Medical Chronicle April 2020 Teaser by New Media Medical

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The doctor's newspaper

APRIL 2020

Time to listen to younger healthcare professionals

In this increasingly demanding environment, it’s time to empower the next generation to transform healthcare. By Nicky Belseck, medical journalist

N ITS FIFTH year, the Future Health Index 2020 report builds on the findings of the previous reports by examining the expectations and experiences of younger healthcare professionals aged under 40 and how they can be empowered to meet the demands of tomorrow’s healthcare. Specifically exploring their perceptions of today’s reality and the role technology plays in supporting them to deliver better care. This is the first global survey of its kind focused on the next generation of healthcare professionals. “The burden of expectation to transform healthcare lies on this group’s shoulders, but too often their views are not widely understood,” said Jan Kimpen, Philips chief medical officer. “Their responses are revealing and inspiring. These younger healthcare

professionals are dedicated to their patients and their careers and are driven by a desire to help others. “We stand at a critical point in healthcare,” said Kimpen. “The world’s healthcare systems are facing unprecedented challenges from both growing and aging populations, and an increasingly burnt-out workforce. “Physicians, nurses and support staff are juggling the challenges of patient care with increased administration, while managers deal with staffing issues and increasing pressure to reduce costs. Those working in healthcare face professional and personal stress. “But there is opportunity,” said Kimpen. “The current generation of younger professionals will soon make up the majority of our global healthcare workforce. They have the responsibility – and the privilege – of delivering the changes that are needed to ensure healthcare systems are fit for purpose.

Value-based care is the ultimate aspiration of this, delivered through the Quadruple Aim of better health outcomes, improved patient and staff experience, and lower cost of care. “But they are concerned by the administrative demands that deflect from their core duties and frustrated by what they perceive as the slow pace of technological change. These are warning signs that need to be addressed at all levels to avoid paying the price later. We cannot afford for these talented professionals to become disengaged or we risk losing their skills and commitment to the sector,” warned Kimpen. EXPLORING THE GAPS IN HEALTHCARE EDUCATION AND TRAINING Younger healthcare professionals see four key gaps in their careers relating to: skills, knowledge, data and expectations:

•T he skills gap Highly trained younger healthcare professionals are unprepared for non-clinical demands, potentially leading to burnout. Forty-four per cent of participants said their medical education had not prepared them at all for business administration tasks. •T he knowledge gap Hospitals and healthcare practices are increasingly shifting towards value-based care models. However, the vast majority of younger healthcare professionals had limited or no knowledge of value-based care prior to taking this survey. This indicates that, despite its growing adoption, the concept is not being covered in medical schools or during on-the-job training. Concerningly 78% of participants only knew it by name, a little, or nothing at all. Reliance on volume-based metrics and the lack of understanding of value-based care hinders continued on page 2

Every fracture needs an action plan

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NEWS

APRIL 2020

continued from page 1

its widespread adoption. • The data gap Younger healthcare professionals are digital natives, but many still need support to use data to strengthen clinical performance. Thirty-five per cent of participants said they don’t know how to use digital patient data to inform patient care. Moreover, the volume of data they encounter in daily practice can be overwhelming. • The career expectation gap Worryingly, many participants (41%) feel a gap between the reality of their career and what they had hoped it would be. The danger is that these disenchanted professionals will leave healthcare prematurely. Appropriate training in technology can help to reduce this career expectation gap. HARNESSING TECHNOLOGY TO HELP TRANSFORM HEALTHCARE Younger healthcare professionals have a positive yet pragmatic attitude to technology. They acknowledge its potential to ease their administrative workload, resulting in a reduction in work-related stress. And, with almost three-quarters of younger healthcare professionals regularly experiencing work-related stress that could ultimately lead to them leaving the profession, it’s vital that technology is harnessed appropriately. Most younger healthcare professionals see digital health technologies as tools to

enhance outcomes (74%) and improve patients’ experiences (79%). Seventy-eight per cent of participants also agreed that the societal benefits of improved patient care from the use of anonymised health data outweigh the perceived data privacy concerns of the individual.

Physicians, nurses and support staff are juggling the challenges of patient care with increased administration, while managers deal with staffing issues and increasing pressure to reduce costs. Those working in healthcare face professional and personal stress CREATING THE IDEAL HEALTHCARE WORKING ENVIRONMENT The next generation of healthcare professionals is well prepared for clinical practice and the responsibility that comes with caring for patients. But this new generation will not stand for the current situation in workplace culture and hours.

They are clear in their desire for a good worklife balance and flexibility, and collaboration within the workplace. Without a collaborative and empowering workplace culture to underpin uptake, the long-term adoption of digital health technologies will fail. Hospitals and organisations that prioritise a culture of collaboration – across data, technology and workplace culture – and appropriate technologies will be more likely to attract and retain staff. CONCLUSION “Global healthcare systems are under strain,” said Kimpen. “But this challenge can bring opportunity – through collaboration, sharing initiatives, and the use of technology and data. “The coming years will see increased emphasis on delivering continuous care outside the hospital and clinic walls. We will also see a push to explore innovative reimbursement models that realise both more value and better outcomes for patients, with technology and data playing a crucial role. “The valuable intelligence younger healthcare professionals have shared with us can be used to maximise the opportunities they offer and, by doing so, shape the future of healthcare. “Change won’t happen overnight, but the insights provided by this generation put healthcare leaders in a stronger position to tackle the high costs and waste in the system.”

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

NEWS Time to listen to younger healthcare professionals...........................1 COVID-19 and cancer....................................3 COVID-19 Q&A with Minister of Health..............................................................4 Telemedicine tug of war.............................5 Testing for COVID-19....................................6

PRACTICE MANAGEMENT COVID-19 resist the urge to exit your investment..............................................7

CLINICAL INFECTION CONTROL COVID-19 infection prevention in care facilities....................................................8 Anaesthetists are at high risk of infection.......................................................10

CANNABIS Medical cannabis – What’s the evidence?..................................9

ONLINE CPDs

We salute you DEAR READER, COVID-19 has dominated global headlines, and our lives, for the past couple of weeks. We have reached a milestone that no one wanted – over one million cases worldwide. We have all been affected, to varying degrees. Some of us are in lockdown while you, our valued healthcare professionals, work tirelessly, putting yourselves at risk, to help save lives. You are our national heroes during this pandemic. To those of you at the frontlines of testing, diagnosing and treating the Covid-19 pandemic, we thank you for your service to South Africa and its people. We feature a Q&A with Dr Zweli Mkhize and look at the debates around telemedicine and its role during this pandemic. The outbreak has also

CONTENTS

Diabetes and COVID-19 ............................11 Antibacterial management of conjunctivitis and blepharitis .......22

had a severe impact on the economy. Resist the urge to exit your investment, as explained by Andrew Dittberner, CIO of Old Mutual Wealth Private Client Securities. If you need a break from COVID-19, our CPD article is on the topic of osteoporosis, looking at the importance of a fracture liaison service in the management of these patients. Prof Chetty, our opinion writer, looks at how we can navigate this crisis. The KwaZulu-Natal Doctors Healthcare Coalition is providing a COVID-19 helpline, manned by a dedicated community of over 450 doctors from around the country. Correction: In February’s CPD article titled Pumping iron: Combating nutrient deficient anaemia, one of the author’s designations was incorrect. Caragh Cooper is a Consultant Medical Writer and Pharmacist.

CRITICAL CARE Alternatives to hazardous chemicals in medical devices.............................................12

WINTER AILMENTS COVID-19 or a cold?....................................14 COVID-19 and the flu vaccine ...............15

OSTEOPOROSIS Every fracture needs an

action plan........................................................16

PSYCHIATRY How to deal with COVID-19 anxiety..........................................19

RHEUMATOLOGY New concepts in an old disease .........21

ONCOLOGY New treatment provides hope for advanced ovarian cancer patients....23

DIABETES Study results: Basal insulin in patients

Have you had your say in our Reader Survey? Scan this code to take part. Happy reading and stay safe!

who fast during Ramadan......................25

OPINION Post COVID-19, Where to? ....................26

MEMORIAM A sad farewell to Prof Ramjee.............27

2 APRIL 2020 | MEDICAL CHRONICLE

NEWS

COVID-19 and cancer

Global virtual knowledgebase and novel coronavirus experts’ network to support the cancer community, including weekly live and interactive programming to discuss the latest research and updates. By Nicky Belseck, medical journalist

HE GLOBAL COVID-19 pandemic brings unique circumstances and challenges for cancer treatment. “Cancer patients currently are at a five-fold increased risk of mortality from COVID-19,” said Dr Prasun Mishra, president and chief executive officer of American Association of Precision Medicine (AAPM) and chair of the AAPM Coronavirus Taskforce (ACT), which brings together global clinical, scientific and technological leaders to discover and disseminate strategies for COVID-19 specific prevention, diagnostics, therapeutics and solutions. “To date, there are no official recommendations in terms of ongoing oncology treatments with COVID-19 in mind, and cancer patients are struggling with the reality of undergoing lifesaving treatments that could potentially compromise their immune system, making them more susceptible to the widespread pandemic,” said Dr Mishra. In light of the novel coronavirus (COVID-19) pandemic, GRYT Health, (‘grit‘) creator of the Global Virtual Cancer Conference and the GRYT Health Cancer Platform, has partnered with the American Association of Precision Medicine (AAPM), a non-profit organisation focused on accelerating precision medicine and transforming patient health, to bring timely ongoing updates, expertise, resources,

and connection to those dealing with a cancer diagnosis. To connect cancer patients, survivors, caregivers, and the general public to realtime information and experts to help inform decision making, GRYT Health and AAPM have developed a suite of resources on grythealth.com/coronavirus.

Cancer patients and their families already undergo significant anxiety and mental stress having to deal with difficulties in diagnosis, access to care, treatments and lifestyle changes

“Especially at a time when clear, actionable information is unavailable for those dealing with cancer and the coronavirus simultaneously, our communitybased approach will provide targeted, timely resources where it is needed most – to cancer patients and their caregivers

wondering how the virus affects their disease and treatment,” said Dave Fuehrer, chief executive officer of GRYT Health and two-time cancer survivor. The web portal will provide access to experts shaping public policy, diagnostics, and patient experience highlights, as well as weekly live programming to discuss the latest research and targeted updates to the cancer community in an interactive format. As programmes are offered virtually, users can be anywhere in the world, aligning with the Center for Disease Control and Prevention (CDC) recommendation of social distancing to reduce the spread of COVID-19. “Cancer patients and their families already undergo significant anxiety and mental stress having to deal with difficulties in diagnosis, access to care, treatments and lifestyle changes,” said Fuehrer. “Trying to figure out what precautions they need to take regarding COVID-19 only exacerbates the patient burden. We are proud to offer resources that will not only inform them but offer a way to get questions answered and provide connectivity through our global virtual cancer community in a time of mandated isolation.” In addition to the resources available on grythealth.com/coronavirus, users have the ability to connect with their peers in a variety of chatrooms on the GRYT Health

platform, available at grythealth.com or on the free GRYT Health app, to find support and connections through others who are undergoing similar experiences. The platform also offers access to free 24/7 support through the mental-health tool, Vivibot, which is clinically proven to decrease anxiety and increase resiliency. The series of free, live, virtual programming kicked-off with a COVID-19 patient and a physician treating those with COVID-19 on 28 March, followed by: • COVID-19 Leaders Forum: (4 April 2020) • COVID-19 Global Forum: (11 April 2020) • COVID-19 Global Summit: (18 April 2020) • Authenticity: Cancer & Your Mental Health Summit: (25 April 2020). All programmes will be recorded and available on demand. Users can register for these free programmes by visiting grythealth.com/coronavirus, where they can also connect with our cancer community at any time and receive support. Additionally, users can sign up to receive ongoing updates regarding the latest COVID-19 news impacting their journeys.

Information was correct at the time of print.

