pain intensity (MD ‐7.40, 95% CI ‐8.36 to ‐6.44; 1 RCT, n = 122; very low‐quality evidence), use of rescue analgesic medication (risk ratio (RR) 1.77, 95% CI 1.21 to 2.60; 1 RCT, n = 122; very low‐quality evidence) or absence from work or school (RR 1.00, 95% CI 0.49 to 2.03; 1 RCT, n = 122; very low‐quality evidence). AUTHORS' CONCLUSIONS The current low‐quality evidence suggests that exercise, performed for about 45 to 60 minutes each time, three times per week or more, regardless of intensity, may provide a clinically significant reduction in menstrual pain intensity of around 25mm on a 100mm VAS. All studies used exercise regularly throughout the month, with some studies asking women not to exercise during menstruation. Given the overall health benefits of exercise, and the relatively low

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MEDICAL CHRONICLE | MAY 2020 45

OPINION

The challenge facing SA with the second wave of COVID-19 To ‘forecast’ and prepare for the future, we will need a snapshot of the history of previous pandemics. We need to be prepared and have the necessary resources to deal with the challenges during the aftermath of COVID-19.

T HAS ALREADY resulted in major economic and social costs. Our already ‘fragile’ economy is burdened even more. The social costs are not given enough prominence. The unemployment rate, I guess will be in the region of 40% now. The combined effect of COVID-19 lockdown and the constrained economy has plunged a huge proportion of our people into starvation, hunger, malnutrition and increased susceptibility to spread the virus. The COVID-19 crisis and our response goes beyond just medical provision. It started off as a health crisis, but it is going to become a resource and governance crisis. In the rural areas, it requires humanitarian assistance, food security, livelihood and infrastructure issues, clean water, sanitation and access to healthcare services. Though the transmission mechanisms are essentially the same there is variability with the disease burden, infrastructure capacity and economic vulnerability in the different sub populations within a country. Therefore, a single set of guidelines and a single approach will not suffice. WHAT HAVE WE LEARNT THUS FAR? The COVID-19 pandemic is likely to affect people from many countries as we are witnessing now. We cannot attach the transmission of the disease to any particular ethnicity or nationality. However, we must be aware of its impact on the low income sector with fewer resources and fragile health systems. There is diminished availability of hospital beds, ICU and critical care services, physician and healthcare worker capacity, essential equipment like ventilators and quarantine facilities. ANTICIPATING THE NEXT WAVE OF COVID-19 We need to reflect back to the historical pandemics and the epidemiological lessons that we can draw on to understand the possible future impact of COVID-19. The 1918 Spanish Flu Pandemic is the worst in modern history. The pandemic occurred in three waves, infecting a third of the world’s population and killing 50 million people. WAVE 1: Movement of the troops at the end of World War I (1918), contributed to the spread. WAVE 2: In the fall of 1918, the deadliest surge occurred. WAVE 3: The pandemic subsided in the summer of 1919, some 15 months later. The lessons from the 1918 influenza

46 MAY 2020 | MEDICAL CHRONICLE

pandemic remain relevant to the COVID-19 response for three reasons: 1. The costs of an unmitigated pandemic overwhelmed the global landscape. More people died in the 1918 Flu Pandemic in 15 months than from four years of conflict during World War I To put this into the present perspective, a high estimate of an equivalent pandemic today would kill 200 million people. 2. Pandemics may have multiple waves until a sufficient number of individuals become immune either surviving the infection or from effective vaccination The shape and frequency of the future waves with the COVID-19 pandemic will depend largely on how the global community’s current approach to slowing the pandemic. China reported a case load shift from a sustained community transmission to ongoing imported cases, requiring a high level of alertness to detect, contain and prevent a large second wave. Hong Kong increased new cases recently from travellers and ‘“imported’ from overseas. Waves of pandemics are typical in many infections. This was exemplified with the Cholera Pandemic of 1961, that resurfaced in Haiti in 2010 and in Yemen in 2017-2018. Studies of genomic lineage of cholera in Africa demonstrates that the infection was introduced in Africa in 1969 but is not entrenched here but has been repeatedly re-introduced from Asia 3. A domestic approach to contain Pandemic disease must align with the International Containment and Mitigation efforts more broadly as subsequent waves can be more deadly than the first. A number of concerns are raised by many Infectious disease experts, World Health Organization (WHO) and epidemiologists, that will help us understand the challenges the COVID-19 can pose. Like the 1918 influenza pandemic, war will facilitate the transmission of today’s pandemic. This will particularly be noticed with the conflicts in Syria, Yemen, Libya, Afghanistan and the Democratic Republic of Congo. These areas represent potential epicentres for populations caught in war zones. There will always be a debate around us rolling back social distancing and other containment measures. Social distancing is not feasible for any prolonged period of time in many instances. There are populations living in shelters, victims of inequalities, crowding, and need to travel in crowded transport to acquire food and essentials. Poor healthcare systems and public