MEDICAL CHRONICLE | APRIL 2020

NEWS

COVID-19 Q&A with Minister of Health

Four days before President Cyril Ramaphosa announced the 21-day lockdown, Minister of Health Dr Zweli Mkhize sat down for a COVID-19 Q&A session with SAMA members appealing to them to share their experiences and suggestions. By Nicky Belseck, medical journalist

TRESSING THE IMPORTANCE of tracing the spread of the disease, Dr Mkhize raised concerns over the cost of the COVID-19 test. “At least 97% of the patients that have been diagnosed have come from the private sector. The problem is many people who have tested positive but have a mild case and don’t need to be admitted to hospital, go home afterwards and when they feel better they don’t go back to have another test to see if they’re now negative. “The symptoms are gone; they feel fine and don’t want to spend another R1 200R1 400 to confirm they’re fine. This makes it hard for us to follow up and confirm recovered cases. This is why we need proper coordination and need assistance from private doctors. When people are tested the first time take as much details as possible so that it’s easier for us to follow up on them. The tracking and tracing of confirmed cases is a real problem. We’re going to get an NGO that can help us to do the mop up after patients have tested positive. So, 14 days after they’ve tested positive, we can go to their door to take a follow up test to confirm they’re negative. Dr Mkhize stressed the importance of a strong coordination between NICD, NDoH, and provinces broken down all the way to district level. It’s important because the real war we’re having now, where we have a weak element, and we’re trying to catch up with it, is tracing of contacts. We’ve recruited close to 2 000 tracers so far and are coordinating the system and looking at how to improve the contact tracing. We need to be able to match the rate at which the infection is spreading.” Highlighting the importance of working together Dr Mkhize said: “The bulk of the people who are going to see the presentation of the disease are members of SAMA. We need to know what your challenges are so we can meet each other half way to find a way to resolve those challenges, to improve your capacity to detect the infection, to prevent the infection from going from the patient to you, and to prevent the infection from going from one patient to the next person. That is the fight we need to wage. GOING TO WAR Dr Mkhize described doctors as being on the frontline saying, “We’ve passed the

4 APRIL 2020 | MEDICAL CHRONICLE

the DoH to look at strengthening primary healthcare facilities. Perhaps the biggest concern raised was the lack of personal protective equipment (PPE) and other controls for primary healthcare staff like GPs and clinic staff. “If we have a situation where doctors and nurses are getting sick then the whole healthcare system is going to collapse,” one doctor said. PUBLIC EDUCATION ON TESTING REQUIREMENTS Another concern raised was that GPs had several incidents where patients requested the COVID-19 test because their company insisted staff had to have a negative test before they’d be allowed to work. However, when patients don’t meet the testing requirements, doctors aren’t able to do more than give them a letter on the practices’ letterhead explaining as much to employers, which they’ve refused to accept.

planning phase, the deciding what we will or won’t do when the disease gets here phase, it’s here, we’re in the battle now. This enemy is spreading rapidly and targeting us where we’re most vulnerable. So now we must mobilise our forces to target the enemy. We’re in hard combat territory. It’s going to be hard for all of us but if we’re focused and determined we are going to be able to make an impact with regard to the infection. It’s up to each and every one of us to say we want to reduce the fatalities. We can’t have the numbers just rising uncontrollably, we want to make sure we talk to our people as much as possible so we can delay a peak of this infection, so that we can contain the number of cases up until we get to a point where maybe we won’t be very far from a vaccine. “Our estimations are that in any community 60-70% will be affected by the disease. We can’t hide from that. Most of us in SA will have this virus, but it doesn’t mean it’s going to be a severe disease for all of us. It will be severe for 20%, so let’s make sure that each and every time the 20% is small so we don’t have the strain of trying to open up new ventilators and all those things.” Asking doctors for their suggestions Dr Mkhize said: “You’re shining a light in our blind spot. We aren’t where you are, we need to know what you’re experiencing, what

challenges you’re facing. With those suggestions we’ll know if we have to change policies, guide everything to make sure your detection and prevention measures are helpful.” He went on to say, “We don’t want a situation where a health worker is infected. There shouldn’t be any health worker infected. We need to innovate so we can change the course of this virus.” Acknowledging SA’s unique population Dr Mkhize said: “No one else has seven million people who are HIV positive with many on antiretrovirals. No one else has as much TB as us. No one else has inequality and distribution of poverty to one part of the country, and affluence on the other like us. We need to come up with unique, innovative solutions.” Encouraging SAMA members, Dr Mkhize stressed that the country was behind them. “You’ve got support from President Ramaphosa, you’ve got support from government, the cabinet, and political parties, you’ve got support from religious leaders and communities. The entire South African nation is behind you. Together this out break can be defeated. Let’s flatten this curve. PROTECTING HEALTHCARE WORKERS Members of the audience appealed to

Health Minister Dr Zweli Mkhize

TELEMEDICINE A doctor’s appeal for the need to seriously consider telemedicine and virtual consultations was met with echoes of support from SAMA members in attendance. “The problem at the moment is that the Health Professions Council of South Africa (HPCSA) guidelines on virtual consultations are really highly restrictive,” she said. “Perhaps from the DoH we could have a directive which at a minimum suspends these guidelines? But I think we need this to happen fast. Other requests included more detailed updates on new cases, step-by-step protocols for practices once a patient has tested positive for COVID-19, and an appeal to seek information from colleagues in countries like China who have already peaked and gone through what SA still faces.

Telemedicine

NEWS

tug of war

Enthusiasm for the HPCSA’s new telemedicine guidelines was short-lived. By Nicky Belseck, medical journalist

OT ONLY WAS the Minister of Health, Dr Zweli Mkhize, clearly listening to doctors when he met with the South African Medical Association (SAMA) members on 19 March, but he wasted no time taking action. During the Q&A an appeal was made for the urgent need to consider telemedicine and virtual consultations during the COVID-19 pandemic. “The problem at the moment is that the Health Professions Council of South Africa (HPCSA) guidelines on virtual consultations are really highly restrictive,” a doctor said. “Perhaps the DoH could provide a directive, which at a minimum suspends these guidelines? But I think we need this to happen fast.” Exactly one week later the HPCSA issued new guidelines on telemedicine. The association recognised that, ’practitioners are faced with an ethical dilemma of how to contribute to the national endeavours of self-isolation and social distancing and continue to be accessible to their patients within the current Telemedicine framework of the HPCSA’. The association stated clearly that the existing guideline had been amended for the period of the COVID-19 pandemic and will cease to apply once it is over. MEDICAL ORGANISATIONS REJECT NEW GUIDELINE Unfortunately, after closer inspection of the new guidelines, any enthusiasm from healthcare professionals was shortlived. Organisations representing medical doctors, medical schemes and medical scheme administrators expressed deep concern and – in an open letter – protested the guidelines, asking the HPCSA to immediately review its decision. The organisations described the HPCSA’s view that doctors can only consult with patients remotely using telemedicine technology if they have a pre-existing relationship with the patient, they are consulting, as baseless. The only exception is for consultations conducted by mental health professionals. GUIDELINES BRANDED DANGEROUS However, SAMA, the Board of Healthcare Funders, the Health Funders Association, the South African Private Practitioners

Forum, the South African Society of Anaesthesiologists, the United Forum of Family Practitioners, and the IPA Foundation, say the guideline is wrong and dangerous. “There is no rational basis for the guideline. The HPCSA has not presented any facts or evidence nor has it explained the basis for maintaining its position. Why would a doctor need a prior relationship with a patient to give advice about COVID-19?” asked Dr Angelique Coetzee, chairperson of SAMA, on behalf of the group of bodies. Adamant the HPCSA’s position is

Every country we are aware of is actively encouraging tele consultations to protect the health of their critically needed frontline medical doctors, as well as to prevent patients from unnecessary travel and exposure to potential cross-contamination and infection

incongruent with telemedicine regulations across the globe, the group said: “Every country we are aware of is actively encouraging tele consultations to protect the health of their critically needed frontline medical doctors, as well as to prevent

patients from unnecessary travel and exposure to potential cross-contamination and infection.” Furthermore, the organisations said the guideline creates an immediate and material risk for doctors in the country. “Instead of being able to provide

sound advice remotely, they are being forced to see patients in person. By removing infected doctors from the front-line of healthcare delivery, this ruling will also lead to the weakening of our healthcare system as a whole, precisely at the time when we should be doing everything in our power to strengthen it,” the group said. “We do not understand why allied health professional are allowed to use t elemedicine, but medical doctors are restricted to do so?” The organisations demanded the HPCSA change the guideline for medical doctors with immediate effect during the COVID-19 pandemic relating to telemedicine. It has also called on the HPCSA to thoroughly review its position on telemedicine once the pandemic is over, and to allow doctors to consult virtually as and when they believe it appropriate, as is the case in most other countries. MEDICAL CHRONICLE | APRIL 2020

NEWS

Testing for COVID-19 Dr Boitumelo Semete, CEO of SAHPRA, recently sent out a communication to stakeholders on the issue of COVID-19 rapid tests.

T EXPLAINED THAT in line with the recommendation of the South African National Institute for Communicable Disease (NICD) and the recommendation of the World Health Organization (WHO), serological tests that are being offered for the diagnosis of COVID-19 are not

suitable for the diagnosis of COVID-19 at the acute stage. â&#x20AC;&#x153;They are not helpful to guide decision making regarding patient management, decisions regarding the need for quarantine, isolation or contact tracing at the point of the pandemic in the country,â&#x20AC;? the statement said.

TESTS USED TO DIAGNOSE COVID-19 1. COVID-19 is the disease caused when a person is infected by the novel coronavirus called SARSCoV-2. 2. An in vitro diagnostic test can be performed to determine if a person has been infected with SARS-CoV-2 and therefore

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has COVID-19. 3. Two different types of in vitro tests are possible: a.T ests that detect the presence of the SARS-CoV-2 virus (molecular tests). These tests are performed on material obtained by means of nasopharyngeal and oropharyngeal swabs. b. Tests that detect antibodies to the SARS-CoV-2 virus (serological tests). These tests are conducted on finger-pick blood samples. MOLECULAR TESTS 4. These tests detect the presence of genetic material (nucleic acids) of the actual SARS-CoV-2 virus. Such tests are good at detecting the virus early in the infection and can detect the virus in a person before they become unwell. 5. Nucleic acid tests (reverse transcriptase polymerase chain reaction; RT-PCR) are laboratory-based tests, requiring access to specialised equipment. SEROLOGICAL TESTS 6. Serological tests detect the presence of IGM and/or IgG antibodies to SAR-CoV-2. 7. These tests can be conducted at the point-of-care, as they rely on lateral flow methods and can be conducted on a small finger-prick blood sample. 8. Serological tests are not suitable for the diagnosis of COVID-19, as the period between acute infection and detection of antibodies is unknown at this time. They are not helpful to guide decision making regarding patient management, decisions regarding the need for quarantine, isolation or contact tracing. REGULATORY REQUIREMENTS 9. At this time, diagnosis of COVID-19 should be made by means of approved molecular diagnostic tests, not by serological tests. 10. The sale of serological tests, whether for self-testing or testing under the supervision of healthcare professional is not advised. 11. In SA, only companies that are licensed by SAHPRA may manufacture, import or sell diagnostic tests. TESTING FOR COVID-19 12. All COVID-19 testing must be done using molecular testing, under the supervision of a healthcare professional, by an accredited public or private sector laboratory. 13. Please see the SAHPRA website for updates relating to COVID-19 (www.sahpra.org.za). 14. Please report any company/individual/ website selling COVID-19 serological testing kits to SAHPRA so that the necessary action can be taken in this regard. Source: SAHPRA

6 APRIL 2020 | MEDICAL CHRONICLE

PRACTICE MANAGEMENT

COVID-19 resist the urge to exit your investment Maintain a long-term perspective, even in the face of severe market swings.

HE EXTREME MARKET Volatility currently being experienced due to concerns around the spread of COVID-19, commonly referred to as Coronavirus, is seeing investors exiting global equity markets in attempt to cut their losses. However, this approach is counterproductive and instead, investors should ignore the daily fluctuations and remain focused on their long-term investment objectives. “While it’s natural for investors to want to guard against further pull-backs during market drawdowns, it is vital to maintain perspective as steep, short-term downturns ultimately smooth out over the long term,” says Andrew Dittberner, chief investment officer at Old Mutual Wealth Private Client Securities. “History shows that volatility and drawdowns are inherent in equity investing. It’s not uncommon to experience intra-year declines well over 10%, yet, more often than not, markets recover from those drawdowns within the calendar year. It’s therefore highly probable that exiting the market during periods of heightened volatility will result in investors missing the upside that inevitably materialises.” A KNOWN UNKNOWN Dittberner describes COVID-19 as a ‘known unknown’, a reference to former US Secretary of Defence, Donald Rumsfeld’s 2002 response about whether Iraq had been supplying weapons of mass destruction. In his response, Rumsfeld separated military intelligence into ‘known knowns’, describing things we know that we know. ‘Known unknowns’, referring to things we know we don’t know; and ‘unknown unknowns’, which are those things we don’t know that we don’t know.

Dittberner says, “COVID-19 is a known unknown because it isn’t possible yet to predict the true extent of its impact on the global economy and markets.” “Needless to say, trying to predict the future is a futile exercise. The Coronavirus is a black swan event that nobody could have foreseen. Market participants and economists alike, have been for some time trying to predict what will derail the global economic recovery and record-breaking financial markets. Trade wars, debt, Brexit, geopolitical tensions were all among the suspects, yet no one foresaw a virus potentially doing the job. This is a great example of why forecasting is close to impossible. A far more efficient and effective approach is ensuring that we remain invested in high-quality businesses that can withstand the market volatility that ensues from the onset of unknown events.”

COVID-19 is a known unknown because it isn’t possible yet to predict the true extent of its impact on the global economy and markets ACCEPT THE VOLATILITY Accepting the volatility in markets will help investors maintain the perspective and fortitude required to stay the course through both good and bad times. The danger for investors lies in withdrawing from the market and missing out on the early, possibly rapid price recovery. Historical market data shows

that periods of volatility and downturns are typically followed by enduring upward swings. Furthermore, Dittberner points out that going back to the late 1800s, the S&P 500 Index has never yielded a period of negative real returns for investors who have remained invested for a 20-year period. These periods include both World Wars, the Great Depression and the Global Financial Crisis. “This highlights the power of remaining invested for the very long-term. We acknowledge that not all investors have a 20-year investment horizon, which is where effective asset allocation comes into play.” According to Dittberner, the strength of an investment portfolio’s returns is correlated to the quality of its underlying assets. RETURNS ON CAPITAL “When investing in a business, our philosophy seeks to identify companies that can generate superior returns on capital. This is typically achieved by companies that have high and sustainable margins. Alongside this, we aim to identify businesses that can grow to deploy capital at those higher rates of return. “From a leverage perspective, we prefer lower debt levels. We acknowledge that some level of debt may be positive for certain companies, provided that there are sufficient earnings and cash to cover the interest and debt repayments multiple times. While we would expect to pay a higher price for these quality businesses given that they are superior to the market, we ensure that we do not overpay.” Dittberner concludes by saying that these fundamentals should stand a well constructed, diversified portfolio in good stead over the long term.

Andrew Dittberner, Chief investment officer, Old Mutual Wealth Private Client Securities

SEPARATING THE FACTS FROM THE HYPE While previous viral outbreaks such as SARS and MERS also caused global panic, the proliferation of social media has increased the speed and breadth at which information (and misinformation) spreads around the world. The net result is that the typical panic that follows a viral outbreak has been significantly amplified this time around. Early in February, the World Health Organization (WHO) called the Coronavirus “a massive infodemic” due to the overabundance of both true and false information. The narrative regarding COVID-19 has evolved with time. Following the initial panic at the beginning of the year, comparisons to the common flu and the 2003 SARS virus dominated headlines, with the main message being that people should stop overreacting as we’ve been through this before. However, just over a month later it became clear that the outbreak was far more serious than the common flu and SARS. As this reality settled in, the narrative evolved and China and the WHO were accused of underreporting statistics to cover up the true magnitude of this outbreak. This is a frightening possibility. At this stage, it is important to remember that the narratives surrounding COVID-19 are exactly that - narratives. Therefore, it is far more prudent to remain calm, focus on the facts and prepare adequately for the risks that may present themselves. Right now, COVID-19 is one such risk and is unfortunately, what Donald Rumsfeld would have referred to as a ‘known unknown’ since we cannot predict the true extent of its impact on the global economy and markets.

CLINICAL | INFECTION CONTROL

COVID-19 infection prevention in care facilities

The World Health Organisation (WHO) has provided interim guidance to prevent COVID-19 infection in long-term care facilities (LTCFs), such as nursing homes and rehabilitative centres. HESE ARE FACILITIES that care for people who suffer from physical or mental disability, some of who are of advanced age. The people living in LTCF are vulnerable populations who are at a higher

risk for adverse outcome and for infection due to living in close proximity to others. So, LTCFs must take special precautions to protect their residents, employees and visitors.

IPC FOCAL POINTS LTCFs should ensure that there is an Infection Prevention and Control (IPC) focal point at the facility to lead and coordinate IPC activities, ideally supported by an IPC

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8 APRIL 2020 | MEDICAL CHRONICLE

team with delegated responsibilities and advised by a multidisciplinary committee.

DDB SA 45388

At a minimum, the IPC focal point should: • Provide COVID-19 IPC training to all employees, including: – An overview of COVID-19 – Hand hygiene and respiratory etiquette – Standard precautions – COVID-19 transmission-based precautions • Provide information sessions for residents on COVID-19 to inform them about the virus, the disease it causes and how to protect themselves from infection • Regularly audit IPC practices (hand hygiene compliance) and provide feedback to employees • Increase emphasis on hand hygiene and respiratory etiquette: – Ensure adequate supplies of alcoholbased hand rub (ABHR) [containing at least 60% alcohol] and availability of soap and clean water. Place them at all entrances, exits and points of care – Post reminders, posters, flyers around the facility, targeting employees, residents and visitors to regularly use ABHR or wash hands – Encourage hand washing with soap and water for a minimum of 40 seconds or with ABHR for a minimum of 20 seconds – Require employees to perform hand hygiene frequently, in particular at the beginning of the workday, before and after touching residents, after using the toilet, before and after preparing food, and before eating – Encourage and support residents and visitors to perform hand hygiene frequently, in particular when hands are soiled, before and after touching other people (although this should be avoided as much as possible), after using the toilet, before eating, and after coughing or sneezing – Ensure adequate supplies of tissues and appropriate waste disposal (in a bin with a lid) – Post reminders, posters, flyers around the facility, targeting employees, residents, and visitors to sneeze or cough into the elbow or to use a tissue and dispose of the tissue immediately in a bin with a lid • Maintain high standards of hygiene and sanitation practice • Provide annual influenza vaccination and pneumococcal conjugate vaccines to employees and staff. Source: Infection Prevention and Control guidance for Long-Term Care Facilities in the context of COVID-19. WHO Interim guidance 21 March 2020.

CLINICAL | CANNABIS

Medical Cannabis – What’s the evidence?

Clinical evidence of the indications for the use of medical cannabis is currently supported by a limited evidence base, but the field is evolving.

EDICAL CANNABIS HAS been shown to be effective for certain conditions, but the benefit for most investigated indications is limited. THC and CBD are the most widely researched phytocannabinoids. CANNABINOIDS AND MEDICAL CANNABIS The pharmacologically active ligands in medical cannabis are the cannabinoids. Over the past years, almost 200 cannabinoids have been identified, and the type of cannabinoids differs depending on whether they are endogenous (endocannabinoids), plant derived (phytocannabinoids) or synthetic. The endocannabinoid system consists of endogenous lipid-based neurotransmitters that bind to cannabinoid receptors expressed widely throughout the body. The endocannabinoid system purportedly has two types of receptors, CB1 and CB2. CB1 receptors are abundant in the brain and central nervous system but are also found in various other tissues. CB1 receptors are thought to regulate functions such as memory, nausea and vomiting, nociception, sleep and appetite. CB2 receptors are mostly found in immune cells and the cardiovascular, gastrointestinal and reproductive systems, where it is considered to regulate various functions. The CB1 and CB2 receptors can be stimulated by endocannabinoids, phytocannabinoids or synthetic cannabinoids. An important consideration is that the affinity and potency of the different cannabinoids for CB1 and CB2 receptors differ such that efficacy and safety of one cannabinoid cannot be applied to another. Phytocannabinoids are isolated from the Cannabis sativa and Cannabis indica plants. THC and CBD are the most widely researched phytocannabinoids. The psychoactive effects of cannabis have been attributed to THC, a major compound of the C. sativa plant, while CBD is thought to inhibit these effects. THC functions as an agonist with high affinity for both CB1 and CB2 receptors. CBD has low affinity for CB1 and CB2 and displays antagonism and inverse agonism at these receptors. This implies that the ratio of THC and CBD in phytocannabinoids would affect the ultimate clinical effect. The strain of cannabis and the cultivation environment, such as soil type, irrigation, harvesting and processing, all affect the quality and composition of phytocannabinoids. Different parts of the cannabis plant also have differing concentrations of phytocannabinoids, with THC generally

being most abundant in the flowers and leaves, and CBD in the leaves and stems. CANNABINOID-APPROVED DRUGS To date, the US Food and Drug Administration (FDA) has approved three drugs that contain cannabinoids: A plantderived CBD solution, and two synthetic cannabinoids structurally related to THC, nabilone and dronabinol. A purified form of THC and CBD in a 1:1 ratio, known as nabiximols, has been approved by Health Canada and several other countries. Approved medical cannabis products on the market are oral formulations administered either as capsules, oral solutions or oromucosal sprays. These standardised preparations aim to provide accurate dosing and improve safety. Evidence supporting benefit from the use of medical cannabis exists for two drugresistant childhood forms of epilepsy, Dravet syndrome and Lennox-Gastaut syndrome.

Three randomised controlled trials (RCTs) assessed the effect of a pharmaceutical plant-derived CBD solution, and found that when added as adjuvant therapy at the maximum recommended dose, it led to a significant reduction in the median frequency of monthly seizures when compared with placebo for Lennox-Gastaut syndrome (–18%; 95% confidence interval (CI) –31.8 - –4.4; p=0.009), and for Dravet syndrome (–22%; 95% CI –41.1 –5.4; p=0.01). Based on these findings, the FDA approved the plant-derived CBD for Dravet and LennoxGastaut syndromes, and approval by the EMA followed thereafter. Long-term therapy with CBD in these epilepsy syndromes has also found sustained response and acceptable tolerability. For other conditions, there is moderate evidence for the management of chemotherapy-induced nausea and vomiting (CINV) and multiple sclerosis (MS)-associated spasticity. The synthetic

cannabinoids dronabinol and nabilone showed the best efficacy in reducing CINV, but the risk of bias and lack of consistency of findings in trials limit their recommendation. Nevertheless, dronabinol and nabilone have both received FDA approval for refractory CINV. In April 2019, SAHPRA announced that the first three licences permitting the sale of medicinal cannabis would be issued. We are likely to see many more of these, as a result of their backlog project.

REFERENCES 1. Minister of Justice and Constitutional Development and others v Prince and others [2018] JOL 40399 (CC); 2. Prince v Minister of Justice and Constitutional Development and others and related matters [2017] 2 All SA 864 (WCC)); 3. Mthembu and others / NCT Durban Wood Chips [2019] 4 BALR 369 (CCMA); 4. Item 7, Schedule 8, Labour Relations Act 66 of 1995. 2. Van Rensburg, R et al. Medical cannabis: What practitioners need to know. South African Medical Journal, [S.l.], v. 110, n. 3, p. 192-196, feb. 2020. ISSN 2078-5135. Available at: http://www.samj.org.za/ index.php/samj/article/view/12860.