health measures in low and middle-income countries will have a negative impact when trying to contain COVID-19. The factors contributing to this are: - Poor surveillance and outbreak response infrastructure - Deficit in the built environment and healthcare workforce - Failure of public health with TB and HIV/AIDS. The likelihood of emerging hot spots and lack of aggressive containment measures will result in the risk of multiple waves of COVID-19 and this could extend throughout the year into 2021. WHAT STRATEGY MUST BE IN PLACE? - Better control of the current spread - Reduce risk of subsequent waves - Help lead a global response not only to alleviate the suffering of the world’s most vulnerable but also to protect South Africa (The ‘Hell’: R David Harden and Louise and Ivers {03-24-2020}) The US CDC chief warns that the second wave of COVID-19 may be worse than the first wave. The second wave of COVID-19 is expected to hit the USA next winter and will strike harder than the first because it will likely arrive at the start of the Influenza season. There will in fact be a double viral epidemic which will have a compounding effect on the population. This is what we in South Africa must be mindful of and we cannot be complacent with our social distancing measures and also our adherence to hygiene protocols. FUTURE TRANSMISSIBILITY AND SEVERITY OF COVID-19 It is important to understand that following any premature relaxation of strict interventions post lockdown may lead to a transmissibility exceeding the first wave. This was witnessed in Wuhan, where a second wave was due to returning travellers. What we have not seen in South Africa is the peak of the epidemic. Relaxation of strict protocols might see a resurgence, an exponential rise and destructive second wave. The WHO guideline for Africa: “The Best Advice for Africa is to prepare for the worst and prepare today.” WHO has warned from the onset of the Health emergency of the risk that COVID-19 could spread to countries with weakest health systems, including sub-

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

Saharan Africa where poor sanitation, lack of clean water, proliferation of the informal economy and crowding, pose additional challenges in the effort to combatting a highly infectious disease. “The Fear and Danger” of Post Lockdown - If the COVID-19 resurges at the peak of the flu season in winter. The Health systems will be overwhelmed. The impact will be harder than the original viral outbreak. - With the absence of a vaccine, precautions of deadly outbreak will depend on a combination of other actions: o Strict social distancing as this has had an enormous impact when implemented properly o The country needs to scale up testing, treating and tracking of contacts, so that new COVID cases can be identified before they become large outbreaks o Flu vaccination must increase to minimise the number of “‘flu related hospitalisation’. - Mental Health – the long periods of isolation will witness a wave of mental health issues. Epidemiologists predict a range of mental health issues as people face the prospect of working under the current COVID-19 restrictions: o Effects of isolation o Effects of uncertainty and fear. High up on the mental health issues are anxiety, fear, depression and financial stress. During the SARS epidemic, a study in Toronto shared in addition to mental health issues, isolation can trigger heavier consumption of drugs and alcohol and even increase Post Traumatic Stress Disorder (PTSD). Important that in preparing properly for isolation is to inform them that physical distancing should not mean social isolation. It is the uncertainty of isolation that can trigger extremes for mental illness. COVID-19 pandemic is the defining global health crisis of our time and the greatest challenge we have since World War 2. Countries are racing to slow the spread of the virus by adopting various measures but central to these measures are testing, treating and tracking contacts. The pandemic is moving like a wave. One that may least crash on those least able to cope. COVID-19 is more than a health crisis. It has the potential to create devastating social, economic and political crisis that will leave ‘deep scars’. We are in uncharted territory and there is no way to know when normalcy will return.