MEDICAL CHRONICLE | APRIL 2020

CLINICAL | INFECTION CONTROL

Anaesthetists are at high risk of infection

While confirmed cases of coronavirus have been reported in South Africa, the South African Society of Anaesthesiologists (SASA) warns that the virus poses a threat to us all, including healthcare workers in general, and anaesthetists in particular.

AFETY PROTOCOLS MUST be rigorously applied. According to the most recent available data from the World Health Organization, 71 429 cases of coronavirus have been reported worldwide. There have been 1 772 deaths. The majority of cases are in mainland China. The virus has been spreading rapidly, and SASA has engaged its partners in South African healthcare as a precaution to keep anaesthetists and their patients safe. Anaesthetists are especially at risk of coronavirus infection, says Natalie Zimmelman, chief executive at SASA. “Intubation and caring for critically ill patients elevates the risk of exposure to coronavirus and all contagious pathogens. We call for collaboration and for all facilities - in both private and public sectors - to work with us to ensure adequate plans are in place to protect clinicians.” SASA, she says, has issued safety reminders and guidelines to its members. These were published in the SASA member newsletter last week. The guidelines have also been shared with international anaesthesia societies. They include precautionary steps that should be taken to screen patients for coronavirus. SASA’s advice specifically is not to rely on patient body temperature alone as an indication of infection as the virus has a 14-day incubation period. The SASA guidelines also give anaesthetists advice on steps to take when coronavirus is suspected or confirmed in a patient. The guidelines include providing both patient and doctor with a mask; isolating the patient in a room with negative pressure ventilation and/or remaining at least a metre away from the patient (when attired in regular clothing). The South African Society of

10 APRIL 2020 | MEDICAL CHRONICLE

Anaesthesiologists (SASA) calls upon all healthcare players (and especially on government) to collaborate on ensuring safety protocols are applied to protect clinicians against possible coronavirus infection. “We call on the wider health sector to work with us to keep South Africa’s health personnel safe,” Zimmelman says. “South Africa has decent protective protocols and plans in place to deal with issues like this. It’s important right now that these are revisited and strictly applied.

Diabetes and COVID-19 How do we manage diabetic patients in an age of COVID-19, given the increased risk of mortality experienced by diabetic populations?

HE SPREAD OF the novel SARSCoV-2 coronavirus (COVID-19) has reached pandemic proportions and represents a threat for increased morbidity and mortality, globally. In many regions this increased morbidity and mortality is particularly seen in older persons and those presenting with co-morbidities such as diabetes, obesity and hypertension. The high incidence of diabetes throughout the world makes this particularly concerning as the COVID-19 pandemic progresses. To this point emerging data particularly from China, indicates that patients with diabetes are at high risk for COVID-19 infection. The spread onto the African continent is of great concern for multiple reasons. Large and densely populated areas and townships with widespread poverty and high migration are the most vulnerable populations for airborne pandemics. Moreover, existing epidemics of human immunodeficiency virus (HIV), tuberculosis (TB) and malaria are likely to collide with COVID-19 and may lead to an increased morbidity and mortality. In addition, the wide spread of non-communicable diseases in Africa, such as chronic obstructive pulmonary disease (COPD), heart disease, hypertension and diabetes are known risk factors for severe causes of COVID-19.

be admitted to a hospital, as hospitals are likely to be overwhelmed with the critically ill. It is of utmost importance that those who must self- isolate at home be managed with increased care. Special care will need to be taken by patients with advance disease and comorbidities as medication used in the12:41 PM Sadad_ad.pdf 1 2014/05/22

standard care of diabetes might need to be adjusted or discontinued. These patients need to be monitored for dehydration and possible diabetic ketoacidosis, during their illness as there is an increased risk of both associated with newer diabetic medications. In these times of uncertainty, the only

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

certainty is that it has never been more important to manage diabetic hyperglycaemia and co-morbidities with the arrival of COVID-19.

References available on request.

GLYCAEMIC CONTROL AND COVID-19 To date, there have been only limited experimental studies directly addressing the role of hyperglycaemia in the pathogenesis and prognosis of viral respiratory diseases. However, it has been shown that elevated blood glucose levels can directly increase glucose concentrations in airway secretion. In vitro exposure of pulmonary epithelial cells to elevated glucose concentrations significantly increased influenza virus infection and replication, suggesting that hyperglycaemia may increase viral replication in vivo. Elevated glucose levels may also serve to suppress the anti-viral immune response. Hyperglycaemia may also affect pulmonary function such that influenza virus-induced respiratory dysfunction is exacerbated in patients with diabetes. Collectively, experimental data support the notion that glycaemic control can have beneficial effects on clinical outcomes in patients with coexistent diabetes and viral respiratory diseases such as COVID-19.

CMY

PHARMACOLOGICAL MANAGEMENT Insulin therapy is the agent of choice for the management of type 2 diabetic patients admitted to hospital with the COVID19 virus. Their hyperglycaemia and diabetes will have to be treated optimally, as diabetic patients are at a higher risk of mortality due to their co-morbidities. Due to the constraints on our healthcare system not all patients will

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MEDICAL CHRONICLE | APRIL 2020

CLINICAL | CRITICAL CARE

Alternatives to hazardous chemicals in medical devices

Medical devices play a critical role in healthcare but may contain hazardous substances in their composition that can leach into patients during their use, and compromise patient safety.

ONCERNS HAVE BEEN raised by different societal groups including governmental bodies, healthcare professionals, scientists and civil society organisations, regarding the potential health impacts of chemical exposure from medical devices, particularly for vulnerable population groups. CONCERNING SUBSTANCES Phthalates and Bisphenol A (BPA) are substances of particular concern that are often found in medical devices. Phthalates are commonly used as plastic softeners in PVC-based medical devices, whilst BPA is used to produce certain plastics such as polycarbonates and epoxy resins that have applications in the medical device industry. A major concern surrounding these substances is that they are known endocrine disrupting chemicals (EDCs), which may interfere with the normal functioning of the human endocrine system and therefore present a hazard to different physiological and developmental processes. EDCs can impact upon the human body at very low concentrations and can combine with other endocrine disruptors to produce additive effects.Despite difficulties to demonstrate a causal link, some associations between EDC exposure and diseases are apparent: evidence shows that foetuses, children and pregnant women are the most vulnerable groups. Awareness of actions to eliminate harmful plastics must be increased within the healthcare sector, highlighting that a high level of patient care and safety can

12 APRIL 2020 | MEDICAL CHRONICLE

be maintained. Furthermore, as some of the most highly trusted community figures, healthcare professionals have the capacity and moral obligation to educate the communities they serve and help trigger widespread beneficial behaviour changes in plastic use. The benefit-risk assessment of the presence of hazardous chemicals in certain medical devices should therefore be subject to the most stringent conformity assessment procedures by a Notified Body. In 2017, the European Council adopted the Medical Devices Regulation (MDR), fully applicable to medical devices placed on the EU market as of 26 May 2020. Importantly, some of the provisions within this regulation have the potential to act as an engine for substituting medical devices that contain harmful chemicals with safer alternatives. Devices should be subject to stringent compliance assessment of required labelling by a Competent Authority. The market authorisation process for medical devices needs increased transparency. Sustainable procurement guidelines should provide incentives for the substitution of hazardous chemicals in medical devices Funding for research and development of alternative substances and products and for clinical and epidemiological projects that compare the performance of these alternatives should be prioritised. WHAT IS BISPHENOL A? Bisphenol A (4,4-dihydroxy-2,2diphenylpropane or BPA) is a chemical substance used as a monomer in

the production of polymers such as polycarbonate, epoxy resins, polysulfone, and polyacrylate. BPA is also used as an antioxidant and inhibitor in the polymerisation of PVC and as a precursor for the synthesis of the flame retardant tetrabromobisphenol A (TBBPA). Up to one million tonnes of BPA is manufactured and/or imported in the European Economic Area (EEA) annually, from which over 95% of BPA is used in the production of polycarbonates and epoxy resins. BPA has applications in medical devices that have both direct and indirect contact with patients including those made of polycarbonate, polysulfone and PVC such as medical tubing, catheters, haemodialysers, newborn incubators, syringes and blood oxygenators. BPA has been shown to leach from medical devices into liquids. European PVC manufacturers informed the Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR) that they no longer use BPA as stabiliser or antioxidant in PVC production. CONCLUSIONS Citizens’ exposure to DEHP and BPA during medical procedures contributes to a continuous, long-term, and low-level exposure to a mixture of different hazardous chemicals, which causes or enhances

adverse effects on human health and the environment. European manufacturers of medical devices, under some regulatory pressure, have increased the development of alternatives to both phthalates and BPA in medical devices. Most medical devices containing phthalates can be substituted relatively easily with less hazardous alternatives at an affordable cost. Several companies already manufacture DEHP free medical devices either by using PVC plasticisers other than DEHP or not using PVC material at all. Since widely available and safer alternative medical devices exist, we can protect foetuses, neonates, pre-pubescent children, and other vulnerable patients from exposure to DEHP by insisting on DEHP free, PVC-free and BPA-free products. The use of DEHP should not be granted to any medical device when safer alternatives are available. Further development of safer medical devices by manufacturers, along with greater demand by caregivers and hospitals, could result in a complete transition away from DEHP and BPA.

REFERENCE Non-toxic healthcare: Alternatives to Hazardous Chemicals in Medical Devices: Phthalates and Bisphenol A - second edition (2019). November Korrektur 01.indd. linical Nutrition 2017;3,623-650.

WHAT ARE PHTHALATES? Phthalates are a group of chemical substances, primarily used as plasticisers (softeners) in plastics to make them more flexible. Depending on the number of carbon atoms in their alkyl side-chains they are divided into: • High-chain length – with more than six carbons (eg DINP, DIDP, DPHP, and DIUP) • Transitional-chain length – with three to six carbons (eg DEHP, DBP, DIBP and BBP) • Low-chain length – fewer than three carbons.(eg DEP and DMP). Phthalates are abundant in polyvinyl chloride (PVC) medical devices such as blood bags, intravenous bags, tubing, catheters, respiratory masks or disposable gloves – approximately 40% of all plastic-based medical devices are made from PVC. Di-2-ethylhexyl phthalate (DEHP) has for many years been the most commonly used phthalate ester plasticiser in medical devices. A 2014 survey in the Danish Medical Device Industry found that 95% of products contained DEHP. DEHP can contribute up to 40% of weight of intravenous bags and up to 80% of weight in medical tubing. Leaching of DEHP from PVC medical devices has been documented since the late 1960s. Use of PVC medical devices may lead to a higher exposure to DEHP than everyday sources affecting the general population.

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CLINICAL | WINTER AILMENTS

COVID-19 or a cold? COVID-19 has led to more than 455 000 illnesses and more than 20 550 deaths worldwide. In the US alone, influenza has caused an estimated 38 million illnesses, 390 000 hospitalisations and 23 000 deaths this season, according to the Centers for Disease Control and Prevention (CDC).

OVEL CORONAVIRUS DISEASE (COVID-19) often presents as a common cold-like illness.

COVID-19 vs FLU Both seasonal flu viruses (which include influenza A and influenza B viruses) and COVID-19 are contagious viruses that cause respiratory illness. According to the Centers of Disease Control and Prevention (CDC), typical flu symptoms include fever, cough, sore throat, muscle aches, headaches, runny or stuffy nose, fatigue and, sometimes, vomiting and diarrhoea. Flu symptoms often come on suddenly. Most people who get the flu will recover in less than two weeks. However, in some patients the flu causes complications, including pneumonia. So far this flu season, about 1% of people in the US have developed symptoms severe enough to be hospitalised. Researchers are still trying to understand the full picture of disease symptoms and severity for COVID-19. Reported symptoms in patients have varied from mild to severe, and can include fever, cough and shortness of breath, according to the CDC. Studies of hospitalised patients have 14 APRIL 2020 | MEDICAL CHRONICLE

found that about 83% to 98% of patients develop a fever, 76% to 82% develop a dry cough and 11% to 44% develop fatigue or muscle aches, according to a review study on COVID-19 published at the end of February in JAMA. Other symptoms, including headache, sore throat, abdominal pain and diarrhoea, have been reported, but are less common. A less common symptom, loss of smell, has also been reported in some COVID-19 patients. In another large recent study, researchers from the Chinese CDC analysed 44 672 confirmed cases in China between 31 Dec 2019 and 11 Feb 2020. Of those cases, 80% were considered mild, 13% severe and 4% critical. "Critical cases were those that exhibited respiratory failure, septic shock, and/or multiple organ dysfunction/failure," the researchers wrote. It's important to note that, because respiratory viruses cause similar symptoms, it can be difficult to distinguish different respiratory viruses based on symptoms alone, according to the WHO. VIRUS TRANSMISSION Although data from China shows that it is more contagious than influenza, we should

bear in mind that at this point, the actual risk of infection isn’t any higher per se, and that it’s simply about the spread being quicker, Orly Vardeny, associate professor of medicine at the Minneapolis VA Health Care System and University of Minnesota said. According to the New York Times, a person infected with the Covid-19 virus appears to infect 2.2 people, on average, whereas for the seasonal flu it’s 1.3. But, again, the new coronavirus figure is skewed by the way in which the disease was handled in the beginning. As it comes under control, so will this figure subsequently drop. RISK OF INFECTION Flu kills between 6 000 -11 000 South Africans every year, according to the National Department of Health. About half of those deaths are in the elderly, and about 30% in HIV-infected people. The highest rates of hospitalisation are in the elderly (65 years and older), HIV-infected people and children less than five years old. Pregnant women are also at increased risk of hospitalisation and death from flu infections. People with chronic illnesses like diabetes, lung disease and heart disease are

Look out for Medical Chronicle’s Winter Ailments Focus digibook, which will be in your inbox soon. This made possible by Adcock.

also at increased risk of being hospitalised from the flu. People with TB infection are also at higher risk of hospitalisation and death from the flu. During the flu season in South Africa, about 14% of patients are hospitalised for pneumonia and 25% of patients with flu-like illness (fever and cough) will test positive for flu. People who live in areas where there is ongoing community spread are at higher risk of exposure of COVID-19, as are healthcare workers. DEATH RATE Globally, seasonal flu generally kills far fewer than 1% of those infected. By comparison, about 3.4% of reported Covid-19 virus cases have died. The death rate for COVID-19 appears to vary by location and an individual's age, among other factors. For instance, in Hubei Province, the epicentre of the outbreak, the death rate reached 2.9%. In other provinces of China, that rate was just 0.4%,

*Information in this article is correct at time of print.

CLINICAL | WINTER AILMENTS

COVID-19 and the flu vaccine

The National Institute for Communicable Diseases (NICD) recommends for everyone who can, to get a flu vaccine in 2020. The flu virus is different from the new coronavirus 2019 and, as such, a person can get both COVID-2019 and the seasonal influenza.

HE SIGNS AND symptoms of COVID-19 significantly overlap with the symptoms of seasonal flu. This means that it may not be easy to differentiate between the two infections based only on the symptoms. The influenza virus has existed for a long time, which means there has been enough research to understand how it spreads, who is at risk of severe disease, how infection can be prevented, and how it can be treated. Little information is currently available on the COVID-19 virus and the disease it causes. Research is still underway to possibly develop a vaccine for the COVID-19 virus. The same precautionary measures for preventing the spread of seasonal flu apply to the COVID-19 virus. A MESSAGE FROM THE DoH According to the Department of Health’s COVID-19 website, “We must inform our people that South Africa received a very limited stock of flu vaccines. These are pre-ordered a year in advance. At the time the country (both public and private) placed its orders, we had not anticipated this COVID-19 pandemic. This means that as it stands, our flu vaccines are understocked.” As government we have engaged with the pharmaceutical industry and it became clear that the distribution of this vaccine has to be rationalised and prioritised. We have therefore taken a decision that health workers in the country will be given priority in receiving the flu vaccine. This is precipitated by the fact that the country cannot afford to have them sick especially as the flu season approaches.” Flu vaccinations are the most effective way of preventing infection and reducing hospital admissions related to flu complications. The flu vaccination continues to offer protection when given at any time during the flu season. The ideal time for vaccination is before the start of the flu season (March to August in South Africa). It takes the body about two weeks to develop antibodies against the flu virus. In South Africa, the best time to get a flu vaccine is as soon as the vaccine becomes available, or before the end of April. In other words, it’s best to get vaccinated before the flu season sets in and before the virus spreads. However, if you miss this period, the vaccine can still be effective at any time during winter.

Flu vaccination should be done annually because the strains of the seasonal flu virus change every year. There are certain people

who should not have a flu vaccination. This includes those with a severe allergic reaction to a previous flu vaccination and people

who have a severe allergy to eggs. Children younger than six months should also not have a flu vaccination.

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MEDICAL CHRONICLE | APRIL 2020

CPD | OSTEOPOROSIS

Every fracture needs

an action plan The goal of a fracture liaison service (FLS) is to ensure that patients with clinical signs of osteoporosis receive appropriate evaluation and treatment.1

HE CONCEPT OF Fracture Liaison Services (FLS) was born as an initiative of the International Osteoporosis Foundation (IOF) because of a huge care gap in people with osteoporosis.3 The IOF, through the Best Practice Framework, initiated a coordinator-centred care model that outlines this care with set goals to ensure efficacy and data capturing. “FLS have been shown to significantly increase identification, assessment, diagnosis, treatment initiation as well as adherence rates, whilst also proving significant cost-saving benefits,4” said Dr Hayley de Wet, specialist physician based in Johannesburg. Patients receiving osteoporosis treatment are increased by 135%, in addition 95% of fracture patients are accurately diagnosed with osteoporosis within this care model. Refracture rates were shown to be roughly halved and mortality decreased by a third in a large meta-analysis by Chih-Hsing Wu et al.4 “The risk of fracture is highest within the first two years of the first major osteoporotic fracture. This is why FLS are so important, to identify these patients soon after their first fracture,” said Dr Zane Stevens, Endocrinologist at Netcare’s Chris Barnard Hospital in Cape Town.3 Long-term studies show that approximately 75% of patients who sustain fragility fractures would benefit from medical interventions following surgery. A fracture liaison service follows patients who have sustained fragility fractures and/or osteoporotic fractures from the

16 APRIL 2020 | MEDICAL CHRONICLE

time of injury presentation until care is transitioned to the primary care provider. It is an interdisciplinary service combining orthopaedic surgery, primary care, osteoporosis experts (eg endocrinology and rheumatology) and ancillary services such as physical therapy and dieticians to ensure that patients are properly assessed and managed.1 According to Dr Stevens, the IOF looked at various models of how access to treatment could be improved, and this model, the FLS, was found to be the best in terms of the greatest number of people receiving post fracture treatment, and it has been shown as a cost-effective model of treating people with osteoporosis.3 An FLS coordinator will meet with patients and begin the process of coordinating osteoporosis education, evaluation and management. Physical therapy is consulted to assess fall risk and start a fall prevention programme. Dieticians are consulted to assess for nutritional deficiencies that contributed to the patient’s suspected decreased bone mineral density.1 During a patient’s enrolment in an FLS, a patient may see specialties as an inpatient or outpatient. Other possible consultations include occupational therapy and endocrinology depending on the patient and institution. During the hospital stay, the patient is started on calcium/vitamin D supplementation. Once discharged, the FLS coordinator continues to stay involved in the patient’s post-operative care by coordinating with orthopaedic surgery and primary care providers to obtain DEXA

imaging and assess the need for further medical intervention. The coordinator individualises the management of each patient including continuation of physical therapy or additional consultations. Once the patient is deemed fit enough to be discharged from orthopaedic surgery care, the FLS coordinator then transitions care to the designated team (primary care or other osteoporosis expert) for long-term osteoporosis management before discontinuing care.1 In South Africa, there are different ways in which this can happen at different facilities, depending on resources. According to Dr Stevens, “You would start off with an audit of the facility to see the numbers of people presenting with hip fracture, which is the major break we are trying to prevent in the future. Of those patients presenting with a hip fracture, how many of them were adequately screened for underlying secondary causes of osteoporosis, how many patients had a bone density test, and how many of them were ultimately treated? We know that in SA generally, these numbers are quite low.3” "If you start off with hip fracture, the most ideal model is to have a dedicated Fracture Liaison Officer. That person could be a nurse in the orthopaedic ward or a dedicated nurse that does only fracture liaison. This is the model that ensures that the most patients are appropriately screened. This person would identify all the people in the ward with hip fractures; communicate with the person in charge of caring for them about appropriate tests that need to be done to look for underlying

causes. Not everyone develops osteoporosis because of advanced age, there might be underlying conditions predisposing them to bone loss, which would need to be investigated. These tests are often blood and urine tests, and these patients should have bone density screening during hospitalisation. Their first treatment for osteoporosis should be started in hospital. A very important role of the FLS officer, is to coordinate care between all the role players including the GP to ensure long-term treatment adherence3,” commented Dr Stevens. RISK FACTORS FOR OSTEOPOROSIS “Age is one of the most important risk factors for osteoporosis and fragility fractures. As life expectancy increases globally we are faced with an ever-growing ageing population, this will mean that by 2050, there will be just over two billion people 60 years and older, resulting in an exponential rise in fragility fractures. Fractures have devastating consequences in particular hip fractures,” said Dr De Wet. • Mortality – 28% of women and 37% of men with hip fractures die within the firstyear post-op • Reduced quality of life with increased pain, loss of mobility and independence • After 12 months 30% of hip fracture patients cannot walk independently vs 7% of controls • Significant cost burden.4 Fifty percent of hip fracture patients have suffered a prior fragility fracture of

CPD | OSTEOPOROSIS either the hip, wrist, humerus or other skeletal sites prior to breaking their hip.4 “In this way, half of all hip fracture patients have already ‘warned us’ when they presented with their incident fracture. An incident fragility fractures refers to the first presenting fragility fracture. Incident fractures are one of the strongest predictors of imminent fracture risk,” said Dr De Wet.4 Imminent fracture risk refers to the nearterm risk of fracture or re-fractures within the next 12-24 months. The greatest risk of re-fracture is highest in the first three months of the incident fracture after which it begins to decrease and plateaus around 24 months post-fracture. These patients are often not screened for underlying osteoporosis or initiated on treatment. Patients with a high imminent fracture risk should be prioritised for investigation, assessment and treatment initiation.4 Identifiable imminent fracture risks: • Incident fracture (especially multiple vertebral fractures) • Advanced age • Multiple co-morbidities • High falls risk • Frailty.4 FLS TOOLKIT2 The primary objectives of an FLS are to establish critical procedures to ensure identification and tracking of fracture patients, initiation of treatment and assessments of the FLS system. These criteria are summarised under five major categories:

Identify the patients • Identify the patients presenting with fragility fractures (criteria 1) and establish reliable mechanisms within a hospital or health system to identify all women and men aged ≥50 years who present with fragility fracture. • Vertebral fracture patients represent a different challenge for case finding given the majority will be detected by chance (criteria 4): develop a system whereby patients with previously unrecognised vertebral fractures are identified and undergo secondary fracture prevention evaluation. The gold standard is more aspirational as vertebral fractures are difficult to identify however, since vertebral fractures are the most common fragility fracture, it would be remiss to not include an attempt to identify them in this framework. Investigate Undertake assessment of risk factors for osteoporosis, falls and future fractures in accordance with relevant clinical guidelines: • Patient evaluation (criteria 2): ascertain what proportion of all patients presenting to the institution or system with a fracture are evaluated for future fracture risk • Post fracture assessment timing (criteria 3): ensure a formal fracture risk assessment is performed at an appropriate time after the fracture. • Assessment guidelines (criteria 5): ensure

the assessment for fracture risk is consistent with local/regional/ national guidelines and where appropriate include bone density testing. • Secondary causes of osteoporosis (criteria 6): ensure that patients with low BMD/high fracture risk are screened for secondary causes. • Multifaceted risk-factor assessment (criteria 8): ensure that underlying lifestyle factors are assessed and, if found, addressed. • Medication review (criteria 10): ensure patients that have fractured whilst receiving treatment for osteoporosis are assessed for compliance and consideration of alternative

osteoporosis medications/ optimisation of non-pharmacological interventions.