PLACEBO

Retinal cryoprobe

celebrated on South African Mint's newest collectable coin

HE SOUTH AFRICAN MINT continues to unearth virtuous examples of South African ingenuity and innovation to further enrich the coin collecting experience. The Retinal Cryoprobe, invented and commercialised by South African ophthalmologist and biomedical engineer Dr Selig Percy Amoils is the subject of the new 2020 2½c tickey and R2 Crown series.

President Nelson Mandela had the cataract in his left eye removed days after his swearing in as democratic South Africa’s first black President The ‘South African Inventions’ theme was introduced on the Crown and tickey coin series in 2016 to highlight globally relevant inventions and firsts by South Africans. In 2019 Pratley Putty, the world’s first epoxy adhesive invented by South African engineer George Pratley and used by NASA aboard its Ranger moon-landing craft over 50 years ago. This year the series features the retinal cryoprobe, invented in 1965 at Baragwanath Hospital, Africa’s largest hospital located in Soweto, Johannesburg. The cryoprobe is a large, pen-like instrument commonly used in cryosurgery, a technique that uses extreme cold to remove abnormal or diseased tissue. The retinal cryoprobe emits analgesic nitrous oxide, at below freezing temperatures

of -80oC. When inserted into a cut in the eye it freezes the cataract, which is then removed effortlessly. The procedure only targets damaged tissues without affecting any adjacent tissue. Cataract surgery is one of the most common procedures performed worldwide and is considered among the most successful treatments in all of medicine. Cataract has been identified as a national health priority in the country and remains the leading cause of blindness according to the South African Optometric Association. Amoils received global recognition for his invention and in 1975 was awarded the Queen’s Award for Technological Innovation. He also received the Medal of Honour of the US Academy of Applied Science. His cryoprobe remains on display at the Kensington Museum in London. His most famous patient, President Nelson Mandela had the cataract in his left eye removed days after his swearing in as democratic South Africa’s first black President. For his work, Amoils was also bestowed with the Silver Order of Mapungubwe ‘for excellence in the field of ophthalmology and for inspiring his colleagues in the field of science’. The Order is awarded to South African citizens for achievements that have impacted internationally and served the interests of the Republic of South Africa. “We created this beautiful coin for coin collectors who cherish the prospect of adding unique themes

to their collections, as well as those whose lives have been changed due to this extraordinary invention. This is an everlasting way in which one can cherish the wonderful contributions made by South Africans," says Ms Honey Mamabolo, managing director, South African Mint. The crown coin features the anatomy of an eye on the reverse, the years ‘1965’ and ‘2020’, the words ‘Retinal Cryoprobe’, and the denomination ‘R2’. On the obverse, the national coat of arms, the words ‘South Africa’ in all the official languages, and the year of issue, ‘2020’, are featured. The reverse of the much smaller tickey coin depicts a gloved hand holding the retinal cryoprobe, the letters ‘SPA’ for ‘Selig Percy Amoils’, and the denomination 2½c. The obverse shows a King Protea, the words ‘South Africa’, and the year ‘2020’. When the tickey is placed on top of the crown in the designated area, the surgical procedure is recreated.

We created this beautiful coin for coin collectors who cherish the prospect of adding unique themes to their collections, as well as those whose lives have been changed due to this extraordinary invention Only 1000 of the 2020 South African Inventions sterling-silver R2 crown coins and the single 2½ c sterling-silver tickey coins will be produced individually, and 700 in a set including a sterling silver miniature sculpture of the eye and packaged in a beautiful piano finish varnish, walnut wood box. The range also includes the Krugerrand and Crown Launch set, which consists of a proof sterling-silver R2 Crown and a proof fine silver Krugerrand with a privy mark. Only 500 of these sets will be produced. MEDICAL CHRONICLE | MAY 2020 47

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