Initiate • Medication initiation (criteria 9): ensure patients who are eligible for treatment are initiated on osteoporosis medications • Fall prevention service (criteria 7): evaluate all patients to determine whether falls prevention services are needed • Communication strategy (criteria 11): ensure the FLS management plan is communicated to relevant clinical colleagues in primary and secondary care. Adherence • Long-term management (criteria 12):

check osteoporosis treatment adherence and tolerability by six and 12 months to inform treatment reinforcement or switching within relevant clinical guidelines.

Database • Database standard (criteria 13): record all identified fragility fracture patients in a database locally, regionally and/ or nationally. TREATMENT FOLLOW-UP If the patient starts on an oral treatment for osteoporosis, someone needs to follow up on this treatment, as adherence needs to be 70-80% for these drugs to be effective.

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MEDICAL CHRONICLE | APRIL 2020

CPD | OSTEOPOROSIS

The risk of fracture is highest within the first two years of the first major osteoporotic fracture

SIX APPROACHES TO EXPAND AN FLS SYSTEM2 • Increase the scope of FLS based on fractures types: starting with hip fracture then incorporating other fracture types (non-hip patients, then outpatients and finally vertebral patients) • Implement an FLS Centre of Excellence with subsequent expansion to other localities • Increase gradually in the intensity of the FLS model from a 2iM model to a 3iM model that includes monitoring at 6 and 12 months • Enhance the intervention based on patient identification from regional/ provincial healthcare administrative databases or other electronic medical record systems • Implement a region/province wide Type A (3i) model of FLS from the outset to maximize health gains in the shortest time-frame possible • Case find vertebral fractures through diagnostic imaging. This communication with the GP is very important. The FLS officer or coordinator would also spend time with the patient to educate the patient about what osteoporosis is, what lifestyle measures and dietary interventions, calcium supplementation and vitamin D supplementation should be part of the ongoing care. Discuss that once they have recovered, that weight-bearing exercise would be important. The idea is that FLS falls within an overarching orthogeriatric unit, which would go beyond identifying underlying osteoporosis causes and treatment. It would mean that the rehabilitation process would include a fall 18 APRIL 2020 | MEDICAL CHRONICLE

risk assessment and as well as a fall-risk intervention. This is where a physiotherapist or biokineticist works with the patient to minimise the risk of future falls.3 An alternative approach, if there is no fracture liaison coordinator would be to have standard protocols set up within an institution, so that when a patient presents with hip fracture, there is a standard set of investigations that would need to be completed. Together with this, a letter should be sent out to the patient’s GP to say the patient presented with a possible osteoporotic fracture, bone density tests and screening blood tests have been done, and ask if the GP could assess the patient for further treatment. Most studies have concluded that when you have a dedicated person coordinating the care, the underlying causes, such as osteoporosis are focused on. In a hospital that is doing well with inpatients, you might extend that FLS to the trauma unit where you could have a protocol for people who present with fractures. Studies have concluded that an FLS model including a liaison officer is most effective. These patients could at least get a letter to give to their GP when they are sent home, suggesting that the patient could have an osteoporotic fracture.3 It is reported that only between 9-50% proceed to have a formal bone health assessment. By responding to the incident fracture we can reduce the incidence of subsequent fractures, particularly the hip fracture, which is associated with high morbidity and mortality. Despite the availability of effective osteoporosis treatments with the potential to reduce secondary hip fracture incidence by 50% currently less than 20% of patients presenting with an incident fragility fracture receive any form of therapy or secondary prevention. This includes either calcium, vitamin D or any osteoporosis-specific drug.4

This lack of management and recognition of the underlying disease has been termed ‘the post-fracture osteoporosis gap’ and seems to occur as the fracture is treated as an acute event. There is emphasis on best immediate fracture management by the treating health care professionals with a disconnect between various other medical role-players responsible for chronic care and secondary prevention.4 The care gap includes lack of identification of patients at risk, lack of investigation, delayed and decreased diagnosis, and low rate of appropriate osteoporosis secondary prevention initiation.4 Thus allowing an ongoing cycle of recurring fractures often referred to as ‘the fracture cascade’, each with an increased associated morbidity and mortality within the life of the osteoporotic patient.4

REFERENCES 1. Bonanni S, Sorensen AA, Dubin J, Drees B. The Role of the Fracture Liaison Service in Osteoporosis Care. Mo Med. 2017;114(4):295–298. 2. IOF Capture the Fracture international fracture liaison service toolkit. https://capturethefracture.org/ sites/default/files/2014-IOF-CTF-FLS_toolkit.pdf 3. Rush, C. FLS: GPs are part of the system. Medical Chronicle 2018:08;26. 4. Rush, C. The challenge in monitoring osteoporosis therapy. Medical Chronicle 2019:07;30. Lilly VVPM APPROVAL CODE: PP-TE-ZA-0244 EXP 31 March 2022.

CPD click here:

https://www.medicalacademic. co.za/courses/every-fractureneeds-an-action-plan/

WHAT THE NUMBERS SAY Since the first Fracture Liaison Services in the early 2 000s, multiple studies have been conducted to investigate the utility of these fracture care models. Studies in the UK assessing the long-term efficacy of these services have shown that the FLS model not only reduces the frequency of subsequent fractures and improves adherence to treatment, it also provides cost savings. An 8-year audit in Scotland found that approximately R380 000 is saved per 1 000 patients with a prevention of approximately 18 re-fractures in that same amount of time. Utilisation of a FLS increases the rate of diagnosis of osteoporosis and long-term adherence to medical management. The diagnosis rates of osteoporosis following fragility fractures are between 5–30% without a FLS. Following enrolment into an FLS, this diagnosis rate improved to over 80%. The FLS also provides a 30–40% reduction in risk of refracture, with a number needed to treat of 20 to prevent one re-fracture in three years.1 • 95% of patients within an FLS are accurately diagnosed with osteoporosis • 135% increase in osteoporosis patients within FLS receiving osteoporosis specific treatment • Average 37% reduction in refracture • 35% reduction in mortality over two years • Cost-effective • 4 QALYs gained.4

CLINICAL | PSYCHIATRY

How to deal with

COVID-19 anxiety

COVID-19 is causing anxiety, panic and unrest across the globe. It’s dominating press headlines, conversations, and is hard to escape it.

OVID-19 IS EXTREMELY stressful for many, especially those who already have a mental health issue, but even those without a predisposing illness feel stressed and anxious during this time – it is completely normal to feel that way considering the situation. Fear, panic and anxiety about the Coronavirus can be overwhelming and cause strong emotions in adults and children. "It’s natural to feel worried and overwhelmed about our safety and wellbeing. So, if you’re feeling concerned about the Coronavirus, you're not alone. Yet, for some of us, this concern can quickly grow into anxiety, even panic. Hearing about shortages of hand sanitizer, people stocking their homes with food, and the number of deaths worldwide only fuels this fire," says clinical psychologist, Dessy Tzoneva.

the immediate challenges we face. In this way, we can solve problems in a more constructive manner that can meaningfully improve the situation for ourselves and others,” adds Lewis.

SADAG

always expected something bad to happen to me’, or ‘Why me?’ Furthermore, worrying about the future and asking yourself questions such as ‘Am I perhaps going to fall ill and die?’, or ‘Will the economy crash

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:

It’s natural to feel worried and overwhelmed about our safety and wellbeing. So, if you’re feeling concerned about the Coronavirus, you're not alone “In this time of global health crisis, South Africans from all walks of life are confronted with new realities in a challenging and uncertain environment, requiring of all of us to work on building and strengthening personal resilience. Being resilient means to be psychologically flexible, to take hold of our minds in order to calm our emotions and face the new realities that confront us with clear sight and thought.” So advises Sandy Lewis, a clinical social worker and head of therapeutic services at Akeso mental health facilities, who was commenting on the mental effects that the COVID-19 outbreak in South Africa could have on individuals, families and communities. Lewis provides the following insights and advice on how people can cope with the potential future challenges that the pandemic may hold for us as individuals, families and the country at large. “Anxiety and worry are understandable emotions when looking into a future we simply cannot know. Our anxiety serves little constructive purpose and tends to erode our personal resilience in the face of challenges. However, what we should be trying to do is to accept our rapidly changing reality for what it is and turn our minds to confronting

Y E A RS

T WENT Y

BUILDING PERSONAL RESILIENCE Lewis says that one can start by not getting stuck in negative thinking and not dwelling on the past with thoughts like ‘I

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

MEDICAL CHRONICLE | APRIL 2020

CLINICAL | PSYCHIATRY and leave us destitute?’, tend to just lead to more anxiety. “We should direct our energy towards focusing on what we need to manage today and solving those issues. In other words, we should focus fully on the present, without any other noise and clutter from either the past or the future to stress our body and mind, and work towards dealing with the practical daily tasks at hand.” Lewis says patients can practise social distancing and take all practical steps to safeguard their health. “If you are at home with your children, plan their day to provide them with the necessary structure and

routine to keep them feeling safe. Focusing on and addressing the practical aspects of today is much more useful than worrying about a future that none of us are able to predict,” she added. AVOID YOUR ANXIETY OR DEPRESSION TRIGGERS By establishing what triggers anxiety or other distractive responses such as selfblame, patients can try to either steer clear of those particular triggers or find ways around them that will stop them from feeling anxious or negative. “Staying present with the reality that you are faced with

today, focusing on your current tasks and distracting yourself if you find you are having trouble coping, can all assist in developing greater resilience.” “In the interim, strength, grace and tenacity are needed, so that we can all get through this together. We need each other, both to prevent the spread of this disease, and to offer each other the support to cope with it until it is over. “Now is the time to be generous, thoughtful, kind and compassionate, with an attitude that embraces the well-being of all. And if the world is a different place after COVID-19, then we will face that

new reality with renewed strength, coping with its challenge’s day by day, in the same way that we dealt with this pandemic,” concludes Lewis. STATEMENT FROM SADAG “SADAG are aware that during this time many people might feel even more anxious or stressed. While we don’t want to add any further to the panic or hysteria, we want to offer help and support to so many South Africans who feel scared, confused, anxious and overwhelmed. SADAG Helplines are a critical service to many, and since the development of the Coronavirus SADAG has received many calls from people who are already feeling stressed and anxious.” LIVING WITH A MENTAL ILLNESS AND COPING DURING COVID-19 For many people living with a mental health issue, the current situation may be worsening or intensifying symptoms so it is important to take extra care during this time with more support and self-care steps to ensure your mental wellness: 1. Be sensitive to patients with a compromised immune system or a medical condition that they’re worried about 2. Some therapists offer online sessions

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.

3. Advise patients to avoid searching online, media sourcing or having conversations throughout the day around the virus as this will cause increased anxiety that may lead to panic. Again – filter what you are reading, watching and exposing yourself too, especially since it can be very negative and scary. Try to set specific times to check for updates – but rather spend more time that could be adding value to your wellness such as doing things that you enjoy, doing more relaxation and stress relieving activities 4. Don’t use smoking, alcohol or other drugs to deal with emotions. If patients (or you) feel overwhelmed, talk to your mental health professional, counsellor, family or friend. Have a plan, where to go to and how to seek help for physical and mental health needs if required 5. Use online tools, online forums, helpful websites and online support to help you through this time – try a new app that helps to manage your sleep, or provides mindfulness techniques, listen to a meditation podcast. SADAG RESOURCES:

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

20 APRIL 2020 | MEDICAL CHRONICLE

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.

SMS 31393 or 32312 and a counsellor will call you back – available 7 days a week, 24 hours a day. SADAG Helplines providing free telephonic counselling, information, referrals and resources 7 days a week, 24 hours a day – call 0800 21 22 23, 0800 70 80 90 or 0800 456 789 or the Suicide Helpline: 0800 567 567. Akeso Psychiatric Response Unit 24 Hour: 0861 435 787.

CLINICAL | RHEUMATOLOGY

New concepts in an old disease Gout is characterised by recurrent acute joint inflammation (gouty arthritis) in the extremities, caused by crystals that are deposited in and around the joints.

CCORDING TO Prof Bridget Hodkinson, head of Rheumatology at UCT’s department of medicine, chronic elevation of serum uric acid above the saturation point for monosodium urate crystal formation (6.8mg/dl) results in the deposition of these crystals in and around joints. “This growing epidemic is due to diet and lifestyle (urbanisation plays a role here); medications – such as thiazides and loop diuretics and low-dose aspirin; metabolic syndrome, especially obesity; and an ageing population,” she said in her presentation at the recent Physicians Conference, held in Cape Town. The arthritis may become chronic and cause joint deformity. Tophi – small, hard lumps of urate deposits – may also form around the ankles, hands, tips of the elbows and earlobes. The tophi may erupt, causing a discharge. HOW CAN WE IMPROVE MANAGEMENT? In an acute attack, the first objective is to resolve symptoms. This is done by ice, NSAIDs in high dose (check for renal function first). Colchicine used in high doses can cause acute diarrhoea. Low-dose colchicine (0.5mg BD) has been found to be just as effective, Prof Hodkinson illustrated. If NSAIDs are contraindicated, intra-articular corticosteroid injections, intramuscular methyl prednisone (160mg) and oral prednisone (30mg/day x 2-5/7) are options. During an acute attack, don’t alter uric acid lowering therapy. Don’t start, stop or change. Once the flare resolves, attend to the hyperuricaemia through lifestyle and diet modification, review medication, and uric acid-lowering therapy.

Acid-lowering therapy Acid-lowering therapy is indicated for recurrent acute attacks (>2 per year) and tophi. When using allopurinol, aim for uric acid of 0.36mmol/l or lower. This prevents further acute attacks, joint damage and shrinks tophi. Start at a low dose (100mg nocte), slowly increasing at 100mg

increments over four weeks. Start 50mg daily if stage 4 chronic kidney disease (GFR <30). Titrate up (monitoring the patient) to 700-900mg daily. The most commonly prescribed dose of 300mg is inadequate in reaching the target uric acid level in two/three or more patients.

WHY ARE WE FAILING? Gout is not regarded as particularly important by patients and doctors. There is poor continuity of care and often suboptimal management. There is lack of patient confidence in GPs and poor understanding plus misconceptions held by patients and physicians alike.

NO-ONE SHOULD DIE BECAUSE THERE IS NO MATCH

HELP US SAVE LIVES!

Prof Bridget Hodkinson, head of Rheumatology at UCT’s department of medicine.

Lifestyle modification Weight reduction should be controlled and gradual, as crash diets can precipitate acute attacks. Increase fluid intake to produce 2L urine a day. Vitamin C supplementation is suggested at 500-2000mg daily, with caution for gastrointestinal effects and renal calculi). Cherry and lemon juice might be beneficial. Where possible, substitute drugs that cause hyperuricaemia: Low-dose aspirin for cardio-protection should not be stopped, and don’t stop diuretics.

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MEDICAL CHRONICLE | APRIL 2020

ONLINE CPD

Antibacterial management of conjunctivitis and blepharitis

Conjunctivitis and blepharitis can be caused by a variety of bacterial strains, which need to be identified and managed appropriately.

ACTERIAL CONJUNCTIVITIS Conjunctivitis, also informally known as "pink eye," is the most common ophthalmologic disorder seen by primary care providers. Patients often present complaining of eye redness, which may or may not be accompanied by pain,

itching, and discharge. Dilation of the conjunctival blood vessels secondary to viral or bacterial infection, chemical exposures, or allergies results in the redness seen during examination and leads to hyperaemia and oedema of the conjunctiva.

BACTERIAL BLEPHARITIS Blepharitis is a common chronic ocular inflammation that primarily involves the eyelid margin and is a common cause of chronic ocular irritation. The pathology of the condition is not yet completely understood, but low-grade bacterial

MANAGEMENT Blepharitis can be difficult to treat, usually with little chance of a complete cure. While there are no products approved by the US Food and Drug Administration (FDA) specifically for the treatment of blepharitis, current therapeutic approaches aim to control and minimise symptoms and signs of inflammation. Eyelid hygiene may provide symptomatic relief for both anterior and posterior blepharitis.

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

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.

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

Anti-bacterial agents Topical antibiotics have been shown to provide some symptomatic relief in both bacterial blepharitis and conjunctivitis, and they have been effective in decreasing bacteria from the eyelid margin in cases of anterior blepharitis. Topical therapy can control bacterial blepharitis and conjunctivitis but is especially important for Pseudomonas aeruginosa keratitis. A topical antibiotic ointment such as tobramycin can be prescribed and applied on the eyelid margins one or more times daily or at bedtime for a few weeks. Topical antibiotic treatment can be repeated on an intermittent basis using different kinds of medications with different mechanisms of action to prevent the development of resistant organisms. The frequency and duration of treatment should be guided by the severity of the blepharitis and response to treatment.

S I G N S

MYTH vs FACT

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

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

22 APRIL 2020 | MEDICAL CHRONICLE

Tobramycin Tobramycin is a topical antibiotic i ndicated in the treatment of external bacterial infections of the eye and its adnexa caused by susceptible organisms. Tobramycin is sometimes used with loteprednol etabonate (LE) as a combination therapy against blepharitis. References available on request.

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WH-AD297x130.indd 1

infection (primarily Staphylococcus), Demodex mites, environmental factors, and certain systemic disease, have all been implicated as potential contributors. Blepharitis can be classified according to its location: anterior blepharitis affects the eyelid skin, base of the eyelashes and the eyelash follicles, and posterior blepharitis affects the meibomian glands. Blepharitis has traditionally been clinically subcategorised as staphylococcal, seborrheic, meibomian gland dysfunction (MGD), or a combination thereof.

2019/06/11 2:57 PM

This article is a summary of a longer, CPD-accredited article. Go to medicalacademic.co.za’s Clinical/CPD section to find the online article and answer the questions, for 1 CPD point

New treatment

CLINICAL | ONCOLOGY

provides hope for advanced ovarian cancer patients Breakthrough HIPEC procedure can improve quantity and quality of life.

HE SOUTH AFRICAN medical community has made important strides in treating ovarian cancer in the country, after three breakthrough procedures were recently performed at the Life Entabeni Hospital in Durban. Hyperthermic intraperitoneal chemotherapy (HIPEC) is a highly sophisticated procedure for the treatment of abdominal cancers and when it is performed with cytoreductive surgery, it results in longer recurrence-free survival and overall survival than surgery or chemotherapy alone. This is according to a landmark study conducted in the Netherlands and Belgium and published in the New England Journal of Medicine in 2018. The nine-year randomised control trial included 245 patients with newly diagnosed stage III epithelial ovarian, fallopian tube, or peritoneal cancer. What the study results revealed was that the combination of HIPEC and surgery could improve the survival rate in patients by 12 months. Peritoneal cancers include ovarian cancer, fallopian tube cancer, primary peritoneal cancer, pseudomyxoma peritonei, appendix cancer, colorectal cancer and mesothelioma. “The prognosis for ovarian cancer is poor, with the majority of patients only being diagnosed in stage 3 or 4. So when the study came out, we identified many of our patients who would benefit from the technology but, at the same time, there were no centres in the country performing HIPEC,” says Dr Naseem Bhorat, the surgeon at Life Entabeni Hospital who performed all three HIPEC procedures. “The study gave me hope that the treatment could give our patients a better chance of beating the disease.” Understanding the need in South Africa for a new treatment breakthrough like HIPEC, Dr Bhorat, together with gynaecology oncologist Dr Kamendran Govender, travelled to Vienna, Paris and Mumbai to learn the specific techniques and bring this knowledge back to the country. The team also spent time in the

Netherlands, where they were trained by the experienced surgeon, Dr Ignace HJT de Hingh. In a process that took over two years of planning and preparation, hospital staff were specifically trained and a multidisciplinary team of specialists, including an anaesthetist and a perfusionist, was assembled to ensure the safety and recovery of each patient.

Dr Naseem Bhorat.

According to Dr Bhorat, “The HIPEC technology and equipment is expensive, which is partly why the procedure isn’t widely performed in South Africa. Fortunately, we could partner with Tau Medical Supplies who sponsored the machines and disposables, enabling us to perform the procedure on two patients with pseudomyxoma and one with primary peritoneal cancer.” Tau Medical Supplies is the exclusive South African distributor of the Performer HT HIPEC system, which is manufactured in Italy by RanD. “With all three surgeries taking place at Life Entabeni Hospital, we are incredibly proud to affiliate ourselves with this groundbreaking procedure. There’s a dire need

for it in this country and with HIPEC having such a positive impact on patients’ lives, we hope there’ll be many more of these lifesaving procedures done at our hospital,” says Bhaviksha Maharaj, Hospital Manager at Life Entabeni Hospital. THE BENEFITS OF HIPEC Before the HIPEC procedure, all visible tumours or cancerous lesions are removed throughout the peritoneal cavity using cytoreductive surgery. A highly concentrated dose of chemotherapy is then heated to 43° Celsius and delivered into the peritoneal cavity. A surgeon continuously circulates this solution for 60-90 minutes, ensuring that all abdominal organs come into contact with the chemical, helping to destroy any remaining microscopic cancer cells. Combining surgery and chemotherapy achieves several important goals. As the solution is delivered directly to the abdomen, the patient receives a higher and more concentrated dose, while heating improves effectiveness. Being largely isolated in the peritoneal cavity and then subsequently removed, there is minimal exposure to the rest of the body, which reduces the normal side effects of chemotherapy. “While HIPEC is routine in leading cancer centres in Europe, India and the US, it’s a breakthrough procedure in South Africa,” explains Evette Le Roux, Country Manager at Tau Medical Supplies. “We fully understand the burden on hospitals and theatres, but with the large number of ovarian, pseudomyxoma peritonei and gastric cancer patients in the country who can benefit from HIPEC, we’re delighted that we can sponsor the machines that are helping these doctors change lives. Of course we would like this treatment to be accessible to many more people, and so we

have submitted an application for medical aid approval, and we are currently waiting for the outcome on that decision.” MULTIDISCIPLINARY APPROACH Tau Medical Supplies is also supplying machines to the recently opened Peritoneal Centre at Capital Hospital in Durban, a centre specifically for patients with peritoneal cancer. The centre is important in the fight against cancer as it helps doctors, patients and their families plan the treatment in a multidisciplinary way. Pathologists, radiologists, general surgeons and gynaecology oncologists are available, together with support affiliates including dieticians, psychologists, psychiatrists, physiotherapists, anaesthetists and physicians. “Working together, all the specialists and affiliates guarantee that treatment won’t be fragmented,” says Dr Govender. “We’ve taken this approach as it ensures that the treatment offered to the patient is as safe as possible, and that the patient gets the best outcome physically and psychologically.” The centre is also important as a source of knowledge. Many peritoneal cancer patients in the country are unaware that HIPEC is an alternative, innovative method of delivering chemotherapy, and that the procedure, when combined with cytoreductive surgery, is successful in improving the length and quality of a patient’s life. By educating and informing people that HIPEC is available, more patients will be identified who fit the criteria for successful treatment.

MEDICAL CHRONICLE | APRIL 2020

NO-ONE SHOULD DIE BECAUSE THERE IS NO MATCH

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CLINICAL | DIABETES

Study results: Basal insulin in patients who fast during Ramadan

A real-world study has evaluated a second-generation basal insulin used alongside IDF-DAR guidelines. The results contrast with literature reports of increase in events during this period. *Content supplied

Download the Diabetes and Ramadan mobile app

RION IS A prospective, observational study evaluating the safety and effectiveness of the second-generation basal insulin analogue Gla-300 in people with type 2 diabetes (T2DM) who fast during Ramadan. Adults with T2DM who intended to fast for ≥15 days during Ramadan, had taken Gla-300 for ≥8 weeks prior to inclusion, and intended to continue its use during Ramadan were enrolled in 11 countries. During Ramadan, Gla-300 treatment was adjusted as per routine practice by the treating physician. Overall, the majority of people (85%) fasted for the entire Ramadan period and 10% fasted for ≥25 days but with at least one missed day. Mean (SD) age was 54 years old, just over half were male, BMI was 29.7kg/m2, and duration of diabetes was 10 years. Risks of diabetes-related complications associated with fasting were assessed by

physicians according to IDF-DAR fasting risk category. “Risk was low/moderate in 82%, high in 14%, and very high in 2% of people. The proportion of people with ≥1 severe and/or documented symptomatic (SMPG ≤70mg/dL) hypoglycaemia event was low (2.2% [event rate: 0.021 per participant-month (PPM)] in pre-Ramadan, 2.6% [0.039 PPM] in Ramadan and 0.2% in post-Ramadan [0.003 PPM]),” according to the authors. The study showed that overall, 0.8% of participants experienced severe and/or documented symptomatic hypoglycaemia at SMPG <54mg/dL, and only during pre-Ramadan. No participants had severe hypoglycaemia during Ramadan or postRamadan. One participant had severe hypoglycaemia pre-Ramadan. Most of those who experienced symptomatic hypoglycaemia during Ramadan did so

during fasting hours. “Reductions were shown pre- to postRamadan for mean (SD) HbA1c (8% [1.29] pre-Ramadan to 7% [1.05] post-Ramadan; change of −0.44 % [0.97]) FPG (144.3 [45.8]mg/dL pre-Ramadan to 128.5 [37.8] mg/dL post-Ramadan; change of −13.5 [44.1]mg/dL) and fasting SMPG (130.7 [32.9] mg/dL pre- Ramadan to 126.8 [28.5]mg/dL post-Ramadan; change of −3.3 [26.6]mg/dL),” said the study authors. Mean Gla-300 dose was reduced slightly between pre-Ramadan and Ramadan (25.6 [11.9] U/0.32 [0.14]U/kg pre-Ramadan to 24.4 [11.5] U/0.30 [0.13]U/kg in Ramadan) and returned to 26 (12.2) U/0.32 (0.14)U/kg in the post-Ramadan period. AE incidence was low (5%). Three (0.6%) participants had an AE of hyperglycaemia, two (0.4%) during Ramadan.

CONCLUSION Incidence of hypoglycaemia was low in people with T2DM treated with Gla-300 who fasted for Ramadan, with no incidence of severe hypoglycaemia during the Ramadan period; HbA1c, FPG and fasting SMPG reductions were also observed These results contrast with the landmark Epidemiology of Diabetes and Ramadan (EPIDIAR) study that reported an increase in incidence of severe hypoglycaemic events in people living with T2D who observed Ramadan.

REFERENCE Hassanein M et al. SUN-LB126 - Real-World Safety and Effectiveness of Insulin Glargine 300 U/ML (Gla-300) in People With Type 2 Diabetes Who Fast During Ramadan. Oral poster presentation x, 102nd Annual Meeting and Expo of the Endocrine Society, March 2020, San Francisco, USA.

MEDICAL CHRONICLE | APRIL 2020

OPINION

Post COVID-19, Where to?

A disaster like COVID-19 poses numerous challenges and problems across all sectors of healthcare and for global economies.

N THE SHORT term we will see a concerted effort by all sectors. To mention a few: - Economic sector - Religious / faith-based - Healthcare sector - Governments. These efforts championed by each group is to complement the strategies in place to contain this pandemic. Daily updates on this pandemic are posted by McKinsey and Co. We have collated these messages to provide a 'helicopter' view. WHAT SHOULD DISASTERS TEACH US? - We need to work together at multiple levels to reach an optimal level of disaster preparedness - We need to improve structures we have and not ’dismantle‘ them (Dr Nabil Shabeeb). - Learn from the mistakes and shortcomings of our system and structures. We are not going back to the 'normal' we had before Coronavirus (Kevin Sneader – McKinsey & Co). One thing we are sure of is that nothing is going to be the same. This will 'set' a new normal and is a different way of operating (Kevin Sneader). Healthcare, commerce and the entire economy are in a conundrum – not just for the future but how do we get past the present challenges. We cannot predict the future. The present is a state of unfamiliarity and uncertainty. So, Kevin Sneader asks, if we cannot go back to the way it was before, what is the next normal? Provider behaviour (health professionals) and patients is changing. “Will it go back to the way it was?” The general consensus is, no. We notice the increased focus on AI, IT and telemedicine, telehealth and online efficiencies. These efficiencies will become reinforced and entrenched as a new way to care for the sick and will not go back to where we were before. We witnessed in this pandemic, poor preparedness and lack

26 APRIL 2020 | MEDICAL CHRONICLE

of efficiency of our healthcare supply chain. We need to make this more resilient. The question we need to ask is what will the strategies be towards the next ‘normal’. What have we learnt from being poorly prepared to re-engineer and reform our present healthcare offering? The present challenges have pointed us to: - Need for integrated health platforms versus solo platforms - Telemedicine and telehealth – will be the new normal - Coordinated care pathways will result in quality outcomes and increased efficiencies - Value-based reimbursement – will force us into delivering care that is reimbursed for measured outcomes and value - Increased emphasis of preventing illness versus treating people who are already ill.

We will move to a Wellness System versus the Sick Care system that we are currently in. We will not just innovate technological advanced ways to treating illness but focus on prevention and public health efficiencies. So, the net result is that we will need to re-engineer, restructure, remodel to make healthcare fit for purpose and to be resilient. Healthcare workers will not only have to change the way they practice, but the whole healthcare system must be remodelled to manage the challenges ahead.

The issues we face today will change the way we look at healthcare in the future. What is certain is that the future of health is not the normal we had before the Coronavirus global crisis. HOW DO WE NAVIGATE THIS HEALTHCARE CRISIS? This Pandemic was not the first – there were others. The recent epidemics were more regional. Unlike the Ebola and Zika virus, Covid-19 is global. Certainly, no country was prepared for the rapid spread, the high morbidity and certainly a disproportionate number of deaths. What is even more difficult to explain is that the high socio-economic countries were more inflicted. Certainly, in South Africa, we were unprepared, and the rate of the spread globally resulted in too short a period to prepare. McKinsy and Company describe five stages, leading from the crisis of today to the next normal that will emerge after the Coronavirus is over: Resolve; Resilience; Return; Reimagination and Reform. 1. RESOLVE Presently Healthcare is in crisis and our response is in full motion. We are challenged with shortages of medical supplies, test kits and PPEs. There are numerous strategies in place to alleviate these shortages. The challenge we are facing is that healthcare services must go on despite the shortages of essential items, no vaccines and definitive treatment guidelines. 2. RESILIENCE “The Pandemic has affected the economy to such an extent that healthcare is also in crisis and its ability to protect public health is jeopardised.” (Kevin Sneader – McKinsey & Co). The duration of this crisis is unknown. The McKinsey Institute Analysis states, the shock and economic impact could be the

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

biggest in a century. They go onto state that in the face of these challenges, resilience is a vital necessity, as much of the country will be experiencing uncertainty. 3. RETURN • Return to business after a severe shutdown is extremely challenging • Most businesses need to reactivate their entire supply chain • The Return will have its own challenges for the health sector – o State of health Increased burden of disease Health system strengthening Rebuilding public health, etc. 4. REIMAGINATION The shock of this health crisis and economic crisis will see new shifts to the way we manage the post viral era. The challenges and vulnerabilities must be worked through but we need to also look at the opportunities that present to improve the performance of the healthcare business. “We will see opportunities to push the envelope of technology for the future of health. IT and AI will pave the way to bring in efficiencies.” In the light of an escalation of NCDs, AI will set the platform to achieve efficiencies. 5. REFORM “Business leaders need to anticipate popularly supported changes to policies and regulations as society seeks to avoid, mitigate and pre-empt a future health crisis of the kind we are experiencing today.” (McKinsey & Co). We will need to find ways to manage increased patient loads. “This may mean seamlessly across in-patient and virtual care” (Kevin Sneader). We need to remodel and restructure the way our supply chain functions optimally – this will include increased medical devices, equipment, medication and facilities. We will need to reflect on the past inefficiencies and shortcomings and put programmes and systems in place to fast track a new normal. Healthcare will not be improved unless we restructure and improve alongside the global economic sector. The success of the future will depend on how we reflect on the past and how we set about developing a new normal from the shortcomings and inefficiencies of the past. The stock and aftermath will bring healthcare stakeholders together as we all will need to commit to a new way in which we deliver healthcare.

MEMORIAM

MEDChronicle

A sad farewell

to Prof Ramjee

EDITORIAL EDITOR: Claire Rush McMillan Claire.Rush@newmedia.co.za NEWS WRITER: Nicky Belseck Nicky.Belseck@newmedia.co.za SUB-EDITOR: Gill Abrahams

Super specialist contributes to the advancement of medicine in province.

EDITORIAL CONTRIBUTORS Andrew Dittberner, Prof Morgan Chetty

Prof Ramjee worked tirelessly to find HIV prevention solutions for women

T WAS WITH great sadness that the medical community received the news of Prof Gita Ramjee’s untimely passing from the virus that has gripped the world. Prof Ramjee is a South African scientist renowned for her work to expand women’s access to HIV treatment and prevention. She was the chief scientific officer of the Aurum Institute, a nonprofit organisation based in Johannesburg, focusing on HIV and TB research. She had just returned from a symposium in the UK when she became ill with the virus. She was 64 years old. Prof Ramjee grew up in Uganda and then moved with her family to India and later to the UK. In 1980, she obtained a degree in chemistry and physiology from the University of Sunderland in northeast England, and then relocated to South Africa with her husband in 1981. She obtained a PhD in paediatrics from the University of KwaZulu-Natal in Durban in 1994. After her PhD she became involved in research with women at risk of HIV infection. “She went on to head the South African Medical Research Council’s HIV prevention research unit in Durban where she oversaw many trials on HIV prevention tools, including vaginal microbicides, products that could help women protect themselves against HIV infection. She also held honorary professorships at the London School of Hygiene and Tropical Medicine (LSHTM) and the University of Washington in Seattle, among others,” reported The Scientist.

Prof Ramjee worked tirelessly to find HIV prevention solutions for women. “The world has lost a bold and compassionate leader in the response to HIV,” said Professor Gavin Churchyard, Group CEO of the Aurum Institute. “Gita Ramjee firmly believed in health as a fundamental human right. Her ground-breaking research in HIV prevention contributed to the global response to HIV and AIDS. Our thoughts during this difficult time are with her family, colleagues and the many people her life and work touched,” he added. Prof Ramjee was a critical player in the field of HIV prevention clinical trials and was acknowledged internationally for her expertise in the field of microbicide research, including a Lifetime Achievement Award for HIV Prevention. In 2018, she was honoured with the “Outstanding Female Scientist” Award by the European Development Clinical Trials Partnerships (EDCTP) for her life’s work that has focused on finding new HIV prevention methods. Professor Ramjee has published more than 200 research articles. She was a reviewer and editor of several scientific journals and a member of several local and international committees and advisory groups including the Academy of Science of South Africa (ASSAf) and the South African National AIDS Council (SANAC). “The Aurum Institute and the global HIV research community will mourn Gita Ramjee’s passing and celebrate the huge contribution to the response to HIV she made in her life," said Churchyard.

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Medical Chronicle April 2020 Teaser

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